Analysis of 344 Hand Injuries in a Pediatric Population

Distribution and pattern of hand fractures in children and adolescents

Hand fractures represent commonly encountered injuries in pediatric patients. However, due to modern means of mobility and product safety, the occurrence and distribution of these fractures have changed during the last decades. Therefore, it was the aim of this study to present an update of the epidemiology, pattern, and treatment of hand fractures in a large pediatric cohort. All patients aged between 0 and 17 years treated in our Department in 2019 with fractures of the phalanges, metacarpus, or carpus were included. The medical records were reviewed for age, gender, injury mechanism, fracture localization, season, and treatment. Patients were divided into three different age groups (0-5, 6-12, and 13-17 years). A total of 731 patients with 761 hand fractures were treated during the 1-year study period. The mean age was 11.1 ± 3.5 years, and the majority was male (65%). Male patients were significantly older compared to female patients (p = 0.008). Also, 78.7% of the fractures affected the phalanges, 17.6% the metacarpals, and 3.7% the carpal bones. The proximal phalanges were the most commonly fractured bones (41.5%). Patients with fractures of the carpus were significantly older compared to children sustaining fractures of the metacarpus or phalangeal bones (p < 0.001). Sixteen percent of our patients were treated surgically; these patients were significantly older compared to conservatively treated patients (p = 0.011).  Conclusion: The epidemiology, mechanisms of injury, distribution, and treatment of hand fractures significantly varies among different age groups. This knowledge is of importance for educational purposes of younger colleagues entrusted with care of children and adolescents as well as development of effective prevention strategies. What is Known: • Pediatric hand fractures represent the second most common fractures in children. • The epidemiology of pediatric hand fractures has changed during the last decades and therefore there is a need for an update regarding distribution and epidemiology of pediatric hand fractures. What is New: • In this retrospective cohort study, 761 pediatric hand fractures of 731 patients were analyzed in detail. • The main mechanisms of younger patients were entrapment injuries, older children most commonly sustained their fractures due to ball sport injuries. There was an increasing rate of metacarpal and carpal fractures with increasing age, and these fractures had to be treated operatively more often than phalangeal fractures.

Finger injuries by eyebrow razor blades in infants

Infants are occasionally injured while playing with their mother's eyebrow razor, and we have treated several infants with flexor tendon injuries, which in some cases were accompanied by damage to the corresponding digital nerves and/or vessels. Here, we report the outcomes in a retrospective case series, with a review of literature. Between January 2013 and October 2019, 8 patients who met our inclusion criteria were initially investigated. The inclusion criteria were: (1) injured by an eyebrow razor during fiddling or grasping, and (2) the availability of complete medical records and radiological data, with follow-up of at least 2 years. The core sutures were performed using a modified Becker (4-strand) method for flexor digitorum profundus (FDP). Nerves and/or vessels were repaired under microscopy. A long-arm mitten cast was then applied, with the fingers slightly flexed in a resting position, for 3 weeks. Then, the children were allowed to return to unrestricted activity. Formal outpatient hand therapy was not performed. Mean postnatal age was 6.3 months. The FDP was injured in zones 1 and 2 in 3 and 5 infants, respectively. Most of the infants were injured near a dressing table, in the bedroom used by their mother. The colors of these razors were all bright, except for one achromatic (white) razor. All of the razors had been left uncovered, without their cap, or were left open in the case of hinged razors. At a mean follow-up of 35.8 months, range of motion was evaluated by the Strickland and modified Strickland methods; all results were "excellent". We encountered no significant complications in any digit: neuroma, tendon retear, stiffness or necrosis. Uncapped or unfolded colorful eyebrow razors pose a high risk of tendon section with concurrent neurovascular injury in infants. Although satisfactory outcomes can be expected, it seems important to prevent the injury through fastidious parental care and changing razor design and color. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparison the Range of Motion Following Early Versus Late Active Mobilization after Repairing Surgery on Flexor Tendon Injury in the Zone II: A Randomized Clinical Trial

Background

Early or delayed mobilization of limb after flexor tendon rupture repairing has an effect on postoperative outcomes, however it is not yet clear whether early or late organ mobilization leads to more likelihood of recovery. We aimed to assess the effects of early and late active limb mobilization through rehabilitation after surgery on the range of motion and hand recovery.

