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Pediatric Flexor Tendon Treatment
204 Plays4 days ago
In this episode, Miranda and Josh dive into the challenges and strategies of treating pediatric patients with flexor tendon injuries. They share their insights on assessment, treatment approaches, and the unique considerations when working with younger patients. Tune in for valuable tips on managing these complex injuries in pediatric hand therapy.
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Transcript
Introduction to Pediatric Flexor Tendon Injuries
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:07
Miranda Materi
and I'm random material and we are Hand Therapy Academy.
00:00:10
josh MacDonald
Let's talk about how to treat flexor tendon injuries, but specifically in the pediatric population, how to work on them with kids.
00:00:18
Miranda Materi
Yes, I think um this is definitely more your jam and your topic area. It's something I'm kind of interested in hearing if like something has changed or anything like that.
00:00:28
Miranda Materi
It's been a while since I've had any pediatric
Decision Influencers in Treatment Approaches
00:00:31
Miranda Materi
patients. So what do you do with these?
00:00:32
josh MacDonald
Yeah, yeah.
00:00:34
Miranda Materi
and
00:00:35
josh MacDonald
Yes, so that I don't feel like anything significant has changed. um I was just on a panel at AAHS, the conference this last, in January, and they talked about it in this whole case series thing. And so pediatric flexor tendon came up.
00:00:48
josh MacDonald
and It's kind of like everyone wants a specific age where I should do this with this age and this with this age and this with this age, but it's really more about the family dynamic and the kid to know like, is this one we should lock down because we can't trust them? Is this one we should get them moving a little bit and treat them more like a normal flexor tendon patient, not a pediatric?
00:01:07
josh MacDonald
um So it kind of depends on age and demographics and stuff. um The first thing of which is knowing did the kid rupture a flexor tendon. um So interesting kind of like um like fun party trick is if you just squeeze the forearm, your flexor tendons will in response shorten, right? Like that that tension you apply on the forearm causes the flexor tendons to pull the fingers down in the natural cascade.
00:01:34
josh MacDonald
So, without telling the kid what you're looking for, just say, come here for a sec, and squeeze that forearm across the flexor tendon muscle belly, across that common flexor mass. And if one of those fingers does not follow the cascade, then they are um ah thought to have had maybe a flexor tendon rupture. So, that's a quick, easy, basic screen to see like, okay, this kid may be at risk for that. so If that's the case, then you start to go down the decision tree of should we cast them, should we do a removable splint, should we do a removable splint, but with a volar piece that really locks them in, all these different options.
Post-Surgery Treatment Options
00:02:08
Miranda Materi
And this is after surgery, right? So.
00:02:11
josh MacDonald
Yes, for sure. the the The squeeze test is a preoperative like, you know, out in the field, you're at a kid's soccer game or something, you're not sure whatever um or Or, you know, some family gathering and a kid picks up a knife or something.
00:02:14
Miranda Materi
Right.
00:02:21
josh MacDonald
But yeah, so after surgery, um there's there's kind of this gray area of when's the right time to cast a kid, up until what age?
00:02:33
josh MacDonald
And so that some people will say like six six years old plus or minus somewhere in there. And it really depends on that kids like are they nervous are they a more squirrely super active kid are they like a little bit more also obstinate that they want to take that thing off and if it's removable it's coming off.
00:02:52
josh MacDonald
um Or is it going to fall off because they're climbing on stuff? Do you need to cast them to protect them? And unlike adults, kids won't scar in as aggressively. And so you can truly immobilize a younger child without the fear as much of them having that that scarring in nearly as much.
00:03:09
Miranda Materi
Right, and then who knows that kid best, right? It's usually the caregiver, so I feel like it's really asking them.
00:03:13
josh MacDonald
Yeah. Yeah.
00:03:17
josh MacDonald
Absolutely. Especially when they're in that younger bracket and you're not going to get a good history out of a four-year-old, right? Like you don't expect that.
00:03:24
Miranda Materi
Right.
00:03:24
josh MacDonald
So you're asking the parent and sometimes it's, you can, you can look at a kid and say, I think this kid's going to be okay at six years old with a removable. They seem, you know, they're, they're calm and organized about this and they seem to to be aware of things and they're understanding the precautions.
00:03:41
josh MacDonald
but the parent may be a nervous Nellie about it. And so maybe for the parent's purposes, you're putting them in a cast, Delta cast, plaster cast, but it may be because the parent is apprehensive about it. And I know that a six year old, if I cast them, they're probably gonna be okay as far as flexor tendon goes. Even if they do scarring a little bit excessively, I'm more likely to get them mobile afterwards than an adult who may be scarred in and is stuck now as
Role of Family Dynamics in Treatment Plans
00:04:06
josh MacDonald
a result. So I may do it because the parent is the bigger,
00:04:09
josh MacDonald
red flag for that than the kid is.
