PEDIATRIC SPORTS AND ACTIVITY-RELATED HAND

INJURIES

July 21, 2017

Mayron Lichterman, DO, MPH

Cynthia L. Vennix, OTR/L, CHT, CEAS, CLT

• Define common hand injuries seen in pediatric patients as a result of sports and other physical activities

• Gain an understanding of basic symptoms, diagnosis and work-up of common pediatric hand injuries

• Describe non-operative and operative treatment of pediatric hand injuries including rehabilitation and expectations for recovery and return to activities

Objectives

• Children not small adults

• Many treatment principles used in adults applicable to children – Special considerations required

• Accurate clinical diagnosis dependent on clinical history, careful observation, skilled physical exam – More difficult history – Smaller size of affected structures – Abundant surrounding subcutaneous fat and soft

tissues

Considerations

• Fractures – Fingers

– Hand

• PIP Joint – Sprains

– Dislocations

– Volar Plate Injuries

• Thumb UCL

Common Injuries

• Fractures – Fingers

– Hand

• PIP Joint – Sprains

– Dislocations

– Volar Plate Injuries

• Thumb UCL

Common Injuries

• Superior healing potential compared to adults

• Reduced risk of delayed union and nonunion

• Smaller window of opportunity to correct deformities

Pediatric Fractures

• Twisting

• Fall

• Crush

• Direct contact

• Combined bending and torsional force most common

Mechanism of Injury

• Swelling

• Pain/Tenderness

• Deformity

• Inability to move

• Shortening/Depressed knuckle

• Crossover

Signs/Symptoms

• History

• Exam – Position of fingers

– Palpation

– ROM

– Condition of skin

– Sensation

• X-rays

Diagnosis

Salter-Harris Classification

• Assess rotation

– Malrotation with finger flexion

• Exhibits little remodeling

• Can compromise hand function

Rotation

• Presence of growth plate allows for remodeling with growth

• Greatest remodeling potential – Displacement in plane of adjacent joint motion

– Close to physis

– More years of remaining growth

• Rotational deformity and radioulnar angulation do not remodel well

Treatment Considerations

• Most hand fractures managed non-operatively

– 10-20% pediatric patients require surgery

• Majority treated with simple splint or cast

– 4-6 weeks with excellent healing and outcomes

• Importance of preserving physeal growth may influence treatment

Treatment

• Closed reduction

– Malrotation overlap or underlap

– Greater than 10o angulation

• K-wire fixation • Closed or Open

• Not reducible or unstable

Operative Treatment

• Serial X-rays to monitor for maintained position/loss of reduction and articular congruity

• Immobilization discontinued at 4-6 weeks +/- pin removal

• ROM exercises and gradual return to activity

Treatment Continued

• Varying degrees of compliance with post-injury and post-op care

– Trend favors more restrictive immobilization

• Not associated with stiffness or loss of function seen in adults

Pediatric Compliance

• Neck fractures in up to 70%

• Small Finger most common

• Treatment similar to adults and finger fractures

• Significant angulation acceptable (RF/SF) – Compensatory MP and CMC joint motion – Metacarpal physis distal

• Cast immobilization for 4-6 weeks (+/- closed

reduction)

Metacarpal Fractures

Evaluation on the field of play….

• Resting posture of hand/fingers—STOP!!!

Observe hand at rest!!! • AROM • PROM • Jt laxity tests • Swelling • Pain • Bruising • Strength • Position played– “skilled– non-skilled”

• NOTE: Reductions should not be completed during game or practice– this could further injure a ligament or fracture

