Scooter Fractures, Buckle Fractures, and Beyond: Pediatric Hand and Wrist Injuries in the ED
Author: Michael S. Beeson, MD, MBA, FACEP, Professor of Clinical Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Department of Emergency Medicine, Summa Health System, Akron, OH
Peer Reviewer: Andrew D. Perron, MD, FACEP, FACSM, Residency Program Director, Maine Medical Center, Portland, ME
Pediatric hand and wrist injuries are an extremely common entity seen in every emergency department (ED) in the United States. A wide spectrum of injury occurs regardless of age—from the toddler exploring with his hands to the adolescent athlete falling on an outstretched hand. The history and physical examination may be challenging, but in the majority of situations are all that is needed to guide diagnostic imaging and management. Child abuse must be considered when atypical injuries are seen (e.g., circumferential burns, burns on the dorsum of the hand, incompatible history with injury). In children, because the ligaments often are stronger than the underlying bone that is being connected, fractures more commonly will occur when typically a sprain would result in an adolescent or adult patient. Pediatric patients also frequently sustain injuries to their growth plates: Salter-Harris type fractures. The small compact hand of the child, with many critical structures coursing through the wrist, hand, palm, and digits predisposes the child to injuring a significant underlying structure, such as a nerve or tendon, with a simple laceration; therefore, lacerations of the hand deserve very thorough evaluations. The authors provide a comprehensive review of pediatric hand and wrist injuries with a special emphasis on the unique aspects of management. — The Editor
Introduction
Pediatric hand and wrist injuries commonly are encountered in emergency medicine practice. The severity may vary from minor damage to soft tissues to severely disfiguring and debilitating wounds. The diagnosis of pediatric hand and wrist injuries is complicated because the patient’s history is often difficult to obtain, and the physical examination can be extremely challenging and limited. Evaluation also is complicated by the unique aspects of pediatric bone growth and development and the small size of any affected area.
It is critical that reliable pediatric referral patterns be developed from the ED with specialists who can promptly evaluate patients either in the ED or within an appropriate period of time and are comfortable in the management of the pediatric patient with an injured hand or wrist. This article will provide practical points related to the early identification, diagnosis, and treatment of pediatric hand and wrist injuries.
Epidemiology
Although the exact number of children that sustain hand and wrist injuries is unknown, there have been many studies conducted in the United States and abroad during the past 10 years that provide valuable information regarding common mechanisms of injury, frequently sustained injury patterns, and injury patterns suspicious for abuse that may be of benefit in the care and treatment of the general pediatric population.
A large urban pediatric emergency center in the United States reported 382 hand injuries in 17,859 patients seen during an eight-month period. Of the reported 382 hand injuries, the majority were male (1.4:1), their median age was 10 years, and most injuries occurred outdoors (47%). Lacerations were the most common injury (30%), followed by fractures (16%). Only five patients required hospitalization (1.3%). The phalanges were the most commonly injured part of the hand, particularly the thumb (19%); fingertips were involved in 21% of cases. Infection occurred in 14 (3.7%) patients.1
A second retrospective study of hand injuries conducted in 1993, reported 464 patients with hand and wrist injuries during a six-month period in a pediatric ED. The authors found the most common injuries were lacerations (38.1%), soft-tissue injuries (28.7%), fractures (19.3%), and sprains (8%). The fifth finger was the most commonly fractured digit (37%), and the fifth metacarpal was the most commonly fractured bone. Sixty percent of the injuries were sustained at home. Younger children suffered more lacerations and burns and older children incurred more fractures, sprains, and sports injuries to the hand. The majority were male (287 of 464) with a median age of 10 years.2
A study in Nottingham, England, found that the hand was the second most common site of fracture in children age 12 years and younger and that the incidence of hand fracture rose sharply after the age of 8 years, especially in boys. The most common site of injury was the fifth finger and fifth metacarpal, especially around the metacarpophalangeal (MCP) joint. However, fractures in the metacarpals were more frequently greenstick fractures, and epiphyseal injuries were more common in the phalanges. The most common cause of fracture was a fall in or around the home (37.5%), followed by sports injuries (22.8%), and 22.8% were the result of altercations.3
To study the incidence of fractures within the United States, Chung and Spilson extracted cases from the National Hospital Ambulatory Medical Care Survey in 1998. They found 1,465,874 cases of hand/forearm fractures reported in children and adults, accounting for roughly 1.5% of all ED cases that year. Radius and/or ulna fractures were the most common fractures sustained (44%) and five- to 15-year-old children were the most affected age group (26%). Most of the fractures occurred at home (30%), and most were caused by falls (47%).4
Other reported sources of significant injury of the hand and wrist of younger children include home exercise equipment. One of the most frequently offending pieces of equipment is the stationary exercise bicycle. Even with adult supervision, stationary exercise bicycles represented a predictable source of severe injury to the digits (e.g., index and long) in children between the ages of 18 months and 5 years, from both the wheel-spoke (which produced less severe injuries) and chain-sprocket mechanisms (which produced much more severe injuries).5
Youth participation in organized sports creates a greater potential for hand and wrist injury than any other activity, but sports injuries tend to present later in childhood.1,2,6,7 A ten-year study at The Cleveland Clinic found nearly 15% of all athletic participants sustained some type of upper extremity injury before the age of 16 years. Sixteen percent involved the hand, and 9% involved the wrist. The types of injuries ranged from traumatic fractures, which most often were seen in contact sports (e.g., football and hockey) to stress and overuse injuries seen in gymnastics, racquet sports and golf.8
