Hand and WristCase Studies & Pearls of Wisdom

Jenna M. Godfrey, MDHand Surgeon

25th Annual Orthopedic & Sports Medicine UpdateDecember 2nd, 2017

Disclosure Information

• Presenter• Jenna Godfrey, MD, has nothing to disclose.

• Planning Committee• Jim Chesnutt, MD, has nothing to disclose• Brick Lantz, MD, has nothing to disclose• Erin Owen, PhD, has a spouse who receives a salary from Wright

Medical

Cases 1 & 2

• Both patients are:• 8yo females• Fall off monkey bars• Wrist pain• No other injuries

• PE: swelling and tenderness about distal radius

Patient 1

Patient 2

Pediatric Distal Radius Fractures

2 flavors:

• Extra-physeal: Buckle or Complete Fracture

• Physeal (eg. Salter Harris Fracture)

Patient 1

• Extra physeal

• Buckle fracture: cortex is INTACT, 2 inflection points seen on either view

Patient 2

• Physeal

• Salter Harris 2 Fracture: Fracture line extends to the physis, ONE inflection point

Treatment Algorithm

• Buckle Fractures are INHERENTLY STABLE• Removable brace for 2-4 weeks

• Extra Physeal Fracture (e.g. cortex is disrupted)• Possible reduction and casting

• Physeal Fractures• Possible reduction, casting, FOLLOW until normal growth seen on XR

Follow up…

• Patient 1 no further issues

• Patient 2• 18mo later returns with a “big bump” on the ulnar side of the

wrist per Mom

Injured Comparison

MRI:Negative for Physeal

Bar

Case 3

• 21yo male• c/o “jammed finger” • Playing flag football• Ball hit the end of the finger• Pain, swelling and limited motion at PIP joint• No previous injuries

• PMH: neg

Case 3: “Jammed Finger”: The Differential

#1 Most common: Volar Plate Injury

BUT YOU COULD ALSO HAVE:• Collateral ligament injury• Dislocation of the PIP• Fracture of the proximal phalanx• Fracture dislocation of the proximal phalanx• Dislocation of the PIP

Get a dedicated FINGER XR!!!!

NORMAL!! = Volar Plate Injury

Intracondylar Fracture = Surgery

Dislocation = Reduction

Fracture/Dislocation = Surgery

Volar Plate Treatment Do’s and Don’ts DO:

• Mobilize early• Buddy tape FOR COMFORT ONLY• Hold out of sport until full finger motion

DON’T:• Immobilize >1 wk• Cast• Use an alumifoam splint (DON’T DO IT!!)

Case(s) 4

• Hand lacerations in:

• 2 yo – fingertip slammed in door

• 10 yo – fall onto a mason jar

• 60 yo – man vs. table saw

Child vs. Door Injury

•Most common in toddlers•Rule of 1/3s:

• 1/3 will completely heal if you put back on the tip

• 1/3 will partially heal if you put back on the tip

• 1/3 the tip WON’T heal BUT• Only 10% need a revision amputation

Palmar Laceration

• Glass can do A LOT of damage• Never judge it by the SIZE of the wound

• Look at the finger cascade

• Test sensation

Fingertip vs. Table Saw

• Remove the nail plate• Look at how much is INTACT• Does the tip have good capillary refill?• Wash, wash, wash• Antibiotic

CLINICAL KEY: The Block - 1 Shot

• 1% Lidocaine WITHOUT EPI5-10ml syringe: 1-2cc into the the sheath27g needle

• Make a wheal over flexor tendon• WAIT...• Go into tendon sheath and BUMP

the bone

Nail Plate OFF!

Don’t guess, it won’t hurt if you’re wrong but it will if you miss a nail bed injury!!

Wash it...WELL

Repair with CHROMIC

Keep Eponychial Fold Open

Tenets of the Laceration• Thou shalt:

• Administer IV antibiotics• NEVER throw away the tip of a child’s finger• Use chromic!!!!• Remove a nail plate for all distal fingertip lacerations • Look at the cascade of the digits• Test sensation

• We fix nerves in the PROXIMAL digit• We DON’T fix nerves in the tips of the finger

Thank You!QUESTIONS?