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Bruce R.Johnstone F.R.A.C.S.

Royal Childrens Hospital, Melbourne
In one and two year olds, the majority of injuries occur when they are exploring their
environment and still unaware of the dangers. Lacerations, burns and crush injuries are most
common. In children between 5 and 10 years, fractures are more numerous but lacerations are
the most frequently injury. Whilst a history is taken and rapport developed, the posture and any
movement of the involved part is carefully observed. The resting posture of the fingers should
form a cascade. Clear evidence of neurovascular or tendon injury warrants exploration under
general anaesthesia and this often makes removal of dressings for wound inspection
unnecessary. Surgical exploration is frequently the only reliable way of assessing the extent of
paediatric hand injuries. Great care should be taken prior to the reversal of anaesthesia to
ensure that the dressings and plaster splint maintain the hand in the desired posture and that
the finger tips are visible for monitoring circulation and checking for infection. A long plaster slab
can be applied to both the volar and dorsal surfaces, passing around the elbow and effectively
sandwiching the forearm and hand in a bivalved plaster. A "Tubigrip sling should be worn
underneath the child's top layer of clothing. If this is done consistently, the child will quickly
forget the injured arm. Unlike in adult hands, generalised stiffness is not a problem in children
even after many weeks of immobilisation. Unless complications intervene, a dressing and splint
should remain intact until the surgeon is happy for the toddler to start using the hand without
Hand trauma is common in children and fortunately most injuries are relatively minor. Of
children under 5 years of age, the majority of injuries occur in one and two year olds, when they
are exploring their environment and still unaware of the dangers. Lacerations, burns and crush
injuries are most common. In children between 5 and 10 years, fractures are more numerous
but lacerations are still the most frequently seen injury. By 10 to 15 years, fractures are the most
common type of injury,
Table 1: Common Causes and Types of Paediatric Hand Injuries
Under 5 years
(especially 2 years)
5-10 years
10-15 years
Clinical assessment of the hand in a traumatised child is a challenging but important exercise. A
calm, unhurried examination, once the confidence of both the child and the parents has been
won, should be able to be performed by all levels of practitioners dealing with paediatric
A thorough history identifying, if possible, the exact mechanism of injury is of paramount
Whilst a history is taken and rapport developed, the posture and any movement of the involved
part is carefully observed. Any fingers protruding from the dressing can be checked for viability
and, surprisingly easily for sensation. A "game of light touch sensory testing using a tissue and,
even in older children, a game of two point discrimination, which is initiated on the normal hand
can assess the digital nerve function.
It may be possible to have the child wriggle the fingers within the dressings in such a way that
the examiner can exclude, at least complete division of the profundus or flexor pollicis longus
tendons. Similarly, complete division of the anterior interosseous or proximal median nerve is

also excluded. Ulnar nerve division prevents a child from crossing its fingers. The tenodesis
effect gently flexes and extends the fingers when the wrist is passively extended and flexed.
The resting posture of the fingers should form a cascade of lesser to greater flexion from the
index to the little finger. Firm pressure over the central volar forearm will also cause some
flexion of the finger if the tendons are intact. Disproportionate pain when attempting to use an
otherwise clinically intact tendon, may indicate an incomplete laceration
Clear evidence of neurovascular or tendon injury warrants exploration under general
anaesthesia and this often makes the painful removal of dressings for wound inspection
unnecessary. In some cases, however, taking a "peak at the wound, may establish the need
for more complex wound closure, aid planning and allow a more informed consent to be
obtained from the parents. The possibility of a compartment syndrome should be particularly
considered in closed injuries. Marked pain, compartment tenderness, swelling and pain on
passive stretching, are important features. Firmly applied dressings temporarily tamponading
significant arterial bleeding usually should not be removed until the patient is anaesthetised and
a pneumatic tourniquet, which can be promptly inflated, is in place. Pre operative x-rays with a
minimum of dressings will identify fractures and possibly indicate the presence of foreign
Surgical exploration is frequently the only reliable way of assessing the extent of paediatric
hand injuries. Only under optimal conditions of general anaesthesia, good
lighting, skilled assistance and a bloodless field provided by exsanguination and a pneumatic
tourniquet, can all potentially injured structures be visualise.
Table 2: Clinical Assessment
Develop rapport - Put parents at ease
Observe posture and movements
Non threatening examination
Remove dressings?
Examine amputated parts
Surgical exploration
The late presentation of injuries, as well as post repair follow-up, demands assessment using a
number of simple clinical techniques. Sensory innervation or reinnervation in a digit is
accompanied by the presence of sweating. The tactile adherence (resistance of running a
plastic pen across the finger tips) is reduced in deinnervated fingers. Deinnervated finger pulps
do not wrinkle when soaked in water. Once rapport is developed, light touch and even two
point discrimination may be tested for. Sensation can be accurately documented with SemmesWeinstein monofilament testing. There is little place for pin prick testing in paediatric practice.
Much can be learnt about the functional status of the muscles, tendons, motor nerves and the
skeletal structures by observing a child at play. If the fingers are passively flexed and suddenly
released, a competent long flexor musculotendonous unit will momentarily maintain the flexed
posture. Forearm and intrinsic muscle wasting is an important sign, however, this may be
masked in chubby infant limbs. Careful deep palpation of the flexor sheath over the proximal
and middle phalanges may reveal an empty sheath when compared to adjacent fingers in cases
of late presentation of distally divided or ruptured profundus or flexor pollicis longus tendons.
Local Anaesthesia
Simple lacerations may be sutured under local anaesthetic without sedation in co-operative,
emotionally mature children who understand the procedure. Suitability for local anaesthesia
involves a careful assessment of the injury, the child, both cognitively and emotionally, and the
parents. Premedication is uncommonly required but may include analgesia, possibly a narcotic,
depending on the extent of the injury. Intra nasal or oral midazolam (0.3 to 0.4 mg per kg) is
more reliable and faster acting than other sedatives, such as chloral hydrate, promethazine etc..
Exploration, debridement, lavage and repair
The vast majority of paediatric upper limb trauma should be treated under a general
anaesthetic. Wounds should be thoroughly explored under ischaemic conditions identifying all

