Advances in Hand Therapy: Best Practice in Conservative Management of Proximal Phalangeal Fractures in Children
Rebecca Kilty1, Sarah Baxter1, Marnee J McKay2
1The Children's Hospital at Westmead, Westmead.
Insights
Shortening splinting duration for pediatric proximal phalangeal fractures to 3 weeks is safe and effective when fractures show clinical healing. This approach can improve patient outcomes and streamline care for common hand injuries in children.
Area of Science:
- Orthopedic surgery
- Pediatric hand surgery
- Traumatology
Background:
- Proximal phalangeal fractures are common pediatric hand injuries.
- Current conservative management involves 5 weeks of splinting, often exceeding clinical healing time.
- This study evaluates a reduced 3-week splinting protocol for clinically healed fractures.
Purpose of the Study:
- To compare the efficacy of 3-week splinting versus 5-week splinting for pediatric proximal phalangeal fractures.
- To assess total active motion (TAM), grip strength, and parent-reported outcomes.
- To determine if a 3-week splinting protocol is noninferior to the standard 5-week protocol.
Main Methods:
- A randomized controlled trial (Level 1 evidence) involving 80 children (aged 5-16 years).
- Participants with non-displaced or minimally displaced, stable proximal phalangeal fractures, assessed as clinically healed at 3 weeks, were randomized.
- Primary outcome was TAM at 5 weeks; secondary outcomes included grip strength and parent questionnaires.
Main Results:
- A 10% loss to follow-up was observed.
- Total active motion (TAM) 90% confidence intervals (CIs) for the 5-week group were 17.7 to 5.4 degrees, and for the 3-week group were 4.7 to 1.6 degrees.
- All CIs between groups overlapped by >10%, indicating noninferiority.
Conclusions:
- Reducing splinting duration to 3 weeks for pediatric proximal phalangeal fractures that are clinically healed is a viable alternative to the standard 5-week protocol.
- Therapist assessment of fracture healing is a reliable indicator for discontinuing immobilization.
- This supports a shift towards therapist-led care models for these common pediatric hand injuries.
Background:
Proximal phalangeal fractures are one of the most commonly treated hand injuries in children. Conservative management of these fractures is often to splint for 5 weeks post injury, despite children presenting as clinically healed at 3 weeks post injury. Therefore, we investigated the effect of splinting for only 3 weeks in children who present with clinically healed proximal phalangeal fractures at 3 weeks compared with usual care.
Methods:
Participants (n=80, aged 10.3 ±2.5 years) presenting to the Hand Clinic of a tertiary Children's Hospital in Sydney, Australia, were randomly allocated into a Current Protocol and a New Protocol group. Following were the inclusion criteria: aged between 5 and 16 years; present with an non-displaced or minimally displaced and stable fracture; no surgical intervention; assessed as clinically healed at 3-week visit. The primary outcome measure was total active motion (TAM) of the injured digit compared with the contralateral digit (deg), at 5 weeks post injury. Secondary outcome measures were grip strength, and a parent-reported questionnaire. Statistical analysis used χ 2 test and the absolute difference described by a 90% CI. The New Protocol was considered noninferior if the 90% CI overlap was > 20% of the Current Protocol. Analysis was by intention to treat.
Results:
There was a 10% loss to follow up at 5 weeks (Current Protocol =4, New Protocol =4). All CIs between groups overlapped by >10%. TAM 90% CI for Current Protocol was 17.7 to 5.4 degrees and for the New Protocol was 4.7 to 1.6 degrees.
Conclusions:
A change in practice is warranted to cease immobilization for children with conservatively managed proximal phalangeal fractures who present as clinically healed at 3 weeks. Therapist assessment of fracture healing is an appropriate indicator for intervention and can be utilized in a therapist-led model of care.
Level Of Evidence:
Level 1-noninferiority randomized control trial with 2 parallel arms.
