Dr Ian Hargreaves Hand surgeon , St Luke ’ s Hospital and Sydney Adventist Hospital , Sydney , NSW , and St John ’ s Hospital , Hobart , Tasmania .

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First published online on 26 February 2021

INTRODUCTION

IN his 1974 textbook Rang ’ s Children ’ s Fractures , Mercer Rang ( 1933-2003 ), one of Canada ’ s most famous paediatric orthopaedic surgeons stated : “ Children are not just small adults .”

Although the basic structures are the same , the mechanical functions often differ , and ongoing differential growth is always relevant .

As adults , we are independent individuals with the capability of consent

. Children generally have a parent or guardian in a nurturing role until they are of an age to have complete independence . This role often involves protection , and a recurring theme is that prevention of injury and complications may be easier in children than in adults .

This How to Treat covers the history , examination , investigations and management of common hand injuries in children .

ASSESSMENT

History

AT the extremes of childhood , from the preverbal toddler to the taciturn teenager , history is hard to elucidate

. The author prefers to talk to the

child directly , in the least threatening manner , and to ask them what has happened to them . Although some parents are reluctant to be quiet , direct information from the child is of paramount importance . The injury pattern and the likely microbial culture is very different from a gardening injury , a kitchen injury or a bite .

The child may be reluctant to say they have been doing something naughty , and the teenage boy who

has punched someone in the playground may not want his parents to find out . Sometimes asking parent and patient separately is beneficial .

Physical examination

Trying to minimise hurt to your patients is important . The author always starts on the normal hand , which builds the child ’ s trust and allows examination of the degree of ligamentous laxity and how the child reacts to pressure on different parts of the anatomy .

While the traditional litany is look / feel / move , in hand examination generally , and in children , encourage active movement before touching

the child and possibly causing extra

pain . Many toddlers will respond to “ Can you wave ?” or “ Can you do the scissors ?”, especially if the examiner demonstrates the action .

Investigations

X-ray is the mainstay of imaging . An experienced radiographer , judicious use of sandbags and a parent wearing a lead gown to help restrain the child will allow most plain films to be taken . In an obviously deformed fracture

or open wound , analgesia may be given immediately after examination and before imaging .

Ultrasound is highly operator dependent , and ultrasound of a painful area requires experience and skill . It is the best means of finding a small radiolucent foreign body , such as a wood splinter , which does not show on other modalities ( see figure 1 ).

Modern CT scans have very rapid cycles , so accurate images are possible in all but the most restless child . Four-dimensional machines have rapid image capture designed to show movement and may provide a good image in a moving child .

MRI is particularly useful in

the compliant older child , as it can

diagnose the subtle fracture that does not show on plain X-ray or CT , as well as soft-tissue lesions ( see figure 2 ). The slow cycle time means that general anaesthetic is necessary in a restless child , so the benefit , such as diagnosing a deep infection , must be weighed against the logistical difficulties and risks .

Nuclear medicine studies have declined in popularity as MRI has become more available because they

involve a radiation dose and are still very slow . They remain the most sensitive test for occult fracture or deep infection ( osteomyelitis / septic arthritis ), with current generation single-photon emission CT offering excellent anatomic localisation .

SPECIFIC EXAMINATION

Skin

HAND skin is highly specialised , with the skin of the palm thicker than any other skin apart from the sole of the foot . It contains eccrine glands , which are essential for grip , and lacks hair . The skin on the dorsum of the hand appears redundant in all but

the chubbiest baby — able to be