Expert’s Corner: Three tricky hand and upper extremity injuries

child wrist cast hand upper extremity surgery

Accurately diagnosing and treating hand and upper extremity injuries can be tricky. Several injuries are commonly misperceived in the referring physician community, says Andrea Bauer, MD, a hand and upper extremity specialist and orthopedic surgeon who recently joined Boston Children’s Hospital’s Orthopedic Center.

Bauer highlights several of these injuries and reviews how treatment paradigms for some have evolved.

Brachial plexus treatment and monitoring

Brachial plexus injuries— when a network of nerves in the neck and shoulder are compressed or stretched during birth—remain one of the most common birth injuries, occurring in up to 3 in 1,000 live births.

Providers may hesitate to refer infants with a brachial plexus injury to an orthopedic surgeon. “There’s still some misunderstanding that there isn’t much to be done for babies with brachial plexus injuries,” says Bauer. In the last 10 years, however, orthopedic surgeons have refined nerve reconstruction techniques.

The standard procedure still relies on a nerve grafting from the leg to reconstruct the plexus and requires nerve growth from the neck down the length of the arm. In some babies, however, surgeons can now transfer a local nerve branch into the muscle that isn’t functioning.

“The distance the nerve needs to grow is very small,” explains Bauer. This translates into results in a 3- to 6-month time frame, compared to up to one year with the standard procedure. In addition, using local nerves means less invasive surgery and does not result in additional surgical scars on the baby’s legs.

If a baby diagnosed with a brachial plexus injury shows signs of residual nerve damage at two months of age, it’s the ideal time to refer her to an orthopedic surgeon, as nerve surgery results are generally better in the first six months of life.

Orthopedic surgeons at Boston Children’s also have started using ultrasound, rather than x-ray or MRI, to determine whether or not the shoulder is growing properly in babies with brachial plexus injuries. This eliminates the need for radiation and sedation in these infants.

More severe scaphoid fractures

Fractures in children of the scaphoid—the most commonly fractured carpal bone, particularly among boys between 11 and 17—have started to resemble adult fractures. Research completed at Boston Children’s shows that the most common type of scaphoid fracture is now at the scaphoid waist, as in adults, rather than at the distal pole of the scaphoid as previously thought. The likely reason for the change, Bauer notes, is that kids have gotten larger, and sports participation has increased.

This change impacts management because scaphoid waist fractures require prolonged cast treatment and possibly surgery to heal.

“Although most acute fractures can be treated with a cast,” she explains, “this research suggests scaphoid fracture nonunions are not healing in a cast and require surgery. So surgeons are beginning to operate sooner.”

Seymour injuries: Easy to miss

Seymour fractures, which commonly occur when a toddler or young child smashes a finger in a drawer or door, can lead to osteomyelitis and growth plate disruption. “The physis can be displaced into the nail bed, but this can be missed,” Bauer explains. She adds that bleeding under the nail could be a sign of an open fracture and a nail bed injury. “These cases need to be treated operatively.”

An accurate diagnosis of this tricky injury requires an imaging exam. Bauer recommends that any child with a fingertip injury have a lateral x-ray, so the radiologist can see if the growth plate has been disrupted. If the x-ray is positive, the child should be referred to an orthopedic surgeon.

If you have questions about the management of hand or upper extremity injuries in your patients, contact Boston Children’s Hand and Upper Extremity Program.


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