management of upper extremity injuries in the pediatric
TRANSCRIPT
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Management of Upper Extremity Injuries in the Pediatric Athlete
REETI DOUGLAS, OTD, OTR/L
ASSISTANT PROFESSOR
DOCTORAL CAPSTONE COORDINATOR
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Overview
•Hand Injuries
•Wrist Injuries
•Elbow Injuries
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HAND INJURIES
2/3/2020
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Mallet Finger
•Occur during contact sports:
•Softball
•Baseball
•Football
•Basketball
•Soccer
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Mallet Finger
• Force against finger from:
• Ball
• Fall
• Another player
• Mechanism of injury:
• Jamming force against fingertip while DIPj is in extension
• Force causes DIPj into flexion resulting in avulsion of extensor tendon
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Mallet Finger Symptoms
• Pain
• Swelling on dorsal aspect of DIPj
• DIPj in flexed position
• Unable to actively extend DIPj
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Mallet Finger Immobilization
**DIPj must stay in hyperextension at all times
• Immobilize for 6-8
weeks
• Splint with DIPj in
slight hyperextension,
PIP free
• Stack splint, cast,
custom splint
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Mallet Finger Rehabilitation
•Focus on DIPj extension ROM
•Careful of aggressive DIPj flexion: No passive flexion if extensor lag greater than 10 degrees
•Ensure composite fist ROM
•Address grip strength
•Continue night splint for 2-4 weeks
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DDIP ROM Exercises
DIP blocking extension
Composite finger flexion Composite fist flexion
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DIP Extension Play Exercises
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DIP Extension Strengthening
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DIP Extension Strengthening
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Mallet Finger
• Return to sports:
• After 10-12 weeks of
rehabilitation
• Strength regained
• Splint or cast if returning
early and cleared by MD
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Mallet Fingers
• Sports specific exercises to ensure ready to return to sport:
• Basketball: Dribbling and passing
• Baseball/Softball/Soccer goalie: repetitive catching
• Football: tackling, catching
** If using splint/cast, make sure fits properly in glove
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Jersey Finger
•Occur during contact sports:
•Football
•Soccer
•Rugby
•Basketball
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Jersey Finger
• Grasping jersey of opponent
• Avulsion of flexor digitorum
profundus (FDP) off volar
aspect of distal phalanx
• Due to forced
hyperextension of DIPj while
finger is actively flexed
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Jersey Finger
• Testing FDP function:
• hold PIP in extension
and have patient actively
flex DIP joint
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Jersey Finger Treatment
•Most treated operatively with Zone 1 flexor tendon repair
•Delayed mobilization best for young athletes
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Jersey Finger Rehabilitation
•4 weeks post-op:
•Dorsal blocking splint:
•Wrist in 20 degrees flexion
•MPs in 70 degrees flexion
•IPs in full extension
•Composite AROM/PROM in flexion/extension within splint
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Jersey Finger Rehabilitation
•6 weeks post-op:
•AROM exercises completed out of splint
•7 weeks post-op:
•PROM exercises completed out of splint
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Jersey Finger- 8 weeks post op
•Initiate light strengthening
• Rubber bands• Light gripping• Theraputty
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Jersey Finger- 10 weeks post op
•Progress strengthening
• Grip strength• Hand weights
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Jersey Finger
•Return to sports :
• After 10-12 weeks of rehabilitation
• Functional AROM regained
• Minimal to no pain
• Grip and pinch strength greater than 80% of uninjured side
**Heavy weight lifting not recommended till 14 to 16 weeks post-op
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Jersey Finger
•Sports specific exercises to return to sports
•Basketball: dribbling, catching
•Racquet sports: power gripping with torque
•Football: tackling, throwing, catching
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WRIST INJURIES
2/3/2020
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Scaphoid Injury
• One of most common wrist injuries that occur while playing sports
• Mechanism of injury: Falling on an outstretched hand
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Scaphoid Injury Symptoms
•Radial sided wrist pain
•Tenderness at anatomic snuffbox
•Soft tissue swelling
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Scaphoid Injury Treatment
•Immobilization with casting ( nondisplaced or minimally displaced) for 8-12 weeks
