Pediatric Hand Injuries - Evaluation, Diagnosis

The Child’s Hand C. Noel Henley, MD

Goalswww.noelhenley.com

Goals• To review upper extremity neurovascular examination high points www.noelhenley.com

Goals• To review upper extremity neurovascular examination high points• Avoid some common pitfalls in diagnosis and splinting www.noelhenley.com

Examination

Inspection• can often predict likelihood of nerve or tendon injury based solely on wound location and hand/digit posture• a wound over a fracture deﬁnes an open fracture; the diagnosis until you (or I) prove otherwise www.noelhenley.com

Small Lacerations• concerns • injury to underlying structures (tendons, nerves, arteries) • infection • retained foreign bodies www.noelhenley.com

Small Lacerations• assessment • tendon function - resting posture - tenodesis www.noelhenley.com

Note the location of this wound and the posture of the finger -normal flexor tone is absent from the middle finger.Diagnosis = laceration of profundus and superficialis flexor tendonsWhat other injury should you suspect? www.noelhenley.com

Tendon Exam• flexor digitorum profundus - each finger tested separately - MCP, PIP held in extension; ask the patient to flex the DIP - isolates the FDP tendon www.noelhenley.com

Testing for ﬂexor digitorum profundus musculotendinous function www.noelhenley.com

Tendon Exam• flexor digitorum superficialis - each finger tested separately - MCP, PIP, DIP joints of adjacent fingers are extended - tested finger allowed to flex at PIP joint - isolates FDS from FDP www.noelhenley.com

Testing for ﬂexor digitorum superﬁcialis musculotendinous function www.noelhenley.com

Small Lacerations• referral windows for primary repair • tendons: 2 weeks • nerves: 2 weeks Flexor tendon repair www.noelhenley.com

Nerves - sensation• Methods - light touch The black areas represent reliably speciﬁc areas to test sensibility for each of the three main peripheral nerves. www.noelhenley.com

Nerves - sensation• Methods - Two point discrimination - averages 5-6 mm adults - widens with age - wrinkle test - sweat test www.noelhenley.com

A Word on Anesthesia• Two point discrimination test prior to any digital block! www.noelhenley.com

Nerves - motor• median nerve - thenar muscles = thumb opposition - the “OK” sign in kids - FPL and index FDP ﬂexion www.noelhenley.com

Nerves - motor www.noelhenley.com

Nerves - motor• ulnar nerve - interosseus muscles www.noelhenley.com

Nerves - motor• ulnar nerve - interosseus muscles - Scott Earle sign = “crossed ﬁngers” sign www.noelhenley.com

Nerves - motor• ulnar nerve - interosseus muscles - Scott Earle sign = “crossed ﬁngers” sign - spreading ﬁngers www.noelhenley.com

Nerves - motor• radial nerve - extensor pollicis longus - retropulsion - thumb IP joint extension beyond 0 degrees - extension of MCP joints to neutral! www.noelhenley.com

Frequently Missed• ulnar nerve laceration• FDP rupture www.noelhenley.com

Frequently Missed• ulnar nerve laceration • findings - otherwise benign laceration over ulnar hand, wrist, forearm or elbow • avoiding misdiagnosis - exam for interosseous-specific function - cross-finger test www.noelhenley.com

Frequently Missed• FDP avulsion • history/findings - no active DIP joint flexion - ring finger = most common; “jersey finger” in football • avoiding misdiagnosis - exam for isolated FDP function - radiograph may show bone fragment www.noelhenley.com

Dressings and Splints• goals of a hand dressing • comfort • durability • allow motion of uninjured parts • securely applied • keeps the hand in a good position • atraumatic removal www.noelhenley.com

Dressings and Splints• parts of a dressing • inside - next to wound/skin • outside - padding and splint www.noelhenley.com

Dressings and Splints• inside • nonadherent, permeable layer (Xeroform, Adaptec) • gauze • ﬂuffed gauze + “tweeners” • small rolled gauze (Kerlix or kling) www.noelhenley.com

www.noelhenley.com

Dressings and Splints• outside • “cast padding” or Kerlix (rolled gauze) • ﬁberglass or plaster slab • cool or lukewarm water • avoid casts in acute injuries www.noelhenley.com

www.noelhenley.com

Dressings and Splints• splint position • safe position = default • flexor or extensor injury = exceptions • flexor injury: flex fingers and wrist • extensor injury: extend fingers and wrist www.noelhenley.com

Safe Position www.noelhenley.com

Dressings and Splints• ﬁnger dressings, splint • alumafoam • dangers (tube gauze and Coban) www.noelhenley.com

www.noelhenley.com

Avoiding Disaster• Most problems can be eliminated by telling parents not to ignore a restless child in pain www.noelhenley.com

Dressings and Splints• elevating the injured hand • careful with a sling • when walking, sitting up • when sleeping www.noelhenley.com

www.noelhenley.com

Dressings and Splints• child’s hand dressing • the smaller the child, the bigger the dressing www.noelhenley.com

Dressings and Splints• bad dressings (primum non nocere) www.noelhenley.com

5 days later www.noelhenley.com

open fracture www.noelhenley.com

Won’t Somebody Think of the Children?• pediatric hand lacerations • use absorbable sutures! • plain gut (5-O, 3-O) www.noelhenley.com

Thanks! Find out more athttp://www.noelhenley.com www.noelhenley.com

Pediatric Hand Injuries - Evaluation, Diagnosis

by C Noel Henley MD on Feb 28, 2011

Accessibility

Categories

Tags

Upload Details

Usage Rights

2 Embeds 1,289

Statistics

Pediatric Hand Injuries - Evaluation, Diagnosis — Presentation Transcript

http://www.ozarkorthopaedic.com	1287
http://ifinddoctors.com	2