• Fractures – Fingers

– Hand

• PIP Joint – Sprains

– Dislocations

– Volar Plate Injuries

• Thumb UCL

Common Injuries

• PIP injury most common ligamentous injury in the hand

• Injuries range from simple sprain to challenging fracture-dislocations

Background

• Key to stability “Boxlike” complex

– Collateral ligaments laterally

– Volar plate volarly

• Must be disruption in at least two planes for dislocation

– Collaterals fail proximally

– Volar plate fails distally

Relevant Anatomy

• Swelling

• Pain/Tenderness

• Deformity

• Inability to move

finger

Signs/Symptoms

• History

• Exam – Position of finger

– Palpation

– ROM

– Condition of skin

– Sensation

• X-rays

Diagnosis

• Treatment determined by two-phase test after digital block

• Active Stability

– Voluntary full or near-full ROM

• Passive Stability

– Gentle manipulation

– Lateral stress in full extension and 30o flexion, A/P

– Compare to contralateral

Test for Stability

• PA and True Lateral finger X-rays

– May have spontaneously reduced

• “V” sign dorsally to identify incongruence or subluxation

• Fractures

Radiographic Evaluation

• “Jammed Finger”

• Collateral Ligament Injury Classification

– Grade I: Pain, no laxity

– Grade II: Laxity but firm endpoint, stable arc

– Grade III: Grossly unstable, no firm endpoint

• “Buddy Taping” and early ROM

PIP Sprain

• Can dislocate in one of three directions

– Dorsal

– Volar

– Lateral

• Pure dislocation – collateral ligaments intact

– Small avulsion fractures common

PIP Dislocations

• Stability examined after reduction

• Stable through full ROM

– Immediate motion

– Protection with “Buddy Taping”

Dislocations Continued

• Extension block splint at 10o more flexion than point of instability

– Consider surgery if requires >30o flexion to maintain

– No more than 3 weeks in a splint

Unstable Dorsal Dislocations

• Fracture-dislocations with volar fragment

< 40% articular surface and concentric – Inherent stability from collaterals

– Acts like simple dorsal dislocation

• Splinting in slight flexion places avulsed volar plate in near-anatomic position – Conducive to healing

• Likely requires fixation if > 40%

Unstable Dorsal Dislocations

• Ligaments heal when joint reduced and early controlled motion begun

– “Buddy Taping”

• Greater than 20o deformity on lateral testing in extension

– Complete collateral disruption and injury to at least one other secondary stabilizer

– May require repair vs. reattachment

Lateral Dislocations

• Rare injuries

• Difficult to reduce

• Often associated with extensor mechanism injuries

Volar Dislocations

• Stiffness from prolonged immobilization most common complication – Not instability

– May have permanent stiffness

• Expect at least 6 months of occasional pain and stiffness – Recovery typically prolonged

• Can have swelling for up to 1 year

Overall Expected Outcomes

Hyper-Extension PIP

Swan Neck Deformity Volar Plate Injury–Unstable Dorsal Dislocation

Volar Plate Injury – Rehab - RTP

• Joint is stable

• Splints will be dorsal based restricting full PIP extension AND allowing full MP and DIP flexion – Splint in 10 degrees more than stable point of testing

• Depending on pain, swelling, stability – 3-4 weeks start buddy tape

• Buddy tape and dorsal blocking splint for practice/game play

• Control edema

• Isolated and composite joint AROM

• Protection with foam wrap for practice/game play

• Specific hand strengthening at 3-4 weeks

BOUTONNIERE DEFORMITY- Hyper Flexion-Volar Dislocation

On the Field Check: Elson Test - Central Slip Injury

1. Position the patient’s PIP in 90-

degrees flexion. This normally

keeps the central band taut and the

lateral bands loose

2. Ask the patient to extend the PIP,

while the provider’s finger applies

counterforce at the middle phalanx

A: Normal- inability to fully extend B: Abnormal- DIP flops into extension In absence of central slip injury DIP remains floppy because the extension force is now placed entirely on maintaining extension of the PIP joint; the lateral bands are not activated

Unstable Volar Dislocation–RTP

• Start with PIP extension splinting within athlete's comfort. Obtain as much PIP extension as soon as possible.

– Splinting usually starts with static and gradually moves to dynamic (only if needed)

– Splint should not impede MP or DIP flexion

– DIP active and passive flexion exercises are immediately started to avoid ORL (oblique retinacular ligament) tightness

– Monitor for full MP flexion and extension AROM

Volar Dislocation – RTP

• 3 Weeks: Start PIP Flexion exercises

– Monitor for extensor Lag

– Reverse PIP extension exercise to improve stiff PIP joint

• PIP remains splinted in extension full time– up to 6 weeks

– May need to splint at night an additional 3 weeks

• Boutonniere may not be noticeable until 2-3 weeks

– You’ll see either a PIP extensor lag or PIP contracture starting.

