Pediatric Hand Injuries

Abstract

The hand is the most frequently injured part of the child’s body. Household injuries dominate in the younger child and sports-related injuries account for the majority of hand injuries in older children and adolescents. The child’s hand is important for exploration, socialization, and development, and its function in these realms can be affected by serious injuries.

Appendices

Summary Points

The frequency of hand injuries in children and the wide variety of injury type and severity together pose challenges for the general surgeon treating the injured child.

Thorough examination, though difficult, is crucial for determining the severity of injury. Always check for rotational deformity in injured digits.

Dedicated radiographs of the injured digit are essential for evaluation of finger fractures. Similarly, forearm radiographs are not adequate for assessment of carpal fractures.

Because of the rapid healing of fractures in the child’s hand, permanent malunions may develop quickly unless definitive fracture treatment is provided within the first 1–2 weeks.

Severe swelling in the hand with increasing analgesic requirements should raise suspicion for hand compartment syndrome.

Major soft tissue injuries in the child’s hand demand prompt and specialized care, but the rapid and reliable soft tissue healing in children usually allow rewarding results.

Editor’s Comment

Definitive care of hand injuries requires a great deal of expertise and experience, preferably by a dedicated hand surgeon, but the initial assessment and treatment are important aspects of the care of the injured child. General and pediatric surgeons therefore need to be prepared to deal with these situations and should not be intimidated when they occur. In general, a minimalist approach is best: observe and gently examine the hand without excessive manipulation, try to assess distal neurovascular function, obtain appropriate dedicated radiographs, and discuss the case personally with a pediatric hand surgeon as soon as possible. If there is bleeding, one should apply direct pressure by hand, never with a “pressure” dressing or weights. Apply only the minimum pressure necessary to stop the bleeding; excessive pressure occludes the artery and causes distal ischemia. Severe ischemia or pulsatile bleeding should always prompt emergent surgical exploration, not additional diagnostic studies. Always assume that a subungual hematoma could be the result of an underlying distal phalangeal fracture and perform a dedicated radiograph to rule this out. To preserve amputated parts for possible reimplantation, it is probably best to wrap the tissue in saline-soaked gauze, place it in a specimen cup, and place this into a specimen bag containing ice and water.

Finally, remember to document every aspect of the physical examination and any therapeutic maneuvers in great detail in the medical record as this will help the hand surgeon during subsequent follow up and could help reduce medical liability if the functional outcome is less than optimal.

Differential Diagnosis

Bony fracture

Soft tissue injury

Dislocation

Tendon injury

Nerve injury

Vascular injury

Hand compartment syndrome

Diagnostic Studies

Dedicated radiographs with multiple views

Computed tomography

Magnetic resonance imaging

Measurement of compartment pressures

Preoperative Preparation

Prophylactic antibiotics, if appropriate

Tetanus prophylaxis, if appropriate

Meticulous physical examination and imaging studies

Parental Preparation

The primary goal is the best long-term functional result possible.

Some injuries require immediate or emergent treatment while others are best managed in a delayed fashion.

Reimplantation of an amputated digit is not always indicated or possible and, when they are attempted, because of the small size of the blood vessels in children, the ultimate outcome is somewhat unpredictable.

As with all trauma, prevention is best.

Technical Points

Always carefully examine the hands of children who present with severe or multi-system injuries.

Examination of the child’s hand requires patience, careful observation, and passive tests as they are often frightened and in pain and therefore rarely cooperative.

Control pulsatile or severe bleeding with direct pressure, not with a tourniquet.

Never try to clamp or ligate a bleeding vessel without proper instruments, lighting, magnification, and experience, as nerve injuries are frequently the result.

Do not attempt to reduce metacarpophalangeal dislocations by applying longitudinal traction, as this creates a vacuum that can draw in the volar plate or other soft tissue and prevent proper healing. If the dislocation cannot be reduced by gentle manipulation, it should be performed in the operation room.