Chapter 217

This brief section is meant to cover the upper extremity conditions that are commonly seen or are important for timely diagnoses and treatment or referral. This section is not meant to be comprehensive or inclusive of all upper extremity conditions that may be seen, but rather is a brief overview of conditions that every pediatric resident and practicing pediatrician should know about. A “triage” list is provided along with a list of references at the end of the section.

### Trauma

Physical examination of the hand injured by trauma is critical to determine if tendons or nerves have been damaged. Assess the active range of motion of the fingers distal to the injury as well as directly inspect the depths of the wound for partial or complete tendon injuries. Assess sensation in all fingers, and assess function of the intrinsic muscles in the hand, while inspecting the wound for evidence of nerve injury. The presence of arterial injury makes the possibility of nerve injury much higher.1

If an injury is confirmed or suspected, refer the patient to a hand surgeon.

All open wounds should be gently cleansed and assessed for nerve, vessel, and tendon injury. If bleeding cannot be adequately controlled by direct pressure or if the distal circulation has been compromised, the patient should be referred to an emergency department for further evaluation. Open wounds should never be clamped to control bleeding. If sensation is normal in all fingers, and tendon function intact, the wound can be closed and the entire forearm and hand splinted to allow the wound to heal. If there are deficits in tendon or nerve function, follow-up evaluation and definitive treatment by a hand surgeon should be arranged within the next 5 to 7 days.

It is important to note that some finer amputations do not have to go to the emergency department when they occur. If no bone is exposed, the finger wound can be gently cleansed and then covered with a nonadherent dressing (telfa, adaptic, xeroform gauze, petrolatum gauze, etc). Fluffed gauze can then be put between all the fingers and then over the injured finger that can then be wrapped with cast padding, followed by a short or long arm cast, and examined subsequently by an orthopedic hand surgeon for further care. If a child is under 5 years, a long arm cast with the elbow bent to 90° is preferred. For a child older than age 5 years, a short arm cast is appropriate. The wound will heal by secondary intention, and after approximately 3 weeks in a cast, most of these minor injuries will be healed and pain free. If bone is exposed or if the nail plate has been pulled out of the eponychial fold (otherwise known as an open Seymour physeal fracture), the patient with this injury would need to be referred to the emergency department for urgent care. ...

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