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 so my goal for today is to talk a little bit about pediatric finger fractures and lacerations and um um and, you know, mostly want to focus on the injuries that are often and um missed or, or often take a while to get, get further care as a wide variety or wide majority of these cases can be treated with, you know, with not non operatively with minimal intervention. 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 catch early or, or address 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 failing deal 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 three or four weeks of immobilization and buddy taping and then progressive motion. Um But, you know, I know that most of us here are probably already quite familiar with this and I'll try to uh touch on and focus on some of the commonly missed injuries um to hopefully, you know, prompt a more useful and prompt and uh probably a good discussion. So as I mentioned, mostly nonsurgical, so I'll keep this case based and so I'll start off with the patient that I saw a couple of months back. This is a 11 year old male and was referred for a non displaced um uh index finger fracture. So he's right handed and unfortunately was at school and another classmate um uh pulled on his finger and bent it backwards. He was seen uh an emergency room and was splintered and then presented two weeks out from injury with the following radiographs and have him sort of in a larger format here. And so here we can see a minimally displaced uh likely Salter Harris to fracture of the index finger, approximate failing space. But overall, you know, I agree it looks the radiographs theme 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, you know, non displaced was, was as advertised, there's clearly a rotational deformity of his index finger. Um you know, overlapping or under lapping his middle finger, depending on the position. So, um generally when these uh fractures occur, um you know, if it's acute, you can consider closed reduction in the emergency room or if needed in clinic where you can sort of numb up the finger, provide pain control and try to realize the finger. However, after a certain amount of time, um depending on the age of the child, the fracture tends to heal. And in this case, in a male united or sub optimal position. And so I talked with the family about options. And while, you know, at a young, 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 be willing to try that in clinic. And they ultimately felt like this is something they weren't comfortable taking care of in the clinic. And um you know, they wanted to make sure that we got this, uh you know, deformity corrected as perfectly as possible. So we went to the operating room and, and we're able to realign his finger and pin it to make sure I didn't go back to its original position. And while he's still early in his treatment course, about six weeks later, you can see that his hand is in much better alignment, his index finger is no longer overlapping his um his middle finger and he shows improvement in his rotational deformity 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 cingulate id or crooked or shortened, um you know, often deserve 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 clinical pictures like this that show that, that there is a deformity that we're not not fully understanding on X ray and that, that, you know, won't just correct itself with time. Um Other sort of opera of indications that many of us are familiar with is 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 nerve or artery injury, then then that generally prompts further evaluation. But it's common that these subtle, these radiographs with subtle findings but very clear clinical findings, uh you know, have a rotational deformity that, that where it's treatment to move on to another type of sort of common finger fracture that merits discussion. This is the extra octave uh finger fracture. So um this is a six year old right hand dominant girls and she um had a small finger fracture and her father tried to buddy tape it, which is a, you know, excellent dream. And 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 haven't had a picture of when it first happened. And so they have this, you know, unfortunately limited picture, but you can see that the small finger both clinically and also on her radiographs is abducted. Um, and uh in early DVD, so pointed off towards the inner side of the hand. Um And so overall, her x rays are consistent with sort of a salt areas to fracture of the small finger, um approximate failing space. Um And you know, clearly from the x rays, we can see that it's crooked and, and um you know, in a sub optimal alignment. So, you know, um this patient was uh was six but overall, um you know, we, we saw her within a few days after her injury. Um and her mom was actually uh ICU nurse at UCSF and we talked about how often times 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 for a delayed presentation, um you know, one could consider close reduction pinning. Um but, you know, in the right patient and the right child, one can consider a closed reduction clinic if they're able to tolerate it. And the mom felt that her child would be able to tolerate that. So after numbing up that finger, we're able to realign the finger and treat it with four weeks of casting. And here we can see her X rays four weeks out showing improved alignment of for a small