Methods

This randomized clinical study was performed in Sina Hospital, Tehran, Iran in 2022 on 80 patients with flexor tendon damage in the zone II, who underwent reconstructive surgery of superficial and deep tendons. Patients were randomly (using random number table) divided into two groups that for one group, rehabilitation was done early (starting after three days, n = 53) and for the other group, rehabilitation was done late (starting after three weeks, n = 27). The patients were examined postoperatively and following occupational therapy and the range of motion of their involved joints was calculated.

Results

The means PIP extension Lag, PIP active flexion, DIP extension Lag, DIP active flexion and total active motion were all significantly higher in those patients planned for early mobilization as compared to those who considered for late mobilization(P=0.031). Such a significant difference was also revealed adjusting baseline parameters.

Conclusion

Compared to the delayed start of hand flexor tendon mobility, the early start of these activities is associated with a much greater improvement in the movement function of this tendon.

Epidemiology of Pediatric Hand Injury at a Pediatric Department in Japan

OBJECTIVE

The hands and fingers are frequently injured among children. Therefore, this study aimed to describe the epidemiological characteristics of hand and finger injuries among Japanese children and identify preventive strategies.

METHODS

This was a retrospective review of data of pediatric patients who visited the Kitakyushu City Yahata Hospital in Japan, between April 2018 and March 2019. All patients 15 years or younger who experienced hand and finger trauma were included. Data on age, sex, injured part, location of the incident, mechanism of injury, objects, diagnosis, consultation with specialists, treatments, and outcomes were collected and analyzed by classifying the participants based on age into the following 5 age groups: younger than 1, 1 to 2, 3 to 5, 6 to 10, and 11 to 15 years.

RESULTS

A total of 554 patients were included in this study (male, 57.2%; median age, 4.5 years). The most commonly injured part of the hand was the index finger (22.4%), followed by the middle (18.9%) and ring (16.8%) fingers. A total of 111 patients (15.1%) had palm or dorsal hand injuries. Burn by touching hot objects at home was the leading cause of injuries to the palms during infancy, whereas door-related contusion and abrasion of the index, middle, and ring fingers were most common in preschool children. Sports-related fingertip fractures and sprains most frequently occurred in the thumb and little fingers of school children. Approximately half of the patients (53.3%) did not require any specific treatment. Most patients (98.2%) were treated at the outpatient department.

CONCLUSIONS

This study provides the epidemiology of age-specific hand and finger injuries among Japanese children. Therefore, the childhood hand and finger injury prevention strategy should focus on age as a characteristic.

Pediatric Wide-Awake Local Anesthesia No-Tourniquet Technique Hand Surgery: A Practical Approach

Pediatric wide-awake local anesthesia no-tourniquet technique (WALANT) hand surgery is feasible for the treatment of the spectrum of pediatric hand surgeries, which can include traumatic injuries and congenital hand differences. The key component for success is identifying the appropriate patient for this technique, with the typical patient frequently being >10 years of age. The discussion with the patient and adequate preparation for maximum efficiency become key for patient and surgeon comfort. Here we describe a practical approach for successfully performing this valuable technique for the pediatric population.

Epidemiology of pediatric hand surgery emergencies. Retrospective study of 245 patients seen over 10 months in two referral centers

BACKGROUND

The primary objective of this retrospective study was to analyse the epidemiology and assess the characteristics of all paediatric hand injuries requiring emergent surgery.

HYPOTHESIS

Paediatric hand emergencies that require surgical treatment have a specific epidemiological distribution.

