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
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 & volar radioulnar ligaments

4. Central disc is avascular and aneural.
TFCC
Central disc is avascular and aneural.
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 TFCC
Painful snap wrist with rotation if sheath is damaged
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.

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

10. Functional Orthotics
The Wrist Widget F

11. ECU Snap wrist Damage to the ECU sheath.
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. Pisiform Boost Terry Skirvin: Philadelphia Hand Center
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 surrounding ligaments 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 the flexor 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 volar subluxation 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

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), Retrieved January 29, 2012, from ProQuest Nursing & Allied Health Source. (Document ID: ).

42. Pearls Orficast Dr. Roy Meals
: mallet splint
pattern
Wrist Widget: Sammons and Preston

43. Thank You! Preferred Physical Therapy 712 1st Terrace
Lansing, KS