Pediatric emergency medicine trisk 838

FIGURE 109.7 These lateral radiographs of the finger demonstrate two examples of fractures at the base of the distal phalanx in the setting of a mallet finger (Courtesy of Children’s Orthopaedic Surgery Foundation.) FIGURE 109.8 Operative exploration of a Jersey finger injury, demonstrating the ruptured flexor digitorum profundus tendon (Courtesy of Children’s Orthopaedic Surgery Foundation.) Proximal phalanx injuries are some of the most common pediatric hand injuries and are managed similarly to middle phalangeal injuries The base of the proximal phalanx often endures a Salter–Harris II fracture (see Fig 111.2 for Salter-Harris Classification system), with the small (i.e., the fifth) finger being the most frequently affected Many are managed with splinting/casting following closed reduction when necessary Reduction can be an emergency room procedure in appropriately trained hands using the “pen-in-the-web-space” technique Nondisplaced shaft fractures are generally managed with immobilization Displaced and angulated fractures may require surgical stabilization Phalangeal neck fractures can be difficult to diagnose Oblique view radiographs may be of assistance ( Fig 109.10 ) These fractures require very close outpatient care, as displacement and rotation may have long-term consequences on the flexion of the adjacent IP joint Finally, intra-articular condyle fractures may involve one or both condyles and long-term management may depend on the degree of displacement and severity of the injury ( Fig 109.11 ) Close follow-up is required in these injuries; many require surgical stabilization It is important to note that a finger splint does not provide adequate support for a proximal phalanx fracture A hand- or forearm-based splint is necessary FIGURE 109.9 This lateral radiograph demonstrates a small volar avulsion fracture of the proximal middle phalanx (A ), then a larger pilon fracture of the proximal middle phalanx (B ) (Courtesy of Children’s Orthopaedic Surgery Foundation.) Proximal phalanx injuries to the thumb are unique In adolescents and adults, a skier’s or gamekeeper’s thumb occurs with rupture of the ulnar collateral ligament (UCL) during an abduction stress of the thumb In children, a fracture of the base of the proximal phalanx is more likely than a UCL injury, with Salter– Harris I and II fractures predominating in younger children and Salter–Harris III fractures in older children Thumb spica splinting is appropriate for this constellation of injuries in the emergency department Extra-articular injuries may require closed reduction prior to immobilization Displaced intra-articular fractures require operative management Early hand specialist referral is appropriate DISLOCATIONS CLINICAL PEARLS AND PITFALLS MCP dislocations can be difficult to identify on radiograph and may simply appear hyperextended Avoid longitudinal traction with MCP joint reductions Clinical Considerations Dislocations of the IP and metacarpophalangeal (MCP) joints are generally uncommon in younger patients, although adolescents tend to have incidence similar to adults, particularly when involved in contact sports Initial Assessment and Management IP dislocations most often occur with the distal bone placed dorsal to the proximal After management of pain with either systemic analgesics or a digital block, prompt relocation is performed with inline distraction and hyperextension in the IP joints MCP joint dislocations most frequently involve the thumb ( Fig 109.12 ) These dislocations occur most often with the proximal phalanx dorsal to the metacarpal and the metacarpal head palpable in the palm In the immature patient, these dislocations may be difficult to clarify on radiographs because of the joint consisting mainly of cartilage or in the case of lesser digits, adjacent digit overlap on imaging that makes diagnosis challenging Therefore, the digit may simply appear to be hyperextended Reduction attempts should maintain or exaggerate the hyperextension while applying pressure toward the palm on the base of the phalanx In general, straight longitudinal traction is not recommended in MCP dislocations, to avoid soft tissue interposition and converting a reducible injury into an irreducible dislocation If the joint is not easily relocated, hand specialist involvement is required for likely open reduction In these cases, the tendons and volar plate involved may prevent reduction with inline traction  ... Children’s Orthopaedic Surgery Foundation.) Proximal phalanx injuries are some of the most common pediatric hand injuries and are managed similarly to middle phalangeal injuries The base of the... are managed with splinting/casting following closed reduction when necessary Reduction can be an emergency room procedure in appropriately trained hands using the “pen-in-the-web-space” technique... in older children Thumb spica splinting is appropriate for this constellation of injuries in the emergency department Extra-articular injuries may require closed reduction prior to immobilization