Hand complications in children from digital sucking

Ultrasound diagnosis of pyogenic flexor tenosynovitis in a 9-month-old infant: a rare case report

Pyogenic flexor tenosynovitis (PFT) is an aggressive infection of the flexor tendon sheath, requiring prompt intervention to minimize adverse outcomes. The diagnosis of pediatric PFT is often delayed due to the variable presence of Kanavel's signs in children and communication difficulties. A 9-month-old male presented to the emergency department with one of four Kanavel signs. The diagnosis of PFT was delayed until ultrasound was used to identify a fluid collection within the flexor tendon sheath. He was successfully treated with surgical debridement and antibiotic therapy, achieving full recovery by 6-month follow-up. This represents the youngest reported case of PFT. Difficulties with communication and physical exam as well as the variability of Kanavel's signs in young children can delay the diagnosis of pediatric PFT. Ultrasound can be a useful adjunct when clinical history and exam are equivocal, especially in children who present prior to language acquisition.

Digital sucking induced trophic ulcers caused by nerve deficit from amniotic constriction band

Two infants presented with amniotic constriction bands (ACB) in the distal third of the forearm. After teeth eruption they developed recurrent skin ulcerations mainly in the distribution of the median nerve from digital sucking. Both patients underwent reconstruction with multiple Z-plasties, followed by neurolysis of the ulnar nerve and sural nerve grafting of the median nerve. This neurological complication presented late in ACB as ulcerative lesions and secondary infection from digital sucking on the insensate digits. Thorough physical examination of the extremities at an early stage in children with ACB is essential to exclude an occult neurological dysfunction. Exploration of peripheral nerves is warranted in cases of deep forearm ACB during their soft tissue reconstruction.

Causative microorganisms in surgically treated pediatric hand infections

PURPOSE

The causative organisms in many pediatric musculoskeletal infections are distinct from their adult counterparts. We investigated the organisms found in surgically treated hand infections in the pediatric population.

METHODS

We reviewed the hospital charts and computer records of all patients who had surgical intervention for infections of the forearm, wrist, and hand from 1996 through 2002 at The Children's Hospital of Boston.

RESULTS

Thirty-eight surgical procedures were performed on 31 children for 32 different upper-extremity infections. One patient was treated for 2 separate infections. In the 32 primary procedures 7 cultures grew mixed aerobic/anaerobic organisms, 19 grew aerobic organisms only, 6 grew no organisms, and 2 patients had no cultures. One culture from a secondary surgery was positive for Candida parapsilosis. Staphylococcus aureus was isolated in 15 of the primary cases and was the primary organism in 12. Five of 7 mixed infections were associated with paronychia; 2 of the paronychial infections were complicated by flexor tenosynovitis. Chronic nail biting caused 2 infections and 1 was associated with thumb sucking.

CONCLUSIONS

In the adult population S aureus is the primary organism cultured in 50% to 80% of cases and anaerobic or mixed infection may occur in upward of 29% of patients. In this series S aureus was the primary organism in only 37%. Group A Streptococcus pyogenes was present in 20% of cases. The percentage of children with a mixed aerobic/anaerobic infection was similar to that found in adults; however, the presumed route of introduction was digital sucking/biting. Based on the number of anaerobic/mixed infections without predisposing factors we recommend a broad-spectrum antibiotic regimen including anaerobic coverage as the initial antibiotic in the setting of pediatric hand infections.

Finger sucking digital deformities

We report our experience with severe digital deformities caused by prolonged finger sucking. Our analysis of nine patients demonstrated that the deformity was mainly located in the proximal and middle phalanges of the affected digit(s). We have reviewed the literature, enumerated the common patterns of "finger sucking" and explained the resulting deformities. Corrective osteotomy, preferably at the metacarpal base level, is required in severe deformities.

Dystrophic calcinosis in a child with a thumb sucking habit: case report

We present an uncommon case of a 3-year-old boy with a finger sucking habit who developed dystrophic calcification in his left thumb. Two years after excision, there was no recurrence, and the thumb retained full range of motion. We also discuss its probable pathogenesis and present a brief review of the literature about orthopedic complications in the hand due to this habit.

Oral habits. A behavioral approach

Thumb-sucking, pacifier use, and other oral habits are not so harmful or beneficial to the child to justify ill-timed aggressive discontinuance. Indeed there is ample time to guide the child to forming desired behaviors. In nearly every case success in habit management depends on the child making a personal commitment to discontinue the habit. Control can be placed in the child's hands after that decision is made.