•Surgery ( nonunion, displaced fracture, carpal instability) cast for 6 weeks
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Wrist/Thumb Orthosis
• Transition to orthosis
after casting
• Provides stability of
thumb and wrist during
rehabilitation phase
• Low profile and “athletic
look”
• Bars are removable
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Scaphoid Injury Rehabilitation
•3 phases:
1. ROM
2. Strengthening
3. Sport-specific exercises
** Wrist important for sports and ADLs
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Scaphoid Injury
• Phase 1: ROM
•AROM and PROM
•Wrist flexion/extension
•Wrist radial/ulnar deviation
•Forearm supination/pronation
•Thumb flexion/extension/abduction/adduction
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Scaphoid Injury
•Phase 2: Strengthening
•Begin once ROM pain free and fracture healed
•Hand, wrist, forearm strengthening
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Scaphoid Injuries
•Phase 3: Sports Specific Exercises
•Throwing sports: begin with unweighted balls and progress to
weighted medicine balls
•Gymnastics: begin with plyometric pushups and progress to
high impact tumbling
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Scaphoid Injury
•Return to play depends on:
•Sport (contact vs non-contact)
•Location and stability of fracture
•Ability to participate in a cast or splint
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Scaphoid Injury
•Other considerations:
•High rate of reoccurrence and complications due to impact of sports
•Pay close attention to pain and inflammation when introducing new exercises
•Pediatric athletes more likely to reinjure scaphoid
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Gymnast Wrist
• Repetitive stress injury from tumbling
• Inflammation of growth plate at distal end of radius
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Gymnast Wrist Symptoms
•Wrist pain with impact activities
•Reduced wrist motion
•Swelling at wrist
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Gymnast Wrist
• To excel in gymnastics:
•Full, painless arc of wrist motion
•Ability to exert and sustain strong grip
•Place wrist in extremes of extension
•Bear significant loads through wrist
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Gymnast Wrist • Sport-Specific Demands:
• Bear weight in high-impact maneuvers
• Forceful pronation and sustained power grip
• Transmission of loads more than twice
• Axial stress on distal radial physis
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Gymnast Wrist
•Wrist pain reported in in 46%-80% of all gymnasts
•37% of gymnasts trained through wrist pain
•50% reinjury rate of wrist overuse injuries
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Gymnast Wrist Treatment
**Treatment is Rest:
•Time off from gymnastics
•No UE weight bearing activities
•4-12 weeks of splinting or casting
•No weight bearing till pain free
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Gymnast Wrist Rehabilitation
•After rest period:
•Regain wrist mobility
•AROM/PROM of wrist and forearm
•Progress to strengthening of grip, wrist, and forearm
•Must remain pain free to progress to weight bearing
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Gymnast Wrist
•Gradual return to weight bearing
•Wall push-ups
•Modified push-ups
•Bridges
•Handstands
•Cartwheels
•Round-offs
•Back Hand Springs
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Tiger Paw
• Wrist support assists with hyperextension
• More stability added with inserts
• Do not use inserts without foam
• Make sure to break wrist support in
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ELBOW INJURIES
2/3/2020
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Supracondylar Fracture
•Mechanism of injury:
• Fall onto an outstretched arm
• Fall directly onto the elbow
• Direct blow to the elbow
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Supracondylar Fracture
•Child is casted in 90 degrees of elbow flexion for 4-6 weeks
•Child often stops using the involved arm even when out of cast
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Supracondylar Fracture
•Goals for treating supracondylar fractures:
•Pain free elbow
•Functional elbow
•Stable elbow
**Unique goals for pediatric athletes
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Supracondylar Fracture
• Pediatric Athlete Goals:
• Gymnastics- obtain end range of elbow extension for rings and tumbling
• Basketball- obtain end range of elbow extension for success in free throw shooting
• Cheerleading- obtain end range of elbow extension for stunts, formations, and tumbling
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Supracondylar Fracture Rehabilitation
• Most treated with home program including:• Early active assistive ROM
• Early active ROM
• Early gentle passive ROM
• If full elbow ROM not obtained, serial orthoses for end range of elbow extension
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Supracondylar Fracture-Serial Orthoses
• One time a week
• PROM and heat to involved elbow
• Remold orthosis for increased extension
• 4-6 weeks of orthosis adjustments depending on improvements and compliance
