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Pediatric Hand Injuries

Krister Freese, MD

Pediatric Hand Surgeon

Shriners Hospital for Children -Portland

Background

– The child’s hand is vulnerable to injury• Used as an organ of exploration

• Poor motor control

• No fear

– The hand is the most frequently injured part of a child’s body• 10-20% of all fractures

– Incidence of hand injury is increasing• Sports injuries in older children

• Household injuries in younger children

Background

– Hand fractures

• 56% Nondisplaced

• 64% Extraphyseal

• Approx 75% are benign

– Key is to recognize problem injuries

Nondisplaced

Displaced

Extraphyseal

Physeal

• Border digits most commonly affected

Physical Examination

• Examining a child’s injured hand can be difficult

– Can’t communicate what’s wrong

– Can’t answer difficult questions

– Won’t follow commands

– Afraid/in pain

• Passive tests and clinical signs are very useful

Physical Examination

• Always examine cascade of fingers

– With wrist in neutral:

• Fingers rest flexed at MCP, PIP, DIP joints

• Flexion is greatest in small finger, least in index

• Thumb MCP rests flexed, IP slightly flexed

– Abnormal cascade = tendon incompetence

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Physical Examination

• Wrist tenodesis

– Tests competence of flexors/extensors

– Examine rotational alignment

• Passively extend wrist:

– All finger and thumb joints should flex

• Passively flex wrist:

– All finger and thumb joints should extend

Physical Examination

• Passive wrist extension painlessly causes enough finger flexion to pick up rotational malalignment

Physical Examination

• Skin moisture and texture rely on intact sensory nerve function

• Presence/absence can be used to detect nerve injury

– Follow nerve recovery in young children

Wrinkle test

• Use skin wrinkles to assess nerve function

• Wrinkling of pulp skin in water requires intact sensory nerves

• Soak in lukewarm water for 5 minutes

Physical Examination

• Watch the child play

– Spy on them while taking a history

• Earn the child’s trust

– Break the ice

– Save anything painful for the end

– Don’t be the bad cop (have someone else remove dressings, casts, etc)

Imaging

• In young children, image more of extremity to identify location of injury

• Then get dedicated views of injured part

– Especially isolated lateral radiographs of any injured finger

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Imaging

• Normal growth plates

Imaging

• Normal variants

Immobilization

• Children are escape artists

– If immobilization is crucial, use a cast rather than a splint

Immobilization

• In infants and some older children, use a long arm cast with elbow flexed 90 degrees to prevent cast from sliding off

Immobilization

• Cast more than you think you need

– MCP joints may be immobilized in full extension in young children

– Stiffness generally not a problem

• Reinforce the rules of cast care!!

Locations of Injection

• SIMPLE block – Single Injection midline proximal phalanx with lidocaine

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Lidocaine vs Bupivacaine

• Intravascular bupivacaine cardiotoxic

• Pain relief w/ bupivacaine lasts 50% of time that hand has touch/pressure numbness

• Bupivacaine has longer duration

– Procedures >2.5 hours

Minimizing Pain

• Buffer lidocaine

– 10cc lidocaine 1cc bicarbonate

– Speeds time to onset

• Warm solution prior to injection

• Uses small gauge needle

– 27 or 30

• Inject subcutaneous fat in cases w/ open wounds

• Insert needle at 90 degrees to skin

Minimizing Pain

• Inject subdermally

– Avoid intradermal injection

• Inject 0.5ml then pause 45s

– Inject again when pt can no longer feel needle

• Inject slowly

• Keep wheal 1cm ahead of needle tip

• Reinsert the needle >1cm from edge of blanched skin

• Buffered local into one hand

• Non-buffered into the other

• VAS score

– Buffered 4.6

– Nonbuffered 6.5

– P<0.001

• 25 medical students/residents

• Patients recorded number of pain episodes

• 75% pain with initial injection only

• 25% two episodes of pain

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• Needle free device

• Lower VAS scores than EMLA for IV placement

• Noisy – warn patients/parents

• Use in conjunction with typical block

Hand Injuries

• From fingertip to metacarpals

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Time Considerations

• Pediatric hand fractures heal rapidly

• Closed reduction <1 week old

• Established malunion by 3 weeks

• Early recognition and refer key

Remodeling Potential

• Age dependent– <10 - 30 degrees of flexion and

extension

– >10 – 20 degrees of flexion and extension

• Plane dependent– Flexion/extension >>> radial/ulnar

deviation

– Rotation does not remodel!

