Common Hand & Wrist Injuries - scripps.org · Snuff box tenderness
12162015 presentation of hand and wrist injuries
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Bringing Basic Orthopedic and Concussion Care to the Pediatric Medical Home: PPOC/CHICO Learning Community & Integration Program © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] Didactic Session #3 Hand and Wrist December 16, 2015
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Transcript of 12162015 presentation of hand and wrist injuries
Bringing Basic Orthopedic and Concussion Care to the Pediatric Medical Home:PPOC/CHICO Learning Community
& Integration Program
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Didactic Session #3 Hand and Wrist
December 16, 2015
Disclosure
We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods
or services consumed by, or used on, patients relevant to the content we are planning, developing, presenting, or
evaluating.
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Barry Zallen, MDChief Medical Officer
Children’s Hospital Integrated Care [email protected]
Louis Vernacchio, MD, MScPediatrician, Longwood PediatricsDirector of Research and Analysis
Pediatric Physicians’ Organization at Children’[email protected]
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Madeleine Kuhn, MPHProgram Coordinator
Children’s Hospital Integrated Care [email protected]
Peter Waters, MDOrthopaedic Surgeon-in-Chief
Boston Children’s Hospital
Course Directors
Follow-Up Emails and Course Work
Please make sure you are receiving course emails from [email protected]
If you would like a specific email address to receive update emails contact us
They will be sent out every other Monday with documents discussed in webinar, surveys, and upcoming information.
ORTHOPEDIC AND CONCUSSION LEARNING COMMUNITY NEWSLETTER AND UPDATES
We Recommend Printing These NewsLetters and Any Attachments
Updates
The Didactic Webinar scheduled on Thursday 12.10.2015 has changed to: Wednesday 12.16.2015 from 7 am to 8:30 instead of 7:30 to 9.
New Schedule Below and in attach.
We understand that this may pose disrupt clinic and we count the below as attendance:
1. An email after watching the link
2. Blackboard login watches
Please remember to fill out the post-survey after you watch the Webinar. It helps us improve and counts towards CME credits.
Next Webinar: Thursday, October 29, 2015, from 7:30 – 8:30 am with Dr.
Coursework
Process mapping: The assignment is on Blackboard. You can access it by clicking the Blackboard link above and typing in your username: [bch.firstinitiallastname] and password.
Process Map Instructions
Process Map Worksheet
You can email or fax this document to Madeleine Kuhn or upload this document on Blackboard
Fax: 617-730-7542
Click Contact above if you have any questions.
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Learning Community ScheduleWebinars
7:30am – 8:30amDate ContentThursday, June 11, 2015 Concussion
Wednesday, September 9, 2015 Foot and Ankle
Wednesday, December 16, 2015 Hand and Wrist
Wednesday, February 24, 2016 Everything Knee
DateWednesday, July 15, 2015
Thursday, August 13, 2015
Thursday, October 29, 2015
Thursday, March 24, 2016
Wednesday, April 27, 2016
Didactic Webinars7:30am – 9:00am
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
In-Person Sessions7:00am – 9:00am, BCH Waltham
Date ContentWednesday, January 20, 2016 Practical Session
Wednesday, May 25, 2016 Practical Session
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Agenda 1. Welcome and review
2. Hand and wrist anatomy and common injuries
3. Review of Hand and Wrist Algorithm
4. Coursework, next session, and wrap-up
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Upper Body Orthopaedics
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Hand and Wrist Exam
• Exam conducted by Dr. Bae from Boston Children’s Orthopedic group
• Link to videos is included in follow-up email and on Blackboard in Orthopedic Folder(There are 3 parts)
Office Examination for Hand and Wrist
Peter Waters, MDBoston Children’s Hospital
Objectives
• Anatomy & physical examination of child’s hand and wrist
• Clinical findings of common upper extremity conditions
• Treatment principles, indications for referral
Orthopedics “Principles”
• Orthopedics injuries hurt
• Anatomy is everything
• Consider intrinsic and extrinsic causes of pain
• Trauma, sports, overuse
Physical Exam of Hand and Wrist
Hand
• Challenges in examination
• Presence of Physis
• Small musculoskeletal structures
• Most restrictive immobilization
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Hand
• History: mechanism of injury
• Examination: tenodesis– Finger malrotation with
proximal phalanx fracture
• Radiographs: appropriate imaging of affected part
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Hand
Efficient examination
• Inspection• Tenodesis• Tenderness• Flexor-extensor function• Nerve function
Wrist
• Complex anatomy– Bones– Soft tissue structures– Patients
• Common conditions– Sprains / strains– Fractures– Physeal stress injuries
Wrist
• Efficient examination:– Inspection (ganglia)– ROM– Snuffbox tenderness– Joint stability
• Specific maneuvers:– Snuffbox tenderness
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Wrist
• Range of Motion
– Flexion-extension
– Supination-pronation
– Radial-ulnar deviation
Wrist
• Tenderness
– Radius & ulna
– Hook of hamate
– Scaphoid
– Tendons
