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.
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. ...