The six most common sports implicated were basketball (19.5%), football (17.1%), baseball/softball (14.9%), soccer (14.2%), in-line skating(Rollerblading)/skating (5.7%), and hockey (4.6%). Thirty-two percent of the sports-related injuries were sprains/strains, 29% were fractures, 19.3% were contusions/abrasions, and 9.7% were lacerations. The most common injury location was the wrist/hand (28%), followed by head/face (22%) and ankle/foot (18%). The most common mechanism was contact with person or object in more than 50% of the sports-related injuries.9
Even backpacks have been reported to cause more hand (14%) and wrist/elbow injuries (13%) than actual back injuries (ranked sixth at 11%) in school-aged children presenting to 100 EDs throughout the United States. In 28% of the cases, the injuries were due to children tripping over the backpack, 13% were due to children incorrectly wearing them, and 13% were due to children being hit by them.10
Common wrist and hand sports-related injuries include distal radius fractures, distal radial physeal injuries, triangular fibrocartilage tears, scaphoid fractures, wrist ligamentous injuries, thumb metacarpophalangeal ulnar collateral ligament injuries, proximal and distal interphalangeal (IP) joint injuries, and finger fractures.11
Another all too common and unfortunate cause of hand and wrist injury in children is child abuse. The incidence seems to be higher in younger children. Burns of the hand may represent abuse and should raise suspicion if found.12 Children’s Hospital in Columbus, Ohio, reviewed 944 reports of child abuse and found that the hand was involved in 94 cases; it was the sole injury reported in 19 of those patients. When encountering an atypical hand injury, or an injury that doesn’t match the history, child abuse must be suspected.13
The Unique Aspects of the Pediatric Skeleton
The bony matrix in children is different than in adults; it includes a thick and active periosteum, a growth plate (physis), an epiphysis (secondary ossification center), and perichondrial rings. A child’s bones are considerably more porous and pliable than an adult. Because of this increased porosity, stiffness and overall bony strength are less, and the incidence of fractures is greater in children than in adults. During growth, pediatric bones undergo changes that cause different anatomic regions to be more susceptible to fracture at certain stages of development. In general, the ligaments attaching one bone to another have greater strength than the epiphyseal plates and perichondrial rings, resulting in a greater incidence of fractures and periosteum being torn from the bony cortex. For that reason, the incidence of ligamentous injuries and dislocations is reduced in children.14 (Please see Figure 1 for a review of the nomenclature.)
Fracture healing is also different in children. Because of their thick and extremely osteogenic periosteum, healing occurs more rapidly than in adults.15 A child’s broken bone will continue to develop as it heals and will grow faster for the first six to eight months following an injury.16 The fracture pattern can differ due to varying amounts of cartilaginous anlage present in immature bone. For example, in a forearm injury fracturing the radius, a persistent bony deformity in the ulna can occur when it is bent beyond its elastic recoil potential.17
Possibly the greatest difference between children and adults is the presence of multiple maturing growth plates and ossification centers. A growth plate rests between the epiphysis and metaphysis. (See Figure 2.) It consists primarily of cartilage and is separated into zones.
The germinal and daughter cells reside closest to the epiphysis. Their blood supply comes from the epiphyseal vessels. As these cells undergo division and differentiation, they secrete a cartilage matrix; this zone eventually calcifies. After calcification, metaphyseal vessels will enter the area, remove some of the matrix, and lay down bone on top of the cartilage matrix. The area between the calcification and uncalcified area is the plane of separation and is the weakest area of the maturing growth plate. This plane through the growth plate is predominantly bloodless; therefore, any separation in this area will not cause a great deal of swelling.18 (See Figure 3.) Fractures that occur through this area initially will be filled with fibrin. Then, widening will commence as cartilage continues to grow. Later, vessels will invade the area, and calcification will begin again.19
Anatomy of the Distal Forearm
The distal forearm consists of the radius and ulna connected by an interosseus membrane. This membrane separates the forearm into two compartments: the anterior compartment consisting of flexor muscles (i.e., flexor muscle box) and the posterior compartment consisting of the extensors (i.e., extensor muscle box). Of particular note is the relationship between the flexor digitorum profundus and the flexor digitorum superficialis. The flexor digitorum superficialis inserts onto the volar aspect of the middle phalangeal shafts of the index through small fingers, and the flexor digitorum profundus tendons insert onto the volar aspect of the base of the distal phalanges of the same digits. This is important to differentiate during the physical examination, as noted below. The flexor digitorum profundus has a common muscle for all four digits. This anatomic constant is taken advantage of during physical examination. The pronator quadratus rotates the wrist. It is rarely important in clinical practice, except that it is deep to the other flexor muscles, and inserts into the distal portion of the radius. Fractures of the radius that are subtle may result in a bowing out of the pronator quadratus muscle due to bleeding from the fracture site anteriorly, which can result in a bowed out pronator quadratus fat stripe seen on the lateral view of a wrist x-ray series.
The median and ulnar nerves travel in the flexor surface of the distal forearm. The median nerve is just radial and deep to the palmaris longus tendon at the wrist. The ulnar nerve is located radial to the flexor carpi ulnaris tendon at the wrist. The radial nerve at the wrist is superficial and sensory, located on the radial side of the distal forearm posteriorly. The radial artery at the wrist is radial to the flexor carpi radialis and fairly superficial (the “radial pulse”). The ulnar artery travels with the ulnar nerve.
Anatomy of the Hand and Wrist
The bones of the hand and wrist consist of the carpals, metacarpals, and phalanges. The carpals consist of two rows: proximal and distal. The proximal row consists of the scaphoid (carpal navicular), lunate, triquetrum, and pisiform. The distal row consists of the trapezium, trapeziod, capitate, and hamate.