• Once reach end range of motion, maintain with night time splint for 3 months
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Medial Epicondyle Fracture
•Significant in overhead athletes
•Mechanisms of injury:
•Direct force to medial epicondyle
•Avulsion force from valgus or extension loading
•Elbow dislocation
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Medial Epicondyle Fracture Rehabilitation
•7-10 days post-op:
•Posterior splint or hinged brace
•Early gentle passive ROM
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Medial Epicondyle Fracture Rehabilitation
•Active ROM initiated once palpation of medial epicondyle is pain-free
•Outpatient occupational therapy initiated at 6-8 weeks if full ROM not achieved
•Return to sports and throwing at 3 months
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Olecranon Stress Fracture
•Occur during sports:
•Baseball pitchers
•Javelin throwers
•Gymnasts
•Divers
•Weight lifters
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Olecranon Stress Fracture
•Result of repetitive microtrauma caused by olecranon impingement
•Pitchers present with posterolateral olecranon pain in throwing
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Olecranon Stress Fracture Rehabilitation
•Immediately post-op:•Elbow splinted at 90 degrees
•Begin wrist, hand, and shoulder ROM
•7- 10 days post -op:•Unlimited passive ROM of elbow
•No active elbow flexion beyond 90 degrees
•Full active ROM of forearm
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Olecranon Stress Fracture Rehabilitation
•6 weeks post-op:•Full active ROM of elbow
•8 weeks post-op:• Initiate light strengthening and throwing program•Thrower’s Ten Program
•12 weeks post-op:•Advanced throwing program and full strengthening
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Interval Throwing Program
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Interval Throwing Program
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Interval Throwing Program
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References
• Bachora, A., Ferikes, A., & Lubahn, J. (2017). A review of mallet finger and jersey finger injuries in the athlete. Current Review of Musculoskeletal Medicine, 10, 1-9.
• Binkley, H., Smith, D, & Wise, S. (2012). Rehabilitation and return to sport after scaphoid fractures. Strength & Conditioning Journal,34(5),24-33.
• Chawla, A. & Wielser, E. ( 2015). Nonspecific wrist pain in gymnasts and cheerleaders. Clinics in Sports Medicine, 34, 143-149.
• Chung, J. (2017, May). Is it all wrist sprains and jammed fingers? Presented at Sports medicine for the young athlete : An update for pediatric providers, Frisco, TX.
• Diana, Furey, & Stone. (2014). Functional outcomes of supracondylar elbow fractures in children: a 3- to 5- year follow up. Canadian Journal of Surgery, 57, 241-246.
• Doornberg, Ring, & Jupiter. (2006). Static progressive splinting for posttraumatic elbow stiffness. Journal of Orthopedic Trauma, 20, 400- 404.
• Ellington, M. D., & Edmonds, E. W. (2016). Pediatric elbow and wrist pathology related to sports participation. Orthopedic Clinics of North America, 47(4), 743-748.
• Goldfarb, C., Puri, S., & Carlson, M. (2016). Diagnosis, treatment, and return to play for four common sports injuries of the hand and wrist. Journal of the American Academy of Orthopaedic Surgeons,24(12), 853-862.
• Halim, A., & Weiss, A. (2016). Return to play after hand and wrist fractures. Clinics in Sports Medicine, 35(4), 597-608.
• Ho, Roy, Stephens, Clarke. (2010). Serial casting and splinting of elbow contractures in children with obstetric brachial plexus palsy. Journal of Hand Surgery, 35, 84-91.
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References
• Jaworski, C., Krause, M., & Brown, J. (2010). Rehabilitation of the wrist and hand following sports injury. Clinics in Sports Medicine,29(1),61-80.
• Kox, L., Kuijer, P., Kerkhoffs, G., Maas, M., & Frings-Dresen, M. (2015). Prevalence, incidence, and risk factors for overuse injuries of the wrist in young athletes: a systematic review. British Journal of Sports Medicine, 49, 1189-1196.
• Lawrence, Patel, Macknin, Flynn, Cameron, Wolfgruber, & Ganley. (2013). Return to competitive sports after medial epicondylefractures in adolescent athletes. The American Journal of Sports Medicine, 41, 1152-1157.
• Nandi, Mashke, Evans, & Lawton. (2009). The stiff elbow. Hand, 4, 368-379.
• Redler & Dines. ( 2015). Elbow Trauma in the Athlete. Hand Clinics, 31, 663-681.
• The Hand Rehabilitation Center of Indiana. ( 2001). Diagnosis and treatment manual for physicians and therapists: Upper extremity rehabilitation, 4th edition. Indianapolis, Indiana: Author.
• Wang, Chang, Hsu, Sun, Wang, Wong. ( 2009). The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. Journal of Orthopedic Trauma, 23, 120-125.
• Zionts, Woodson, Manjra,& Zalavras. ( 2009). Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clinical Orthopedics and Related Research, 467, 2007-2010.
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THANK YOU !
2/3/2020