Pediatric emergency medicine trisk 837

CLINICAL PEARLS AND PITFALLS Special attention is required for injuries to the phalanges looking for rotational deformity; the tenodesis effect is very useful even in the noncooperative child A finger splint does not provide adequate support for proximal phalanx fractures; a wrist or forearm splint is necessary Small fragments or flecks on radiographs can represent larger injuries due to immature ossification Clinical Considerations Clinical Recognition Phalanx injuries are very common in children since the fingers of a child are a first exploration into their world Mechanisms of injury most frequently include crush, hyperextension, and “jamming.” Careful examination with particular attention to rotational deformity is required Passively flexing and extending the wrist allow for observation of the tenodesis effect which is very useful for the assessment of rotational deformities and for complete tendon injuries ( Figs 109.1 and 109.5 ) Often, identifying which bone is involved in an interphalangeal (IP) joint injury can be challenging due to pain and swelling Initial Assessment and Management Distal phalanx injuries are very common and often associated with nail and nail bed injuries, as discussed in the section on fingertip injuries above When associated with nail bed injuries, after the nail is removed (if necessary), the open fracture should be copiously irrigated and the nail bed repaired, followed by splinting These should be referred to a hand specialist for follow-up in case further intervention, such as pin fixation, is required Seymour fractures comprise a special type of injury, with a Salter–Harris I or II fracture of the distal phalanx associated with exposure of the proximal aspect of the nail and damage to the germinal matrix ( Fig 109.6 ) The distal interphalangeal (DIP) joint is often held at some flexion Early consultation with a hand specialist is recommended, as tissue interposed into the physis may prevent the fracture from healing which can lead to infection and potential nail deformity FIGURE 109.5 Image depicting a small palmar laceration at the base of the middle phalanx leading to abnormal tenodesis in the setting of a flexor tendon injury (Courtesy of Children’s Orthopaedic Surgery Foundation.) Mallet finger injuries are avulsion fractures of the distal phalanx that commonly result from a finger jam mechanism In adolescents, the injury is often seen on a lateral radiograph ( Fig 109.7 ) A similar tendon avulsion in a younger child might not have an associated fracture Mallet finger injuries are managed in an extension splint In the emergency room setting, AlumaFoam and stack splints may be utilized However, providers should be mindful of appropriate sizing, as splints designed for adults commonly not fit Many of these injuries are treated with immobilization alone Even large fragments may not require surgical care, however all mallet finger injuries should be referred to a hand specialist FIGURE 109.6 Seymour fracture A : Lateral radiograph depicting a displaced distal phalangeal physeal fracture in the setting of a nail bed injury B : Intraoperative photograph after nail plate removal depicting the tear in the germinal matrix of the nail bed and underlying bony injury (Courtesy of Children’s Orthopaedic Surgery Foundation.) Jersey finger injuries refer to traumatic avulsion of the flexor digitorum profundus tendon at the level of the distal phalanx These commonly occur when the finger is held in flexion and then sustains forceful extension, for example, when a football player is attempting to tackle another player with their fingers There is often pain on the volar aspect of the finger, with the affected finger held in slight extension ( Figs 109.2 and 109.8 ); the patient cannot actively flex the DIP joint These injuries commonly occur without an associated fracture but require urgent referral to a hand specialist for operative repair Most middle phalanx injuries are managed by closed management, although surgical reduction and stabilization may be required in displaced fractures Fractures of the head of the phalanx require close management by a hand specialist because of a high rate of complications Avulsion fractures of the middle phalanx at the insertion of the volar plate or extensor central slip are common Avulsions on the volar side generally are from hyperextension Often, the fragment does not reattach Prolonged immobilization may result in chronic stiffness and has potential for permanent loss of range of motion Splinting is performed initially, but early range of motion is often started a week later Small avulsions on the extensor side are treated similarly, though larger fragments are treated with longer splinting, and injuries with displaced and larger fracture fragments with articular involvement may require open reduction ( Fig 109.9 )  ... not have an associated fracture Mallet finger injuries are managed in an extension splint In the emergency room setting, AlumaFoam and stack splints may be utilized However, providers should be