finger. And just a couple weeks after that, we can see that her finger is now sort of in improved alignment and she's able to make a full fist and, um, and strain out all the way. Um, And isn't sort of in that same position that they, that they noted when prior to referral. So just as a, you know, overall learning point, I think um here's her comparing both of her hands uh and showing that she's, she's doing quite well. So as an overall learning point, I think that as I mentioned, most pediatric finger fractures are amenable to non operative management. Um And this is primarily helpful for patients who have non or minimally displaced fractures with no rotational deformity as we talked about. Um and the treatment, you know, three or four weeks of a mobilization depending on the age of the child and the age and how, how soon it has been since injury is often sufficient and then working on progressive motion and, and buddy taping for comfort as patients return to activity um is often times uh sufficient for most fractures. Um Go on to the next slide, there's a number of sort of peri articular fractures of the failings that are, are bad actors and I think do merit um further treatment. Um And so I think that, you know, unlike, you know, failing deal shaft fractures, as I presented thus far, um these are fractures at the joint surface that tend to uh cause late deformity and problems. Um And uh generally are benefit from early referral to a hand surgeon or a hand specialist. So here's a case of a 13 year old male who entered his right ring finger after a soccer injury. And unfortunately, he presented about a month out with the inability to remove 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 something that, that doesn't look quite right. Um And you know, the articular surface or the joint surface here doesn't look perfectly symmetric. And um when I get a painting other views here on screen, right, you can see that actually part of the failing Jill head or the con dial was, was fractured and flipped backwards. And here on the screen left, you can see the CT scan images demonstrating a flipped uh condor head fracture. And you can imagine that if he's trying to straighten his finger, he's being blocked by his this displaced fragment as you can see on screen, right? Uh And interestingly enough. Um And, and so very clearly this is articular um injury that's displaced and blocking his motion and, and, and would benefit from a surgical treatment. Um I think that in general, the consensus is in basically all parts of the body if you have a displaced particular fracture. So at the level of the joint, especially in a young child, if you were to uh leave it as is, then that is a high risk of developing post traumatic arthritis. Um And so, you know, generally, um you know, operative treatment is recommended and particularly if it's causing a block to motion, um there's a physical block to motion, there's, you know, essentially no way that this, this will sort of improve on its own. And um so inter operatively, um we found that the, again, this is his finger from the backside and you can see this is that part of his um his feelings will head that sort of flipped backwards and um was interpose into his extensive mechanism, the tendons that helped straighten the finger and clearly preventing his motion. And so these are challenging cases when acute. And unfortunately, um you know, when they're chronic, they are sometimes not reconstruct herbal because the size of this piece is about, you know, two millimeters in thickness and a, you know, a few millimeters in length, right? Um But we were able to thankfully realign his 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 better spot. Um These are bad injuries that do carry a risk of not only post traumatic arthritis that we talked about, but also a vascular necrosis. Um but sort of the best chance of, of a, of a positive outcome is is obtaining and maintaining a perfect articular reduction. So, going back to our original learning points about, you know, reasons to intervene for a pediatric finger fracture. I think as we talked about um angular ation and rotational deformity or 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 a regulation, then that often, you know, prompts further treatment. But at some, sometimes these subtle displaced in particular fractures, particularly for the for the fingers, it's the approximate and middle failings is the failing Jill heads that have a condo or fracture that is, is not noted or irreducible fracture that definitely merits a second, you know, further treatment and oftentimes uh surgical treatment, um I'll briefly go through a couple of other sort of commonly missed injuries um just for the sake of completion. Um Here we have pediatric feelings, you'll neck fractures. Um And uh well, there's this all cotton classification that's not relevant to this talk. You can see that uh you can have progressive amounts of displacement if there is a fracture through the neck of the either middle feelings or the proximal feelings. 