structures that could possibly be damaged. The adage that broken glass stops only at bone, is
frequently proven to be true. One usually finds that more structures are lacerated or partially
lacerated than clinical examination would suggest. The tourniquet cuff selected should be
approximately as wide as the diameter of the limb at the site of application. It should be inflated
to 100 mmHg above systolic pressure and maintained for no more than one and a half hours.
Foreign bodies should be removed. Tissues impregnated with dirt, grease etc.. should be
conservatively but thoroughly excisionally debrided. The wound is then irrigated under pressure
with copious amounts of saline, prior to definitive primary repair of all deep structures and
osseous fixation. Further lavage is carried out after the tourniquet has been released and
meticulous haemostasis is completed prior to wound closure with appropriate drainage.
Perioperative antibiotics should be administered, though the application of the surgical
principles outlined within 24 hours and preferably within 8 hours of the injury, results in a very
low infection rate.
Bupivicaine blockade should always be considered for post operative analgesia in children. This
may be in the form of a digital block following nail bed or finger tip repair, local infiltration in the
hand or forearm or a more proximal nerve block. Severe injuries, including replantation, can be
well managed with an indwelling brachial plexus catheter, for a number of days. This provides
motor, sensory and sympathetic blockade. Theoretically, in a child with a repaired tendon, a
distal sensory block without a motor block, may risk rupture of repair. Once the child awakens
the fingers will be moved without the protective inhibition of pain. Usually skin closure is
achieved with absorbable suture material such as interrupted 5/0 cat gut for the hand and
fingers. Forearm lacerations can be similarly closed. If the wounds can be converted into a
reasonable straight incision-like laceration with minimal need for drainage, then continuous
subcuticular closure with polyglycolic acid, polyglactin 910 or polydioxanone suture is possible.
Haematomas can be avoided by careful haemostasis and immobilisation in a plaster of Paris
slab, supportive dressings and non constrictive but firm bandages. Wound drainage can be
promoted by leaving a long Penrose drain in the most proximal part of the wound which can be
left unsutured. This will drain dependently when the arm is elevated post operatively. The drain
can be withdrawn from the limb without disturbing the dressings or plaster with minimal
discomfort in 12 to 24 hours.
Great care should be taken prior to the reversal of anaesthesia to ensure that the dressings and
plaster splints maintain the hand in the desired posture and that the finger tips are visible for
monitoring circulation and checking for infection. Finally the plaster should be strong enough not
to break and should be fixed to avoid slippage and altering of protective positioning. This can be
achieved by generously painting adhesive , such as mastic paint or tincture of benzoin
compound to the skin just before a forearm plaster slab is applied. Alternatively, a long plaster
slab can be applied to both the volar and dorsal surfaces, passing around the elbow and
effectively sandwiching the forearm and hand in a bivalved plaster. Advantages of such a splint
include it's strength and support without being circumferential, it's resistance to migration, its
relatively easy atraumatic removal and it's maintenance of the elbow in 90 degrees of flexion.
Elevation immediately after surgery can be achieved by safety pinning a large soft pillow about
the arm or elevating the arm in a non constricting sling from an I.V. pole beside the bed.
Table 3: Surgical Repair
Thorough exploration under tourniquet (100 Hg above systolic pressure)
Absorbable suture closure
Bupivicaine blockade
Plaster splint immobilisation
Post Operative Care
Unlike in adult hands, generalised stiffness is not a problem in children even after four or more
weeks of immobilisation. Children appear to mount an intense fibrotic response at the site of

