With a focus on often-missed injuries and the value of early detection, orthopedic surgeon Gopal Lalchandani, MD, describes his process of evaluating finger fractures and lacerations in children, using photos and X-ray images to illustrate. His tips cover when nonsurgical treatment should suffice as well as subtle signs that indicate a need for emergency care or prompt assessment from a hand surgeon (including how finger positions and skin tone changes can reveal tendon or nerve damage). Learn how appropriate primary care can preserve dexterity.
Thank you, thank you for that kind introduction and um so uh my goal for today is to talk a little bit about pediatric finger fractures and uh uh lacerations and um um and you know, mostly wanna focus on the injuries that uh are often. And, um, uh, missed or, or often take a, uh, a while to get, uh, uh, get further care, uh, as in wide variety or wide majority of these cases, uh, can be treated with, um, you know, with non, non-operatively with minimal intervention. Oops. There we go. Um, and I have no disclosures and I'll try to be brief and sort of stick to the highlights in terms of things that, um, you know, we can try to, uh, catch early or, or address, um, if, if needed. So to start off with finger fractures, um, as a disclaimer, um, I think most pediatric finger fractures can and should be treated non-operatively and I'd say that a wide majority of the patients that I see in clinic have non or minimally displaced, uh, uh, phalangeal shaft fractures and as long as they don't have any rotational issue or, or shortening, um, they can usually do well with non-operative treatment with uh 3 or 4 weeks of immobilization and buddy taping and then progressive motion. Um, but, you know, I know that most of us here are are probably already quite familiar with this and I'll try to, uh, uh, touch on and focus on some of the commonly missed injuries, um, to hopefully, you know, prompt a more, uh, useful and prompt, uh, and, uh, uh, prompt a, a good discussion. So, as I mentioned, mostly non-surgical. So I'll keep this case based and so, um, I'll start off with a patient that I saw, uh, a couple of months back. This is uh uh 11 year old male and was, uh, referred for, uh, a non-displaced, um, Uh, index finger fracture. So he's uh right-handed and, uh, unfortunately was at school and another classmate, um, uh, pulled on his finger and uh bent it backwards. He was seen at, uh, in the emergency room and was, uh, splinted and then presented uh two weeks out from injury with the following radiographs and I have him sort of, uh, in a larger format here. And so here we can see a uh minimally displaced uh uh likely Salter-Harris II fracture of the index finger proximal phalanx space. Uh, but overall, you know, I agree, it looks, the radiographs seem relatively benign. Um, however, when I saw him in clinic, this is what his hand looked like, um, and we can see that there is, um, even though the radiographs looked relatively, you know, minimally displaced or, or all, you know, non-displaced was, was as advertised, um, there's clearly a rotational deformity of, of his index finger, um, you know, overlapping or underlapping, um, his middle finger depending on the position. So, um, generally when these, uh, uh, fractures occur, um, You know, uh, if it's acute, you can, uh, consider a closed reduction in the emergency room or if needed in clinic, uh, where you can sort of numb up the finger, uh, provide pain control, and, uh, uh, try to realign the finger. However, after a certain amount of time, um, depending on the age of the child, the fracture tends to heal, uh, and in this case, in a malunited or suboptimal position. And so I talked with the family about options and, um, while, you know, at a young, you know, at an earlier time point, you could consider a closed reduction. Um, depending on the age of the child, they may or may not be able to tolerate that or, or be willing to try that in clinic, and, uh, they ultimately felt like, um, this is something they weren't comfortable taking care of in clinic and, um, you know, they wanted to make sure that we got this, uh, uh, you know, deformity corrected as perfectly as possible. So we went to the operating room and, and, uh, we're able to, uh, realign his finger and, and pin it to make sure it didn't go back to its original position. And while he's still early in his treatment course, uh, about 6 weeks later, you can see that his hand is, uh, in much better alignment. Um, his index finger is no longer overlapping his, uh, uh, uh, his middle finger, and he shows improvement in his rotational, uh, deformity, uh, and, and good motion. So, you know, as I mentioned, while most times non or minimally displaced finger fractures, you know, can and should be treated non-surgically. Um, I think that obviously the ones that are quite angulated or crooked