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12162015 presentation of hand and wrist injuries
- 1. Bringing Basic Orthopedic and Concussion Care to the Pediatric Medical Home: PPOC/CHICO Learning Community & Integration Program © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu Didactic Session #3 Hand and Wrist December 16, 2015
- 2. Disclosure We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content we are planning, developing, presenting, or evaluating. © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
- 3. Barry Zallen, MD Chief Medical Officer Children’s Hospital Integrated Care Organization barry.zallen@childrens.harvard.edu Louis Vernacchio, MD, MSc Pediatrician, Longwood Pediatrics Director of Research and Analysis Pediatric Physicians’ Organization at Children’s Louis.vernacchio@childrens.harvard.edu © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu Madeleine Kuhn, MPH Program Coordinator Children’s Hospital Integrated Care Organization Madeleine.kuhn@childrens.harvard.edu Peter Waters, MD Orthopaedic Surgeon-in-Chief Boston Children’s Hospital Course Directors
- 4. Follow-Up Emails and Course Work Please make sure you are receiving course emails from Madeleine.kuhn@childrens.harvard.edu If you would like a specific email address to receive update emails contact us They will be sent out every other Monday with documents discussed in webinar, surveys, and upcoming information. ORTHOPEDICAND CONCUSSION LEARNINGCOMMUNITY NEWSLETTERANDUPDATES We Recommend Printing These NewsLetters and Any Attachments Updates The Didactic Webinar scheduled on Thursday 12.10.2015 has changed to: Wednesday 12.16.2015 from 7 am to 8:30 instead of 7:30 to 9. New Schedule Below and in attach. We understand that this may pose disrupt clinic and we count the below as attendance: Coursework Process mapping: The assignment is on Blackboard. You can access it by clicking the Blackboard link above and typing in your username: [bch.firstinitiallastname] and password. Process Map Instructions Process Map Worksheet You can email or fax this document to Madeleine Kuhn or upload this document on Blackboard
- 5. 4 Learning Community Schedule Webinars 7:30am – 8:30am Date Content Thursday, June 11, 2015 Concussion Wednesday, September 9, 2015 Foot and Ankle Wednesday, December 16, 2015 Hand and Wrist Wednesday, February 24, 2016 Everything Knee Date Wednesday, July 15, 2015 Thursday, August 13, 2015 Thursday, October 29, 2015 Thursday, March 24, 2016 Wednesday, April 27, 2016 Didactic Webinars 7:30am – 9:00am © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu In-Person Sessions 7:00am – 9:00am, BCH Waltham Date Content Wednesday, January 20, 2016 Practical Session Wednesday, May 25, 2016 Practical Session
- 6. 5 Agenda 1. Welcome and review 2. Hand and wrist anatomy and common injuries 3. Review of Hand and Wrist Algorithm 4. Coursework, next session, and wrap-up
- 7. 6 Upper Body Orthopaedics © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
- 8. Hand and Wrist Exam • Exam conducted by Dr. Bae from Boston Children’s Orthopedic group • Link to videos is included in follow-up email and on Blackboard in Orthopedic Folder(There are 3 parts)
- 9. Office Examination for Hand and Wrist Peter Waters, MD Boston Children’s Hospital
- 10. Objectives • Anatomy & physical examination of child’s hand and wrist • Clinical findings of common upper extremity conditions • Treatment principles, indications for referral
- 11. Orthopedics “Principles” • Orthopedics injuries hurt • Anatomy is everything • Consider intrinsic and extrinsic causes of pain • Trauma, sports, overuse
- 12. Physical Exam of Hand and Wrist
- 13. Hand • Challenges in examination • Presence of Physis • Small musculoskeletal structures • Most restrictive immobilization
- 14. 13
- 15. Hand • History: mechanism of injury • Examination: tenodesis – Finger malrotation with proximal phalanx fracture • Radiographs: appropriate imaging of affected part
- 16. 15
- 17. Hand Efficient examination • Inspection • Tenodesis • Tenderness • Flexor-extensor function • Nerve function
- 18. Wrist • Complex anatomy – Bones – Soft tissue structures – Patients • Common conditions – Sprains / strains – Fractures – Physeal stress injuries
- 19. Wrist • Efficient examination: – Inspection (ganglia) – ROM – Snuffbox tenderness – Joint stability • Specific maneuvers: – Snuffbox tenderness
- 20. 19
- 21. Wrist • Range of Motion – Flexion-extension – Supination-pronation – Radial-ulnar deviation
- 22. Wrist • Tenderness – Radius & ulna – Hook of hamate – Scaphoid – Tendons – Ligaments
- 23. 22
- 24. 23
- 25. 24
- 26. Management of Common Injuries of the Hand and Wrist
- 27. Tiered Level Approach • Office Evaluation • Office Care • Referral – Evaluation – Testing Decisions – Testing Interpretation – Treatment – Follow up • Comfort Level • Competency • Subspecialty Alternatives
- 28. Radiographs for Hand / Wrist Injuries • AP/Lateral/Oblique • Focused to zone of injury/exam findings – Finger • Specify digit/s – Thumb – Hand – Wrist – Scaphoid • Include details of point of maximal interest • Wider field if less specific
