Pediatric hand and wrist injuries

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.

Hands-On Workshops Improve Emergency Department Physicians' Self-Reported Understanding of Pediatric Hand Injuries

OBJECTIVES

The aims of this study were to assess emergency department (ED) physician perception of hand injuries and improve their understanding and confidence in treating these injuries.

METHODS

Combined didactic and hands-on workshops for ED physicians were developed and run by a team of medical students, plastic surgeons, and ED physicians. The workshops consisted of a short review by a hand surgeon followed by hands-on sessions involving radiograph assessment, administration of local anesthetic, closed reduction, and splinting. Two sessions, 6 months apart, were provided. The workshops were evaluated using preworkshop and postworkshop questionnaires to assess the following domains: confidence and competence in treating hand injuries, knowledge of basic hand injury care, and feedback on the intervention itself.

RESULTS

Fifty physicians participated in the workshops. After the workshops, physician recognition of hand fracture reduction as a critical skill increased. Self-efficacy ratings of fracture assessment, administration of local anesthetic, performing a reduction, and applying postreduction immobilization increased. Median scores on knowledge-testing questions also increased postintervention from 73.3% (95% confidence interval, 70.2-78.5) to 86.7% (95% confidence interval, 79.3-86.2) (P < 0.05). Finally, physicians reported that they found the intervention educational, useful, and important, and approximately 90% of participants indicated they intended to change their practice based on this intervention.

CONCLUSIONS

Knowledge sharing between specialists and generalists through combined didactic and hands-on workshops is an effective and well-received method of refining physician knowledge and increasing confidence in treating subspecialty-specific clinical presentations.

Managing children's forearm fractures in the emergency department

Forearm fractures are the most common fractures among children and young people aged up to 19 years and these patients frequently present to the emergency department (ED). Many of these fractures can be treated in the ED without the need for inpatient admission. This article examines the assessment, diagnosis and management of forearm fractures. The authors also use a case study format to demonstrate best practice in the treatment of forearm fractures in this age group. The information in this article will enable ED nurses to enhance the experience of children and their families who present with forearm fractures.

Subcapital phalangeal fractures in children: A retrospective review

Introduction: Phalangeal neck fractures represent a subset of pediatric hand injuries which pose challenges to the treating physician. The aim of this study was to understand which radiographic or clinical variables were associated with the need for closed reduction and percutaneous pinning or were associated with the need for open reduction internal fixation. Methods: A retrospective review was performed on pediatric patients treated for subcapital phalangeal neck fracture of the middle or proximal phalanx between 2009 and 2014. Non-operative and operative groups (open reduction internal fixation, closed reduction percutaneous pinning) compared displacement and angulation of the distal fragment at the time of initial injury, displacement, and angulation of the distal fragment at the time of final follow-up, mechanism of injury, delays in treatment, time to union, and rate of complications. Results: One hundred seventy seven patients met eligibility criteria for the review. Average age was 9.1 years for the surgical group and 8.5 years for the non-surgical group. Time to union was significantly higher for the surgery group (53 vs 30 days, p < 0.001). The degree of sagittal plane translation and sagittal angulation were predictive factors for surgical treatment. Sagittal plane angulation was higher in the surgical group (26.5° vs 9°, p < 0.001). A delay in treatment with subsequent surgery was not predictive of a need for open reduction internal fixation over closed reduction percutaneous pinning ( p = 0.19). Final sagittal angulation was corrected to a median of zero, an eight degree difference from the non-surgical group ( p = 0.002). Conclusions: This study demonstrates that a strong correlation between initial sagittal plane angulation and a need for surgery. A longer time to union and decreased range of motion may be expected in patient's requiring operative intervention. Delay in treatment was not associated with open reduction over closed reduction percutaneous pinning within the surgical group.

Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations

Background: Seymour fractures in children are prone to complications without prompt and appropriate treatment. This study investigated outcomes of Seymour fractures with delayed presentations; specifically, if deep infection predisposed to operative treatment, if antibiotic administration improved fracture healing, and if oral clindamycin had fewer treatment failures than oral cephalexin. Methods: A single-institution retrospective cohort study was performed of patients with delayed Seymour fracture presentations (defined as greater than 24 hours post-injury) between 2009 and 2017. Data collected included demographics, time to presentation, infection on presentation, operative treatment, antibiotic use and duration, fracture union, and complications. Statistical testing used logistic regression and Fisher's exact test, with results reported as P-values (P), odds ratios (ORs), and 95% confidence intervals (CIs). Results: There were 73 patients with delayed Seymour fracture presentations, with mean age of 11.1 years (standard deviation: 2.9), with 56 (77%) males, and median time to presentation of 7 days (interquartile range: 3-17). Deep infection on presentation was a risk factor for operative intervention (OR = 34.4, P = .0001, CI, 5.5-217.2). Antibiotic administration protected against the development of a nonunion or delayed union (OR = 0.11, P = .008, CI, 0.021-0.57). Time to antibiotics did not protect against nonunion or delayed union (OR = 0.77, P = .306, CI, 0.37-1.3). Clindamycin had fewer treatment failures than cephalexin (P = .039). Conclusions: Deep infection is a risk factor for operative treatment of Seymour fractures with delayed presentations. Clindamycin is a better antibiotic choice for Seymour fractures that present in delayed fashion.