or, or shortened, um, you know, often des deserve a a closer look, but particularly rotational deformity, um, the X-rays don't always show the full picture and, and usually it's pictures like, uh, uh, clinical pictures like this that show that, that there is a, a deformity that we're not, not fully understanding on X-ray and that, that, um, you know, won't just correct itself with time. Um, other sort of operative indications that, uh, many of us are familiar with is, uh, if it's displaced at the level of the joint or unstable or not able to be reduced or if it's open or there's a, a nerve or artery injury, then, then that generally prompts further evaluation, but it's common that these subtle, uh, these radiographs with subtle findings, but, uh, very clear clinical findings, uh, um, you know, have a rotational deformity that, that merits treatment. To move on to another type of, uh, sort of common finger fracture that, that merits discussion. Um, this is the extra octave, uh, uh, uh, finger fracture. So, um, this is a six year old right-hand dominant girl, and she, um, uh, uh, had a small finger fracture and her father tried to buddy tape it, which is a, uh, you know, excellent treatment in general for finger fractures. Um, but when they took it off, they said the finger looks, still looked crooked. And um I got, you know, I asked mom for if they happen to have a picture of when it first happened and so they have this, you know, we, unfortunately, have this limited picture, but you can see that the uh small finger both clinically and also on her radiographs uh is abducted um and uh uh ulnarly deviated, so pointed off towards the ulnar side of the hand. Um, and so overall, her X-rays are, are consistent with sort of a, a, a Saltarius 2 fracture of the, uh, small finger. Uh, um, proximal phalanx base, um, and, you know, clearly from the X-rays we can see, see that it's, uh, uh, crooked and, and, um, you know, in a suboptimal alignment. So, you know, um, this patient was, uh, uh, was, uh, 6, but, uh, overall, um, you know, we, we saw her within a few days after her injury, um, and her mom was actually a, uh, ICU nurse at uh UCSF and we talked about how oftentimes if this shows up to the emergency room, which is something we can treat with a closed reduction, um, um, and, you know, surgically that if for a delayed presentation, um, you know, one could consider closed reduction and pinning. Um, but, you know, if, in the right patient and the right child, um, one can consider, uh, uh, um, closure action in clinic if they're able to tolerate it, and the mom thought that her child would be able to sort of tolerate that. So after numbing up that finger, we're able to realign the finger and treat it with, uh, 4 weeks of casting, and here we can see her X-rays 4 weeks out showing improved alignment of her small finger. And just a couple of weeks after that, we can see that her finger is now sort of in improved alignment and uh she's able to make a full fist and Um, and straightened out all the way, um, and isn't sort of in that same position that they, that we, that they noted when, uh, prior to referral. So just as a, you know, overall, um, learning point, I think, um, and here's her, she's comparing both of her hands, uh, uh, and showing that she's, she's doing quite well. So as an overall learning point, I think that as I mentioned, most um pediatric finger fractures are amenable to non-operative management um and this is primarily helpful for patients who have non or minimally displaced fractures uh with no rotational deformity as we talked about. Um, and the treatment, you know, 3 or 4 weeks of immobilization depending on the age of the child and the age and how, how soon it has been since injury. Uh, is, is often sufficient and then working on progressive motion and, and body taping for comfort as patients return to activity, um, is, is oftentimes, uh, uh, sufficient for most fractures. Um Go on to the next slide. There's a number of sort of peri-articular fractures of the phalanx that uh are, are bad actors and I think do merit um uh further treatment. Um, and so I think that, you know, um, unlike, you know, phalangeal shaft fractures as I presented thus far, um, these are fractures uh at the joint surface that tend to, uh, um, cause late deformity and problems, um, and, uh, generally, uh, our benefit from early, uh, referral to a hand surgeon or a, or a hand specialist. So here's a case of a 13 year old male who injured his right ring finger after a soccer injury, and unfortunately he presented about a month out with the inability to move his to move his finger. Um, he, his initial radiographs were read as negative, um, and I know the injury, these images are small, but When you blow them up, um, you can see that at the ring finger, there's just, uh, something that, that doesn't sort of look quite right. Um, and, you