Patient Presentation
A 10-year-old male came to the emergency room 24 hours after getting his thumb caught in another player’s football helmet. It was painful and swollen, despite some ice treatment. He was otherwise well. The pertinent physical exam showed a healthy boy whose dominant right thumb was swollen at the thenar eminance without bruising. The thumb was not in an abnormal position. He was able to move all the thumb joints but had pain especially with flexion. There was no pain in the anatomic snuff box and his sensation was intact. There was no laceration and the other fingers and rest of the hand was normal. The diagnosis of a soft tissue injury after trauma was made. Because of the location, a splint was placed for comfort and protection from additional injury. The family was advised to take the splint off and gently move the thumb. Ice and elevation was also recommended. The family was to return to their regular physician if symptoms worsened or did not seem to be improving in 3-5 days.
Discussion
The thumb has two phalanges anda metacarpal and articulates with the trapezium bone in the wrist. It gives humans prehensile abilities. Children can be difficult to examine because of their developmental age including non-compliance, fear and ability to understand. Pain also does not help the examination. Pain, decreased range of motion and swelling along with abnormal position may indicate a fracture or dislocation. Crepitus and abnormal skin findings such as dimpling, and a filled in normal crease may indicate a more serious problem.
Almost all injuries are treatable by immobilization and as necessary surgical treatment with open reduction and possible fixation. If there is doubt about the treatment, a referral should be made to the appropriate local resource such as an orthopaedic or hand surgeon. Outcomes are related to the amount of energy causing the injury. Low energy usually has very good outcomes, while higher energy is more variable because there often is more extensive damage including the physis and intraarticular surfaces. Complications include loss of motion because of immobilization (usually amenable to range-of-motion exercise), decreased function, stiffness and/or degenerative posttraumatic arthritis.
Learning Point
Fractures
Distal phalanx injures are often crush injuries. If it is only the distal phalanx that is fractured, then repair of any laceration with careful attention to nailbed repair if needed usually gives appropriate realignment of the fracture. A transverse distal phalanx injury may be unstable and require surgical treatment.
Hyperflexion injuries can cause Salter-Harris fractures. Salter-Harris fractures, especially type I and II often found in children, can often be treated with splinting if the displacement and angulation are small. Displaced physeal injuries should be referred. Salter-Harris fracture type III is more common in adolescents and may require surgical treatment with open reduction and fixation.
Proximal phalanx fractures often angulate and may rotate because of the phalanx’s intrinsic muscles. If the displacement and angulation are minimal then splinting with followup in 3-5 days is usually appropriate. If there are concerns about the angulation or displacement then the patient should be referred.
Mallet thumb (mallet finger is sometimes called baseball finger) is caused when the extensor tendon is injured. It is usually treated with splinting for several weeks.
Gamekeeper or skier’s thumb (caused by falling onto ski poles) is an avulsion of the ulnar collateral ligament of the proximal phalanx. Falling onto bike handlebars is also a common cause. This is usually treated with casting but may require surgery.
Thumb metacarpal fractures of the neck or shaft usually are treated like other phalanx injuries. Metacarpal base fractures often require surgical fixation because of the physis and/or intraarticular involvement.
Disclocations
Dislocations are often hyperextension injuries. The proximal interphalangeal joint is usually easily reduced. Metacarpal-phalangeal dislocations are more difficult and may require surgical reduction. Any dislocation that appears to be unstable after more conservative treatment may require surgical treatment. Surgical treatment is usually indicated if there is a dislocation that is not reducible, or the joint is unstable after relocation, or if there is an open injury or a chronic dislocation.
Questions for Further Discussion
1. What are indications for radiographs of the hand?
2. Why is the vaccination history important for a child with a hand injury?
Related Cases
- Disease: Finger Injuries and Disorders
- Symptom/Presentation: Upper Extremity Trauma
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Finger Injuries and Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:681-682.
Kozin SH. Fractures and dislocations along the pediatric thumb ray. Hand Clin. 2006 Feb;22(1):19-29.
Laub DR, Priano SV. Thumb Fractures and Dislocations. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/1287814-overview (rev. 9/7/2010, cited 10/4/2011).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 