injury leading to adherence of repaired flexor tendons etc...Unless complications such as

infection intervene, a dressing and well designed plaster of Paris splint should remain intact
until the surgeon is happy for the toddler to start using the hand without restriction.
Immobilisation is usually maintained for 10 days following simple suturing, 2 1/2 to 3 weeks for
grafting, particularly full thickness grafting and 3 1/2 to 4 weeks for tendon repairs. A protective
thermoplastic splint may then be manufactured by a hand therapist. All patients should,
however, be reviewed at one week to check for any abnormal odour, discharge, pain or redness
of exposed finger tips. The wound should only be inspected if there is any suspicion of infection.
A sling should always be worn except for activities such as bathing, closely supervised by
preferably two adults. Either a traditional cloth sling sealed with safety pins at each end or an
elastic tubular bandage such as "Tubigrip should be fitted. A "Tubigrip sling should be wide
enough to avoid any constriction. The length required is three times the length of the arm. A slit
is cut halfway along the length and the arm eased through it. The ends can be tied or safety
pinned behind the neck thus elevating the hand. The parents should be instructed not to thread
the arm through the sleeves as this disturbs the position of the plaster. The sling should be
worn underneath the child's top layer of clothing. If this is done consistently, the child will
quickly forget the injured arm and adapt to functioning with one hand.
The splint should have been designed to be fairly easily removed by the surgeon at the
appropriate time without requiring a plaster saw. A plaster saw can raise the levels of fear and
anxiety in the child to a point where co-operation is lost and subsequent attempts to involve the
child in therapy is viewed with suspicion. If flexor tendons have been repaired the risk of rupture
is dramatically increased by the child's fear-induced physical struggle.

Table 4: Post Operative Care

Dressings should avoid constriction and leave the finger tips exposed
Plaster splints should usually be above elbow, not circumferential and well padded
Immediate post operative elevation by pillow or sling on I.V. pole
Discharge from hospital with a secure sling under clothing
Leave dressings and plaster intact until unrestricted activity is permitted unless complications
develop such as persistent pain or evidence of infection
Simple lacerations: 10 days to 2 weeks
Skin grafting: 2 1/2 to 3 weeks
Tendon repairs: 4 weeks
Hand therapy
Hand Therapy.
The general principles of immobilisation, wound healing and mobilising for children are broadly
the same as adults with just a few exceptions. With children, however, there are many other
practical factors which compound the task of establishing rehabilitation protocols.
One factor is the small size and lack of bony prominences, which makes handling and splinting
the child's hand a substantial challenge. Another factor is the involvement of parents and
carers. They should be regarded as agents of therapy whose commitment to and understanding
of therapy is necessary. They must feel empowered to incorporate time consuming therapy
and/or vigilant splint wearing into their child's daily routine. Within the context of a busy family,
and considering the guilt and anger often associated with the circumstances surrounding the
injury, the parents are not always available to make that commitment. It is often necessary to
motivate parents to increase their feelings of worth and competence prior to the successfully
establishment of a child's therapy programme.
The most challenging factor, particularly in a child under five years of age, is the child itself. At
every stage of therapy, the child is influenced by developing and rapidly changing sensorimotor,
cognitive and psychosocial behaviours. These will often dictate what therapy techniques can be
introduced into the programme. Sensorimotor development includes neuromuscular maturity
and fine motor skill acquisition. Cognitive behaviours include attention span, concept formation
and problem solving. Psychosocial behaviours refer to those related to interests, self expression
and self control.