know, the, the, uh, articular surface or the joint surface here doesn't look perfectly symmetric. And, um, when, uh, get obtaining other views here on screen right, you can see that actually part of the phalangeal, uh, head or, or the condyle was, was fractured and flipped backwards and here on the screen left, you can see the CT scan images demonstrating a, uh, a flipped, uh, phalangeal condylar head fracture. And you can imagine that if he's tried to straighten his finger, he's uh uh being blocked by his, this displaced fragment as you can see on screen, right? Uh, and interestingly enough, um, and, and, and so very clearly this is an articular um injury that's displaced and blocking his motion and, and, uh, and would benefit from uh uh surgical treatment. Um, I think that in general, the consensus is in basically all parts of the body. If you have a displaced articular fracture, so at the level of the joint, especially in a young child, if you were to, uh, uh, um, uh, leave it as is, then that is a high risk of developing post-traumatic arthritis. Um, and so, you know, generally, uh, um, you know, operative treatment is recommended and particularly if it's causing a blocked motion. Um, there's a physical blocked motion, there's You know, essentially no way that this, this will sort of improve on its own. And um so intraoperatively, um, we found that the, again, this is his finger from the backside and you can see this is that part of his um of his phalangeal head that sort of flipped backwards and um was interposed into his extensor mechanism, the tendons that helped straighten the finger and uh clearly preventing his motion. And so, um, these are challenging cases when acute and unfortunately, um, you know, when they're chronic, they are sometimes not reconstructible, um, because the size of this piece is about, you know, 2 millimeters in thickness and uh, you know, a few millimeters in length. Right. Um, but we were able to thankfully realign, um, his, uh, uh, uh, fragment and get it sort of reduced in the right spot and, and fix it with tiny, tiny screws, um, um, to help sort of get his joint surface in a, in a better spot. Um, these are bad injuries with, with that do carry a risk of not only post-traumatic arthritis that we talked about, but also avascular necrosis, um, but sort of the best chance of, of a, uh, of a positive outcome, um, is, is, uh, is, is obtaining and, and maintaining, uh, um, a perfect articular, uh, reduction. So going back to our original uh learning points about, um, you know, reasons to intervene for a pediatric finger fracture, I think as we talked about um angulation and rotational deformity are oftentimes, you know, more clear when you look at the hand, if the hand is, is sort of crooked or, or, or if there's angulation, then that often, you know, prompts further treatment. But it's sometimes these subtle displaced intraarticular fractures, particularly for the um uh for the fingers, it's the uh uh proximal and middle phalanxes, the phalangeal heads that have a A condylar fracture that is, uh, is not noted or an irreducible fracture that, um, definitely merits, uh, a second, uh, you know, further treatment, uh, and oftentimes, uh, uh, surgical treatment. Um I'll briefly go through a couple of other sort of commonly missed injuries, um, uh, just for the sake of completion. Um, here we have pediatric phalangeal neck fractures, um, and, uh, while there's this Al-catan classification that's not relevant to this talk, you can, um, see that, uh, that you can have progressive amounts of displacement if there is a fracture through the neck of the either middle phalanx or the proximal phalanx. And if there is persistent displacement and, you know, you can see it can be either tilted fully back or flipped, um, then this can be at risk of uh uh um of uh either stiffness, instability, or post-traumatic arthritis depending on the amount of uh uh uh displacement. Given these injuries are peri-articular and because in kids the phalangeal physis is at the base of the finger, um, these injuries at the distal, at the phalangeal neck have a very low remodeling potential given the distance from the physis and a number of small theories have found really poor results with, um, non-operative management of, of displaced injuries, so, you know, grade 2 to 3. They often heal, but they often heal in extension, so you can imagine if it's tilted back that it'll heal um tilted back and this means that when they bend their finger down, it will uh lead to a blocked inflection. And so generally, uh, if there's a displaced phalangeal neck fracture, um, the consensus is that this should, you know, can and should be treated with closed reduction percutaneous pinning and you can see here at the top left there's a phalangeal neck fracture that after, uh, a reduction in pinning, um, uh, you know, is in a, in better