- 29. Radiographs for Hand / Wrist Injuries • AP/Lateral/Oblique • Focused to zone of injury/exam findings – Finger • Specify digit/s – Thumb – Hand – Wrist – Scaphoid • Include details of point of maximal interest • Wider field if less specific
- 30. Radiographs for Hand / Wrist Injuries • AP/Lateral/Oblique • Focused to zone of injury/exam findings – Finger • Specify digit/s – Thumb – Hand – Wrist – Scaphoid • Include details of point of maximal interest • Wider field if less specific
- 31. Radiographs for Hand / Wrist Injuries • AP/Lateral/Oblique • Focused to zone of injury/exam findings – Finger • Specify digit/s – Thumb – Hand – Wrist – Scaphoid • Include details of point of maximal interest • Wider field if less specific
- 32. Common Finger Injuries Sprains and soft tissue injuries
- 33. Common finger injuries • Finger fractures – Non-displaced non-salter fractures • We will review buddy taping and splinting at in-person session – Displaced or salter fractures • Require orthopedics advice / management
- 34. Displaced fractures > Reduction
- 35. Common Finger Injuries • Mallet Finger
- 36. Mallet Finger Injury • Adolescent = adult –Soft tissue vs bony mallet –Joint must be reduced –Loss of flexion more problematic than loss of extension at DIP joint –Most treated in a DIP extension splint, PIP free –4-6 weeks full time splint wear, then 2 wk transition –Rare CRPP or ORIF
- 37. Seymour’s Fracture: Nail bed • Looks like Mallet finger • Physeal fracture • Requires ED or OR Rx
- 38. Common Thumb Injuries • Soft tissue injuries / sprains – Thumb spica splint – Beware UCL sprains / laxity – thumb spica splint and refer to Orthopedics • Thumb fractures – Refer to Orthopedics
- 39. Trigger Thumb and Finger
- 40. Common Wrist Injuries • Sprains – Cock-up wrist splint
- 41. Common Wrist Injuries • Distal radius fractures – If buckle fracture only, cock-up wrist splint for 3 weeks – refer if not improving – If non-displaced fracture other than buckle fracture, apply cock-up wrist splint and refer to orthopedics for casting – Any other wrist fractures, consult or refer to orthopedics
- 42. Common Wrist Injuries • Scaphoid Injuries – Poor healing due to limited blood supply – If scaphoid tenderness, even with negative x-ray, apply thrumb spica splint and refer to orthopedics
- 43. Finger and Wrist Splinting Will be covered in detail during January 20 In-Person session
- 44. Splints: Limitless choices • Finger splints – Prefer dorsal to volar – Prefer to buddy tape to adjacent digit
- 45. Mallet finger splint Preferred Technique
- 46. Useful but risky Coban Wrap 3M (No conflict of interest) • Great product for swelling, discomfort, rehabilitation • Dangerous product for vascular compromise – Patient and family education critical
- 47. Standard temporary treatment • Wrist cockup and thumb spica splints
- 48. BCH Orthopedic Specifics COW = Clinical Orthopedist of Week • Covers urgent clinics • Supports OOW OOW = Orthopedist of the Week • 7am ED xray rounds • 730am NPO walk ins • Surgery, ED and emergencies all day • No elective care
- 49. Urgent Clinics • Daily clinics Boston Waltham am and pm • Twice a week Peabody – Tues and Wed • South Shore – Tues • MLP with COW Orthopedic Attending Back up • Direct MD line – 617 355 4774 • PPOC Direct Line 617 435 8661 urgentortho@childrens. harvard.edu
- 50. © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu Orthopedic Advice and Urgent Access
- 51. Orthopedic Advice and Urgent Access • Answered live between 7:00AM and 5:00PM, Monday through Friday – Text messages and emails will be answered within 5-10 minutes during these hours • Immediate call backs for any missed calls (there are cellphone dead spots in BCH) • If appointment needed: a scheduler from the Department of Orthopedics will call the patient’s family or primary care practice right back to complete scheduling and registration – Appointments will be made in Boston or a BCH satellite based upon the patient’s location, day of week and urgency
- 52. Algorithm
- 53. Red Flags
- 54. Finger
- 56. Wrist
- 58. Your Feedback Helps Us Succeed! Please take a moment to fill out the session evaluation Survey and provide us with your feedback so that we can continue to improve and meet your expectations! © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
- 59. Learning Community Schedule Webinars 7:30am – 8:30am Date Content Thursday, June 11, 2015 Concussion Wednesday, September 9, 2015 Foot and Ankle Wednesday, December 16, 2015 Hand and Wrist Wednesday, February 24, 2016 Everything Knee Date Wednesday, July 15, 2015 Thursday, August 13, 2015 Thursday, October 29, 2015 Thursday, March 24, 2016 Wednesday, April 27, 2016 Didactic Webinars 7:30am – 9:00am © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu In-Person Sessions 7:00am – 9:00am, BCH Waltham Date Content Wednesday, January 20, 2016 Practical Session Wednesday, May 25, 2016 Practical Session Follow-up email will have Algorithms, videos, recording, survey, calendar and coursework information
- 60. 59 Thank You!