Of particular interest is the scaphoid. The scaphoid receives its blood supply distally. Fractures to this bone may result in avascular necrosis proximally. (See Figure 2.)
There are five metacarpals and three phalanges for each digit, except the thumb, where there are two. The digits conventionally are named as thumb, index, long, ring, and small fingers. Each phalange is labeled as proximal, middle, or distal.
Sensation to the hand is from the radial, median, and ulnar nerves. (See Figure 4.) The radial nerve supplies the radial dorsal side of the hand, including the thumb, index, long, and radial side of the ring fingers, up to the point of the proximal interphalangeal (PIP) joints; the median nerve completes the innervation. The median nerve supplies the volar aspect of the thumb, index, long, and radial side of the ring finger. The ulnar nerve supplies the volar and dorsal aspects of the ring (ulnar side) and small finger.
The flexor digitorum profundus tendons insert at the volar base of the distal phalanges of the index through small fingers. It travels through a central slip of the flexor digitorum superficialis at the level of the proximal phalanx. The flexor digitorum superficialis inserts along the midshafts of the middle phalanges.
The epiphyses for the phalanges are located proximally. The epiphyses of the metacarpals are located distally, except for the thumb, where it is located proximally. (See Figure 2.)
Growth Plate Injury
Physeal integrity is critical for the future growth of the child. The Salter-Harris Classification commonly is used to describe the various types of growth plate injuries.20 (See Figure 5.)
Type I. In a type I injury, the epiphysis and the diaphysis are separated. Typically, the periosteum is not torn, and displacement does not occur. Many times the radiograph will be normal, but clinically the patient will have tenderness over the growth plate. Most of these injuries occur by shearing, torsion, or avulsion forces. In the majority of patients, healing occurs within three weeks, and there are few complications.
Type II. In a type II injury, the fracture extends through the physis, and out through a fracture fragment of metaphyseal bone. The injury usually is caused by a lateral displacement force that tears the periosteum. The periosteum is torn away from the diaphysis, but adheres to the epiphysis. Growth usually is preserved because the layers of the physis maintain position with the epiphysis. This is a common injury, and diagnosis usually is made by noting a metaphyseal fracture fragment with what appears to be an intact epiphysis.21 Most of these fractures may be treated by closed reduction followed by immobilization in a splint, application of ice, elevation, analgesia, and orthopedic follow-up. Usually an over-reduction does not occur because of the section of intact periosteum.
Type III. This fracture passes through the growth plate, through the epiphysis and into the joint. Accurate reduction is needed to prevent malarticulation, and open reduction is commonly necessary.
Type IV. This fracture begins at the epiphysis and passes through the physis and into the metaphysis. Evaluation by an orthopedic surgeon is needed because joint stiffness, deformity and malunion can occur without proper care. Open reduction commonly is required for these injuries.
Type V. This growth plate disruption is caused by a crush injury. Not all of the plate must be affected by the crush. Initially, the diagnosis may be difficult and made retrospectively when premature closure of the physis is observed.
History and Physical Examination
History. As with any evaluation of a patient a good history is essential. The injury mechanism and timing are critical, especially in open fractures and amputations that may be viable for replantation. The mechanism of the injury often can direct the examiner to certain fracture types that are seen with that type of incident. Inconsistencies in the history, mechanism, and injury patterns may provide clues to cases of child abuse. The location of the pain, ability to use an extremity, and parental observations regarding areas of swelling and tenderness may help the clinician localize the injury. Although a fracture may not be appreciable on film, pain at the growth plate is concerning.
Past medical history, specifically previous injuries and/or fractures also can be a clue to abuse cases, especially when repeated fractures have occurred. Many times, analgesia will be needed; therefore, information about known allergies will be important. The handedness of every patient should be documented; how aggressive the orthopedist wants to be in management may be dependent upon this fact. (See Table 1.)
Physical Examination. The steps for physical examination include observation; palpation of the upper extremity; evaluation of vascular, sensory, and motor nerve integrity; range of motion assessment; and finally, assessment of tendon function.
Observation is the first step in the evaluation of a child. How does he hold his hand and forearm and to what extent is he using them? Will he grasp for objects on his own while at play, or will he protect the extremity regardless of the activity? Note any cuts or lacerations to the skin. An open fracture will change the management of the patient. Exposure is essential; thus, all splints and dressing should be removed.
Examination of the injury should occur in a step-by-step manner, even if an obvious deformity is present. Palpation of the upper extremity should begin at the shoulder girdle and extend distally. Many of the injuries of the hand and wrist are associated with a fall on an outstretched hand, and other injuries (e.g., a supracondylar fracture of the humerus) may be present. Avoid initial palpation of the painful area. Examine the anatomic area where the child indicates pain last; the examination may be difficult after that is done. Palpation may reveal other potential injuries as well as bony deformities not immediately evident on inspection. As the extremity is palpated, each joint can be put through a range of motion looking for limitation or areas of pain.
The vascular system can be assessed with minimal discomfort. Document both radial and ulnar pulses as well as capillary refill. An Allen Test can be performed on both the radial and ulnar arteries. Compress both vessels and have the patient flex and extend the fingers rapidly. Then, release one of the vessels, and the hand should turn pink immediately.22 Capillary refill of the nail beds should be assessed and the refill should take fewer than two seconds. If an arterial bleed is obvious on physical examination, do not attempt to control bleeding with the blind application of a hemostat as it may result in nerve injury; rather, apply direct pressure.