alignment, but if left as is would lead to a block inflection that would be problematic in the future. And finally, uh, an, uh, a controversial yet common, uh, topic, uh, is, uh, Seymour fractures, which is where, um, you can have a, a fracture through the, uh, uh, of the distal phalanx where the nail plate is interposed in a, uh, Salter Harris one growth plate fracture, um, and this is commonly diagnosed, um, You know, either clinically, as you can see this picture is to the left or if not, if you're not present in person radiographically where you can see that there is, you know, clearly a fracture through the physis and that there is high concern that there may be some interposed tissue, particularly given the proximity of the nail plate to the uh distal phalanx uh growth plate. And so, well, um there is a fair amount of controversy regarding this topic amongst hand surgeons about the optimal location of treatment, uh, duration of antibiotics, and, uh, a need for, um, Uh, uh, pins or not. I think the general consensus is that this injury reflects an open fracture even though, um, the presentation may not be as obvious as it is in these two pictures to the left and because it is an open fracture, it merits, uh, uh, some sort of irrigation debris and, and, and, uh, treatment either in the emergency room or in the operating room. And so here you can see in these pictures, um, um, that, uh, uh, a standard You know, treatment is to reflect back the nail fold, remove the nail, and when you look underneath the nail, you'll see that the nail, uh, uh, the, uh, matrix is interposed inside the, uh, growth plate, and then only after taking it out can you, uh, actually reduce this, uh, uh, uh, this distal phalanx, um, and then, um, you know, you can repair the nail plate, uh, the nail bed and the nail plate after that. Um, we do know that because this is an open fracture that um where the outside world is basically allowed to uh communicate with the um with the uh distal phalanx and the distal phalanx visis that uh this can be a risk factor for osteomyelitis and so while again, the, um, location of treatment and, you know, some of the technical details about need for pins can be debated. I think the general consensus is that Um, to minimize late infection and deformity, um, treatment either in the emergency room in a, in a child that can participate or in the operating room in a child that may not be amenable to a bedside treatment with irrigation, debridement, nail bed, uh, repair, and, uh, um, uh, uh, trying to get the, uh, uh, improve the bony alignment is generally recommended and these are, um, You know, injuries that while initially often appear benign, um, merit, uh, you know, uh, a referral to the emergency room for, uh, a hand surgical evaluation. So I'll change tracks a little bit um cause I, you know, I've hopefully uh highlighted a number of the um finger fractures that can be problematic, um, and, and often merit um further treatment and I'll transition over to, uh, finger lacerations. And I think as we're all aware, uh, finger lacerations can come in all sorts of shapes and sizes. And so, um, since I've been doing a lot of talking, I'd, I'd love to get everyone's thoughts. So I think, um, and, and obviously, you know, it's a relatively straightforward question, but, um, I'd love to get your thoughts as to, you know, what, what sort of injuries are we, are, are, is everyone comfortable treating on their own and what would they send to the emergency department. So if, um, if I can get everyone's, you know, thoughts, uh, if you go to the following website, mentee.com and input Um, this code, I'd love to see what everyone thinks as to what they would sort of manage on their own versus send to the emergency room and, and how quickly. Looks like we're already getting some answers. That's great. I'll pause for a couple seconds to get, get the group's input. So it looks like we're having a lot of votes for C and some, some votes for, for B. Maybe I'll give everyone a, a couple more minutes. I know it takes a moment to log in to get on your device and go to this website, but um I think there's a number of sort of discussion points I'd love to um sort of bring up. All right, I think most, most anybody started getting, getting to a consensus that Um, clearly, option C is something that, um, you know, merits, um, urgent treatment and maybe, maybe option B. Um, and so I think, I think this is sort of, uh, when, when talking about a topic like a finger laceration, a very, very common, uh, thing that everyone sort of, kinda, uh, um, you know, has seen, it can really range from something that's, um, Uh, like a paper cut, as you can see in, in, in, in, you know, option A to, um, something more, much, much more severe in, in, you know, the image to the right. And, um, you know, I, I think, well, I think everyone would agree that, you