Developmental Framework Sensorimotor behaviours develop and change most rapidly in the
first 15 months of life. Early hand movements are reflex dominated , with grasp and avoidance
reflexes strongly influencing movement. Fortunately, injuries at this age are rare. Involvement of
the thumb in voluntary opposition occurs from 6 months of age followed by subsequent rapid
refinements in grasp, manipulation and release of objects.
At 9 months the child can isolate index finger extension for poking. When coupled with mobility
from crawling closely followed by walking, there is an increased incidence of fingertip injuries,
which peaks at 15 months.
At 15 months fine pincer grasp and all the essential components of prehension are fully
developed. Developing cognitive and psychosocial behaviours have a great influence on both
the high incidence of injuries and the additional techniques required to immobilise the hand
injured child. At this age they are intensely curious and dominated by an urge to explore and
exploit their environment. They need constant supervision for protection against the dangers of
their exploration. By 2 years of age, they have the necessary refinements of fine motor skill, an
interest in cause and effect and the necessary problem solving skills to swiftly remove a
bandage, plaster or splint.
By three years of age, the child's cognitive and psychosocial development is such that they are
able to anticipate consequences and engage in simple negotiation. Co-operation is more likely if
the child is simply and clearly informed of and involved in the procedure. The child can be
offered some responsibility such as holding and then placing the pieces of sticking plaster over
the completed bandage. The child can be given simple choices such as either lying down or
sitting on mothers' lap while having a K-wire taken out. They can engage in simple role play
which helps them to understand the anticipated procedure. A splint therefore can be fitted on a
doll before attempting one on the child. These techniques will reduce the child's feelings of loss
of control and foster co-operation.
At four years of age children are beginning to accept abstractions. They can be involved in
sharing, taking turns and fair play. They appreciate past, present and future time. At this age it
is sometimes possible to introduce specific exercises into the therapy programme and it may be
possible to do some rudimentary sensibility testing.
By five years, the child has refined fine motor skill to incorporate the use of tools such as a
pencil and a knife. They comprehend the need for order and adherence to rules which allows
for the confident introduction of a supervised exercise programme.
Table 5: Developmental Stages of Hand Function & Therapy
6 months
Rudimentary opposition then grasp and release
9 months
Index finger pointing
15 months
Fine pincer grasp
2 years
Fine motor and problem solving skills
3 years
Development of cognitive and psychosocial skills: co-operation
4 years
Abstract concepts accepted: simple specific exercises possible
5 years
Refined fine motor skills: use of tools
Splintage Splintage is relied on extensively when working with children. Splints are necessary
for protection of damaged structures but can be removed for supervised mobilising. Children of
all ages can be splinted but the degree of difficulty varies according to age and those complex
and dynamic sensorimotor, cognitive and psychosocial factors.
Unorthodox splinting designs and materials will often provide better solutions for paediatric
hand therapy problems than those in more general use. There are now several thin lightweight
thermoplastics available which lend themselves to creative use on small hands.
As a child's reaction to having a splint fabricated on him or her is partially age dependent,
various strategies are required to deal with their individual responses. Explanations, choices

and responsibilities can be used with children over 3 years of age. Distractors and physical
restraint, with the recruitment of parents, is necessary in younger children.
Securing the splint in place is critical. A few millimetres of movement of the hand in the splint
can render it ineffective, or at worst, destructive to the integrity of the skin and repaired
structures. An absence of bony anchor points in chubby childrens limbs make this task
challenging and time consuming. Band-aids and/or adhesive tape will keep splints on fingers.
Proximal uninvolved joints may need to be incorporated in some splints for better anchorage.
Alternatives to Velcro may need to be considered as fasteners on small hands. Velfoam is
texturally kinder on soft skin and can be more easily contoured by cutting and/ or sewing to
achieve a secure fit. Much can be done to prevent a child from removing the splint and/or
exposing it to dirt, water, food and other skin damaging substances. Simply covering it with a
mitten may be effective or it may be necessary to cover the entire arm and immobilise it in a
sling, as with the plaster.
Mobilising: Exercising vs Play and Activities Children under 4 years of age are unlikely to be
able to adequately perform exercises as their concept formation and attention span are not
sufficiently developed. Active movement therefore can only be achieved by utilising the child's
inherent drive to play. Selection of age appropriate activities may enable you to engage the
child and elicit the desired movement. For example, using a 2 year olds love of water play, small
foam sponges can be squeezed creating bubbles, to encourage flexor tendon glide. Passive
mobilising techniques should be utilised with caution. It is often difficult to separate genuine pain
from anticipated pain when passively mobilising a child.
Oedema Control The use of Coban and pressure bandages on fingers is contraindicated in
younger children because they are unable to clearly indicate pain or paraesthesia if it is applied
too tightly. Individually fitted and sewn lycra finger stalls provide the most reliable pressure.
Scar Management As with adults, scar formation and management in children is influenced by
the skin type, the site of the scar, the presence and thickness of grafts and the duration of
wound healing. The application of mechanical pressure and stretch using pressure garments,
splintage, firm massage and manual stretching of the scar are employed to minimise
contracture development and hypertrophy. The increasing use of silicone products in the
treatment of scars has seen an effective reduction in hypertrophy. They are particularly effective
when used where soft tissue and concave surfaces on the hand limit the effectiveness of
pressure therapy.
Soft Tissue Injuries Many wounds can be directly closed without complication if the outlined
principles are followed. Heavily contaminated wounds from animal or human bites or lawn
mower injuries demand particularly thorough surgical cleansing, as well as appropriate
prophylactic antibiotics. Skin loss is ideally reconstructed (in suitable wounds) with full thickness
skin grafts. Given good take, they contract little and, in fact, grow with the patient. If amputated
segments of pulp are available, they can be reattached as composite grafts if they have been
minimally traumatised and have been appropriately preserved. Partial or complete defatting
increases the chance of take. Split skin grafts and linear scars on the volar aspects of the digits
may result in progressive contracture demanding release, inlay full thickness grafting or, simply,
Z plasties. Skin graft donor sites should be inconspicuous. Full thickness grafts are ideally taken
from the groin lateral to potentially hair bearing skin. Split skin grafts are taken from the buttocks
or from non weight bearing sole in racial groups prone to hyperpigmentation. Sometimes local
flaps such as cross finger and thenar flaps and rarely microsurgical free tissue transfer are
indicated. Pedicled distant flaps such as groin flaps are very poorly tolerated in young children.
Table 6: Skin & Pulp Loss
Less than 1 cm sq:
Dress, second intention healing
Greater than 1 cm sq: Consider grafting (or just dress?)
Split skin (will contract)
Full thickness skin (may pigment)

