Pediatric Sports Injuries of the Wrist and Hand

Report
Pediatric Sports
Injuries of the
Wrist and Hand
Sunni Alford, OTR/L,CHT
Preferred Physical Therapy
Wrist injuries
TFCC
ECU/ FCU tendonitis
Instability
Growth Plate Fractures
Ulnar abutment syndrome
Triangular
Fibrocartilage
Complex (TFCC)
Similar to the meniscus in the
knee.
Evolutionary theorist- Used
to be more bony for weightbearing. As we evolved the
ulna retracted and was
replaced with the TFCC.
Triangular
Fibrocartilage
Complex
Palmar and Werner introduced term TFCC 1981
Structures include:
Articular disc
Meniscus homologue
Prestyloid recess
Dorsal & volar radioulnar ligaments
TFCC
Central disc is
avascular and
aneural.
Innervation
Volar, ulnar portions: Ulnar N
Dorsal portion:
PIN, dorsal sensory branch
Central disc relatively aneural
Vascularity
Anterior interosseous & ulnar arteries
Central disc relatively avascular
Peripheral 15-20% well vascularized, will
heal
Attachments
Originates from medial border of distal
radius
Inserts into base of ulnar styloid (fovea)
Conservative management
0-6 Weeks

Splinting in a long arm cast or splint with the elbow in 90° flexion
and the forearm neutral for 0-6 weeks to reduce the symptoms
6 weeks
 Active and active-assistive ROM exercises are initiated to the wrist
and forearm. A wrist immobilization splint is fabricated for comfort
and protection.
8 weeks
 If patient is asymptomatic, progressive strengthening to the
hand and wrist, avoiding a torsion load at the wrist.

If the patient’s symptoms are not alleviated in 4-6 weeks surgical
repair or debridement is suggested.
Central Debridement






Central and radial injuries are avascular and
won’t heal thus they are debrided.
3-5 day post- op bulky dressing removed and
gentle AROM exercises initiated. Splint worn
between exercise sessions.
10-14 days-scar massage initiated within 48
hours following suture removal
3-4 weeks – PROM initiated.
6 weeks progressive strengthening as long as
the patient is pain free. Splint discontinued.
Desensitization of scar often needed
TFCC Peripheral Tear





Surgical repair
10-14 day post op bulky dressing removed and a long arm
cast or splint is fitted with elbow in 90 degrees of flexion and
forearm in neutral-AAROM and PROM of digits.
6 weeks post op-cast removed and splint fabricated if not
already. Splint worn between AROM exercises of elbow,
wrist and forearm. Scar management and desensitization
may be started at this time if patient was casted.
8 weeks post op. PROM can be initiated. Dynamic splinting
as needed as long as pain does not increase. DO not
torque wrist.
10-12 weeks. Progressive strengthening with putty, hand
exerciser and hand weights
Contribution of the ECU






ECU only motor unit w/ a
relationship to the TFCC
Tendon sheath blends with
TFCC
ECU held close to center of
rotation of wrist by the TFCC
TFCC is an important pulley
for the ECU
Disruption of the ECU may
contribute to abnormal
loading & force transmission
through TFCC
Painful snap wrist with rotation
if sheath is damaged
ECU only motor unit w/ a
relationship to the TFCC
Tendon sheath blends with
TFCC
ECU held close to center of
rotation of wrist by the TFCC
TFCC is an important pulley
for the ECU
Disruption of the ECU may
contribute to abnormal
loading & force transmission
through the TFCC.
Long arm elbow
splints
Sugar tong
Muenster
Long arm static
Should prevent pronation
and supination
Functional Orthotics
The Wrist Widget
F
ECU

Tendonitis
Immobilize with splint
for 6 weeks
Gentle PROM twice a
day
(FCU tendonitis similar)
 Snap
wrist
Damage to the ECU
sheath.
Painful snapping with
forearm rotation.
Immobilize-sugar
tong/long arm
elbow.
Carpal Instability
 Ligament
laxity
 Ligament sprains
and tears
Terry Skirvin’s Pisiform Boost
Pisiform Boost
Terry Skirvin:
Philadelphia Hand
Center
Dart Throwing
ROM
Growth Plate-Epiphyseal Plate

15% to 30% of all childhood fractures occur at the growth
plate

Growth plates are the softer parts of children’s bones,
where growth occurs.

Located at each end of a bone, growth plates
are weakest sections of the skeleton, sometimes even
weaker than surrounding ligaments and tendons.