know, if they see a, a finger where, uh, you know, a table saw injury as you can see onto the, you know, to the far right where um the uh small finger is, is sort of clearly, um, you know, uh, injured, uh, and there's a bony involvement and, and clearly, you know, nerve and tendon involvement that, that should be seen, you know, emergently. Um, I think B has a number of, of, of learning points and so To me, I think what I'm what I see from this picture is what's likely um a healed sort of cut or healing cut in the palm of the hand. And I can tell um just from looking at the, the hand that um there's sort of high concern for what's called a flexor tendon laceration that the tendons that, you know, bend the fingers are, have been uh uh cut completely um because of the position of the hand. So as a reminder, there are two tendons for every, uh, for the index uh long ring and small fingers that uh bend the, uh, the fingers. Um, the FDP tendon uh bends the DIP or the distal uh interphalangeal joint. And then the FTS tendon that's the um uh PIP or the proximal uh interphalangeal joint and uh with the laceration of the palm in this location, I think there's high concern that um that the uh uh tendons for both the uh um uh of both the FTP and the FDS have been cut for the uh ring and small finger given the fact that they are, uh, held in relative extension compared to these other, the, um, thumb, index, and long fingers. Um, and so I think that, um, in general for flexor tendons, uh, if they are cut, this, this generally merits, uh, you know, uh, urgent, uh, evaluation by a hand surgeon, um, ideally, you know, um, within a day or two of injury. Uh, and the reason is that when these tendons are cut, they tend to, uh, retract and so on the distal side towards the fingertip, it, it can only go so far. It'll, it'll go up towards the, you know, towards the fingertip, but, but, you know, they'll be preserved length. However, on the proximal side, the tendons tend to retract and so they will go, you know, until they are, you know, stuck by other tissue and so they can go as far as the wrist or, or sometimes into the forearm. And um the further out from uh time from injury, uh, the often, often the harder and the more traction there is and, and, and that there is, uh, it's uh challenging to get a, a sort of a positive result. Whereas if you catch it right when it happens, you can, you know, repair the two tendon edges and get a, um, you know, and, and hopefully get a better result even though these injuries are complicated by stiffness and, and, uh, uh, and, and need a lot of time and therapy for, uh, healing. That being said, I think there are some, you know, positive things and reasons why this doesn't necessarily need to go to the emergency room right away depending on your level of comfort. I think we can see from this picture, the fingers are all pink, right? And so there is clearly, they're clearly perfused, um, and so I think that if the fingers are pink, um, this is something that, uh, um, and, and, uh, this is something that can, that is not an emergency, uh, and it's not gonna compromise, uh, um, you know, the, the, you know, short-term function of the hand. Though I think um it will, you know, benefit from uh uh surgery in the, um, you know, in the near term, uh, within a, you know, within a week for sure, but ideally within a few days to try to repair these flexor tendons. Finally, to the right, we see, um, you know, uh, the effects of a tableside injury to the hand, um, you know, which won't, hopefully won't affect our youngest uh patients but oftentimes can affect, uh, uh, you know, uh, adolescents and, and, you know, and, uh, young, young adults as they, uh, join, you know, the workforce or, or, or learn to use these tools. And I think there are some things just that again to, you know, just from diagnosing the picture, you can uh notice um as we talked about. So clearly the fingers um the ring and small fingers are held in relative extension compared to the other digits which is concerning for flexor tendon injuries. Here, the small finger has, uh, uh, you know, you can see that there's bony involvement and so, um, you know, clearly there's a fracture, an open fracture, uh, that merits treatment. And if you were to take a close look at this picture, we can see that this finger is looking uh wrinkled and um deflated compared to our, the other fingers, right? And this is concerning to me for a uh uh not only uh a nerve injury but also a vascular injury as normally uh fingers. That are profused have, uh, sort of, you know, pinkish appearance, uh, whereas fingers that are not profused, um, are either white, pale white, where they're not getting any blood flow or if sort of crowded by overlying, uh, blood or bleeding, then, um, can have this sort of deflated or, or prune-like appearance. And so here's a quick example