Thick split skin from hypothenar eminence or non weight

bearing sole
Replace any available lost skin after debridement and partial or complete defatting
Burns Compared with adults, the relatively thinner and more delicate structures in a childs
hand predisposes it to deeper thermal injuries. Exploring fingers frequently sustain contact
burns, as well as electrical injuries. Initial dressings may be applied in the form of a boxing
glove, incorporating and covering all digits. Deep partial and full thickness dorsal wounds are
resurfaced with split skin grafts. Metacarpophalangeal joints may need to be temporarily fixed
in flexion with K-wires. Well demarcated and obviously full thickness palmar wounds are
excised, and if conditions are suitable, grafted with full thickness skin. Split thickness grafts
should be avoided on the palm as they are subject to marked contracture. In general, the
treatment of palmar surface burns is more conservative than in other areas, relying heavily on
initial, as well as long term splinting. Full thickness inlay grafting is often required to treat
acquired syndactyly, flexion and extension contractures. Even after very satisfactory primary
treatment, the effects of growth and hypertrophic scarring in a child increases the need for
secondary surgery.
Fingertip and Nail Bed Injuries If these extremely common injuries are meticulously cleansed,
conservatively debrided and closed, they usually do very well. Sub optimal treatment or worse
still, the failure to recognise the significance of dislocation of the nail plate from the proximal nail
fold may result in infection, granuloma formation, osteomyelitis, epiphyseal arrest and
deformities of the nail bed and the distal phalanx. After removing the nail, 6/0 chromic cat gut is
used for accurate approximation of the nail bed under magnification. The adjacent skin is closed
( also with fine cat gut), the nail is replaced and a dressing, plaster and sling are applied for
three weeks. (2) A small part of the tip should be able to be inspected for congestion or
infection. As these usually involve compound fractures of the distal phalanx, perioperative
intravenous Flucloxacillin, followed by five days of oral antibiotics, may be indicated.

Table 7: Nail Bed Injuries

Remove nail plate atraumatically
Thorough lavage
Conservative debridement
Treat any associated open fracture
Meticulous nail bed repair (6/0 cat gut)
Repair associated skin wound
Replace nail plate
Full volar plaster slab and sling
Open Composite Injuries Fortunately these severe and sometimes mutilating injuries are
uncommon in children. All of the previously described principles must be followed. After skeletal
stabilisation has been achieved, often with simple Kirschner wires, all divided structures should
be primarily repaired. Hypodermic needles may also be used instead of K-wires for short term
osseous fixation. Rapid bone healing, remarkable potential for reinnervation and the absence
of generalised stiffness are favourable factors. Rarely it is possible to start early passive
mobilisation. The enhanced healing potential of children probably results in more florid
adhesions about repaired tendons particularly when the surrounding soft tissues and the
subjacent bones and joints have been damaged.
Fractures and Joint Injuries Skeletal injuries in children often involve the relatively weaker
cartilaginous growth plates. These are found proximally in the phalanges and homologous first
metacarpal and distally in the other metacarpals. The epiphyses ossify between 2 and 4 years
of age. The carpal bones ossify from 3 months to 5 years with the sequence of capitate,
hamate, triquetrum, lunate, scaphoid, trapezium and trapezoid with the pisiform appearing at 10
years .
Salter and Harris (3) have classified growth plate (physis) injuries as follows.