Nailbed AnatomyNailbed Anatomy

– Nail bed: composed of germinal and sterile matrix

– Germinal matrix• From nail fold to lunula• Generates 90% of the nail plate

– Sterile matrix• From lunula to hyponychium• Provides adherence to nail plate• Provides 10% of naik thickness

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Subungal Hematoma

– Disruption of nail bed with intact nail plate

– Pain from bleeding into non-compliant compartment

– Can evacuate if involves <50% of surface or with severe pain

– Procedure: drill hole or remove nail 31

Fingertip Lacerations

– Hematoma >50% of surface area is typically associated with nail bed laceration

– Lacerations often extend across paronychium

• This is a helpful indicator of nailbed injury!

– Repair acutely

– Use digital block with finger tourniquet32

Finger Tourniquets Preferred Technique

• IV tourniquet

• Large Clamp

Nail bed repair with absorbable suture!!!

(5-0 chromic)

Replace the nail as biologic dressing

Use absorbable sutures in children for skin laceration repair

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Tips and tricks

• Cyanoacrylate if laceration is amenable to this

– Still requires meticulous alignment of nail bed

– Stellate lacerations

– Cyanoacrylate must be completely dry before replacing the nail

• Protect repairs in a short or long arm splint or cast

– Immobilization should seem “overprotective”

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Distal Phalanx Tuft Fracture

• Soft tissue injury dictates care

• Highest predictive value for nail bed laceration

• Non-displaced: repair as for simple laceration

• Displaced: reduce and consider fixation if unstable

• Radiographic union uncommon, unnecessary

Fingertip Amputation

• Composite grafting works well

– Can survive in infants

– Forms biologic dressing in older children, avoiding dressing changes

• Secondary intention can cover exposed bone in young children

– Do not shorten distal phalanx

– Formal coverage rarely needed

• Opsite or Tegaderm applied directly over wound– Dress with gauze over

tegaderm

• Changed weekly

• Wash finger gently

• Heal ~21 days

Seymour Fractures

• Displaced physeal distal phalanx fracture

• Proximal nail avulsion with nailbed laceration

• Open fracture (Hidden)

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Seymour Fractures: Treatment

• Must remove nail to irrigate and repair

• Extricate interposed nailbed to reduce fracture

• Pin/18g needle if needed for fixation

• Repair nailbed

– May need to utilize counter incisions

Seymour Fractures

• Neglected Seymour fractures lead to infection, osteomyelitis and growth arrest

Timing/Quality of Treatment Infection Rate

Acute, Appropriate treatment 0%

Acute, Partial treatment 15%

Delayed treatment 45%

Acute Appropriate treatment = I+D, Reduction, Abx, nail bed repair, <24 hours

Mallet Finger

• Disruption of extensor tendon’s insertion onto distal phalanx

• Forceful flexion of the distal phalanx

– “Jammed” finger

• May be either soft-tissue or bony

– Need an X-ray 46

Mallet Finger

• Treatment consists of extension splinting for 6-8 weeks

– Must be continuous

• Bony mallet splint as long as joint not subluxated

• Dorsal splint, PIP is left free

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Phalangeal Condyle Fracture

• Intra-articular

• May be treated with immobilization if non-displaced

– Short-arm cast extending to fingertip

– Unstable

– Follow closely

• CRPP/ORIF if displaced

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Phalangeal Neck Fracture

• Almost uniquely pediatric fracture

– Usually displaced

– Anatomic reduction required

• Hyperextension deformity causes block to flexion by obliterating subcondylarfossa

• Remodeling potential limited

Phalangeal Neck Fracture

– Anatomic reduction and pinning is required

Phalangeal Shaft Fracture

• Typically seen in older children

– Spiral

– Closed immobilization (cast) if nondisplaced

– CRPP if displaced/angulated/rotated

PIP Joint Dislocation

• Dorsal dislocation

– Volar plate avulsed

– Early motion if possible

• Depends on patient age

• Temporary splint ~1 week

• Buddy tape

IP Joint Dislocation

• Volar dislocation

– Central slip extensor tendon avulsed off middle phalanx

– Splint PIP in extension

• MCP and DIP may be free

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PIP Volar Plate Avulsion Fracture

• Usually very small fracture fragment

• Hyperextension injury

• Joint subluxation is rare

• Treat with early motion

– Stiffness results from overtreatment

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Proximal Phalanx Base Fracture

