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Background: Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns., Methods: The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed., Results: There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon ( P = .007), fewer required surgery ( P < .001)., Conclusions: Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

Background: Although fingertip injuries are common, there is limited literature on the epidemiology and hospital charges for fingertip injuries in children. This descriptive study reports the clinical features of and hospital charges for fingertip injuries in a large pediatric population treated at a tertiary medical center., Methods: Our hospital database was queried using International Classification of Diseases, Revision 9 (ICD-9) codes, and medical records were reviewed. Frequency statistics were generated for 1807 patients with fingertip injuries who presented to the emergency department (ED) at Boston Children's Hospital (BCH) between 2005 and 2011. Billing records were analyzed for financial data., Results: A total of 1807 patients were identified for this study; 59% were male, and the mean age at time of injury was 8 years. Most commonly, injuries occurred when a finger was crushed (n = 831, 46%) in a door or window. Average length of stay in the ED was 3 hours 45 minutes, 25% of cases needed surgery, and, on average, patients had more than 1 follow-up appointment. About one-third of patients were referred from outside institutions. The average ED charge for fingertip injuries was $1195 in 2014, which would amount to about $320 430 each year (in 2014 dollars) for fingertip injuries presenting to BCH., Conclusion: Fingertip injuries in children are common and result in significant burden, yet are mostly preventable. Most injuries occur at home in a door or window. Although these patients generally heal well, fingertip injuries pose a health, time, and financial burden. Increased awareness and education may help to avoid these injuries.

Background: Fingertip injuries are common in the pediatric population. Composite grafting is a frequently used technique for distal amputations in children given the reported success rate. We sought to study the early clinical results of composite grafting for fingertip injuries in the pediatric population., Methods: A retrospective review was performed over a 5-year period at a tertiary care pediatric hospital to identify those patients who underwent composite grafting of fingertip injuries. Patients were included if they were 18 years old or younger and sustained an injury distal to the distal interphalangeal joint (or thumb interphalangeal joint). Demographic information was recorded. Graft viability was characterized as no take, partial take, or complete take. The number of secondary procedures and number and duration of follow-up appointments were recorded. Hypothesis testing was done using ordinal logistic regression analysis., Results: Thirty-nine patients underwent fingertip composite grafting. The mean age was 5.9 years (1-18 years); there were 24 males (61.5 %) and 15 females (38.5 %). Thirteen patients had no graft take (33.3 %), 23 patients had partial take (59.0 %), and three patients had complete take (7.7 %). Only four patients underwent secondary revision (10 %). The median number of follow-up appointments was 3 and the average follow-up time was 4.5 months. Age did not appear to have a statistically significant influence on graft take., Conclusions: Fingertip composite grafts rarely take completely even in young children. Despite poor viability, however, most patients will have at least partial graft take and do not undergo additional reconstructive procedures.

Background: There have been few attempts to identify classic papers within the hand surgery literature. This study used citation analysis to identify and characterize the top 50 highly cited hand surgery articles published in six peer-reviewed journals., Methods: The 50 most highly cited hand surgery articles were identified in the Journal of Bone and Joint Surgery (JBJS) American, JBJS British, Plastic and Reconstructive Surgery, Journal of Hand Surgery (JHS) American, JHS British/European, and Hand. Articles were evaluated for citations per year, surgical/anatomical topic, and type of study. Clinical studies were further sub-categorized by level of evidence. The distribution of topics was compared with all indexed hand surgery articles. The educational relevance was assessed via comparison with lists of "classic" papers., Results: The most common subjects were distal radius fracture, carpal tunnel syndrome, and flexor tendon repair. There was moderate correlation between the distribution of these topics and all indexed hand surgery articles (rho = 0.71). There were 31 clinical studies, of which 16 were therapeutic, ten were prognostic, and five were diagnostic. These articles assessed the outcomes of an intervention, described an anatomical/functional observation, introduced an innovation, presented a discovery/classification, or validated a questionnaire. There were only three randomized trials. Using citations per year to control for the influence of time since publication, 36 articles were consistently highly cited. Twenty-three articles were on Stern's Selected Readings in Hand Surgery, considered important in education., Conclusions: The top 50 highly cited articles in hand surgery reflect the most common clinical, scientific, and educational efforts of the field.

Functional hand reconstruction following treatment of soft tissue sarcomas (STS) is a difficult surgical problem. Because survival rates between amputation and limb salvage do not differ, there is a trend toward reconstruction. Unlike amputation, hand salvage usually requires multiple complex operations in combination with adjuvant radiation or chemotherapy, prolonged rehabilitation, and carries a high complication rate. We investigated tumor recurrence, survival, and scored functional outcomes to determine if limb salvage is justified after hand STS resection. Patients treated for hand STS between years 1985 and 2005 were reviewed by two surgeons in three medical centers. All patients having functional reconstruction instead of amputation were reviewed. Patient demographics, tumor type and grade, resection extent, reconstruction procedure, timing, adjuvant therapy use, complications, tumor recurrence, survival, and functional outcome were recorded and analyzed. Five patients underwent functional reconstruction for hand STS. All patients underwent attempted curative resections, and four patients received neoadjuvant or postoperative radiation therapy. Three patients received adjuvant chemotherapy. Reconstructive techniques included three modified pollicizations, one free-tissue transfer, and one groin flap. All patients were alive and disease-free at a mean follow-up of 5 years (range 1.5-17 years). Three patients (60%) had local complications, requiring secondary surgeries. Two complications were related to radiation therapy. Hand function was evaluated using the Enneking Scoring System, and ranged from 17 to 28. The average Enneking score was 22.4, representing an average preservation of 74.6% of function. Because most patients retain excellent function and survival is unaffected, we advocate functional reconstruction despite high complication rates.

Non-union after finger fracture is an infrequent complication. Although well described in adults, there are few reported cases in children. We describe a 6 year-old boy who presented with a non-union of the diaphysis of the distal phalanx three years after a finger tip crush injury.