9/20/2017. Background. Background. Physical Examination. Physical Examination. Pediatric Hand Injuries. Border digits most commonly affected

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1 Background Pediatric Hand Injuries Krister Freese, MD Pediatric Hand Surgeon Shriners Hospital for Children -Portland 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 Hand fractures 56% Nondisplaced 64% Extraphyseal Approx 75% are benign Background Nondisplaced Displaced Border digits most commonly affected Key is to recognize problem injuries Extraphyseal Physeal 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 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 1

2 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 Use skin wrinkles to assess nerve function Wrinkling of pulp skin in water requires intact sensory nerves Soak in lukewarm water for 5 minutes Wrinkle test Physical Examination Imaging 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) 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? 2

3 Imaging Imaging Normal growth plates 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 Locations of Injection 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!! SIMPLE block Single Injection midline proximal phalanx with lidocaine 3

4 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 25 medical students/residents Patients recorded number of pain episodes VAS score Buffered 4.6 Nonbuffered 6.5 P< % pain with initial injection only 25% two episodes of pain 4

5 Hand Injuries From fingertip to metacarpals Needle free device Lower VAS scores than EMLA for IV placement Noisy warn patients/parents Use in conjunction with typical block 26 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 Anatomy Nailbed 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 30 5

6 Subungal Hematoma Fingertip Lacerations Disruption of nail bed with intact nail plate Pain from bleeding into noncompliant compartment Can evacuate if involves <50% of surface or with severe pain 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 Procedure: drill hole or remove nail 31 Use digital block with finger tourniquet 32 Finger Tourniquets Preferred Technique IV tourniquet Large Clamp Replace the nail as biologic dressing Use absorbable sutures in children for skin laceration repair Nail bed repair with absorbable suture!!! (5-0 chromic) 6

7 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 37 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 Seymour Fractures Displaced physeal distal phalanx fracture Proximal nail avulsion with nailbed laceration Open fracture (Hidden) Wash finger gently Heal ~21 days 7

8 Seymour Fractures: Treatment Seymour Fractures Must remove nail to irrigate and repair Neglected Seymour fractures lead to infection, osteomyelitis and growth arrest Extricate interposed nailbed to reduce fracture Pin/18g needle if needed for fixation Repair nailbed May need to utilize counter incisions Disruption of extensor tendon s insertion onto distal phalanx Mallet Finger 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 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 47 Intra-articular Phalangeal Condyle Fracture May be treated with immobilization if non-displaced Short-arm cast extending to fingertip Unstable Follow closely CRPP/ORIF if displaced 8

9 Phalangeal Neck Fracture Phalangeal Neck Fracture Almost uniquely pediatric fracture Usually displaced Anatomic reduction required Hyperextension deformity causes block to flexion by obliterating subcondylar fossa Remodeling potential limited Anatomic reduction and pinning is required Phalangeal Shaft Fracture Typically seen in older children Spiral Closed immobilization (cast) if nondisplaced CRPP if displaced/angulated/rotat ed Dorsal dislocation Volar plate avulsed Early motion if possible Depends on patient age Temporary splint ~1 week Buddy tape PIP Joint Dislocation IP Joint Dislocation Volar dislocation Central slip extensor tendon avulsed off middle phalanx Splint PIP in extension MCP and DIP may be free PIP Volar Plate Avulsion Fracture Usually very small fracture fragment Hyperextension injury Joint subluxation is rare 53 Treat with early motion Stiffness results from overtreatment 9

10 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 Heal rapidly physis Proximal Phalanx Base Fracture Proximal Phalanx Base Fracture Unstable in older children CRPP often required AKA Gamekeeper s Thumb Ulnar collateral ligament avulsion fracture Reduction and fixation required if displaced Pediatric Skier s Thumb MCP Joint Dislocation More common in children than adults Thumb and index digits most common Can have associated metacarpal head fracture 10

11 MCP Joint Dislocation Simple dislocation -> irreducible dislocation if longitudinal traction is applied Entraps volar plate Closed reduction by hyperextension and volarly directed translation MCP Joint Dislocation Percutaneous reduction with intra-articular lidocaine Flush volar plate out of joint Metacarpal Neck Fracture Metacarpal Neck Fracture Very common Adolescent boys 70 degrees angulation remodeling potential in sagittal plane 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 11

12 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 Examine carefully Wrinkle test 2-point discrimination if older than 5-7 years (check other hand) Require repair Digital Nerve Laceration Firecracker Injuries Any age, usually 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 12

13 Evaluation Imaging Plan radiographs bony changes, air US/MRI fluid collection Presentation <24 hours No systemic signs Non operative treatment 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 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 OT edema control and mobilization Acute Paronychia Felon No fluctuance oral antibitiotics Purulence surgical decompression Elevate with Freer elevator Finger tip pulp infection Must require surgical drainage Can spread to flexor sheath or bone 13

14 Felon Typically from penetrating trauma Flexor Tenosynovitis 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 <24 hours can consider IV antibiotics and elevation Treatment Purulence or >24 hours surgical intervention in the OR Traumatic wound over MP joint Often intra-articular Can not seen opening into joint #1 staph aureus, also Eikenella corrodens, polybacteria Augmentin first line agent Fight Bites Treatment Require surgical exploration Beware metacarpal head fractures Can be done in ED, must see into joint 14

15 ER side of Hand OR side of Hand Chronic osteomyelitis after a fight bite Summary Thorough physical examination and imaging are critical Recognize problem fractures among seemingly minor finger injuries Recognize tendon and other uncommon soft tissue injuries Questions? Tailor treatment choice for any injury to skeletal and developmental maturity level 89 15