Initially, use light touch to assess for sensory dysfunction. The use of a needle may cause fear in a child. If possible, two-point discrimination should be ascertained. Although calipers may be used, the high-tech paperclip continues to find favor. A measurement of more than 6 mm is considered abnormal.
The radial, ulnar, and median nerve distributions should be examined. Remember to link any injury to potential nerve damage. As an example, a laceration to the volar ulnar side of the wrist may result in an ulnar nerve deficit.
The musculoskeletal system is the last area of examination. Note areas of tenderness or swelling. Also, note any inability or limitation of movement. Joints can be stressed at this point, however, analgesia may be needed.
Assess tendon function, in both open and closed injuries. The tendons and their functions may need to be reviewed. (See Table 2.) Remember that injuries to the volar hand or wrist should have a careful flexor tendon assessment and injuries to the dorsal side should be evaluated for extensor tendon impairment. There is often confusion in evaluation of flexor tendon function to the digits. However, if the underlying anatomy is recalled, the examination is relatively straightforward. The integrity of the flexor digitorum profundus tendons can be evaluated by asking the patient to flex each of the fingers (index through small) individually at the distal interphalangeal joint (DIP). Injuries to this tendon often coexist with flexor digitorum superficialis tendon injury because the profundus tendons are deep to the superficialis tendons in the hand.
To test for flexor digitorum superficialis tendon integrity, the contribution of the profundus tendon must be eliminated. Because the flexor digitorum profundus muscle is common to all four digits, if the digits not being examined are kept in extension at the DIP joints, then, the superficialis tendon can be isolated at each digit (index through small). Test each of these digits by asking for flexion at the metacarapophalangeal joint. (See Table 3.)
Radiographic Technique
A routine radiographic series of the wrist consists of posterior anterior (PA), lateral, and oblique views.23 The x-ray beam is focused on the carpals. The wrist series should include the distal 6-7 cm of the radius and ulna. It is important that the lateral view be judged as to adequacy; the ulna should be superimposed on the radius. A fourth view (i.e., the scaphoid view) can be obtained, and usually must be specifically requested. This view consists of an ulnar deviated PA view and can be requested if a scaphoid fracture is suspected, but is not seen in the routine three-view series.
A routine radiographic view of the hand is similar with the routine three views, but the x-ray beam is focused at the level of the metacarpals. A hand series will not necessarily demonstrate the extent of the distal portion of the radius and ulna. Additionally, often a specific digit can be given attention, if requested.
Specific Injuries
Fractures of the Distal Forearm. The primary ossification center of the distal radial epiphysis appears during the eighth week of gestation. Secondary ossification centers of the radial epiphysis appear around 7 months of age and are triangular. The distal ulnar epiphysis is seen much later, appearing between ages 6 and 7 years.24 Approximately 75-85% of bone growth for both the radius and the ulna will occur from these two sites.25,26
Of all the fractures that occur in childhood and adolescence, those of the distal forearm are by far the most common in older children.14,27 Most forearm fractures occur in children older than 5 years; the distal aspect of the radius and ulna is the most common site of fracture. The injury usually occurs during a fall with the hand being outstretched with the forearm pronated. The hand plants to the ground, and the body supinates the pronated forearm, causing an angular and rotational deformity. Metaphyseal fractures are most common, followed by physeal fractures with the distal fragment in either the radius or ulna usually being extended.28 One study reported a distinct injury associated with the use of a nonmotorized scooter: a fracture of the distal third of the radius and ulna, characterized by volar angulation of the distal fragment. Of the 14 children requiring admission and manipulation, four subsequently needed remanipulation under anesthesia. This study suggested that the scooter is associated with a forearm fracture that is both distinctive and unstable.29
Most fractures of the distal forearm will remodel to an acceptable position; younger children are able to remodel a greater deformity than an older child. It generally is accepted that fractures of the distal third of the forearm will remodel correctly in five years if the angle is less than 35 degrees. Guidelines for an acceptable reduction are as follows: Infants are allowed 30 degrees of angulation in the coronal plane; children between the ages of 5 and 10 years are allowed 15-20 degrees; children older than 10 years are allowed up to 15 degrees in the coronal plane and 10 degrees of radial deviation.30 The deformity of the distal radius should correct at 0.9 degrees a month, or 10 degrees a year. Dorsal angulation will not correct as perfectly as ulnar and volar angulations.30-33 Fortunately, neurovascular complications are rare with distal radius/ulna fractures.34
If there is a complete fracture, the distal fragment usually is displaced dorsally. Reduction occurs with increasing the deformity, which will relax the periosteal hinge. Longitudinal traction and direct pressure are used to restore the length. Then, the angular deformity is addressed. For immobilization, a long-arm splint can be used.
Buckle fractures are extremely common in the distal radius and ulna. (See Figure 6.) Commonly, they occur in the metaphysis of the distal radius and ulna. They are stable fractures that can be treated with a below-the-elbow cast or splint for two to three weeks.