Type I

Separation of the epiphysis and physis from the metaphysis with or

without displacement.
Type II
Separation of the epiphysis and physis with an attached
fragment of metaphyseal bone hinged on periosteum.
Type III Intra articular fracture.
Type IV Unstable intra articular fracture passing through the epiphysis,
and metaphysis.
Type V Undisplaced compression fracture or contusion of the physis causing
growth disturbance and possible progressive deformity. The
periphery of the growth plate may be the most sensitive to this type
of injury.


In types I, II and III the plane of cleavage is through the junction between the calcified and
uncalcified zones of the physeal cartilage. The proliferating cells remain attached to the
epiphysis. Growth in this zone will continue if the growth plate has not been crushed and if the
epiphyseal blood supply is adequate. A bony bridge may develop across the epiphysis
particularly in type III, IV and V injuries or as or as a result of internal fixation. This may result in
progressive angulation with growth of the adjacent uninjured physis.
Types I and II, which are the commonest, can usually be treated with closed reductions, are
relatively stable and unite quickly. Types III and IV usually require open reduction and internal
fixation to restore joint surface congruity and to ensure stability. Type V is often diagnosed
retrospectively to explain growth plate arrest. X-rays soon after injury may appear normal.
Knowledge of the sites of tendon insertions and ligament attachments not only explain
displacement of epiphyseal fractures but assist with planning the most appropriate treatment.
Epiphyseal fractures may be displaced by the traction applied by the opposing flexor and
extensor tendons. Displaced fractures may also be caused by the interplay of lateral impact
and the relatively strong collateral ligaments. Remodelling can only occur in those fractures
angulated in the line of pull of the tendons, that is palmar-dorsal angulation, particularly near the
growth plate. Fractures of the phalangeal neck remodel poorly. Lateral angulation and rotational
deformity will not remodel and requires adequate reduction (4,5). Remodelling is more likely in
metacarpals than in phalanges. Younger children tend to sustain Type I Salter-Harris fractures
of the distal phalanx producing a mallet finger deformity. These are frequently compound and
often disrupt the proximal (germinal) nail bed dislocating the nail plate from the proximal nail
fold. Adolescents tend to avulse only part of the epiphysis to produce a Type III injury. Adults
more commonly rupture the terminal extensor tendon but may also avulse a small bony
Open reduction, usually with internal fixation is indicated when an unacceptable deformity
cannot be reduced or is unstable. Fixation techniques include K-wiring, interosseous wiring,
and uncommonly in children , mini and microplate fixation. The finest suitable K wires, usually
size 28 (28/1000 inch = 0.7 mm) or size 35 (35/1000 inch = .88 mm), are passed as
atraumatically as possible to avoid adding a further mechanical or thermal insult to the injury.
Epiphyseal growth plates can tolerate judicious transfixation with K wires, particularly if they are
centrally located and are removed as soon as adequate union has been achieved. Titanium
plates with screws of less than 1 mm in diameter are now readily available.
Table 8: Hand Fractures in Children
Frequently involve growth plates
Potential for growth disturbance
Type I and II usually need closed reduction
Type III and IV usually need open reduction and fixation
Reduce fractures if:
moderate A-P angulation
slight lateral angulation
rotational deformity
Fix fractures if unstable (usually K-wires, e.g. Size 28, 0.7 mm diametre)
Open the fracture if closed reduction fails or to ensure anatomical reduction of joint surface
Tendon Injuries The operative treatment of both flexor and extensor tendon injuries is the
same as for adults. Flexor tendons are repaired with 4/0 or in smaller hands, 5/0 polyester
using a modified Kessler technique. This is often completed with a continuous epitenon 6/0