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 um of either surface instability or post traumatic arthritis depending on the amount of uh displacement. Given these injuries are peri articular. And because in kids, the failing Jill Fyssas is at the base of the finger. Um these injuries at the distal, at the failing jewel neck have a very low remodeling potential given the distance from the crisis. And a number of small theories have found really poor results with non operative management of of displaced injuries. So, you know, grade 2 to 3, they often heal but they often he'll an extension. So you can imagine if it's tilted back, that it'll heal, tilted back. And this means that when they bend their finger down, it will lead to a block inflection. And so generally, if there is a displaced financial neck fracture, um the consensus is that this is, you know, can and should be treated with closed reduction per Catania spinning. And you can see here at the top left is the financial neck fracture that after our reduction and pinning, um uh you know, is in a better alignment, but if left as is would lead to a block inflection that would be problematic in the future. And finally, a controversial yet common topic is Seymour fractures, which is where um you can have a fracture through the of the digital failings where the nail plate is inter posed in a softer hair, hair is one growth plate fracture. Um And this is commonly diagnosed. Um You, you know, either clinically as you can see pictures still left or if not, if you're not present in person radio graphically where you can see that there is, you know, clearly a fracture through the Fyssas and that there is high concern that there may be some interpose tissue, particularly given the proximity of the nail plate to the distal failings growth plate. And so well, um there is a fair amount of controversy regarding this topic amongst hands, visions about the optimal location of treatment, duration of antibiotics and a need for um uh pins or not. I think the general consensus is that this injury reflects an open fracture even though the presentation may not be as obvious as it is these two pictures left. And because it is an open fracture, it merits uh some sort of irrigation agreement and and treatment either in the emergency room or in the operating room. And so here you can see in these pictures um um that 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, the matrixes interpose inside the growth plate. And then only after taking it out can you actually reduce this uh this distal failings? Um And then um you know, you can repair the nail plate, uh the nail bed at 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 communicate with the, with the distal phalanx and the distal failing spices, that this can be a risk factor for osteomyelitis. And so, while again, the 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 and a child that may not be amenable to a bedside treatment with irrigation debris, mint nail bed repair and uh trying to get the improved, the bony alignment is generally recommended. And these are um you know, injuries that well initially often appear benign merit, you know, referral to the emergency room for hand surgical evaluation. So I'll change tracks a little bit um because, you know, hopefully highlighted a number of the finger fractures that can be problematic. Um and, and often merit further treatment and I'll transition over to finger lacerations. And I think as we're all aware, 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 love to get over his 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 very uncomfortable treating on their own and what would they send to the emergency department. So, if, um, if I can get, you know, thoughts, if you go to the following website menti dot com and input um this code, I'd love to see whatever it thinks as to what they would sort of manage on their own versus sent to the emergency room and, and how quickly looks like already getting some answers. That's great. I'll pause for a couple of seconds to get, get the group's input. 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 couple more minutes, you know, it takes a moment to log in to do it 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 sort of bring up. Alright, I think most, most anybody started getting, getting to a consensus that um clearly option C is something that um you know, merits urgent treatment and maybe, maybe option B. Um And so I think, I think this is sort of when, when talking about a topic like finger laceration, a very very common thing that everyone sort of, uh, you know, has seen, it can really range from something that's, um, 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 think, well, I think everyone would agree that, you know, if they see a finger where, you know, tableside injury, as you can see on to the, you know, to the far right where the small finger is sort of clearly, um, you know, injured and there is a bony involvement and, and clearly no nerve and tendon involvement that that should be seen, you know, emergent Lee. Um, I think B has a number of learning points. And so to me, I think what I, what I see from this picture is what's likely a healed sort of cut or healing cut in the palm of the hand. And I can tell just from looking at the hand that there's sort of high concern for what's called the flexor tendon laceration that the tendons that, you know, bend the fingers have been, uh cut completely, um because of the position of the hand. So as a reminder, there's sort of two tendons for every, for the index, long ring and small fingers that bend the fingers. Um, the FDP tendon bends the D I P or the distal inter financial joint and then the FDS tend invents the P I P or the proximal inter financial joint. And with the laceration of the palm in this location, I think there's high concern that um that the uh attendance for both the uh of both the FTP and F D s have been cut for the ring and small finger given the fact that they are held in relative extension compared to these other, the thumb, index and long fingers. Um And so I think that um in general for flexor tendons, if they are cut, this, this generally merits um you know, urgent evaluation by hand surgeon, ideally, you know, um within a day or two of injury. Um And the reason is that when these tendons are cut, they tend to retract and so on the distal side towards the fingertip, it can only go so far, it'll, it'll go up towards the towards the fingertips. 