Fractures of the radial growth plate also are common, with 80% being Salter-Harris I or II fractures. (See Figure 7.) Reduction will be the same as a complete fracture and immobilization should be with a sugar tong or long-arm splint. On occasion, a displaced Salter-Harris II fracture may not reduce. The best time to reduce fractures is immediately; after 10 days, it is difficult to remanipulate these injuries without excessive force, and growth plate injury may occur. One study demonstrated that two or more attempts at manipulation while under general anesthesia caused an increased incidence of growth arrest when compared with growth in patients who had a single manipulation.35
Carpal Fractures. Fractures and dislocations of the wrist are extremely rare in childhood and adolescence; they may present a dilemma due to the difficulties of examining an injured child and the limited ability of radiographs to detail a child’s immature skeleton.36 Adolescents in the later stages of skeletal maturity may sustain scaphoid (navicular) fractures. Most are nondisplaced through the distal third of the bone.37 Unlike adults who often fracture the middle third of the scaphoid, the mechanism of injury in children involved a fall on an outstretched hand (80%).38 Children are less likely to fracture the proximal pole, which in adults usually results in a scapholunate ligament avulsion.39
Diagnosis of a Scaphoid Fracture. Although the signs are similar in adults and children, identifying the characteristic physical findings may be difficult in a child. Tenderness in the anatomical snuff box is a classic sign of scaphoid fracture. Unfortunately, there often is swelling at the wrist, and the snuff box may be difficult to palpate. One study demonstrated anatomic snuff box tenderness 100% of the time in a series of scaphoid fractures, but swelling in only 36% of cases. A second physical sign of scaphoid fracture is pain with axial loading of the thumb.38
Initial radiographs of a wrist injury should include a lateral, a posterior-anterior (PA), and an oblique view. If a scaphoid fracture is strongly suspected but not seen on initial radiographs, a scaphoid view can be diagnostic. In this view, the wrist is ulnar deviated, and the forearm is pronated. Magnetic resonance imaging (MRI) or a bone scan also may be used, although they generally are not done during the ED visit.40,41 The clinically important aspects of carpal fractures are the frequency of scaphoid fractures, and that initial plain radiographs often are interpreted as negative. A high-degree of suspicion must be maintained to make an accurate diagnosis.
Treatment of a Scaphoid Fracture. Immobilization with a short-arm or a long-arm thumb spica splint is the initial method of treatment of a scaphoid fracture in children.38 Although one study in adults demonstrated decreased malunion incidence with the use of a long-arm cast vs a short-arm cast in scaphoid wrist fractures,42 (the rotational forces are immobilized, and thus, will not displace the scaphoid fracture),43 no similar studies have been conducted in children. The wrist may be kept in slight flexion with radial deviation ending with the MCP joint showing, allowing for interphalangeal joint mobility. Fortunately, nonunion of the carpal scaphoid is exceedingly rare in children, and many sources recommend bone grafting if there is no indication of healing after three months of immobilization.44
If the patient has tenderness of the anatomic snuff box, or if a fracture is suspected and not seen, then, the patient should be treated as if a fracture is present and referred to an orthopedist.
Metacarpal Fractures. The most common metacarpal fracture in children and adults is a fracture of the fourth or fifth metacarpal. This fracture usually results from striking a closed fist on an object, often a wall. During the fracture, rotation of the metacarpal head may occur. It is important that this condition be evaluated by asking the patient to flex the digits, comparing the affected side with the uninjured hand. If rotational deformity occurs, the small finger will tend to curl toward or under the fourth metacarpal. Rotational deformities must be corrected by reduction of the fracture. Reduction of fifth metacarpal fractures should be considered when angulation measured on the lateral hand x-ray exceeds 45 degrees. A hematoma block of the fracture provides excellent anesthesia, prior to reduction. Following reduction, the patient is placed in an ulnar gutter splint.
Fractures of the second and third metacarpals (i.e., index and long fingers) are treated more aggressively because these bones stabilize the entire hand, and rotation revolves around these bones. Fractures of these bones often are ultimately treated surgically following splinting in the ED.
Injuries to the Proximal and Middle Phalanx. Phalangeal neck fractures often are caused by crushing injuries; the severity of the injury often is underappreciated. The pattern of injury to the proximal phalanx appears to be caused by a lateral angulation force separating a small triangular metaphyseal fragment from the base of the phalanx on the side of angulation and the fracture line, then continuing through the metaphysis, 1-2 mm distal to the growth plate.45
Phalanx head and neck fractures that are nondisplaced and nonintraarticular may be treated by splinting alone.46 Rotation of the distal fragment can occur, so a true lateral view should be obtained.
Nondisplaced phalangeal shaft fractures usually will require protection immobilization only. If displacement is minimal, the injured finger can be strapped to the finger next to it, or plaster can be put anteriorly to the finger. The finger should be immobilized for three weeks.47
Oblique fractures of the middle or proximal phalanx are often articular and will require orthopedic follow-up. If nondisplaced, this type of injury may be monitored radiographically for evidence of slippage and intervention if necessary, or pinned with a single oblique K-wire to prevent further displacement.48
A physeal fracture is an extremely common fracture of the proximal phalanx. It occurs when a finger is forced into ulnar deviation (e.g., when wrestling or when stretching the small finger on the piano to reach an extra note). The fracture is usually a Salter-Harris type II injury. Reduction is obtained by flexing at the MP joint, which will tighten the collateral ligaments and keep the fragment in place. A pencil also may be used between the webs of the fingers to act as a fulcrum. Immobilization in an ulnar gutter splint is acceptable; however, consider the age and compliance of the patient.49 (For a summary of hand fracture care, see Table 4.)
Distal Phalanx Injuries. The majority of injuries to the distal phalangeal region are secondary to crush injury. These injuries (e.g., a finger caught in a door) are most common in the toddler and preschool-age groups. Injury may vary from partial or complete amputation, nail bed laceration, to distal phalangeal fracture.
