treatment of hand fractures in...

Treatment of Hand Fractures in Children

Reeti Douglas, OTD, OTR/L

Texas Scottish Rite Hospital for Children

Distal Phalanx Fractures

Distal Tuft Fractures

• Crush injury to fingertip

• Most often in toddler and preschool aged children

• May involve soft tissue lacerations and nail bed injuries


Initial OT Treatment includes:

• Wound care

• Home training vs outpatient clinic

• Least painful and lowest frequency

• Orthosis:

• Protect fingertip

• Allow for ease of dressing changes


After immobilization phase for distal tuft fracture:

• Focus on DIP extension and flexion ROM

• Ensure composite fist ROM

• Address grip strength

• Continue orthosis in crowds and night for 2-4 weeks

Bony Mallet Finger Fractures

• Force against fingertip causes avulsion of extensor tendon resulting in intraarticular fracture

• Occur in adolescents due to force against a finger from:

• Ball• Fall• Another player


• Initial OT Treatment includes:

• Immobilize in orthosis for 6 weeks

• Orthosis to hold DIP in slight hyperextension with PIP free

• Orthosis to be worn 24 hours a day (make 2)

• Cast vs stack orthosis vs custom orthosis


• After immobilization phase for bony mallet injury:

• Focus on DIP extension ROM

• Careful of aggressive DIP 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


• Return to sports after bony mallet injury:

• After 10 -12 weeks of rehabilitation

• Strength regained

• High level athlete can return earlier with splint and MD clearance

DIP ROM Exercises

DIP Extension Play Exercises

DIP Extension Strengthening

Theraputty Exercises

DIP Extension Strengthening

Digi-Extend Rubber Bands

DIP Flexion Strengthening

Theraputty

Digi-Flex Hand Exerciser

Proximal Phalanx Fractures


• Non-displaced fractures treated with immobilization• OT fabricates immobilization

• Buddy straps vs orthosis

• Outcomes expected to be good

• After immobilization,

typically only home program necessary


• Displaced fractures treated with CRPP with casting or CR with casting

• OT home program for ROM initiated after 4 weeks of casting

• If ROM not obtained after 1 month of HEP, initiate outpatient therapy


• Early mobilization and decreased stiffness with children lead to most children returning to full ROM

• With older children, adhesions may occur• Focus on tendon gliding

• Consider a finger-based dynamic proximal interphalangeal joint extension splint

Metacarpal Fractures


• Occurs with adolescents during contact sports

• Football

• Boxing

• Occurs from direct impact against object with closed fist


• Non-operative: treated with immobilization and closed reduction

• Operative: CRPP or ORIF


• While immobilized

• Maintain ROM in noninvolved joints

• After immobilization

• Initiate AROM

• MCPs, PIPs, and DIPs blocking

• Composite fist

• Tendon Gliding


• Sufficient healing required to initiate PROM

• Individual joints

• Composite fist

• Wrist


Grip and finger strengthening once healed


• Return to play considerations:

• Protective cast- healing present, no pain with ROM

• Buddy taping

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.

• Boyer, J., London, D., Stepan, J., & Goldfarb, C. (2015). Pediatric Proximal Phalanx Fractures: Outcomes and Complications after the Surgical

Treatment of Displaced Fractures. Journal of Pediatric Orthopedics, 35 (3), 219-223.

• 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.

• 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.

• Jaworski, C., Krause, M., & Brown, J. (2010). Rehabilitation of the wrist and hand following sports injury. Clinics in Sports Medicine,29(1),61-80.

• Nellans, K.,& Chung, K. (2013). Pediatric Hand Fractures. Hand Clinic, 29(4), 569-578.

• Russell, C. (2015). Therapy challenges for athletes: Splinting options. Clinics In Sports Medicine, 34(1),181-191

• The Hand Rehabilitation Center of Indiana. ( 2001). Diagnosis and treatment manual for physicians and therapists: Upper extremity rehabilitation,

4th edition. Indianapolis, Indiana: Author.

• Tocco, S., Boccolari, P., Landi, A., Leonelli, C., Mercanti, C., Pogliacomi, F., …Nedelec, B. (2013). Effectiveness of cast immobilization in comparison

to the gold standard self-removal orthotic intervention for closed mallet fingers: A randomized-clinical trial. Journal of Hand Therapy, 26, 191-201.

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