METHODS

We conducted a multicentre retrospective descriptive epidemiological study of surgical paediatric hand emergencies seen over 10 consecutive months.

RESULTS

We included 245 patients between the 1st of January and the 31st of October 2016. Irrespective of age, most injuries (69%) occurred at home; 11% (n=26) occurred at school and 4% in a sports centre. Overall, most injuries involved the dorsal aspect and affected the fingers more often than the hand. The most common lesion was crush injury of a distal phalanx (36% of cases). Door guards were in use in only 9% of homes (n=8), and mean age of the patients in this group was 5 years Paronychia/acute infections accounted for 27% of cases. Wounds of the hands of fingers made up 23% of cases, with the palmar aspect being involved in 70% of cases. The wound was often due to the use of a sharp-edged object. Fractures/dislocations accounted for 12% of cases and bites or scratches for 2%.

DISCUSSION

This study showed that the most common hand injuries requiring emergent surgery in a paediatric population are crush injuries of the fingertip such as door-crush injuries, which most often occur at home. Reinforcing prevention strategies should be the main priority in order to decrease the incidence of hand lesions in children. Raising awareness among parents and improving the education of the public could significantly decrease the incidence of these injuries.

LEVEL OF EVIDENCE

IV; retrospective cohort.

Pediatric Hand Trauma: An Analysis of 3,432 Pediatric Hand Trauma Cases Over 15 Years

PurposePediatric hand trauma is common and sometimes causes deformity or disability. The incidence and etiologies of hand trauma in children are different from those in adults. This study analyzed the characteristics of pediatric hand trauma cases and patients over a 15-year period. MethodsWe conducted a retrospective medical record review of 3,432 children (2,265 boys, 1,167 girls, under 18 years of age) with hand injuries from January 2005 to December 2019. We evaluated the sex distribution and injury etiologies. Injuries were classified by type as burns, amputations, crushing injuries, lacerations, extensor and flexor tendon injuries, open and closed fractures, and nerve injuries. ResultsAmong the pediatric hand injury patients, males were predominant (1.94:1). Simple lacerations (58.4%) were the most common injury type, followed by fractures (22.8%). Lacerations and burns tended to be common in younger age groups, while tendon injuries, nerve injuries, and crushing injuries were more frequently encountered in older age groups. ConclusionsHand trauma prevention strategies should be established considering the frequent trauma etiologies in specific age groups. An awareness of age-specific characteristics of pediatric hand trauma patients will be helpful to prevent hand trauma.

Effect of hand dominance on functional outcomes in paediatric patients with flexor tendon injuries: A cross-sectional study

INTRODUCTION

There are limited data in the literature about the short- to mid-term results of children with flexor tendon injuries. We aim to evaluate the short- to mid-term functional outcomes of children with flexor tendon injuries and to disclose whether the injured side affects the results.

MATERIALS AND METHODS

Patients who had undergone primary flexor tendon repair were included in the study. The demographic and clinical characteristics of the patients were recorded. Modified Hand Injury Severity Score was calculated for each patient. Sensory, motor and functional assessments of the bilateral hand were performed.

RESULTS

A total of 44 patients (female = 16, male = 28) with a median age of 13 (6-17) were evaluated. Significant differences between the affected and healthy hands of the patients in terms of grip and pinch strengths and monofilament sensory test results were demonstrated while the Jebson Taylor Hand Function Test (JTHFT) scores were similar. No factor other than the injury side was found to be related to the affected hand functions. In patients with dominant hand injuries, JTHFT results of the affected hands were similar to the results of healthy dominant hands (P = .935). However, JTHFT results were found to be worse in the affected non-dominant hands compared to healthy non-dominant hands (P = .01).

CONCLUSION

This study demonstrated that paediatric population with flexor tendon injuries in their dominant hands has better short- to mid-term functional outcomes. These results may be attributed to use their injured dominant hand more actively in daily activities.