– Ligaments
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Management of Common Injuries of the Hand and Wrist
Tiered Level Approach
• Office Evaluation
• Office Care
• Referral– Evaluation– Testing Decisions – Testing Interpretation– Treatment– Follow up
• Comfort Level
• Competency
• Subspecialty Alternatives
Radiographs for Hand / Wrist Injuries• AP/Lateral/Oblique
• Focused to zone of injury/exam findings– Finger
• Specify digit/s– Thumb– Hand– Wrist– Scaphoid
• Include details of point of maximal interest
• Wider field if less specific
Radiographs for Hand / Wrist Injuries• AP/Lateral/Oblique
• Focused to zone of injury/exam findings– Finger
• Specify digit/s– Thumb– Hand– Wrist– Scaphoid
• Include details of point of maximal interest
• Wider field if less specific
Radiographs for Hand / Wrist Injuries• AP/Lateral/Oblique
• Focused to zone of injury/exam findings– Finger
• Specify digit/s– Thumb– Hand– Wrist– Scaphoid
• Include details of point of maximal interest
• Wider field if less specific
Radiographs for Hand / Wrist Injuries• AP/Lateral/Oblique
• Focused to zone of injury/exam findings– Finger
• Specify digit/s– Thumb– Hand– Wrist– Scaphoid
• Include details of point of maximal interest
• Wider field if less specific
Common Finger Injuries
Sprains and soft tissue injuries
Common finger injuries
• Finger fractures
– Non-displaced non-salter fractures• We will review buddy taping and splinting at in-person session
– Displaced or salter fractures • Require orthopedics advice / management
Displaced fractures > Reduction
Common Finger Injuries
• Mallet Finger
Mallet Finger Injury• Adolescent = adult–Soft tissue vs bony mallet–Joint must be reduced–Loss of flexion more problematic than loss of extension at DIP joint
–Most treated in a DIP extension splint, PIP free
–4-6 weeks full time splint wear, then 2 wk transition
–Rare CRPP or ORIF
Seymour’s Fracture: Nail bed
• Looks like Mallet finger• Physeal fracture• Requires ED or OR Rx
Common Thumb Injuries
• Soft tissue injuries / sprains – Thumb spica splint – Beware UCL sprains / laxity – thumb spica splint and
refer to Orthopedics • Thumb fractures
– Refer to Orthopedics
Trigger Thumb and Finger
Common Wrist Injuries
• Sprains
– Cock-up wrist splint
Common Wrist Injuries
• Distal radius fractures – If buckle fracture only, cock-up wrist splint for 3 weeks –
refer if not improving – If non-displaced fracture other than buckle fracture, apply
cock-up wrist splint and refer to orthopedics for casting – Any other wrist fractures, consult or refer to orthopedics
Common Wrist Injuries
• Scaphoid Injuries
– Poor healing due to limited blood supply – If scaphoid tenderness, even with negative x-ray, apply
thrumb spica splint and refer to orthopedics
Finger and Wrist Splinting
Will be covered in detail during January 20 In-Person session
Splints: Limitless choices
• Finger splints– Prefer dorsal to volar– Prefer to buddy tape to adjacent digit
Mallet finger splint
Preferred Technique
Useful but risky
Coban Wrap 3M(No conflict of interest)• Great product for
swelling, discomfort, rehabilitation
• Dangerous product for vascular compromise– Patient and family
education critical
Standard temporary treatment
• Wrist cockup and thumb spica splints
BCH Orthopedic Specifics
COW = Clinical Orthopedist of Week
• Covers urgent clinics
• Supports OOW
OOW = Orthopedist of the Week
• 7am ED xray rounds• 730am NPO walk ins• Surgery, ED and
emergencies all day• No elective care
Urgent Clinics
• Daily clinics Boston Waltham am and pm
• Twice a week Peabody– Tues and Wed
• South Shore – Tues
• MLP with COW Orthopedic Attending Back up
• Direct MD line– 617 355 4774
• PPOC Direct Line617 435 [email protected]
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Orthopedic Advice and Urgent Access
Orthopedic Advice and Urgent Access • Answered live between 7:00AM and 5:00PM, Monday through
Friday– Text messages and emails will be answered within 5-10
minutes during these hours• Immediate call backs for any missed calls (there are
cellphone dead spots in BCH)• If appointment needed: a scheduler from the Department of
Orthopedics will call the patient’s family or primary care practice right back to complete scheduling and registration– Appointments will be made in Boston or a BCH satellite based
upon the patient’s location, day of week and urgency
Algorithm
Red Flags
Finger
Finger X-ray Positive
Wrist
Wrist X-ray Positive
Your Feedback Helps Us Succeed!
Please take a moment to fill out the session evaluation Survey and provide us with your
feedback so that we can continue to improve and meet your expectations!
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
Learning Community ScheduleWebinars
7:30am – 8:30amDate ContentThursday, June 11, 2015 Concussion
Wednesday, September 9, 2015 Foot and Ankle
Wednesday, December 16, 2015 Hand and Wrist
Wednesday, February 24, 2016 Everything Knee
DateWednesday, July 15, 2015
Thursday, August 13, 2015
Thursday, October 29, 2015
Thursday, March 24, 2016
Wednesday, April 27, 2016
Didactic Webinars7:30am – 9:00am
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]
In-Person Sessions7:00am – 9:00am, BCH Waltham
Date ContentWednesday, January 20, 2016 Practical Session
Wednesday, May 25, 2016 Practical Session
Follow-up email will have Algorithms, videos, recording, survey, calendar and coursework information
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Thank You!