00:04:11
Miranda Materi
Right. Yeah. So you're looking for those cues. Is this kid bouncing around on the chairs and when they're in the front office, right? Or are they, you know, sitting calmly? Is their mom acting nervous? Is their mom asking you a lot of questions, you know?
00:04:23
Miranda Materi
ah
00:04:23
josh MacDonald
Yeah, yeah. And sometimes it's great when you have a kid who comes in with three or four siblings and there's this whirlwind of activity and you know right off the bat, this is not a removable splint patient.
00:04:35
josh MacDonald
Like there's way too much activity. They're a little bit more free range family and they're just kind of going with the flow and they're like, yeah, we're, you know, our, our kids have three dirt bikes and we live on a farm and we're super active and they're in the mud and like, yeah, let's lock them down.
00:04:39
Miranda Materi
Yeah.
00:04:48
josh MacDonald
Let's, let's just margin for error.
00:04:49
Miranda Materi
Yeah.
00:04:51
josh MacDonald
Let's just lock them down.
00:04:52
Miranda Materi
Right, yeah, you definitely can get to go to get a pretty good picture.
00:04:56
josh MacDonald
Yeah, yeah, for sure. um And so six is this soft gray line that we talk about, but there's some kids who are older that I'll leave locked down a little bit more and maybe some kids who are younger that maybe they have major wound concerns if it was a real dirty wound and they've got to keep track of that.
00:05:14
josh MacDonald
If they're a kid who I would maybe say, yeah, I think we should lock them down, but there's maybe some wound or other reason why we can't or shouldn't, I'll make a volar component to that splint and make it a clamshell. So I've got both that really kind of holds them in it, but it is
Collaborating with Pediatric Surgeons
00:05:31
josh MacDonald
removable.
00:05:31
josh MacDonald
And we'll do as much education for the family like, listen, in this three-year-old cannot be left unsupervised. You have to leave it on. And then we start making some of the other tricks and tips to at least slow the kid down on self-removal of this splint, um using some of those other tips we have to help keep splints on.
00:05:49
Miranda Materi
Yeah, that's tricky.
00:05:50
josh MacDonald
Yeah. Yeah.
00:05:51
Miranda Materi
And then sometimes it depends on the surgeon too, right? Like if you have a pediatric surgeon, they're going to tell you what they want.
00:05:57
josh MacDonald
Yeah. Yeah.
00:05:58
Miranda Materi
And then you might need to have a conversation with them like, hey, this kid's like really hyper.
00:05:58
josh MacDonald
Yeah.
00:06:01
Miranda Materi
I don't know if we're going to get the outcomes you want based on the order you provided.
00:06:07
josh MacDonald
And I find at least the pediatric surgeons I work with, they are very receptive to the therapy approach. I feel like more than adult therapy adult surgeons, I feel like they are very comfortable because they know I've just spent more time with that kid and family in my one session than they did post-operatively or at the first follow-up.
00:06:26
josh MacDonald
So I really feel like they are receptive to my recommendations. I mean, we're definitely having a conversation about this and they say, oh yeah, no, I understand what you're saying. I really want to lock them down. Okay, ultimately, they're the ones that are on the hook for that decision, so I'll go with that.
00:06:39
josh MacDonald
um But I feel like most of the pediatric surgeons are receptive to that
Creating a Positive Therapy Experience for Children
00:06:43
josh MacDonald
input.
00:06:43
Miranda Materi
Yeah.
00:06:44
josh MacDonald
Yeah, yeah.
00:06:45
Miranda Materi
And then making sure you have another tip is making sure you have a space like a safe space for that kid, right? So if you're going to do anything that's traumatic to that kid, you want to make sure that space is different than the space that you're going to be regularly treating them in.
00:06:59
josh MacDonald
Yes, yeah.
00:07:00
Miranda Materi
So you want to make sure therapy is a positive experience for them.
00:07:00
josh MacDonald
and
00:07:03
josh MacDonald
Yeah. And we've talked about this in some of our other pediatric podcasts, but if I have a kid who shows any signs of this aversion to the medical community, I want to set myself as a part from that because they're coming back to see me on a regular basis and we've got to work through a lot of stuff. This is not a one and done, make a splint, move on. They didn't like it, but that's okay because they don't come back. So I'll spend sometimes 15 or 20 minutes just playing with the kid before we take off dressings, before we do anything hands on. I won't even touch that hand.