Pediatric Hand and Upper Extremity Injuries Presenting to Emergency Departments in the United States: Epidemiology and Health Care-Associated Costs

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged <18 years associated with a primary diagnosis involving the upper extremity from 2008 to 2012. Patients were divided into 4 groups by age (≤5 years, 6-9 years, 10-13 years, and 14-17 years) and a trauma subgroup. Primary outcomes were prevalence, etiology, and associated charges. Results: In total, 11.7 million ED encounters were identified, and 89.8% had a primary diagnosis involving the upper extremity. Fracture was the most common injury type (28.2%). Dislocations were common in the youngest group (17.7%) but rare in the other 3 (range = 0.8%-1.6%). There were 73.2% of trauma-related visits, most commonly due to falls (29.9%); 96.9% of trauma patients were discharged home from the ED. There were bimodal peaks of incidence in the spring and fall and a nadir in the winter. Emergency department charges of $21.2 billion were generated during the 4 years studied. While volume of visits decreased during the study, associated charges rose by 1.21%. Conclusions: Pediatric upper extremity injuries place burden on the economy of the US health care system. Types of injuries and anticipated payers vary among age groups, and while total yearly visits have decreased over the study period, the average cost of visits has risen.

Surgically Treated Pediatric Hand and Fingers Palmar Wounds Caused by Metal Fences: Analysis Over a 5-Year Period

BACKGROUND

Hand wounds are frequent in children (31% of hand injuries) and one possible mechanism responsible for profound laceration is metal fences while climbing. These injuries usually require a surgical look to explore soft-tissue damages, but the literature is poor regarding surgical findings and outcomes after this kind of traumatism. The aim of the study was therefore to report a consecutive series of hand and finger wounds caused by metal fences in children, focusing on surgical findings and potential complications.

METHODS

All consecutive hand or finger deep wounds caused by metal fences treated between January 2013 and December 2018 were retrospectively reviewed. Inclusion criteria were age below 18 years and a minimum follow-up of 2 years. Complications and surgical revisions were analyzed.

RESULTS

A total of 1265 patients were operated for hand or finger deep wounds during the study period, among which 74 were caused by metal fences. The mean age at surgery was 11.3±0.4 years, and the majority of patients were men (80%). Associated injuries were found in 55.4% of the patients including nerves (n=29) or tendons sections/disinsertion (n=6), and sheath (n=16) and pulleys (n=6) tearing. At a mean follow-up of 2.6±0.2 years, 12% of the patients required revision surgery for an irreducible flexion contracture secondary to a contractile scar and consisted of complete scar excision and zigzag flap. Additional tenoarthrolysis was required during the procedure, for 6 patients because of a persisting flexion contracture after excision.

CONCLUSIONS

Metal fences surgical palmar wounds in children are impressive lesions by their extended skin damages. Serious associated lesions (collateral pedicle or flexor tendons) were found in 1 case of 3. However, these injuries are not benign and should be carefully monitored clinically during the first postoperative month to look for potential contractile scars that can require revision.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Reconstruction of pediatric hand injuries caused by automatic cup-sealing machines in Taiwan

Objective

This study was performed to share our clinical experience and provide treatment strategies for pediatric hand injuries caused by automatic cup-sealing machines in Taiwan.

Methods

Thirteen pediatric patients with an average age of 3.6 years were included in this retrospective study. Treatment was based on the location and depth of the injury and included full-thickness skin grafts, free or local flaps, and digital replantation. Some patients underwent contracture release during follow-up.

Results

Thermal crush injuries affected the left hand in five patients and right hand in eight. Four patients with nine amputated fingers were treated by emergent digital replantation, four were treated by skin grafting, one was treated by nail bed repair, one underwent reconstruction with a local reversed dorsal digital and metacarpal island flap, one underwent reconstruction with a fascia graft for extensor tendon repair and pedicled groin flap coverage, and two underwent reconstruction with free anterolateral thigh fasciocutaneous flaps with a vascularized fascia lata graft for dorsal hand defects. All replanted fingers survived.

