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Pediatric Hand Injuries - Evaluation, Diagnosis

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Get an overview of examination and evaluation of hand injuries in children. Find out more about hand and arm problems at http://www.noelhenley.com

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Pediatric Hand Injuries - Evaluation, Diagnosis

  1. 1. The Child’s Hand C. Noel Henley, MD
  2. 2. Goalswww.noelhenley.com
  3. 3. Goals• To review upper extremity neurovascular examination high points www.noelhenley.com
  4. 4. Goals• To review upper extremity neurovascular examination high points• Avoid some common pitfalls in diagnosis and splinting www.noelhenley.com
  5. 5. Examination
  6. 6. 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
  7. 7. Small Lacerations• concerns • injury to underlying structures (tendons, nerves, arteries) • infection • retained foreign bodies www.noelhenley.com
  8. 8. Small Lacerations• assessment • tendon function - resting posture - tenodesis www.noelhenley.com
  9. 9. 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
  10. 10. 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
  11. 11. Testing for flexor digitorum profundus musculotendinous function www.noelhenley.com
  12. 12. 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
  13. 13. Testing for flexor digitorum superficialis musculotendinous function www.noelhenley.com
  14. 14. Small Lacerations• referral windows for primary repair • tendons: 2 weeks • nerves: 2 weeks Flexor tendon repair www.noelhenley.com
  15. 15. 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
  16. 16. Nerves - sensation• Methods - Two point discrimination - averages 5-6 mm adults - widens with age - wrinkle test - sweat test www.noelhenley.com
  17. 17. A Word on Anesthesia• Two point discrimination test prior to any digital block! www.noelhenley.com
  18. 18. Nerves - motor• median nerve - thenar muscles = thumb opposition - the “OK” sign in kids - FPL and index FDP flexion www.noelhenley.com
  19. 19. Nerves - motor www.noelhenley.com
  20. 20. Nerves - motor• ulnar nerve - interosseus muscles www.noelhenley.com
  21. 21. Nerves - motor• ulnar nerve - interosseus muscles - Scott Earle sign = “crossed fingers” sign www.noelhenley.com
  22. 22. Nerves - motor• ulnar nerve - interosseus muscles - Scott Earle sign = “crossed fingers” sign - spreading fingers www.noelhenley.com
  23. 23. Nerves - motor• radial nerve - extensor pollicis longus - retropulsion - thumb IP joint extension beyond 0 degrees - extension of MCP joints to neutral! www.noelhenley.com
  24. 24. Frequently Missed• ulnar nerve laceration• FDP rupture www.noelhenley.com
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Dressings and Splints• parts of a dressing • inside - next to wound/skin • outside - padding and splint www.noelhenley.com
  29. 29. Dressings and Splints• inside • nonadherent, permeable layer (Xeroform, Adaptec) • gauze • fluffed gauze + “tweeners” • small rolled gauze (Kerlix or kling) www.noelhenley.com
  30. 30. www.noelhenley.com
  31. 31. www.noelhenley.com
  32. 32. 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
  33. 33. www.noelhenley.com
  34. 34. 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
  35. 35. Safe Position www.noelhenley.com
  36. 36. Dressings and Splints• finger dressings, splint • alumafoam • dangers (tube gauze and Coban) www.noelhenley.com
  37. 37. www.noelhenley.com
  38. 38. www.noelhenley.com
  39. 39. Avoiding Disaster• Most problems can be eliminated by telling parents not to ignore a restless child in pain www.noelhenley.com
  40. 40. Dressings and Splints• elevating the injured hand • careful with a sling • when walking, sitting up • when sleeping www.noelhenley.com
  41. 41. www.noelhenley.com
  42. 42. Dressings and Splints• child’s hand dressing • the smaller the child, the bigger the dressing www.noelhenley.com
  43. 43. Dressings and Splints• bad dressings (primum non nocere) www.noelhenley.com
  44. 44. 5 days later www.noelhenley.com
  45. 45. open fracture www.noelhenley.com
  46. 46. Won’t Somebody Think of the Children?• pediatric hand lacerations • use absorbable sutures! • plain gut (5-O, 3-O) www.noelhenley.com
  47. 47. Thanks! Find out more athttp://www.noelhenley.com www.noelhenley.com

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