|ORIGINAL RESEARCH REPORT
|Year : 2021 | Volume
| Issue : 1 | Page : 14-17
Clinical profile and management of pediatric hand injuries in Lagos, South-west Nigeria - A retrospective study
Orimisan Belie1, Bolaji O Mofikoya2, Andrew Omotayo Ugburo2
1 Department of Surgery, Plastic Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, Plastic Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
|Date of Submission||02-Apr-2020|
|Date of Acceptance||09-Jun-2020|
|Date of Web Publication||2-Feb-2021|
Dr. Orimisan Belie
Department of Surgery, Plastic Surgery Unit, Lagos University Teaching Hospital, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: The hand can be described as the sixth-sense organ due to its rich sensory innervations and its irreplaceable role in daily functioning. It is an organ of exploration, especially in the children; hence, higher predisposition to trauma. Early surgical treatment as required is expedient to prevent complications such as contractures due to rapid wound healing in these patients. Methods: The demographic characteristics of the patients, causes of injuries, treatment modalities, and outcome of treatment were documented after retrieving the information from the case notes. Results: A total of 352 hand cases were seen over 5 years. Out of this, 57 (16.3%) were pediatric patients. Burn injury was the most common cause of hand injury seen in 38.6% of patients, and fingertip injury was the most common form of open soft-tissue injury seen in 22.8% of cases. Hand fractures were infrequent. Conclusion: Closer monitoring of children is important for trauma prevention. Early intervention in the form of soft-tissue repair/skin resurfacing is important for improved outcome.
Keywords: Hand, injuries, pediatric
|How to cite this article:|
Belie O, Mofikoya BO, Ugburo AO. Clinical profile and management of pediatric hand injuries in Lagos, South-west Nigeria - A retrospective study. J Clin Sci 2021;18:14-7
|How to cite this URL:|
Belie O, Mofikoya BO, Ugburo AO. Clinical profile and management of pediatric hand injuries in Lagos, South-west Nigeria - A retrospective study. J Clin Sci [serial online] 2021 [cited 2021 Apr 13];18:14-7. Available from: https://www.jcsjournal.org/text.asp?2021/18/1/14/308594
| Introduction|| |
The hand is a versatile component of the body, its special location in the distal most part of the upper extremities makes it more suited for its various adaptation features. The various movements across the joints of the hand including the wrist are made possible by the complex arrangement and interplay between the various components of the hand. It is an organ of identity, the highly tactile nature of the finger tips help the hand to perform fine movements and also function as an extra “eye” in the growing child. It represents an exploratory organ that constantly interact with the environment, hence higher predilection to trauma., Trauma to the hand in this age group is worsened by the fact that they are not aware of the potential danger inherent in many activities they perform hence the tendency to sustain severe trauma. The severity of injury usually ranged from the simple abrasion to multi-structural deficit as seen in traumatic amputation of the hand either in part or in whole and to bony fractures which may communicate with the joint space. The presence of heavy contamination is not uncommon because most of injuries are sustained at the playing sites.
Pediatric hand injury is a common presentation in the emergency room, mechanism of injuries range from crushing injuries, shearing forces, axial loading on the hand, bites, burns, treadmill injuries, sport-related injuries in older children, and injuries from fireworks. Management may be quite challenging, especially in cases of late presentation or late referrer with possibility of hand infection. Vadivelu et al. in University Hospitals of Leicester NHS Trust, Leicester, England documented the injuries to different components of the hand in children with the skeletal fractures as the most affected. Hartley et al. recorded that referrer to a hand specialist could be as low as 6.5% of all children having hand injury in a study conducted in Alberta Children's Hospital, Calgary.
Faster wound healing in this age group gives rise to poor outcome if early management is not instituted. This poor outcome of wound healing will invariably affect the child economically, psychosocially as the hands are main organ for acquiring means of livelihood. Lack of adequate information during history taking due to the absence of eye witness account and difficulty in gaining the cooperation of the affected children are other challenges encountered when managing children with hand injury. The outcome of treatment is usually excellent once early care is instituted. Nigeria with a relatively young population with children below 15 years accounting for 42.5% of the total population hence the higher burden of injury among the children. We document the cause, mechanism of injury, presentation, and treatment of pediatric hand injury in our center.
| Materials and Methods|| |
This is a retrospective study conducted on pediatric patients who sustained hand trauma. The records of all patients 16 years and below presenting to the emergency section of the hospital or the surgical outpatient clinic of plastic and hand reconstruction unit of the Lagos University Teaching Hospital with hand injury from January 2015 to December 2019 were retrieved. The data retrieved included demography, causes of injuries, treatment modalities, and outcome of treatment. The data were entered into a pro forma and transferred into statistical package for social science (SPSS) version 20 (IBM, Chicago, USA). The analysis of continuous variables was documented as mean + standard error of the mean (SEM), whereas discrete variables were presented as ratios, percentages, and proportions. The level of significance was P < 0.05 at confidence interval of 95%. Tables and figures were also used to describe the data as necessary. Approval was obtained from the hospital ethical board.
| Results|| |
There were 352 patients with hand trauma either in isolation or as a part of other injuries within the 5 years study period, out of this there were 217 males and 135 females (male:female = 1.3:1). Among these patients, there were 57 (16.2%) pediatric patients with ages between 8 months and 15 years (mean ± SEM = 5.4 ± 0.53). There were 34 males and 23 females (male:female = 1.5:1). The toddlers and the preschool children were the most affected. The toddlers having hand injury were 19 (33%) [Figure 1]. Thirty-three (57.9%) patients had injury to the right hand and 23 to the left hand, one (1.8%) patient had bilateral hand injury. All the patients above 3 years were right handed which is the age when hand dominance can be determined.
