hand and wrist case studies & pearls of wisdom€¦ · • jim chesnutt, md, has nothing to...
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Hand and WristCase Studies & Pearls of Wisdom
Jenna M. Godfrey, MDHand Surgeon
25th Annual Orthopedic & Sports Medicine UpdateDecember 2nd, 2017
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Disclosure Information
• Presenter• Jenna Godfrey, MD, has nothing to disclose.
• Planning Committee• Jim Chesnutt, MD, has nothing to disclose• Brick Lantz, MD, has nothing to disclose• Erin Owen, PhD, has a spouse who receives a salary from Wright
Medical
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Cases 1 & 2
• Both patients are:• 8yo females• Fall off monkey bars• Wrist pain• No other injuries
• PE: swelling and tenderness about distal radius
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Patient 1
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Patient 2
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Pediatric Distal Radius Fractures
2 flavors:
• Extra-physeal: Buckle or Complete Fracture
• Physeal (eg. Salter Harris Fracture)
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Patient 1
• Extra physeal
• Buckle fracture: cortex is INTACT, 2 inflection points seen on either view
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Patient 2
• Physeal
• Salter Harris 2 Fracture: Fracture line extends to the physis, ONE inflection point
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Treatment Algorithm
• Buckle Fractures are INHERENTLY STABLE• Removable brace for 2-4 weeks
• Extra Physeal Fracture (e.g. cortex is disrupted)• Possible reduction and casting
• Physeal Fractures• Possible reduction, casting, FOLLOW until normal growth seen on XR
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Follow up…
• Patient 1 no further issues
• Patient 2• 18mo later returns with a “big bump” on the ulnar side of the
wrist per Mom
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Injured Comparison
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MRI:Negative for Physeal
Bar
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Case 3
• 21yo male• c/o “jammed finger” • Playing flag football• Ball hit the end of the finger• Pain, swelling and limited motion at PIP joint• No previous injuries
• PMH: neg
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Case 3: “Jammed Finger”: The Differential
#1 Most common: Volar Plate Injury
BUT YOU COULD ALSO HAVE:• Collateral ligament injury• Dislocation of the PIP• Fracture of the proximal phalanx• Fracture dislocation of the proximal phalanx• Dislocation of the PIP
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Get a dedicated FINGER XR!!!!
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NORMAL!! = Volar Plate Injury
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Intracondylar Fracture = Surgery
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Dislocation = Reduction
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Fracture/Dislocation = Surgery
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Volar Plate Treatment Do’s and Don’ts DO:
• Mobilize early• Buddy tape FOR COMFORT ONLY• Hold out of sport until full finger motion
DON’T:• Immobilize >1 wk• Cast• Use an alumifoam splint (DON’T DO IT!!)
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Case(s) 4
• Hand lacerations in:
• 2 yo – fingertip slammed in door
• 10 yo – fall onto a mason jar
• 60 yo – man vs. table saw
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Child vs. Door Injury
•Most common in toddlers•Rule of 1/3s:
• 1/3 will completely heal if you put back on the tip
• 1/3 will partially heal if you put back on the tip
• 1/3 the tip WON’T heal BUT• Only 10% need a revision amputation
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Palmar Laceration
• Glass can do A LOT of damage• Never judge it by the SIZE of the wound
• Look at the finger cascade
• Test sensation
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Fingertip vs. Table Saw
• Remove the nail plate• Look at how much is INTACT• Does the tip have good capillary refill?• Wash, wash, wash• Antibiotic
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CLINICAL KEY: The Block - 1 Shot
• 1% Lidocaine WITHOUT EPI5-10ml syringe: 1-2cc into the the sheath27g needle
• Make a wheal over flexor tendon• WAIT...• Go into tendon sheath and BUMP
the bone
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Nail Plate OFF!
Don’t guess, it won’t hurt if you’re wrong but it will if you miss a nail bed injury!!
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Wash it...WELL
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Repair with CHROMIC
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Keep Eponychial Fold Open
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Tenets of the Laceration• Thou shalt:
• Administer IV antibiotics• NEVER throw away the tip of a child’s finger• Use chromic!!!!• Remove a nail plate for all distal fingertip lacerations • Look at the cascade of the digits• Test sensation
• We fix nerves in the PROXIMAL digit• We DON’T fix nerves in the tips of the finger
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Thank You!QUESTIONS?