• Pseudo Boutonniere: injury to the PIP proximal volar plate resulting from a PIP hyperextension injury – left untreated

• Seen almost exclusively in the ring and small fingers

Pseudo Boutonniere vs Boutonniere

Exercise

• In general, when tissues are stimulated by pain-free movement:

– Favorable clinical responses occur, including lubrication and circulation to promote healing

– The more this happens the better the results

• As is the opposite:

– Movement that results in swelling or pain can actually be detrimental

Isolated DIP Blocking and MP Flexion Exercise

Exercises Isolated PIP and DIP Blocking

Reverse PIP Extension

PIP Splints Buddy splinting

Oval Splints

Advantage: Multiple uses Disadvantage: Individual sizes

Edema Control

• Coban wrapping

• Kinesio tape application

• SHOCKtec Gel

• Cramer Sports Med. ThermoFoam Padding Kit, Trim to Size Custom Padding

– Easily moldable to athlete Body, assorted variety of thicknesses

• Cast protector

Padding

• Fractures – Fingers

– Hand

• PIP Joint – Sprains

– Dislocations

– Volar Plate Injuries

• Thumb UCL

Common Injuries

• Thumb MP joint has little intrinsic stability

• Injuries to Thumb UCL common – 10x more common than RCL – Skiers and ball-handling athletes

• Mechanism sudden, forced abduction/radial deviation

• Distal tears at insertion most common – Occasionally ruptures within substance or avulsion

fractures

Background

• Swelling

• Pain/Tenderness

• Bruising

• Weakened grasp/pinch

Signs/Symptoms

• History

• Exam

– Position of thumb

– Palpation

– ROM

– Stability

• X-rays

Diagnosis

• Radially deviate in extension and 40 degrees of flexion

– 30o laxity of ulnar side

– 15o more laxity than contralateral

• Presence of endpoint to valgus stress more helpful

Ligament Stress

30o

• Standard 3 views in all patients with suspected UCL – Avulsion or condylar fracture

• Stress radiographs not helpful – Primarily a clinical diagnosis

• Other modalities – U/S

– MRI

Radiographic Evaluation

• Ulnar base of proximal phalanx at insertion most common

• May require fixation if >10% of articular surface – Displaced ≥ 2 mm

– Articular incongruity

• No consensus about optimal treatment for small, minimally displaced or non-displaced – Cast immobilization generally adequate

Avulsion Fractures

• Adductor aponeurosis interposed between distally avulsed ligament and its insertion

• Without contact at site of rupture, healing imperfect

– Laxity regardless of length of immobilization

Stener Lesion

• Recommended for complete tears

– More predictable

– Quicker recovery?

• Clinical diagnosis of Stener lesion difficult

– Missed causes prolonged dysfunction and pain

• Repair/Re-attachment vs. Reconstruction

Operative Treatment

Thumb UCL Injury—Conservative Partial Tears-Firm Endpoint to Valgus Stress at MP

• 0-4 weeks: Thumb spica cast immobilization

– Incorporate MP joint (IP free) with thumb in slight adduction of approximately 40 degrees from the palm-cover w/ proper foam for play

• 4-6 weeks: Thumb spica splint with AROM within pain free range and gentle passive in linear plane

• 6-8 weeks: Unrestricted AROM

– Splint only for sport play - progressive strengthening within comfort level, eccentric, isometric and isotonic

• 8 -10 weeks: Strengthening

– Emphasis: Lateral pinch and oppositional

– Splint may be continued or released– dependent on joint tenderness

– Continue with splint until athlete is pain free and complete ROM obtained

• 10-12 weeks: Return to gradual wt training and ballistic activities

• Athletic taping may continue throughout season

• Aching on ulnar side of MP joint for 6 or more months despite no laxity

Thumb UCL Injury—Conservative

Thumb Spica Splints

Poorly Fit Splints

Questions?

Thank you! bronsonhealth.com

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