Most hand injuries in children involve soft tissue. Often these soft tissue injuries are most difficult to evaluate.
Principles of Acute Care
Consider these principles in management:
Emergency room evaluation is limited The distress of the child and family, ER noise, and confusion may preclude an accurate evaluation of the upset child with an injured hand. Some injuries may be apparent by simply observing the child’s hand position. Few conditions require emergency treatment. Dislocations and gross fracture deformity require reduction. Vascular problems need to be addressed. Consider the possibility of child abuse. Prioritize treatment of all injuries but do not neglect the hand.
Child abuse The presence of finger fractures in the infant should bring to mind the possibility of abuse. Order high-resolution radiographs of the hands and feet in suspected abuse cases as part of the skeletal survey.
Anesthesia Delay the anesthetic until the child has been fasting and the staffing situation is optimal for a repair. The skin wound may be closed and definitive treatment delayed a few days without jeopardizing the outcome.
Early reevaluation Schedule a reevaluation the next day in the clinic, where a calmer situation may make an accurate diagnosis possible.
Consider structures at risk Base this on the site of the laceration and the nature of the bleeding.
Tendon lacerations more distal If the finger is flexed during the laceration, the site of tendon laceration may be well distal to the skin lesion.
Arterial bleeding The presence of arterial bleeding means the possibility of a nerve injury, as the artery and nerve often lie adjacent to one another. Partial lacerations of vessels make bleeding most difficult to control.
Fracture evaluation usually requires only a careful examination and radiographs.
Make AP and true lateral radiographs of the individual digits to accurately determine the extent of malalignment. Use the nail as a guide in making the lateral radiograph.
Comparison views of the opposite hand may be helpful if the diagnosis is uncertain.
Evaluate rotational status by assessing the alignment with the finger flexed, if possible.
Fracture treatment Manage most fractures by immobilization for 4 weeks. Some fractures require reduction with or without fixation.
Displaced articular fractures require reduction and fixation.
Malrotated fractures require reduction because rotational deformity does not remodel.
End of growth Avoid overestimating remodeling potential at or near the end of growth.
Physeal fractures, especially crushing fractures of the distal phalanx, may show physeal arrest with deformity and shortening.
Indications for open reduction Perform open reduction on irreducible dislocations and articular fractures of the small joints. Any fracture where reduction cannot be obtained or maintained by closed means requires open reduction, and fixation if necessary.
Fixation Fix most fractures with small transcutaneous smooth K wires. Consider absorbable fixation as an alternative.
Healing fractures Avoid operating on healing fractures. Allow most to heal, and correct any late residual deformity that causes a functional disability by ostetomy.
Soft Tissue Injuries
Fingertip crush injuries These injuries can occur at any age, but are especially common in the toddler. Protect the finger for comfort. Consider draining subungual hematoma for pain relief.
Fingertip amputation Manage these common injuries by leaving the wound open to allow healing by secondary intention. Outcomes in children are excellent even if bone is exposed. When the tip is available, it can be sutured back in place as a composite graft and stabilized with a 25# needle.
Interphalangeal joint sprains These injuries are common, sometimes referred to as baseball fingers. Rule out fracture or tendon injury. No special treatment is necessary. Advise the child and family that these injuries resolve slowly over a period of a few months.
Tendon lacerations take several forms:
Complete flexor tendon lacerations alter the resting position of the hand making the diagnosis simple. Repairs are based on the same principles as with adults. Immobilize for 4 weeks. Some improvement in motion will occur over a period of several years. Outcomes can be excellent in children.
Partial flexor tendon lacerations are more difficult to diagnose. If the tendon sheath is lacerated, a tendon injury is likely. If the tendon is lacerated while the finger is in flexion, the tendon injury will be well distal to the skin lesion once the finger is extended. Because partial tendon lacerations may become complete, unload the tendon by immobilizing the hand with the fingers and wrist in flexion for a period of 3 weeks. Repair the tendon if the laceration exceeds 30% of the cross section of the tendon.
Extensor tendon injuries Manage closed injuries by immobilizing the finger in extension for 4 weeks. Open lacerations require repair.
Nerve injuries Nerve transection should be repaired with magnification and microsurgical techniques. Outcomes are better in children than in adults.
Replantation Replantation should be considered unless the lost tissue is distal and severely crushed. The amputated digit should be cooled but not frozen. In children, about two-thirds of replanted digits survive. Replacement of digits with clean-cut injuries fare best. Results are better when the body weight is over about 25 pounds. Function and sensation return in most. Expect about one-third to have cold intolerance and another one-third to show fingertip atrophy. Growth is slightly retarded, but the shortening is seldom a significant problem.
Burns Most burns occur on the palm. Fortunately, most burns are minor, requiring only a nonadherent dressing. More serious burns require extensive treatment, including debridement and skin grafts, and later reconstruction.
Metacarpophalangeal joint dislocations These dislocations usually involve the index finger or little finger. They usually require open reduction. This should be done early to avoid vascular compromise.
Thumb dislocations Manage by closed reduction. Splint for 3 weeks, then allow active motion. Return to full activity in 6 weeks.
Interphalangeal joint dislocations Manage most with closed reduction. Open reduction may be necessary if articular fracture is present or if reduction is incomplete and the joint unstable.
Scaphoid fractures These are uncommon injuries in children. In most, the diagnosis is not difficult. Tenderness is localized to the anatomic sniff box, and radiographs nearly always show the lesion. Order a scaphoid view in addition to AP and lateral studies. Manage by immobilization in a thumb spica cast for about 7 weeks. Nonunions in children are rare. For children with tenderness but without radiographic changes, immobilize for 2 weeks and repeat the radiographs.
Other carpal fractures The capitate, triquetrum, hamate, and trapezoid are very rare injuries in children. Most can be managed by cast immobilization.
Diaphyseal fracture Obtain true lateral radiographs to assess the degree of angulation. Assess the rotational status with fingers in flexion. Correct rotational malalignment. If reduction is unstable, augment fixation with a smooth K wire. Immobilize with a finger-to-forearm cast with finger extensions in a functional position for 3 weeks.
Distal metacarpal fracture This fracture, also called boxer’s fracture, is a pure flexion fracture that will remodel with spontaneous return of range of motion. If the angulation exceeds 60°, reduce with an ulnar nerve block with the finger flexed to 90°. Immobilize for about 3 weeks with the finger flexed to control rotation. Anatomically reduce and fix intraarticular fractures.
Base of thumb metacarpal fracture This fracture, also called a Bennett fracture, extends through the proximal thumb metacarpal. It requires reduction. Be certain that rotational alignment is correct. If unstable, fix with a transcutaneous K wire and supplement with a thumb spica cast.
Proximal phalanx epiphyseal fractures These are common injuries. Assess rotation in flexion. Use internal fixation if unstable.
Mid and distal phalanx epiphyseal fractures These injuries are uncommon but may cause growth arrest and deformity or instability. Reduction and fixation are needed for displaced or unstable fractures.
Diaphyseal fractures Assess with true AP and lateral radiographs. Assess for rotational alignment. Align and fix internally if unstable.
Mallet finger This may occur as a Salter-Harris Type I fracture in the young child or often a Salter-Harris Type II fracture in the adolescent. Reduce in hyperextension. Stabilize in a finger splint for 6 weeks. The less common Salter-Harris Type III fractures require anatomic reduction.
Tuft fracture These fractures are commonly associated with crush injuries. As these are open fractures, manage with antibiotics, soft tissue care, and follow-up. Complications include osteomyelitis and nail damage.
Growth disturbances These are rare injuries in the fingers. Correct angulation by osteotomy.