The 42nd Bubble Wrap

Cite this article as:
Leo, G. The 42nd Bubble Wrap, Don't Forget the Bubbles, 2020. Available at:
https://dontforgetthebubbles.com/the-42nd-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Vitamin A, B, C…. knowing when to prescribe is not as easy as 1, 2, 3!

Lateral condylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21030

Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…

 

Epidemiology 

This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.

 

History 

The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.

 

Examination

Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.

Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.

It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.

Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.

 

Investigations

AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.

The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.

The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.

The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.

 Lateral condyle fractures can be classified depending on their x-ray appearances.

 

Classification

There are several different classification methods. The most common classifications as below.

Milch Classification
Type 1 The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2 The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.

 

Milch Classification

 

Jakob Classification
Stage 1 <2mm displacement, which indicates intact cartilaginous hinge
Stage 2 2-4mm of displacement
Stage 3 >4mm displacement with rotation of the fragment

 

Jakob Classification

 

Immediate treatment in the ED

Provide immediate adequate analgesia to the child prior to any examination or investigation.

If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.

Keep the child nil by mouth as they may need urgent surgery.

 

Treatment following imaging

Treatment depends on the degree of displacement of the fracture.

Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.

 

Jakob classification Treatment option Follow up
Stage 1 (<2mm of displacement) Conservative management with immobilisation with above elbow cast to 90 degrees. Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation) These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation. 3-6 weeks in above-elbow cast and orthopaedic follow up.

 

Areas of controversy

Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.

 

Potential complications

This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.

The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:

  • Stiffness is the most common complication, usually fully resolving by 48 weeks.
  • Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
  • Non-union is more likely when delayed union occurs.
  • Cubitus valgus deformity occurs with lateral physeal growth arrest.
  • Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
  • Avascular necrosis may develop 1-3 years after the fracture.

Image from wikimedia.org

 

Do not miss bits

Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.

  

William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.

 

 

References

Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.

 

Change the System, not the people: Neil Spenceley at DFTB19

Cite this article as:
Team DFTB. Change the System, not the people: Neil Spenceley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22275

Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety.

This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level.

If you just want to read one key paper to get you started then read this one from paediatric surgeon, Lucian Leape.

Leape LL. Error in medicine. Jama. 1994 Dec 21;272(23):1851-7.

If you want to read two papers (and we suggest you should) then download this one too.

Hollnagel E. Human error. InPosition paper for NATO conference on human error 1983 Aug.

 

 

 

Doodle medicine sketch by @char_durand 

 

©Ian Summers

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button

Selected References

 
Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cognition, Technology & Work. 2010 Jun 1;12(2):87-93.
 
Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, Fastman J, Marsh B, DeMaria S. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ quality & safety. 2019 May 31:bmjqs-2019.
 
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Qual Saf. 2017 May 1;26(5):381-7.
 
Hollnagel E, Amalberti R. The emperor’s new clothes: Or whatever happened to “human error”. InProceedings of the 4th international workshop on human error, safety and systems development 2001 Jun 11 (pp. 1-18). Linköping University.
 
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017 May 1;26(5):417-22.
 
Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ Online 2000

Finger injuries: basics and bones

Cite this article as:
Sinead Fox. Finger injuries: basics and bones, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27577

Introduction

Injuries to the hand are frequent in the paediatric population and are a common reason for presentation to the PED. Despite the frequency of these presentations, assessment and management of hand and finger injuries can be challenging. But never fear! DFTB have come to the rescue with a comprehensive two-part series related to the assessment and management of paediatric hand and finger injuries including some handy tips.

This first post will cover an overview of the basic anatomy of the hand, professional lingo as well as history taking and the clinical examination. Documentation essentials and common phalangeal and metacarpal fractures seen in PED will also be covered.  

First, let’s take a look at the basic anatomy of the bones of the hand.

Outlines the bones of the hand

Professional Lingo: Get to know your pinkie from your pointer!

Although it is helpful to know your pinkie from your pointer when talking to children, it is also important to have knowledge of the professional language used to document and describe hand injuries appropriately. This is not only important from a medico-legal point of view but having the ability to describe the exact location of clinical findings in professional terms makes communication and referral to specialist services much easier.

Clinical History/Documentation Essentials: Take a HAND history

H-          How the injury happened? Ask about mechanism of injury including the environment in which the injury was obtained.

              Hobbies. Ask about the child’s hobbies, sports, activities, career aspirations (in older child) as these may impact on management.

A-          Altered sensations. Ask about any altered sensations such as paraesthesia which could indicate a nerve injury.

N-          Needles/Needs Tetanus? Ask about vaccinations, is the child’s Tetanus vaccination up to date, especially relevant if open wounds or animal/human bites are present.