as to why early referral is so helpful. Um, this is an 11 year old, 11 year old boy who I helped treat in my fellowship who, uh, unfortunately had a flexor tendon laceration, uh, of his long finger, uh, as you can see by the fact that it's held in relative extension, um, and he unfortunately presented a month, uh, after his injury. And so even though um his laceration was sort of at the level of his distal palm, um, you know, and ideally, uh, it stands to good reason that you can find the edge of the tendons on both sides and repair them, um, we found that Um, we couldn't find the edge in his palm and ultimately had to go into his carpal tunnel to find the edge of the tendon to be able to repair it. And you can see just from, you know, straight away that, that, um, the, well, oftentimes if you have an acute repair, you can very quickly restore, uh, and, and consistently restore the cascade of the fingers. You can see that there has been likely some increased tension but across his, uh, middle finger and it's holding in a little bit more flexion. And while these, these injuries tend to loosen up and, and, and move better over time, um, it's harder to obtain the same level of consistent results as you may get, um, uh, with an acute repair. Um, and just for the sake of, of time, I'll, I'll briefly run through the evaluation of volar, uh, and dorsal, uh, finger lacerations, um, just, uh, you know, hopefully for the sake of being able to review the anatomy for the sake of trying to understand, um, you know, if and when to refer, uh, and when, when, you know, something is, is sort of just a paper cut versus when something is clearly something more. Um, and so on the palm side of the fingers, there are, um, You know, I think there are, to keep things simple, I think there are only a, a small number of structures that are, are critical to um evaluate for and make sure are working. So um when looking at this picture to the left, you can see there's an artery and a nerve and so on both sides of the finger, there's a digital artery and a digital nerve. And so if the finger is pink, then the at least one artery is working. Um, and so oftentimes patients present with a cut over their finger and you can assess to ensure that they're getting blood flow by making sure they're, you know, they have good cap refill, they have good trigger as we talked about, good, uh, color in their fingertips, um, good pulse oximetry stats if you have that availability, or you can even Doppler the finger, the digital arteries to confirm they're intact. And then um there's the nerves. The nerves are, are on the palmar side or the volar side of the arteries and so they are oftentimes cut first before an arterial injury that would sort of prompt, you know, make, make someone sure come in immediately. Um, and the signs of a nerve injury are either, um, they don't feel on one side of their finger. Um, you can do a two-point discrimination, see if they're able to assess two points that are, uh, you know, a, a certain 5 millimeters or, or less away from each other. Uh, or in a much younger child, you can actually immerse. Their hand in the warm water and because uh there is a loss of sympathetic tone when there's a nerve injury, you'll see that there is uh absent wrinkling on one side of the finger and that can be consistent with the nerve injury and a much younger child may not be able to tell you that they have a, have a nerve injury. And finally, um, there's two tendons, right? So again, two arteries, 2 nerves, and 2 tendons. And so if they're able to bend at their fingertip and also bend at their At their uh uh PIP joint, then presumably both of those tendons are functioning and so You know, I think that in terms of whether or not something needs surgery or not, if both nerves are working, the arteries are working, and the tendons are working, then this can be treated like a, a simple, you know, laceration, um, with, uh, uh, uh, with wound care, stitches as needed, and, uh, uh, close follow-up, um, but doesn't necessarily need, you know, urgent evaluation. Whereas if any of those are not true, then that, that I think merits, uh, you know, a phone call to try to get someone taken care of sooner. Thankfully, on the other side of the hand, there are less critical structures and uh other than skin and uh uh extensor tendon as you can see here, uh, which merits treatment if the tendon is, is sort of lacerated greater than 50%, it's, uh, um, you know, it can generally be treated non-surgically. So I think unless there's a droopy finger or concern for a tendon injury, uh, you know, dorsal hand lacerations that are superficial can be treated, uh, uh, with observation, uh, uh, and, uh, uh, wound care as appropriately. So I hope that's a helpful sort of overview of, of, of Sarah finger lacerations and I um would love to take the opportunity to take questions.
