Paediatric Hand Trauma: Fractures

Paediatric Hand Trauma: Fractures
Paediatric Hand Trauma:
- Burns, replants and nerve injuries
Occupational Therapy Department
The Royal Children’s Hospital
Melbourne, 2014
Presentation outline
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Paediatric specific considerations
Burns
Replants
Nerve injuries
Paediatric specific considerations
• Healing time frames
• Impact of growth on scarring
• Inability to specify or verbalise pain
• Behaviour and occupations
• Inability to follow instructions-rehabilitation compliance
difficult
• Mobility - stiffness not usually an issue
• Grafting infrequently required
• Prone to hypertrophic scarring
Burns: Incidence
Highest incidence: 0 - 4 age group
• Burns in this age group typically occur in the home.
Common causes are hot drinks, kettles, hot tap
water/water on stoves, heaters irons and ovens
• Thought to be attributable to the child’s impulsiveness,
curiosity, lack of awareness and high activity levels
• Upper body frequently affected, associated with
exploration of surroundings eg. pulling, touching,
grabbing and throwing objects
Burns: therapeutic management considerations
A thorough history is important to guide clinical decision making. The
following represent considerations that may impact upon your care plan:
• Mechanism of injury
• Contact/exposure time to heat source
• Thermal level
• Age
• Tissue type
• Time to medical attention
• First aid
• Co-morbidities
• Nutritional status
• Developmental and behavioural factors
• Support network and environment
Burns: therapeutic management considerations
Location is important as it provides information such as:
• Proximity to flexor creases or joints
• Skin type; for example glabrous or non-glabrous
• Areas of shallow subcutaneous fat deposition related to the skin-to-
bone interface
• Patterns of relaxed skin tension upon problematic scar development
Depth is important as it provides information as to:
• Cutaneous structural destruction
• Possible subcutaneous structural involvement
• Adnexal structures included and their possible impact upon healing
eg. injury to hair follicles may impact upon keratinocyte migration
Depth is difficult to definitively evaluate in the first 72 hours and the concept of
‘Burn Wound Conversion’ is crucial to consider. This concept forms the basis
of Jackson’s Burn Wound Model.
Jackson’s Burn Wound Model
Burn wounds have the unique ability to convert from one burn wound
depth to another within days of the initial injury. Jackson’s Burn Wound
Model is an important theoretical model that therapists use to manage
injuries. This model proposes that the extent of an may be affected by
how we primarily manage oedema and associated ischaemia.
Zone of coagulation:
Area of closest contact with heat
source. Denatured proteins and blood
vessel coagulation create necrotic
tissue
Zone of hyperaemia:
Minor cell damage but significant
vasodilation due to an acute
inflammatory response
Zone of stasis:
Strong inflammatory response potentially salvageable
Burns: therapeutic management –
acute care considerations
Primary goals:
• Oedema management and ischaemia control
• Pain management
• Wound protection
• Protect healing structures and avoid
contractures- Antideformational positioning
• Facilitate mobilisation and return to ADL’s
when indicated
Therapeutic modalities:
• Dressing design
• Mobilisation
• Elevation
• Splinting
• Adaptations to enable ADL participation
Burns: therapeutic management –
post surgical considerations
Surgical management such as debridement, grafting, amputation or
flaps/plasties may be required. Surgery assists with acute healing
phase or with scar revision down the track.
A therapist may be required to provide:
• Oedema management
• Wound and primary dressing protection
• Positioning
• Splinting/Casting
• Pin site protection
Positioning, elevation, splint wearing regimes
and follow-up timeframes will depend on the
individual case, therefore liaison with all team
members is vital.
Burns: Scar management
Scar management may be a long-term undertaking and needs to be
tailored to the individual, according to the scar site and characteristics,
child’s age, co-morbid dermatological diagnoses (eg. eczema), nutritional
status, and ability to adhere to recommendations.
Common management strategies:
• Positioning under tension eg. splinting
• Traction eg. taping
• Manual tissue manipulation eg.massage
• Emollient
• Contact media eg. silicon products
• Mobilisation eg. exercises, play, ADLs
Common scar types:
• Hypertrophic
• Keloid
• Contracted
• Widespread
• Mixed composition
• Atrophic
• Normotrophic
Replants
• Replantation attempted in most cases, unless
severely damaged
• Amputations away from growth plates have
potential for longitudinal growth following
replantation
• Generally good outcomes achieved
Goals of therapy:
• Protect healing structures
• Return to normal hand function
• Protect from damage to insensate parts
Nerve injury: considerations
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Faster regeneration in children than in adults
Danger of injury
Fewer problems with stiffness and contractures
Adaptive behaviours
Assessment challenges
Functional splinting to enable occupational
performance participation
Case study: Lewis
Social history: Eight year old boy, Grade two student, LHD.
Likes swimming and playing mindcraft
History of presenting condition: Left supracondylar fracture
post fall on stairs
Referred to OT: 12 weeks post initial surgery (GAMP and Kwires, K-wires removed six weeks ago)
Occupational performance Issues: Difficulty picking up and
using cutlery, difficulty eating and drinking with his left
hand, difficulty using Ipad, unable to tie his shoes and
difficulty turning pages in a book
Case study: Lewis continued
Week one - Initial assessment:
• Gathered background information
• Assessment:
• Sensation: “Numbness” throughout thumb and index
finger
• ROM: No active thumb abduction or opposition. Full
passive range digits and thumb
• Strength: Reduced strength index finger flexor
digitorum profundus (FDP) and thumb flexor pollicis
longus (FPL)
• Conclusion: Median nerve and anterior interosseous
nerve palsy
Case study: Lewis continued
Week one - Initial assessment continued:
• Treatment:
• Splint/function: Fabrication of a hand-based
thermoplastic thumb splint to assist with writing and
grasping small objects during function. Full passive
range so no splint indicated for night use at present
• ROM: PROM exercises to maintain joint range
• Education: nerve regeneration and safety in regards
to sensation changes
Case study: Lewis continued
Week three:
• Assessment:
• Sensation: Hypersensitivity and tingling throughout
median nerve distribution
• ROM/Strength: Now has active radial and palmar
abduction and weak opposition (able to hold against
gravity once placed in opposition). Full passive range
digits and thumb
• Function: Lewis reporting improved functional capacity
with splint in situ – nil limitations reported at this stage.
Tends to exclude index finger from tasks requiring
pinching
• Conclusion: Improvement in nerve innervation/
regeneration
Case study: Lewis continued
Week three continued:
• Treatment:
• Splint/function: Begin to wean splint. Encouragement
to incorporate left hand into function as much as
possible – particularly with fine motor tasks
• ROM: AROM exercises incorporating newly
innervated muscles. Buddy strap index and middle
finger to decrease exclusion of index finger
• Sensation: Desensitisation
Case study: Lewis continued
Week six:
• Assessment:
• Function: Nil occupational performance issues identified
with splint in situ. Some reduced speed and quality of
tasks with splint off however improved since initial
assessment
• Strength: Increased opposition strength
• Sensation: Tingling throughout median nerve distribution
diminished
• Treatment:
• Continue AROM and strengthening
• Plan:
• Monthly reviews to monitor progress and treatment plan.
General therapeutic games and
activity ideas for burns, replants
and nerve injuries
Flexion
Extension
Thumb
Occupational Therapy Department
The Royal Children’s Hospital
Flemington Road
Parkville 3052
Phone (03) 9345 9300
With thanks to Tanya Cole, Simone West and Josie
Duncan
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