nylon suture. Flat extensor tendons are usually repaired with a horizontal mattress suture. It is
assumed that adhesions in Zone II and possibly tendon rupture is more common in younger
children who cannot either comprehend or co-operate with sophisticated programmes of hand
therapy. A number of studies suggest that this is not the case if either a regimen of early
passive movement or later active mobilisation (no later than four weeks) is followed. (6) (7) (8)
Kleinert dynamic traction for zone II repairs requires consistent self monitoring of finger position
and frequent active extension exercises within a plaster or splint. A child younger than 10 years
is generally unable to sustain the commitment necessary for a successful programme of
Kleinert dynamic traction.
A modified Duran passive mobilising programme requires less frequent but careful passive
finger flexion followed by active extension within a plaster or splint, with immobilisation at other
times. This programme can be successfully applied to most children over 5 years. An essential
requirement, however, is a competent supervising parent or carer who has been trained to
administer the mobilising programme.
In children under 5 years (and those deemed unsuitable for Kleinert or modified Duran
programmes), total immobilisation for a maximum of 4 weeks followed by graded supervised
movement is necessary. Immobilisation in the post surgical plaster is most appropriate and may
incorporate the elbow joint for greater security. After 3 to 4 weeks the plaster should be
removed and a thermoplastic dorsal blocking splint fitted. The child should initially wear the
splint at all times except when it is removed for brief periods of supervised activities,
encouraging flexor tendon glide several times each day. Over the next 2-3 weeks there should
be gradual upgrading of the movement demands and a decrease in the duration of splint
wearing, while still protecting the repair in high risk situations. As with adults, any contractures
that develop need to be corrected by controlled stretching and splinting.
Nerve Injuries Following direct repair or grafting of peripheral nerve injuries, children recover
remarkably good sensation and motor reinnervation. Children under five years of age can
achieve normal two point discrimination following nerve repair.(7) (9).Either 9/0 or 10/0 nylon
epineural sutures are used to accurately approximate nerve ends. Until protective sensation
develops, children should be prevented from injuring insensate extremities.
Vascular Injuries The first aid measures of elevation and accurately applying pressure directly
to a bleeding artery with dressings and a firm bandage, will usually avert the need to either
ligate the vessel or apply a tourniquet. Inexperienced personnel should avoid trying to blindly
clamp a bleeding vessel in the depths of a wound. A pneumatic tourniquet or blood pressure
cuff should be applied with pressure just above systolic, if more proximal control is necessary.
An estimate of the amount of blood lost in relation to the calculated circulating blood volume, as
well as careful assessment of the child's haemodynamic status will determine the urgency for
intravenous resuscitation prior to prompt transfer to the operating theatre. Children and young
adults may compensate well for quite a large loss of blood volume just prior to sudden
circulatory collapse once hyporvolaemia becomes critical.
Under anaesthesia, the application of non crushing vascular clamps to the vessel allows for the
distal extremity to be assessed for adequacy of perfusion by deflating the tourniquet. Limb or
digital ischaemia obviously necessitates either direct vascular repair or vein grafting. It can be
argued that a divided forearm or digital artery should be repaired if this can be achieved with
relative ease despite the adequacy of perfusion via the other intact artery. Forearm vessels are
repaired microsurgically with either interrupted 8/0 or 9/0 nylon sutures and digital vessels are
repaired with 10/0 or 11/0 nylon sutures. Prophylactic fasciotomy should be considered if
muscle ischaemia time exceeds 4 to 6 hours.
Compartment Syndromes All children sustaining significant closed trauma such as fractures
and even significant contusions should be assessed for increased compartment pressures.
Small penetrating wounds associated with arterial injuries can very quickly develop into a
compartment syndrome. This is particularly important for very young children and those with
multiple injuries who are unable to localise or communicate their discomfort. Pain, swelling,
paraesthesia and most importantly, pain on attempting to stretch the involved muscle groups