Nail bed Injuries. Injuries to the nail bed and fingertip are extremely common in children (Figure 8). They frequently are caused by a crushing force, most likely a car or house door.50 Because of the close proximity of the nail bed with the bony distal phalanx, one-half of all nail bed injuries also will have an associated phalangeal fracture. A high index of suspicion is needed to diagnose a subungual hematoma or an open nail bed injury. Small lacerations of the matrix can cause an extensive subungal hematoma. The classic teaching that a hematoma greater than 50% indicates a tuft fracture is not always true.51 There are many references in the literature that recommend removal of the nail plate and repair of the nail if the hematoma is greater than 25%.51,52 A recent prospective study refutes that concept and supports the treatment of all subungal hematomas with an intact nail margin and nail to be treated with trephination only. There were no increased nail deformities in this study group, and the charge to each patient was decreased by nearly $1,000.53
If the hematoma is significant, or if the patient is having a great amount of pain, the hematoma should be decompressed, or the nail should be removed. Various methods of decompression may be used, including a heated paper clip, a cautery tip, a small drill, or a hypodermic needle. If cautery is used, reassure the patient that the blood of the hematoma will prevent burning of the nail bed.54 There is some evidence that a nail deformity will occur without decompression.55 The use of a digital nerve-blocking agent will facilitate nail trephination and relieve the pain that may continue after the patient is discharged from the ED.
If the nail bed needs to be repaired, the plate can be removed with a blunt elevator or round-tipped scissors. Further exposure of the germinal matrix may be obtained with incisions of the eponychial folds. The nail bed is repaired with interrupted 6-0 or 7-0 absorbable suture, which will minimize the nail bed deformity. The bed should be stented so that scarring does not hinder nail growth. The previous nail can be used—if it is not too badly damaged—or a foreign material may be used (e.g., a foil suture pack or a commercially available stent). If the original nail is used, it is sometimes necessary to anchor it in place so that it does not migrate underneath the nail fold.
The healing time will not be inhibited if the nail bed injury is treated conservatively, but an aesthetic deformity may occur in the form of ridging or irregularity of the plate. The deformed fingernail also may predispose the patient to recurrent paronychiae because the nail may be difficult to trim properly.50 Recovery of the nail usually takes about 100 days, but trauma may delay the growth for as much as an additional 20 days.56 It is important to warn the child and parents that a nail deformity may result from nail bed and distal phalanx injuries.
Mallet Finger. A mallet finger injury occurs when a finger that is in active extension is subjected suddenly to a flexion force. An example would be when a baseball catcher’s glove is hit by a foul-tipped ball.57 Children will present with the distal phalanx in flexion and will be unable to extend the tip of the finger. The injury is the result of either an injury to the extensor tendon or an avulsion fracture at its insertion into the distal phalanx. True mallet fingers (pure tendon injury) are rare in the preadolescent child. In this age group, physeal fracture is more common. In the adolescent, mallet injuries with disruption of the extensor mechanism, similar to adults, are more common. These injuries generally can be treated with immobilization of the distal interphalangeal (DIP) joint in full extension.49
Operative repair for this injury is often dependent upon whether it is open or closed, or if the entire epiphysis has been displaced with the extensor mechanism. If the injury is closed and the fracture is not displaced, the fracture can be treated nonoperatively with immobilization in a splint for six to eight weeks.57 Reduction should be attempted in all closed fractures by recreating the injury. Gentle flexion should be used followed by extension. A dorsal or volar splint contoured to provide three points of contact immobilizing only the DIP joint should be applied. The splint should be placed at neutral to 15 degrees of extension. The circulation of the skin over the joint can be precarious; it is wise to make certain the skin is not blanched on application of the splint to minimize the risk of necrosis.58
There are different types of splints for this deformity including the stack splint, the aluminum foam, and the thermoplastic splint. Aluminum splints usually are used because of their availability. Using these splints dorsally can increase the incidence of ischemia and maceration.59 Moleskin or a single layer of tube gauze underneath the splint may minimize or prevent these complications.60 The Stack splint is advantageous because the patient is able to remove it splint easily, thus, minimizing the skin maceration.61 Its disadvantage is that it sometimes causes loss of distal joint flexion.62
Complications are common with a mallet finger. In one study, 45% of all patients had complications largely due to tape allergies, skin macerations, or ulcerations requiring follow-up during the first three weeks.59 Studies have demonstrated mixed results for conservative vs surgical management. Stern and Kastrup demonstrated a nearly 50% complication rate regardless of treatment type (i.e., surgical vs nonsurgical).59 Wehbe and Schneider noted that surgical treatment was difficult and unreliable, and that it offered no advantage over nonsurgical therapy.63 Regardless of treatment, the major complication is a bony prominence on the dorsal surface of the DIP joint.
Burn Injuries of the Hand. Few injuries are as fearful to a parent as a burn. Fortunately, the injury pattern for children is different from adults. In one study, scald injuries were the most common in children, followed by flame, contact, electrical, and other injuries. In contrast, adult burns most commonly are caused by flame injuries, which are usually a more serious burn.64
Burns often are classified by degree, which is dependent upon depth. First-degree burns have epithelial damage. The skin will be red, tender, and painful, but blistering does not occur. The area will heal in several days, and no scarring will occur. This type usually is seen with sunburn or flash burns.
Second-degree burns are subdivided into two types. The first is a superficial partial-thickness burn and involves the epidermis and superficial dermis. Clinically, this burn will present as a pink, moist, painful, injury with blisters. It usually will heal within two to three weeks without scarring. However, deep partial-thickness burns include the epidermis, superficial dermis, and extend to the reticular dermis. Clinically, this burn type will present as a mixture of blanched red and white. Blisters may rupture and are commonly thick-walled. These burns typically will heal within three to six weeks and have an increased likelihood of scarring. Contracture across joints can occur, and they require close monitoring.