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 the further out from time from injury, uh often, often the harder and the more attraction there is and that there is it's challenging to get a sort of a positive result. Whereas if you catch it right, when it happens, you can 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 and, and need a lot of time in therapy for healing. That being said, I think there are some 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 there clearly perf used. Um, and so I think that if the fingers are pink, um this is something that, um, and uh, this is something that can, that is not an emergency and it's not going to compromise, uh, you know, the funk, the, you know, short term function of the hand though, I think it will, you know, benefit from uh surgery in the, you know, in the near term within, you know, within a week for sure, but ideally within a few days to try to repair these flex attendance finally to the right. We see, um, you know, the effects of a table saw injury to the hand, um, you know, which won't, hopefully won't affect our youngest patients, but oftentimes can affect, you know, adolescents and, and, you know, and young, young adults as they 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 notice 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 you know, you can see that there's bony involvement. And so, um you know, clearly there is a fracture, an open fracture that merits treatment. And if you were to take a close look at this picture, you can see that this finger is looking wrinkled and um deflated compared to our other fingers, right? And this is concerning to me for a not only a nerve injury but also a vascular injury as normally fingers that are perf used to have sort of pinkish appearance, whereas fingers that are not refused are either white, pale bite where they're not getting any blood flow or if sort of crowded by overlying blood or bleeding, then can have this sort of deflated or prune like appearance. And so here's a quick example as to why early referral is so helpful. This is an 11 year old, 11 year old boy who helped treat my fellowship who unfortunately had a flexor Tendon laceration of his long finger, as you can see by the fact that it's held in relative extension. Um and he unfortunately presented a month after his injury. And so even though his laceration was sort of at the level of this distal palm. Um, you know, and ideally, it sounds good reason that you can find the edge of the tendons on both sides and repair them. 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 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 put across his middle finger and it's holding in a little bit more flexion and while 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, with Nick you prepare. Um, and just for the sake of time, I'll briefly run through the evaluation of bowler endorse all 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 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, you know, I think there to keep things simple. I think there are only a small number of structures that are critical to 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 are 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 color and 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 there's the nerves, the nerves are are on the palmer side or the volar side of the arteries. And so they are often times 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, you know, a certain five or less away from each other or in a much younger child. You can actually immerse their hand into warm water. And because there is a loss of sympathetic tone when there is a nerve injury, you'll see that there is 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, there's two tendons, right. So again, two arteries, two nerves and two tendons. And so if they are able to bend at their fingertip and also bend at their, at their P I P joint, then presumably both of those tenants 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 in attendance are working, then this can be treated like a simple, you know, laceration with uh with wound care, stitches as needed and a close follow up, but doesn't necessarily need, you know, urgent evaluation. Whereas if any of those are not true, then that, that I think merits, 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 other than skin and uh extensive tenant, as you can see here, which merits treatment. If the tenant is, is sort of lacerate greater than 50%, it's uh you know, it can generally be treated non surgically. So I think unless there's a droopy finger or concern for attendant injury, uh you know, dorsal hand lacerations that are superficial can be treated with observation, uh, wound care as appropriately. I hope that's a helpful sir, overview of, of, of Sarah finger lacerations. And I would love to take the opportunity to take questions.