Conclusion

Pediatric hand injuries, especially those caused by cup-sealing machines, can be devastating. Aggressive treatments including early reconstruction and rehabilitation should be performed for all pediatric hand injuries to achieve satisfactory functional restoration.

Patient-reported quality of life and hand disability in elderly patients after a traumatic hand injury - a retrospective study

Background

Hand injuries occur at any age and cause disability in hand and arm function as well as impaired quality of life, but no study has focused on hand disability and quality of life in the elderly after a hand injury. Globally, the population over 60 years of age is expected to double by 2050 and more hand injuries are estimated among the elderly population. Our goal is to obtain more information and a better understanding of problems elderly patients experience after a hand injury to be able in the future to optimally relocate resources in the health care sector with respect to numbers and injury pattern as well as to health status of these patients.

Methods

Patients aged more than 65 years with a traumatic hand/wrist/forearm injury treated (July 1st 2013 - June 30th 2014) at department of Hand Surgery, Malmö, Sweden were included. Health-related outcome questionnaires, i.e. QuickDASH, SF-36, Visual Analogue Scale (VAS), Cold Intolerance Severity Score (CISS), and general information were mailed to the patients (time from injury: > 1.5–2.5 years). The participants were compared in groups according to age, gender, cold intolerance, injury severity and previous occupation.

Results

One hundred and thirty-seven participants responded [response rate 55%; non-responders (n = 113); only difference between groups was that non-responders were older]. Women were older than men at the time of injury (p = 0.04) and differed regarding living conditions. The main differences in QuickDASH, all VAS questions, and the majority of SF-36 subscales (p < 0.05) were found in the participants with CISS > 50, who experienced more impairment. More serious injuries (Modified HISS) were found to have higher QuickDASH and CISS score as well as more functional impairment (p < 0.05). Few differences were found in groups divided according to age, gender (although men experiencing less functional impairment in QuickDASH), previous occupation and injured hand.

Conclusions

Patients aged more than 65 years at the time a hand injury was sustained, generally experience a high-level quality of life and limited functional problems after such an injury, but patients with CISS > 50 and with a more serious injury were more severely affected.

Flexor tendon injuries

Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles.

Understanding the spectrum of paediatric mechanical finger and hand trauma seeking acute care

PURPOSE

Paediatric hand injuries are a frequent reason for acute medical evaluation. Previous studies have reported only fracture rates, surgical injuries or are limited to database diagnosis coding. The average fracture rates and injury distributions across the hand for all mechanical injuries have not been well-described.

METHODS

We performed a retrospective review of all emergent/urgent care visits over 18 months at a US paediatric tertiary hospital with hand injuries recorded anywhere in the encounter. Patient, injury and encounter details were recorded with additional imaging review, categorized and described.

RESULTS

A total of 523 patient visits (0.64% of all encounters) were for mechanical hand trauma. The injury mechanism was 42% crush, 19% jammed, 12% impact, 12% fall on outstretched hand, 7% hyperextension and 8% other/unclear. Crush was responsible for 80% of injuries in patients aged 0 to six years old but only 17% in patients aged 13 to 18 years. Crush resulted in fractures only 26% of the time, while other mechanisms were more likely to fracture (33% to 87%). Border digits were injured more often than others (21% to 23% versus 13% to 17%), and were most commonly fractured in the proximal phalanx (57% to 67% versus 22% to 34% for non-border digits). Providers correctly coded for basic fracture presence in 89.1% of injuries, but 53% of codes were not finger or laterality-specific, and only 15% specified a bony segment demonstrating that International Classification of Diseases-9 coding was nonspecific for injury patterns.

CONCLUSION

Patients with paediatric hand injuries frequently utilize emergency care and understanding the basic patterns of injury can guide resource utilization and future studies on optimal treatment algorithms in this setting.

LEVEL OF EVIDENCE

IV, Prognostic, Case Series.