Third-degree burns are characterized by destruction of the epidermis and dermis. Clinically, they will appear white and leathery. Any third-degree burn larger than 1 cm in diameter should be grafted for coverage.
Fourth-degree burns include the epidermis, dermis, and deeper structures including fascia, bone, and muscle. These injuries often result in prolonged disability.
It is essential to assess the perfusion of the hand; if circulatory compromise exists, surgical intervention can improve the outcome. The hand should be warm and soft. Pulses should be detected with Doppler in both the palmer arch and digital arteries. With more severe burns, if pulses are lost, the hand becomes cold, or if motion becomes difficult, an escharotomy should be performed.65
Minor burns that include first- and second-degree burns should be cleaned first with sterile saline. However, blister treatment is controversial. On the palms, it generally is recommended to leave blisters intact.66 If there is a large blister not on the palm that interferes with wound dressing, it may be aspirated with a sterile needle or incised with a 15 blade. There is some evidence that the fluid may be deleterious to wound healing.67,68
There are different methods of dressing burn wounds. For minor burns, place sterile fine mesh gauze soaked in sterile saline over the burn. Then, apply fluffed four-by-fours and wrap with gauze.69 A synthetic dressing can be used, but it is more expensive. Synthetic dressings include alginate, hydrocolloidal hydrogel foams, and thin films. They keep the environment moist, potentially improving tissue regeneration.70 Silver sulfadiazine mafenide acetate, and 0.5% silver nitrate solution are the most commonly used antibacterial agents on superficial burns anywhere on the body, including the hands. The disadvantage of silver sulfadiazine is that it may retard wound healing.71 Bacitracin and polymixin B may be less bactericidal, but also are less toxic to the re-epithelialization of the burn wound.66 An excellent dressing, it is reasonably priced, and is applied easily with a gauze dressing.72
Certain burns of the hand should be referred to a burn center (e.g., partial- or full- thickness burns of the hand that may result in functional or cosmetic impairment, a burn of the hand with an involved fracture, or any burns to children who are not at a hospital with qualified personnel or equipment).73
Amputation. An amputation of a finger or thumb is one of the most traumatic injuries that may occur to a child or parent in their lifetime. Frequently, the injury will occur around the house, with exercise or bicycle equipment causing the most incidents, followed by lawnmower and gardening equipment.74 The surgical techniques that allow replantation have been present only for 35 years; the thumb was the first digit to be reattached.75 Although there have been many advances in this area, children—especially those younger than 2 years—have lower replantation survival rates, possibly because of the increased incidence of vasospasm in children, as well as the smaller caliber of vessel in a child of this age.76 Treatment often is more aggressive in pediatric replantation; thus, the increased percentage of attempts of complex repairs may increase the incidence of failure.77
There are other factors that will influence the success of replantation, regardless of the age of the child. The mechanism of injury is important to replantation. An amputation with a crush mechanism has a much worse prognosis than a clean guillotine-type amputation. An avulsion is hypothesized to cause greater distal arterial injury and vessel contusion, obstructing blood flow. The size of the patient is a second variable. In one series, suitable veins were unable to be found in children weighing fewer than 11 kgs.74 There have been improved outcomes with patients treated with prostaglandin E1, which improves vasospasm and wound healing in adults.78
After obtaining the history from the patient and family and performing a physical examination, the wound may be cleansed with sterile saline and then dressed with nonadherent gauze and a compression dressing. Tetanus immunization should be updated. Administer IV antibiotics—typically second-generation cephalosporins— and prohibit oral intake because surgery may be imminent. The hand surgeon or the nearest transplant team should be contacted immediately if the point-of-contact hospital does not perform this procedure routinely.
The amputated part should be cleansed lightly and irrigated with sterile saline; afterward, avoid further manipulation. Then, the part should be wrapped in moistened gauze and placed in a sterile container. The container should be placed in a bag or tub of ice water that will keep the part at the appropriate temperature of 4ºC. Ice should never be placed directly on an amputated part.
Child Abuse and Hand Injury. Abuse continues to be a very prominent underlying cause of pediatric treatment in the ED. In older children, the hand may be put up for protection; in a younger child, the hand may be the primary target of injury. One study of 631 abused children showed hand injuries in 14% of the cases. The hand was the only area injured in 3% (19) of the patients. Most of those injuries were burns (8 patients); however bites, bruises, fractures, and lacerations also were seen.79
Although all injuries, at least, should be considered to be possibly secondary to child abuse, there are certain injury patterns that are potential indicators of abuse. One is a glove-like immersion pattern, which may involve both hands. A retrospective study of nonaccidental burns found bilateral burns of the hands 4.8 times more likely to be due to abuse or neglect compared with unilateral hand injury. This same study also demonstrated scald injuries to be more likely to be placed in the accidental category than the contact, chemical, or electrical burns categories.80 An absence of splash marks also should raise suspicion. Burns to the dorsum of the hand are suspect as this is not the portion of the hand that is used for exploration. A history that is not consistent with the age of the patient (e.g., a 2-year-old child turning on the hot water) also should be viewed with skepticism.79
The bite mark is probably one of the easiest signs of abuse to identify.80 The bite mark probably will not be the primary reason for the child’s evaluation, but may be seen during the examination. Subungal hematomas, initially thought to be a hematologic or immunologic pathology, may be a result of child abuse.81
Fractures of the hand and wrist were first reported with abuse in 1954.82 Child abuse may involve any digit as well as any carpal bone. Bruising and swelling may be absent from any hand or wrist injury, suggesting a twisting or bending mechanism. If there are multiple fractures with different stages of healing, the diagnosis of child abuse also is supported.83
Tendon Injuries in Children. Identifying a tendon injury in a child can be challenging, even with cooperation. With a laceration, the tendons can retract, thus, being absent from the field of view. Other tendons that mimic function of the lacerated tendon may make the physical examination difficult.