Etiologies and pattern of injuries
The most common etiological agent was burn following scald injury and this was seen mostly in toddlers [Table 1]. Trauma from sharp object laceration, crushed avulsion injuries, and laceration were responsible for the majority of soft-tissue injuries after burns. Finger tips soft-tissue injuries [Figure 2] were seen in 13 (22.8%) patients occurring as the second most common form of injury after hand burns.
|Figure 2: Fingertip injury with distally based pedicle. (a) Before repair. (b) After repair|
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Most of the hand injuries were mainly to the soft tissues with only 6 (10.5%) patients sustaining fracture injuries. All the fracture injuries occurred in the dominant hand. All were closed fractures. There were two metacarpal fractures, while the remaining four patients had phalangeal fractures involving the index and middle fingers; of these four patients one had fractures to both fore finger and middle finger and fracture involving the fore finger alone in one patient. The bony fractures were seen in the age group of 6–10 years, they were due to sport injuries and fall from height and accidental injury from the rolling ceiling fan. All the fractures were un-displaced transverse or oblique fractures [Figure 3].
|Figure 3: Phalangeal fracture in a 6-year-old male child. Oblique fracture of the head of the proximal phalanx of the right middle finger|
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Two patients between the ages of 10–12 years had spaghetti hand injury with transection of most of the flexor tendons, median nerve, and radial arteries following accidental forceful collision with domestic glass table and louvers [Figure 4]. One patient had blast injury to the hand following firework explosion while still holding it. There were soft-tissue injuries involving the thumb, other fingers, and the palmer surface of the right hand.
|Figure 4: (a) A 10-year-old boy with a spaghetti injury. (b) After wound exposure. (c) After repair|
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Most of the procedures done in these patients were soft-tissue surgeries ranging from direct closure of laceration, soft-tissue release, skin grafting to repair of nerve, and transected tendons in the two patients with spaghetti injury. The volar and lateral triangular advancement flaps were used in closing fingertip injuries in some older children. The patients who had scar revisions were those referred and those whose parents initially refused skin re-surfacing [Table 2]. The outcomes of surgeries were satisfactory in all the patients. The closed fractures were managed with early splinting for a maximum duration of 3 weeks and followed by physiotherapy. The fractures healing were also satisfactory. The patient with blast injury and those with spaghetti injuries had more complex reconstruction and longer hospital stay due to the severity of the injuries.
| Discussion|| |
Hand injury can be a debilitating condition if not adequately managed, when injury to the hand occur either alone or as part of major trauma, treatment of the hand injury must receive high priority like other important organ systems in the body. The ability to perform useful work with the hand after recovery is to a great degree determined by the management instituted in the acute phase of injury. A carefully planned and skillfully executed surgical procedure is essential for the early restoration of pain-free, useful hand function in children. There were not many studies on the pediatric hand injuries in our environment; however, some studies exist in which children were a component of the study population on hand injuries comprising individuals of all age group.
In a study conducted by Mofikoya et al. in the same region 11 years prior to this study, he found out that male children tend to have more hand injuries than their female counterparts which is in tandem with our study; however, this study showed a narrower male-to-female ratio meaning female children are increasingly having hand trauma. Other studies also confirmed higher male preponderance. Improvement in social amenities and recreational activities in the region of the study center predisposes them to more injuries at playing sites; hence, the need to evaluate current injury pattern in this age group. Hand injuries have also been found to be more common in the dominant hand both in children and adults.
Olaitan et al. in a study conducted in Osogbo South-west Nigeria among 74 patients with hand injuries, 16.2% of the patients were children <10 years. This was in tandem with our study where the pediatric patients among all patients with hand injuries within the study period were similar in proportion, although the maximum age of patient in our study was 14 years. Burn injury to the hand in this age group has been previously documented to be significantly most common in the younger age group., This is probably due to the fact that toddlers have not developed the cognitive capacity to determine the potentially dangerous activities. They also have the tendency to crawl away from care givers hence having interaction with hot liquids resulting to burn. Some other studies outside West-African region however showed distal-most part of the hand as the area with greatest predilection to injuries, including finger tips, nail bed injuries as the most common cause of hand injuries rather than burns., In a retrospective study conducted by Liu et al. among 137 children aged between 0 and 16 years at Prince of Wales Hospital, Hong Kong, it was found out that hand injuries were the most common among children aged 5 years and below. Most of these children were also found to be right handed. These were also similar to our findings. He, however, found that crush injuries were the most common unlike the burn injuries in our patients.
Soft-tissue injuries without fractures are seen mostly in many pediatric hand traumas. The mechanisms of injury that normally result into fracture are usually more violent and seen in older children and occur commonly as a component of multiple injuries within the same individual. The burden of treatment of such severe injuries is significantly higher than that of simple soft-tissue injury. Fingertip re-implantation was not done in these patients because the amputated stump was either poorly stored, or patient is referred very late to preclude anastomosis or the stump is crushed making anastomosis impossible.
The data were collected in retrospect, this prevent on the spot assessment of patients, the bias associated with this was however reduced to the barest minimum by the storage of all patients' information, including photographs in an electronic data base domicile in the unit separate from the hospital storage of records to prevent the loss of information and for easy data retrieval.
| Conclusion|| |
Burn injuries to the hand remain the most common cause of injury to the hand pediatric age group in our environment. Although debilitating hand injuries can also occur in children like the spaghetti injuries, they are not as common as the fingertip injury in children. Adequate monitoring of children, especially the toddlers, is essential in preventing hand injuries in children. Early intervention is necessary in preventing complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]