• Extra-octave fracture

• Most common location of fracture in the child’s hand

• Salter-Harris II or extraphyseal

• Check rotation

Proximal Phalanx Base Fracture

• Stable in young children

• Usually easily reduced

– Digital nerve block

• Buddy tape + cast

• Excellent remodeling

Proximal Phalanx Base Fracture

• Heal rapidly

– physis

Proximal Phalanx Base Fracture

• Unstable in older children• CRPP often required

Pediatric Skier’s Thumb

• AKA “Gamekeeper’s Thumb”

– Ulnar collateral ligament avulsion fracture

– Reduction and fixation required if displaced

MCP Joint Dislocation

• More common in children than adults

• Thumb and index digits most common

• Can have associated metacarpal head fracture

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MCP Joint Dislocation• Simple dislocation -> irreducible dislocation if longitudinal

traction is applied

– Entraps volar plate

MCP Joint Dislocation

• Closed reduction by hyperextension and volarly directed translation

• Percutaneous reduction with intra-articular lidocaine– Flush volar plate out of

joint

Metacarpal Neck Fracture

• Very common

– Adolescent boys

– 70 degrees angulation

– remodeling potential in sagittal plane

Metacarpal Neck Fracture

• Closed reduction, casting with MCP joints extended

– Allows better volar mold

– Stiffness rarely a problem

• CRPP if closed treatment fails

Finger Metacarpal Shaft Fracture

• Check rotation!!

• Closed reduction/casting often enough

– Periosteum stronger in children/adolescents

– Post-immobilization stiffness less of a problem

Finger Metacarpal Shaft Fracture

• CRPP (rarely ORIF) if unstable

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Thumb Metacarpal Base Fracture

• Extraarticular• Excellent remodeling in

young children– Can be treated closed

• Less remodeling when widely displaced in older children– CRPP/ORIF required

Flexor Tendon Laceration

• Uncommon in young children

• Careful exam is essential

– Check tenodesis

– Evaluate for nerve injury

• Ideal repair within 1 week

Digital Nerve Laceration

• Examine carefully

– Wrinkle test

– 2-point discrimination if older than 5-7 years (check other hand)

• Require repair

Firecracker Injuries

• Any age, usually 10-14

• Severity depends on size of device

• Amputated parts cannot be salvaged

• Multiple operations

• Poor outcomes

• Prevention is best treatment

Pediatric Hand Infections

• Less common in children than adults

– Less comorbidities

• Often present in delayed fashion

– Superficial infections progress

Evaluation

• Trauma or exposure history

• Immunization history

• Dorsum of hand often swollen– Loose skin

– May not be site of infection

• Labs– ESR

– CRP

– CBC

– Wound and blood cultures

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Evaluation• Imaging

– Plan radiographs – bony changes, air

– US/MRI – fluid collection

Non operative treatment

• Presentation <24 hours

• No systemic signs

• No fluid collection

• Normal host – not immunocompromised

Non operative treatment

• Early empiric antibiotics

• Elevate hand

• Soft tissue rest via splinting

• Should improvement over 24 hours

• OT – edema control and mobilization

Microbiology

• 40-80% of cases staph aureus or beta-hemolytic strep

– Higher rates of mixed and anaerobic infections in peds

• 30% MRSA + in some places

– >10% MRSA locally empric trimethoprim-sulfamethoxazole

• Not cephalexin

Acute Paronychia

• No fluctuance oral antibitiotics

• Purulence surgical decompression

– Elevate with Freer elevator

Felon

• Finger tip pulp infection

• Must require surgical drainage

• Can spread to flexor sheath or bone

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Felon Flexor Tenosynovitis

• Typically from penetrating trauma

• Spreads rapidly along flexor sheath

• Communicate with deep spaces of the hand

Kanavel’s cardinal signs

• Tenderness over the flexor tendon sheath

• Semi-flexed posture

• Pain with passive extension of digit

• Fusiform swelling of digit

Treatment

• <24 hours can consider IV antibiotics and elevation

• Purulence or >24 hours surgical intervention in the OR

Fight Bites

• Traumatic wound over MP joint

• Often intra-articular– Can not seen opening into joint

• #1 staph aureus, also Eikenellacorrodens, polybacteria

• Augmentin first line agent

Treatment

• Require surgical exploration

• Beware metacarpal head fractures

• Can be done in ED, must see into joint

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• Chronic osteomyelitis after a fight bite

ER side of Hand OR side of Hand

Summary

• Thorough physical examination and imaging are critical

• Recognize problem fractures among seemingly minor finger injuries

• Recognize tendon and other uncommon soft tissue injuries

• Tailor treatment choice for any injury to skeletal and developmental maturity level

Questions?

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