Pediatric Sports Injuries of the Wrist and HandSunni Alford, OTR/L,CHTPreferred Physical Therapy

Wrist injuriesTFCC

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 weight-bearing. As we evolved the ulna retracted and was replaced with the TFCC.

Triangular Fibrocartilage ComplexPalmar and Werner introduced term TFCC 1981

Structures include:

Articular discMeniscus homologuePrestyloid recessDorsal & volar radioulnar ligaments

TFCC

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)

Central disc is avascular and

aneural.

Conservative management0-6 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

F

Functional Orthotics

The Wrist Widget

ECU Tendonitis

Immobilize with splint for 6 weeks

Gentle PROM twice a day (FCU tendonitis similar)

Snap wristDamage to the ECU sheath.Painful snapping with forearm rotation.Immobilize-sugar tong/long arm elbow.

Carpal Instability Ligament laxity Ligament sprains and tears

Pisiform Boost

Terry Skirvin: Philadelphia Hand Center

Terry Skirvin’s Pisiform Boost

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 ChallengesMetal 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 22 degree Ulnar Positive incline.

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

FootballMallet 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

FootballMallet 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 PIPJCollateral 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.

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

Recommended Web Sites

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/21272714 www.freehandbrace.com : mallet splint pattern Wrist Widget: Sammons and Preston www.wristwidget.com

Thank You!Preferred Physical Therapy712 1st TerraceLansing, KS 66043 913-727-2022