Pediatric Sports Injuries of the Wrist and Hand

1. Pediatric Sports Injuries of the Wrist and Hand Sunni Alford, OTR/L,CHT Preferred Physical Therapy

2. Wrist injuries TFCC ECU/ FCU tendonitis Instability Growth Plate Fractures Ulnar abutment syndrome

3. 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 Complex Palmar and Werner introduced term TFCC 1981 Structures include: Articular disc Meniscus homologue Prestyloid recess Dorsal & volarradioulnar ligaments

4. Central disc is avascular and aneural. 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)

5. 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.

6. 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

7. 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

8. 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 the TFCC. • 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

9. Long arm elbow splints Sugar tong Muenster Long arm static Should prevent pronation and supination

10. Functional Orthotics F The Wrist Widget

11. 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.

12. Carpal Instability • Ligament laxity • Ligament sprains and tears

13. Terry Skirvin’s Pisiform Boost Pisiform Boost Terry Skirvin: Philadelphia Hand Center

14. Dart Throwing ROM

15. 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 surroundingligaments and tendons. • Injury that would result in a joint sprain for an adult can cause a growth plate fracture in a child.

16. 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.

19. Salter Harris Classification of Growth Plate Fractures High risk for growth arrest

20. 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.

21. Ulnar Positive • Normal 22 degree Ulnar Positive incline.

22. Finger Injuries • Jersey finger • Mallet finger • Dislocations

23. Tendon Injuries in the Finger • “Jersey finger”—laceration of theflexor 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

24. 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).

25. Flexor Tendon Zones of the Digits

26. Jersey Finger • Zone I Flexor Tendon Injury

27. 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

28. Extensor Zones

29. Mallet Finger

30. 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 volarsubluxation of the distal phalanx

31. Conservative treatment of mallet finger

34. 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.

40. 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

41. 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).

42. 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

43. Thank You! Preferred Physical Therapy 712 1st Terrace Lansing, KS 66043 913-727-2022