The use of esketamine sedation in the emergency department for manipulation of paediatric forearm fractures: A 5 year study

The purpose of this study is to assess the use of esketamine as procedural sedation for the reduction of paediatric forearm fractures in the emergency department (ED). A retrospective analysis was undertaken of forearm fractures between 1^st January 2012 to 31^st December 2016 which were treated with manipulation in ED using esketamine sedation. Patient demographics and fracture configuration were collected. Patient radiographs were evaluated and cast index calculated. 151 patients (103 male, 48 female) were included (average age of 8.5 [1 to 15]). Four (2.6%) patients were lost to final follow up. 11 (7%) fractures were not accepted after initial manipulation and required formal surgical management under general anaesthetic. At one week follow up, a further 5 (3%) fractures displaced requiring operative management. 100% of patients who slipped at one week had a cast index greater than 0.8 [average 0.86, 95% CI 0.80-0.92]. At final follow up successful reduction was achieved in 89.1% (131/144) of patients. No adverse events occurred following administration of esketamine. This study provides evidence that manipulation of paediatric forearm fractures using esketamine as procedural sedation in the ED is comparable to other methods in achieving acceptable outcomes. This is in addition to the potential for cost savings. However, future studies formally assessing cost effectiveness and patient outcomes are needed.

Pediatric Hand Injuries Requiring Closed Reduction at a Tertiary Pediatric Care Center

Background: Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts. Methods: A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included. Results: Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified. Conclusions: Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.

Scaphoid Waist Nonunion in an 8-Year-Old: A Rare Occurrence

Case

Historically, the most common pattern of pediatric scaphoid injury described is at the distal pole, which has a high rate of success with nonoperative management. Injury patterns have evolved as children are more commonly presenting with adult-type fracture patterns. We present the case of a scaphoid waist fracture in an 8-year-old male that resulted in nonunion and required surgical fixation.

Conclusion

This case highlights the trend of adult pattern scaphoid fractures in the pediatric population and the utility of magnetic resonance imaging in patients who do not have complete carpal bone ossification at the time of initial radiographic evaluation.

The Acutely Injured Wrist

Wrist traumas are a frequent clinical emergency for which instrumental imaging assessment is required. The purpose of this article is to review the role of imaging assessment of traumatic wrist injuries, with particular reference to fractures and associated lesions.

Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department: a 2.5-year study

A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation. The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method.

TAKE HOME MESSAGE

Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

National Trends in Operative Treatment of Pediatric Fractures in the Ambulatory Setting

This study evaluated the expanding role of freestanding ambulatory surgery centers in pediatric fracture care based on the only national ambulatory surgery database within the United States. Released by the Centers for Disease Control and Prevention in 1996 and again in 2006, these reports were used to estimate the volume of outpatient pediatric operative fracture care in the United States over a decade, based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedure codes. Particular attention focused on the prevalence of open vs closed vs percutaneous fixation. The estimated number of pediatric patients who presented to outpatient facilities and required operative fracture care between 1996 and 2006 increased by 88%, from 74,577 ± 4663 to 140,152 ± 9138. During this time, the use of outpatient surgical services for pediatric fractures increased threefold, from 10% ± 1% in 1996 to 32% ± 2% in 2006. An even greater preference for freestanding ambulatory surgery centers was observed during this same time by a factor of 7, from 3% ± 1% to 21% ± 4%. Additionally, a trend toward higher volumes of open and percutaneous fixation in freestanding ambulatory surgery centers and not in hospital-associated outpatient centers was observed. This study showed the expanding role of freestanding ambulatory surgery centers in the surgical treatment of pediatric fractures based on data from the only national ambulatory surgery database in the United States. The proportion of open and percutaneous treatment vs closed reduction of fractures in these facilities also greatly increased. Further study is needed to evaluate clinical outcomes and determine which fractures are most appropriately treated in the ambulatory vs hospital setting.

Epidemiologic dynamics contributing to pediatric wrist fractures in the United States

BACKGROUND

The purpose of this study was to explore and evaluate national trends and factors contributing to pediatric wrist fractures.

METHODS

Over a 16-year period from January 1998 to December 2013, we identified and reviewed patients aged 0-17 years old with the primary diagnosis of wrist fracture, as evaluated in US EDs and chronicled by the National Electronic Injury Surveillance System (NEISS) database of the US Consumer Product Safety Commission. We conducted descriptive epidemiologic, bivariate, and chi-square analyses. Patients were categorized into age-defined subgroups and further stratified by sex, race, location, and consumer product/activity associated with injury.

RESULTS

There were 53,265 children evaluated in NEISS EDs (national estimate, 1,908,904) with wrist fractures from 1998 to 2013. Mean age was 10.9 years, with 64 % males and 36 % females. The most common locations of injury were place of recreation/sports, home, and school. The top five consumer-product-related injuries were associated with bicycles, football, playground activities, basketball, and soccer. The highest subgroup associations were with beds (0-12 months), stairs (13-36 months), playgrounds (3-5 and 6-10 years), and football (11-17 years). The greatest increase in fractures occurred between ages 0-12 and 13-36 months, with the second-largest increase between ages 3-5 and 6-10.

CONCLUSIONS

It is essential to develop injury prevention and safety strategies as well as identify individual risk factors for fracture, including activity, sex, and key age transitions. Surveillance is imperative to advance our understanding of these fractures, and in the future may facilitate development of research prediction tools to anticipate or prevent injury.