Early Recognition of Common Pediatric Hand Problems: A Q&A With Dr. Suzanne Steinman
October 4, 2023
Suzanne Steinman, MD, is a pediatric orthopedic surgeon and hand specialist at Seattle Children’s.
Q: What are some of the pediatric hand problems that can be treated in the PCP office?
The common conditions below can be managed in a primary care setting in most cases. I’ve offered a few tips below; for more detailed discussion, consider registering for our upcoming CME on common pediatric hand problems on November 8. PCPs with questions are always welcome to give us a call on the Provider-to-Provider Line.
- Mild clinodactyly
- Jammed fingers/volar plate injuries – These are usually overtreated. X-rays are often unnecessary. If it has been a week since the injury occurred and the finger still hurts, X-ray to check for displaced fracture. Appropriate treatment for a true jammed finger is one week of splinting (not longer) and then buddy tape.
- Paronychiae (nail infection)
- Superficial “responsive” infections
- Herpetic whitlow
- Ganglion cyst – Please watch and wait, as many cases will resolve on their own. Avoid steroids, injections and aspiration. If the cyst persists and hurts, surgery will be required, but this is rare. If in doubt, please refer.
- Closed mallet fingers – Treat only if you have the appropriate splints available; otherwise, please send to us.
- Simple subungual hematomas – These will go away on their own. Do not trephinate, as this may cause infection! Instead, offer Tylenol or ibuprofen for pain.
- Paronychia (nail inflammation) – Consider moist heat, elevation, oral antibiotics, or nail removal for visible nondraining pus. These are more urgent referrals if it’s something you can’t treat.
Q: What conditions should be referred to a specialist?
Nonurgent conditions requiring referral to a hand specialist are listed below. Most of these don’t require imaging in advance, with the exception of radial dysplasia (for which a workup is not needed from an orthopedic standpoint but to ensure no other organ systems are involved). We recommend that if you see a baby with one of these conditions, you perform a full physical exam to ensure nothing else is involved.
- Polydactyly – Can be associated with many other hereditary conditions and other anomalies.
- Syndactyly – Usually no action is needed before age 1 unless tethering is seen between the thumb and first finger.
- Absence of parts
- Amniotic band syndrome (ensnared parts) – This is a true amputation injury that happened in utero after hand development began. Surgery usually happens around age 2 if there is no impending tissue loss prior; early referral is appropriate, however, as appositional overgrowth at the end of the stump can be painful and require a revision; or a splint may be needed.
- Symbrachydactyly (missing bits) – May look similar to amniotic band syndrome (above) but can be distinguished by the presence of nubbins and nails and no bands in other locations. This is isolated to just one limb.
- Trigger digits – Splinting is not needed. Surgery will not be required before age 4 unless painful.
- Severe or worsening clinodactyly
- Hand tumors
- Radial dysplasia – Indicates other possible organ system problems; can be subtle. Please submit a nonurgent referral to Genetics and order CBC with differential, spinal ultrasound, renal ultrasound and cardiac echo (or, alternatively, we will). If there are any questions, please give us a call.
Refer urgently for these conditions:
- Vascular injuries – Emergency
- Compartment syndrome – Emergency
- Crushed or avulsed fingertips and nailbeds, open fractures – Emergency
- For fingertip injury/amputation: Save the tip for use as biologic dressing.
- Trauma and hand fractures: Please order an X-ray and refer urgently if there is any concern for a fracture; finger fractures heal very quickly and treatment is needed within 3 weeks to avoid surgery.
- Hand infections: felons, deep space infection, flexor tenosynovitis, complicated animal bites, any other nonresponding infection
- Amniotic band syndrome with impending tissue loss
- Skeletal injury requiring reduction/stabilization
- Flexor tendon injuries
- Open extensor tendon injuries
- Boutonniere extensor tendon injury
- Nerve injuries
Q: If I refer a patient for a hand condition, who will see them at Seattle Children’s?
We have a large hand team that includes an unusually high number of APPs who have specialized hand training. Surgeons include myself, Dr. Jeffrey Friedrich and Dr. Raymond Tse. APPs include Cheryl Parker, PAC; Douglas Dedo, PAC; and Alphonzo Flying Cloud, PAC, among many others. Occupational therapists (OTs) include Pam Horn, OTR/L; Debbie Howard, MOT, OTRL/L, CHT; Peggy Smith, OTR/L; and Heidi Allen, MS, OTR/L.
Our APPs are often a great option for patients needing appointments sooner because they do many of the same things the surgeons do in clinic and can bring a patient right over to see us if needed. Our OTs in-clinic can see patients in the same visit as the doctor or APP, which is an added convenience for families.
Q: Any parting advice for PCPs on hand care?
If you suture a hand, always use absorbable suture! When nylon stitches are used, we sometimes have to sedate the child in order to remove the stitches later. And lastly, join us if you can on November 8 for a virtual CME where I’ll dive deeper into some of these topics and answer your questions. View the CME flyer.
- Seattle Children’s Hand and Upper Extremity Program
- Tachdjian’s Pediatric Orthopedics. “Disorders of the Upper Extremity”
- Cornwall R, Ricchetti Pediatric phalanx fractures: unique challenges and pitfalls.
Clin Orthop Relat Res. 2006 Apr;445:146-56
- Valencia J, Leyva F, Gomez-Bajo Pediatric hand trauma.
Clin Orthop Relat Res. 2005 Mar;(432):77-86
- Rockwood and Wilkins. “Dislocations of the Hand and Carpus in Children”