Editor's Notes
- Barry
- Green are dates that we changed
- 5
- Alex
- Once a decision has been made that imaging is indicated, in trauma it is almost always best to start with plain radiographs. AP/Lateral and oblique projections have the highest yeild for either making a diagnosis or excluding boney injury. The exception to this is imaging the scaphoid where a additional views are needed due to the 3 dimensional shape of the carpus however can just be ordered as a ‘scaphoid series’. If the injury is clearly to a single digit or digits order specific finger xrays as the yield is higher than ordering hand radiographs. This is especially true in the thumb as it is out of plane from the palm of the hand. I am sure you have all found that there are certainly times especially with small children that it is difficult to pin point the precise location and therefore a wider field is indicated. Including details that point to your area of maximal concern will improve the detail of the report you receive in return. Tender dorsal aspect of index finger or radial side of wrist will add focus. IF after plain radiographs it is still unclear then splinting and referral or repeat evaluation is usually more appropriate than advanced imaging studies in trauma.
- Once a decision has been made that imaging is indicated, in trauma it is almost always best to start with plain radiographs. AP/Lateral and oblique projections have the highest yeild for either making a diagnosis or excluding boney injury. The exception to this is imaging the scaphoid where a additional views are needed due to the 3 dimensional shape of the carpus however can just be ordered as a ‘scaphoid series’. If the injury is clearly to a single digit or digits order specific finger xrays as the yield is higher than ordering hand radiographs. This is especially true in the thumb as it is out of plane from the palm of the hand. I am sure you have all found that there are certainly times especially with small children that it is difficult to pin point the precise location and therefore a wider field is indicated. Including details that point to your area of maximal concern will improve the detail of the report you receive in return. Tender dorsal aspect of index finger or radial side of wrist will add focus. IF after plain radiographs it is still unclear then splinting and referral or repeat evaluation is usually more appropriate than advanced imaging studies in trauma.
- Once a decision has been made that imaging is indicated, in trauma it is almost always best to start with plain radiographs. AP/Lateral and oblique projections have the highest yeild for either making a diagnosis or excluding boney injury. The exception to this is imaging the scaphoid where a additional views are needed due to the 3 dimensional shape of the carpus however can just be ordered as a ‘scaphoid series’. If the injury is clearly to a single digit or digits order specific finger xrays as the yield is higher than ordering hand radiographs. This is especially true in the thumb as it is out of plane from the palm of the hand. I am sure you have all found that there are certainly times especially with small children that it is difficult to pin point the precise location and therefore a wider field is indicated. Including details that point to your area of maximal concern will improve the detail of the report you receive in return. Tender dorsal aspect of index finger or radial side of wrist will add focus. IF after plain radiographs it is still unclear then splinting and referral or repeat evaluation is usually more appropriate than advanced imaging studies in trauma.
- Once a decision has been made that imaging is indicated, in trauma it is almost always best to start with plain radiographs. AP/Lateral and oblique projections have the highest yeild for either making a diagnosis or excluding boney injury. The exception to this is imaging the scaphoid where a additional views are needed due to the 3 dimensional shape of the carpus however can just be ordered as a ‘scaphoid series’. If the injury is clearly to a single digit or digits order specific finger xrays as the yield is higher than ordering hand radiographs. This is especially true in the thumb as it is out of plane from the palm of the hand. I am sure you have all found that there are certainly times especially with small children that it is difficult to pin point the precise location and therefore a wider field is indicated. Including details that point to your area of maximal concern will improve the detail of the report you receive in return. Tender dorsal aspect of index finger or radial side of wrist will add focus. IF after plain radiographs it is still unclear then splinting and referral or repeat evaluation is usually more appropriate than advanced imaging studies in trauma.
- Jonathan
- Madeleine
- Green are dates that we changed
- Jonathan