Overview
Definition:
Hand fractures in children refer to breaks in the bones of the hand, including the metacarpals and phalanges
These injuries are common in pediatric populations due to their active lifestyles and developing skeletal structures
Proper splinting is crucial for healing and preventing long-term deformities.
Epidemiology:
Hand fractures account for a significant proportion of pediatric fractures, with metacarpal fractures being the most common, often resulting from direct trauma or a fall onto an outstretched hand
Phalangeal fractures are also frequent, particularly involving the distal phalanges from crush injuries.
Clinical Significance:
Accurate diagnosis and appropriate management, including precise splinting, are vital to ensure optimal bone healing, restore function, and prevent complications such as malunion, nonunion, stiffness, and growth plate injuries
Effective splinting supports alignment, reduces pain, and protects the injured area.
Splinting Principles
Goal Of Splinting:
To immobilize the fractured segment, maintain reduction if achieved, reduce pain and swelling, protect surrounding soft tissues, and prevent further injury
Splinting in children must also consider growth potential and avoid compromising joint mobility.
Types Of Splints:
Commonly used splints include: plaster of Paris (POP) casts, fiberglass casts, prefabricated splints (e.g., thermoplastic splints, aluminum splints), and dynamic splints
The choice depends on the fracture location, stability, and patient factors.
Splint Application Technique:
Ensure adequate padding to prevent pressure sores
Apply the splint snugly but not too tight to avoid compromising circulation
Immobilize the joint above and below the fracture site to ensure complete stability
Check for adequate distal neurovascular status frequently post-application.
Duration Of Splinting:
Varies based on fracture type, patient age, and healing progress
Generally, 3-6 weeks for metacarpal fractures and 2-4 weeks for phalangeal fractures, with regular radiographic assessment guiding removal or cast change.
Special Considerations For Children:
Growth plate (physeal) involvement requires careful splinting to avoid physeal arrest
The child's comfort and compliance are paramount
thus, lightweight and aesthetically pleasing splints may improve adherence
Parental education on cast care and warning signs is essential.
Common Pediatric Hand Fractures
Metacarpal Fractures:
Often occur from direct blows or falls
Boxer's fractures (fifth metacarpal neck) are common
Immobilization is key, with specific attention to rotational alignment
Splinting typically involves a short arm cast or ulnar/radial gutter splint.
Phalangeal Fractures:
Can be extra-articular or intra-articular
Distal phalangeal fractures are often crush injuries, treated with buddy taping or a small splint
Proximal and middle phalangeal fractures require more robust immobilization, often with a cast or splint that incorporates the wrist.
Thumb Fractures:
Include fractures of the proximal, distal, or base of the first metacarpal
Bennett's fracture and Rolando fracture can occur at the base
Thumb spica splints are frequently used to immobilize the thumb and wrist, providing stability.
Growth Plate Fractures:
Fractures involving the physis (e.g., Salter-Harris types) are unique to pediatric bones
These require precise reduction and immobilization to prevent premature growth arrest
Special care is needed to avoid displacement and preserve physeal integrity during splinting.
Diagnostic Approach
History Taking:
Mechanism of injury (fall, direct blow, crush)
Age of the child
Pain characteristics
Presence of swelling, bruising, or deformity
History of previous fractures or bleeding disorders
Immunization status if tetanus prophylaxis is considered.
Physical Examination:
Inspection for deformity, swelling, ecchymosis, and open wounds
Palpation for tenderness, crepitus, and deformities
Assess range of motion (active and passive) if pain allows
Crucially, evaluate distal neurovascular status: capillary refill, sensation in digits, motor function of intrinsic and extrinsic muscles, and radial/ulnar pulses.
Imaging Modality:
Standard anteroposterior (AP), lateral, and oblique radiographs of the affected hand and wrist are essential
Include contralateral views if needed for comparison, especially in young children
In complex cases or suspected physeal injuries, computed tomography (CT) or magnetic resonance imaging (MRI) may be considered.
Interpretation Of Radiographs:
Assess fracture pattern, displacement, angulation, shortening, and intra-articular extension
Pay close attention to the growth plates
any disruption requires careful assessment
Compare with the contralateral uninjured side if displacement is subtle or in young children where ossification centers may be absent.
Management And Splinting Techniques
Initial Management:
Pain control with analgesics (e.g., acetaminophen, ibuprofen)
Elevation of the injured limb to reduce swelling
Application of ice packs
Gentle reduction and splinting to maintain alignment
Tetanus prophylaxis if there is an open wound.
Closed Reduction And Splinting:
For displaced fractures amenable to non-operative treatment
Gentle manipulation under adequate analgesia or sedation is performed to restore alignment
The chosen splint is then applied to hold the reduction
Radiographs are taken post-reduction to confirm acceptable alignment.
Specific Splint Applications:
Ulnar/radial gutter splints for metacarpal and phalangeal shaft fractures
Thumb spica splint for thumb injuries or those involving the first metacarpal
Volar or dorsal wrist splints for proximal forearm or wrist involvement
Buddy taping for stable distal phalangeal fractures.
Open Fracture Management:
Requires prompt irrigation and debridement in the operating room
Antibiotics are administered
Stabilization is achieved with splinting or external fixation
Definitive internal fixation is typically delayed until soft tissues have healed sufficiently.
Open Reduction And Internal Fixation Orif:
Indicated for significantly displaced fractures, unstable fractures, intra-articular fractures with joint incongruity, or fractures with associated neurovascular compromise that cannot be managed non-operatively
Following ORIF, appropriate splinting is applied to protect the repair.
Complications
Early Complications:
Compartment syndrome (rare but serious), neurovascular compromise, infection (especially in open fractures), cast sores, and excessive swelling
Regular post-splinting assessment is crucial to detect these.
Late Complications:
Malunion (healing in an incorrect position), nonunion (failure to heal), malrotation (leading to functional deficits), joint stiffness, and premature physeal arrest (growth disturbance)
This highlights the importance of accurate reduction and appropriate splinting duration.
Prevention Strategies:
Careful fracture reduction, meticulous splinting technique with adequate padding, frequent neurovascular checks, prompt recognition and management of complications, and appropriate duration of immobilization based on healing
Adherence to weight-bearing restrictions is also key.
Key Points
Exam Focus:
Understand the specific splinting needs for different pediatric hand fractures (metacarpal, phalangeal, thumb)
Recognize signs of neurovascular compromise post-splinting
Know the management of growth plate fractures and their potential complications
DNB/NEET SS often test scenario-based questions on fracture management and immobilization.
Clinical Pearls:
Always perform and document a thorough neurovascular assessment before and after splinting
Use liberal padding, especially over bony prominences and the wrist crease
Involve parents in the child's care and educate them on warning signs and splint care
Consider child psychology when applying splints
making it fun or a "superhero arm" can improve compliance.
Common Mistakes:
Inadequate immobilization leading to displacement
Over-tight splinting causing circulatory compromise or skin breakdown
Failure to include joints above and below the fracture
Insufficient attention to rotational alignment, especially in metacarpal fractures
Neglecting physeal injuries
Inadequate follow-up and premature removal of splint.