The classification system of zones of injury for flexor tendon lacerations is the same for the child as it is for the adult. For extensor tendons, the classification system by Verdan should be used. (See Figure 9.) Understanding the different zones for both extensor and flexor tendons is imperative for the management of these injuries as well as for the discussion with the hand surgeon.
Flexor Tendon Injury. Potential flexor tendon injuries should be considered with any laceration of the volar aspect of the hand and wrist. Because of flexor function contribution at the MCP joints by both the profundus and superficialis tendons, a thorough examination is necessary to not miss functional loss. The profundus and superficialis tendons must be assessed separately in the physical examination (see above). If a flexor tendon laceration is identified, consultation with the hand specialist is necessary. It is never appropriate for the emergency physician to repair flexor tendon lacerations.
Extensor Tendon Injury Zones. The extensor tendon often retracts proximally once the fist is unclenched and the MP joints are extended.24, 84-86
Zones 7 and 8. These tendons reside in the distal forearm and wrist, respectively and often are associated with deep lacerations. Lateral antebrachium, cutaneous and radial nerve injuries often are seen with this laceration. Repairs of these zone injuries should be done by a hand surgeon.
Zone 6. This zone runs from the base of the proximal metacarpals to the base of the heads of the metacarpals. The tendons are superficial, making it very easy for laceration to occur. Nerves that can be injured include the superficial radial and dorsal ulnar nerves. Repair of the extensor tendon at this level may be undertaken by the emergency physician, if privileged.
Zone 5. This zone is at the metacarpal phalangeal level. Lacerations are common in this area. ED management should be initiated with copious irrigation, skin closure, and splinting followed by referral to a hand surgeon secondary to the high complication rate associated with this type of injury.
Zone 4. This zone runs from along the dorsal aspect of the phalanx between the MP and PIP joints. The tendon is broad and conforms to the shape of the phalanx, thus, making it more difficult to lacerate completely. The tendon does not retract extensively, and thus, should be found easily. Repair by the ED physician should be discussed in consultation with the hand surgeon. Central slip lacerations and lacerations that cause an extensor lag usually are repaired by a hand surgeon. Often extensor tendon repair is a separate privilege in many EDs. A history of competency in extensor tendon repair usually is necessary prior to the granting of these privileges.
Zone 3. This zone is over the PIP joint. Exploration of this injury is important because joint capsule intrusion usually results in surgical exploration and irrigation. These repairs usually are managed by a hand surgeon. A common complication of this type of injury is a boutonniere deformity. The central slips rupture, which allows unopposed flexion of the flexor digitorum superficialis. The lateral bands, then, will slip down and become flexors. This deformity also can be seen in a closed injury, but usually will not occur until 10-14 days after the injury. It usually results from a direct blow to the dorsal PIP joint or from an axial load with forced flexion while the PIP joint is extended. If this deformity is suspected, a dorsal splint should be placed so that the PIP joint is kept in extension, without immobilizing the MP and DIP joints.
Zones 1 and 2. This zone includes the area over the middle phalanx and the DIP joint. An injury to this area often results in a mallet finger. If the tendon injury is closed, the finger can be placed in extension with close follow-up. Open lacerations of the tendon with a mallet deformity should be repaired by a hand surgeon. Partial lacerations that are more than 50% may be repaired in the ED. Treatment options should be discussed with the hand surgeon prior to initiation of treatment. If there is no extensor lag and a partial laceration, the injury can be splinted and sent for referral in the next week to 10 days. If the laceration is repaired in the ED, 5-0 non-absorbable suture should be used with a figure-of-eight or a horizontal mattress stitch. The tendon should not be pulled too tightly, otherwise stiffness will occur.
General Principles of Immobilization
Splinting techniques should be modified for use in the child when compared with those in an adult. For adults, the wrist and interphalangeal joint should be kept in extension with flexion at the MP joint. Unfortunately, a child is able to further extend his wrist and flex his fingers, thus, allowing him to ball his hand into a fist. A child will try to slide the whole hand out of the splint if it is not secured at the elbow. To prevent these actions from occurring, the splint may be taken to the fingertips, rather than the MCP joints.
Buddy taping of metacarpal or phalangeal fractures should be used cautiously because of the ease with which the child may remove the tape. Consider immobilization in splints with the hand in the position of function: the wrist in 30 degrees of dorsiflexion and the metacarpophalangeal (MCP) joints in 50 to 70 degrees of flexion.17
For hand dressings in small children, Smarrito and colleagues suggested applying the dressing in the shape of a puppet, which at first can appear to be funny, but uses the general principles of sterile technique and standard dressing application.87
Conclusion
Pediatric hand and wrist injuries are extremely common and can take many forms. The evaluation of these injuries can be difficult due to the age of these patients. Diagnosis of specific injuries is even more difficult because of the need to evaluate the growth plates in the areas of injury. It is essential that the emergency physician is familiar with the spectrum of pediatric hand and wrist injuries, and referral patterns should be well established for these common injuries.
Acknowledgments: The author wishes to thank Paul Bilstad, MD, and Bryan Klich, MD, for their research assistance; to Steven Getch at Summa Health System for his drawing expertise; and to Minnette L. Beeson, RN, MSN, for her research and editing expertise.
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