Injury that would result in a joint sprain for an adult can
cause a growth plate fracture in a child.
Growth Plate-Epiphyseal Plate
During adolescence, the growth plate is replaced
by solid bone. The long bones in
the body include:

The bones of the hand and fingers

Both bones of the forearm (radius and ulna)

The bone of the upper leg (femur)

The lower leg bones (tibia and fibula)

The foot bones (metatarsals and phalanges).
If any of these areas become injured, it’s important to
seek professional help from a qualified surgeon.
Salter Harris Classification of
Growth Plate Fractures
High risk for
growth arrest
Orthopedic Challenges
 Metal
hardware, if fixation is
required, can stunt growth.
 Fractures
of the radius can change
the normal alignment between the
radius and ulna causing ulnar
abutment.
Ulnar Positive
 Normal
incline.
22 degree
Ulnar Positive
Finger Injuries



Jersey finger
Mallet finger
Dislocations
Tendon Injuries in the Finger

“Jersey finger”—laceration of the flexor digitorum
profundus (FDP)
 FDP

flexes the DIP joints
Can occurs during tackling in football
 History
of failure to grab an object (e.g., football jersey
or car door handle)
 Painful, swollen finger, especially of the volar DIPJ
 Ring finger commonly involved
Jersey Finger






Inability to flex at the DIPJ
PIPJ and MCPJ flexion preserved
Radiographs (AP, lateral, oblique) to assess for
tendinous rupture or bony avulsion fracture.
Surgical repair required
Immobilization 3 to 4 weeks for younger children.
Rosalyn Evans or Indiana Flexor tendon protocol for
older children if compliant. Surgical repair should be
strong…Four to 6 strand core stitch. New, stonger
suture techniques are being developed (see
references).
Flexor Tendon Zones of the Digits
Jersey Finger
 Zone
I Flexor Tendon Injury
Football
 Mallet






Finger
Flexion deformity of the DIPJ secondary to the
inability to extend. Terminal extensor tendon
rupture.
Painful, swollen fingertip
May have occurred when trying to catch a ball
Inability to extend the distal phalanx at the DIPJ
Radiographs (AP, lateral, oblique)
Two forms of mallet finger:
Tendinous--extensor tendon rupture
 Bony--bony avulsion fracture of the distal phalanx

Extensor Zones
Mallet Finger
Football
 Mallet Finger Treatment
 Continuous splinting 6 to 8 weeks
 Wear splint in between exercises and gradually decrease
wearing time up to 10 weeks. Children heal faster then
adults. Monitor extension lag..wear at night.
 DIPJ
must not be allowed to drop in flexion

Bony avulsions < 1/3 of articular surface can be reduced
with dorsal pressure and dorsal splinting - 6 to 8 weeks.

Post-reduction radiographs are essential

Refer failed non-surgical treatment, bony avulsions that
are irreducible or involve 1/3 or more of the articular
surface, or volar subluxation of the distal phalanx
Conservative treatment of
mallet finger
Dorsal Dislocations of the PIPJ
Collateral ligament and volar plate injuries
Dorsal extension block at 30 degrees. Full
flexion allowed. Extension block is decreased to
20 degrees at week 4 and to 10 degrees at
week 5. Splint is discontinued at week 6.
Extension gutter splint at night if patient unable
to extend PIP to neutral. Seriel casting if
needed.
Recommended Web Sites

http://www.stopsportsinjuries.org/sports-injury-prevention.aspx

http://orthoinfo.aaos.org/menus/children.cfm#sports_exercise

http://www.sciencedaily.com/releases/2010/03/100310083441.htm

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/1/
154

http://orthoinfo.aaos.org/topic.cfm?topic=A00038)

http://orthoinfo.aaos.org/topi.cfm?topi+A00048)

http://orthoinfo.aaos.org/topic.cfm?topic+A00328

http://www.indianahandcenter.com
Resources/References
Cannon, N., Beal, B., Walters, K., Roscetti, S., Brandenburg,
G., Lewis, S. et al. Diagnosis and treatment manual for
physicians and therapists: Upper extremity rehabilitation.
Fourth Edition. The Hand Rehabilitation Center of Indiana.
Skirvin, T., Osterman, L. Fedorczyk, J.,Amadio, P. (2011).
Rehabilitation of the hand and upper extremity, sixth edition.
Elsevier.
Roslyn B Evans. (2005). Zone I Flexor Tendon Rehabilitation
with Limited Extension and Active Flexion. Journal of Hand
Therapy, 18(2), 128-40. Retrieved January 29, 2012, from
ProQuest Nursing & Allied Health Source. (Document
ID: 849902421).
Pearls
 Orficast
 Dr.
Roy Meals
http://www.ncbi.nlm.nih.gov/pubmed/2127
2714
www.freehandbrace.com : mallet splint
pattern
 Wrist Widget: Sammons and Preston
www.wristwidget.com
Thank You!
Preferred Physical Therapy
712 1st Terrace
Lansing, KS 66043
913-727-2022

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