9/20/2017 1 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
15
Embed
Displaced Extraphyseal Physeal...Mallet Finger • Disruption of extensor tendon’s insertion onto distal phalanx • Forceful flexion of the distal phalanx – “Jammed” finger
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
9/20/2017
1
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
9/20/2017
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
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
?
9/20/2017
3
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
9/20/2017
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