are key features. The intrinsic muscles are stretched by flexing the interphalangeal joints with
the metacarpophalangeal joints extended. Clear clinical evidence of a compartment syndrome
demands urgent fasciotomy and when indicated, carpal tunnel release. Incisions should be
planned to provide access for internal fixation of associated fractures but to avoid exposure of
vital structures. Intracompartmental pressure measurement may be helpful when clinical
assessment is difficult. (10) (11) The Stryker 295 Intracompartmental Pressure Monitoring
System is an easily used commercially available device (Stryker Instruments 4100E Milham,
Kalamazoo, Michigan 49001, USA). If in doubt, decompress. The cost will be a scar. A
Volkman's contracture is a very high price for a missed diagnosis.
Amputations Every effort should be made to replant complete amputations of the thumb, hand,
forearm and possibly at higher levels, depending on the mechanism of injury and the period of
ischaemia to the muscles. Compared to adults, the prognosis for sensory and motor recovery is
relatively good assuming that the muscle fibres in the replanted part survive. Similarly, multiple
digits, and in many paediatric cases, single digits should be replanted if it is technically feasible.
Problems of generalised stiffness of the involved hand and issues of time off work are not
important considerations in children. Adherence of repaired tendons, stiffness of injured joints
and growth disturbances are common. Very distal replantations, particularly beyond the distal
interphalangeal joint, do well cosmetically and functionally. Ideally two vessels are identified for
repair. At this level it is difficult to distinguish between arteries and veins, however, the veins
are often found just deep to the volar pulp skin. Digital nerves have ramified and may not
warrant repair. It is often only possible to use four 10/0 or 11/0 sutures in these 0.5mm vessels.
Venous congestion following single vessel repair can be relieved either by encouraging
bleeding from the skin edge, pulp or nail bed. Small quantities of heparin (100 units in 0.02 mls)
can be injected into the site of "chemical leeching" with an insulin syringe.(12) Alternatively,
leeches may be used with the associated increased risk of aeromonas hydrophilia and other
gram negative infections. Continuous bleeding to relieve ongoing venous congestion whilst
awaiting the establishment of a capillary network, frequently results in anaemia and the need for
transfusion. This should be explained to the parents before such treatment is undertaken and
the haematocrit should be checked twice daily.
Finger tips replaced as composite grafts are frequently disappointing and the mummified
failures often take many weeks to separate. Occasionally they are successful and it is reported
that cooling the part during the first three days improves success.(13) The chance of a small
part such as the tip beyond the mid nail bed taking as a graft, are greater. It also functions as a
"biological dressing" for the conservative treatment of distal amputations if it fails to take.
Children under five, and particularly, under two years of age can spontaneously heal distal
transverse amputations with remarkably good cosmetic and functional results. The raw surface,
including exposed cancellous bone granulates rapidly prior to epithelialisation from the skin
edges which also contract, to give very a satisfactory tip.
Table 9: Amputation (with exposed bone)
Less than 5 years (or possibly older): Dress, second intention healing
Consider reattach as a composite graft if at level of proximal nail bed
local flaps e.g. V-Y advancement
regional flaps e.g. cross finger or thenar flaps
Aim to preserve length and avoid shortening the bone to simplify skin closure
Secondary Surgery Treatment for children with delayed presentations of nerve and tendon
injuries should be planned after careful assessment. Young children may achieve good
spontaneous recovery following digital nerve injury. Tactile adherence should be carefully
checked. The scarred ends of completely divided nerve trunks are usually separated to an
extent that necessitates nerve grafting. The retracted proximal stump of a divided or avulsed
flexor tendon may, at times, be salvaged by a sharp, accurate dissection from within the palm.
Further proximal dissection in the form of a tenolysis and a period of sustained traction applied
via a strong suture, may stretch out intramuscular fibrosis and allow for a direct repair within the
pulley system once the flexor sheath has been teased open and dilated. Wrist and
metacarpophalangeal joint flexion minimises the tightness of the repaired flexor. The finger

should be serially splinted into extension in the months following sound tendon healing.
Alternatively, secondary repair with staged tendon grafting may be indicated. This may also be
considered for tendon repairs that have either ruptured or have become densely adherent and
are not remediable with tenolysis.As the results of staged tendon grafting may be less reliable in
children, one should carefully consider the possible functional gain in the single digit with intact
flexor digitorum superficialis function. Clearly profundus function should be reconstructed when
both flexor tendons have been lost. One may choose to passively maintain a full range of
interphalangeal joint motion whilst awaiting cognitive and psychosocial maturation that occurs at
about 5 years of age. This will allow for co-operation with the all important post operative
regimen of therapy to maximise gliding of the grafting tendon within it's sheath. Tendon transfer
such as a ring or middle finger superficialis can very effectively restore flexor pollicis longus
Conclusion Apart from the considerations of size and potential growth, the technical aspects of
repair are the same for children as they are for adults. Inadequately trained surgeons can cause
irreversible harm through scar, contracture and deformities which may become progressively
worse through growth. In an emergency, make a diagnosis, clean the wound, stop the bleeding
and splint the hand prior to referral to a centre where there is an experienced paediatric hand
surgeon with the support of paediatric nurses and hand therapists. The administration of post
operative care and consent for secondary procedures must be obtained from the parents. An
understanding of the sensorimotor, cognitive and psychosocial developmental stages of
children, assists the surgeon and the hand therapist to provide a suitable programme of post
operative management that will optimise the functional results.
Table 10: Complications of Hand Injuries in Children
Displacement of reduced fractures
Rupture of repair e.g. tendon
Graft or flap failure
Scar contractures
Nail bed and finger tip deformities
Skeletal deformities
Tendon adhesions
Victorian Injury Surveillance Systems, June 1994.
Monash University Research Centre, P.O. Box 197, Caulfield East 3145.

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Wakefield A.R.
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B. J. of Plas. Surg. 1989, 42: 556-558
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