00:07:33
josh MacDonald
for 15 to 20 minutes so they understand we can play together and that's one aspect we have to do this thing but then we'll play again after and I establish a really good rapport with them before we jump in and I'm just stripping down that hand and making a split the process is going to go better they'll understand and and tolerate it better yeah yeah
00:07:51
Miranda Materi
Yeah, and then understanding where they're at developmentally, right? Like what how much you can explain how you explain, right? Because you're not going to explain the same way to a three year old that you would a five year or a six year old, right? And also, like, I feel like sometimes I'll hear someone else will like, should we take off your split now?
00:08:07
Miranda Materi
Or should we take off your cat? You're not going to ask them that, right? Because they're going to say no.
00:08:11
josh MacDonald
Right?
00:08:11
Miranda Materi
So You're gonna say, hey you know just give them some like autonomy and ask them a question, but it's like, hey should we take off um this strap right here? Which strap do you want to take off first? you know So then you're giving them choices, but you're not giving them the choice to not do it.
00:08:25
josh MacDonald
Yes, yeah. Never ask a kid a question that gives them the opportunity to say no if you're not prepared for the no.
00:08:32
Miranda Materi
Right.
00:08:32
josh MacDonald
You can say, do you want to play with that toy? They say, no. OK, I got a closet full of them. Do you want to take your splint off? If they say no, then you're stuck. So if you're not prepared for the no, don't ask it in a question.
00:08:39
Miranda Materi
Yeah.
00:08:42
josh MacDonald
But it's just our nature with kids. We want to be like buddies with them. Don't ask questions.
00:08:49
Miranda Materi
Yeah, don't ask questions, especially when it comes to paper. Should we stretch your finger? No.
00:08:52
josh MacDonald
Yeah, yeah.
00:08:53
Miranda Materi
but I would say, which finger do you want to stretch first? you know
00:08:56
josh MacDonald
Yep, yep. Sometimes I'll give them the choice, do you want to play with this toy first and then stretch, or do you want to stretch and then play with the toy? And you do a sequence option for them, and then they get to pick, and then maybe I set a timer, okay, let's play with this for five minutes, and then we'll stretch after that for five minutes.
00:09:04
Miranda Materi
Uh-huh.
00:09:10
josh MacDonald
And so I'm using a timer, and then the timer is the objective third party, so to speak, that governs, okay, the timer went off, so I guess it's time to stretch. Not foolproof, but it helps.
00:09:20
Miranda Materi
Yeah, definitely.
00:09:21
josh MacDonald
Yeah. Another tip when I'm making a splint on a kid, one of the things I like to do is kids don't understand that warm and hot does not always mean danger and pain. And so when I pull the splint material out,
00:09:34
josh MacDonald
and I put it on their hand, it's warm, it's hot even, but it's not painful and it's not going to cause them harm or damage, but they don't understand that. They just feel hot is bad. So I'll take a little scrap piece.
00:09:45
josh MacDonald
When I throw the piece I'm using in, I'll throw another piece in. It heats it very quickly. I pull it out and I show it to them. I say, look, look, now it's super squishy and soft because I showed them the rigid first and I give it to them and they can touch it and feel that it's okay.
00:09:59
josh MacDonald
and feel that that is 150 degrees by the time I give it to them, but it's okay and it doesn't hurt. And so now I'm gonna put a bigger piece and we're gonna shape that on your hand. I've made splints on dolls before, I've made splint on mom before, just so they see like, oh, this is an okay process.
Summary and Contact Information
00:10:15
josh MacDonald
So that the first time I'm putting that on, they don't yank that hand back, make a full fist, you know real back and pinging, let them have some exposure before I just throw this confusing thing at them.
00:10:22
Miranda Materi
Right.
00:10:28
Miranda Materi
Yes for sure.
00:10:29
josh MacDonald
Yeah, yeah. So I could talk about pediatric stuff all day long, but there's some basic stuff about about pediatric flexor tendon. Six is kind of our decision point. If it's under six, I'm leaning towards immobilization. If it's over six, I'm considering um removable, maybe clamshell if they're a little bit more squirrely. Boys a little bit older, girls a little bit younger, but it's all about the family and the patient dynamics. You got to read the situation, um but know that immobilizing them fully is not as big a deal with kids as it is with adults.
00:10:58
Miranda Materi
yeah Thanks for all those tips. Those were great.
00:11:00
josh MacDonald
All right, if you have any questions, reach out to us on our email, info at handtherapyacademy.com, or you can find us on our social medias, Hand Therapy Academy.