NAI        Like all paediatric injuries consider the possibility of NAI, especially in the younger child. A comprehensive history is essential to detect the possibility of intentional injury from physical abuse or an unintentional injury as a result of neglect. Consider injuries that are self-inflicted in the older child/adolescent age group.

D-          Dominance. Ask and record the child’s hand dominance as this can impact injury management.

Physical exam – look, feel, move

Clinical assessment of hand injuries involves a systematic exam of both hands including inspection, palpation, and range of motion (ROM).

1. Look

  • Once the child has received appropriate analgesia and you have established a rapport with the child and their parent, begin by looking at the hand without touching, observe the child’s hand at rest and play, involve a play specialist if available- they always bring the right amount of magic to get even the sorest of little hands and fingers moving!
  • Look for bruising, swelling, abrasions or open wounds. Assess for nail bed injuries.
  • Check for any clinical deformities including a rotational deformity which may not become apparent until the child makes a fist. Minimally displaced fractures may be clinically significant if they result in a rotational deformity, so it is vital to routinely assess for same. It is good practice to include the presence or absence of a rotational deformity in your documentation.
Rotational deformity – the normal cascade should point to the thenar eminence

2. Feel

  • Examine the child’s unaffected hand first and keep the child chatting throughout the exam, it helps reduce the child’s anxiety and allows the child to build trust in you.
  • Remember to examine the whole hand. It is important to develop a systematic approach to the examination of the hand including palpation of the wrist, carpal bones (including anatomical snuff box and scaphoid tubercle) metacarpals, metacarpophalangeal joints (MCPJs), phalanges, proximal interphalangeal joints (PIPJs) and distal interphalangeal joints (DIPJs).  Systematic palpation of the entire hand can help localise underlying fractures and concomitant injuries.
  • Evaluate and document neurovascular status.

Examination Pearl: The Wrinkle Test

Neurological assessment in young children or children/adolescents with difficulties communicating can be particularly challenging as they may be unable to report the presence or absence of sensation. The wrinkle test measures autonomic function of peripheral nerves via placement of the child’s hand in warm water for 10 minutes, wrinkles on the fingers indicate intact neurological function.

3. Move

  • Getting a child to move an injured hand can be challenging but certain familiar gestures such as high fives, thumbs up or fist bumps can be used to assess active range of movement in a young or uncooperative child.
  • A game of paper, rock, scissors is a fun and systematic way to test peripheral nerves in children with upper limb injuries. 
  • Be vigilant for tendon injuries. Check out the DFTB finger tendon and ligament injuries post for further details and clinical pearls related to the assessment of specific tendon functions. These functional tests should be included in every clinical examination of an injured hand.

Phalangeal Fractures

Approximately 20% of hand injuries in children are fractures. In particular, the phalanges are the most frequently injured bones of the hand with distal phalangeal and proximal phalangeal base fractures being the most commonly diagnosed fractures.

Proximal phalangeal base fractures

It’s a sunny June afternoon and Patrick a 9-year-old boy is brought to your ED by his Dad. Patrick reports it is the last day of school term before the summer holidays, he tells you he was so excited that when the final bell rang he threw his book bag in the air but, as the bag landed his left little finger got caught in the strap. It sounds like his finger was forcefully abducted by the weight of the bag. He shows you his swollen, bruised, and painful pinkie.  

Mechanism

Typically, proximal phalangeal base fractures result from a finger being abducted beyond acceptable limits of the MCP joints.

Presentation

A child with a proximal base phalangeal fracture will typically present with swelling, ecchymosis, and focal tenderness on palpation to base of proximal phalanx. A displaced fracture to the base of the proximal phalanx can cause malrotation of the finger. A significantly displaced fracture or a fracture that causes a rotational deformity requires closed reduction to correct the deformity.

Imaging

Oblique, PA, and lateral X-rays of the injured fingers should be obtained. True lateral X-ray is the most effective way to examine joint congruity. Angulation of proximal phalanx fractures is best seen on the lateral projection.

Salter-Harris Classification

Fractures involving the physis are described by the Salter-Harris Classification system as types I-V.  Salter- Harris type II fractures of the proximal phalanx are a common type of finger fracture in children.

  • Salter-Harris type I fractures involve only the physis and can be difficult to diagnose because X-Rays typically appear normal unless there is displacement.
  • Salter-Harris type II fractures involve extension through the physis and metaphysis.
  • Salter-Harris type III fractures extend through the physis and epiphysis.
  • Salter-Harris type IV fractures extend through the physis, metaphysis and epiphysis.
  • Salter-Harris type V fractures involve crush injuries that shatter the physis. 

Treatment

Non- Operative: Un-displaced or minimally displaced Salter-Harris type I or II fractures of the proximal phalanx without clinical deformity are usually managed with buddy taping to an adjacent finger for support and encouragement of early range of motion, typically for 3-4 weeks.

For displaced Salter Harris type II fractures of the proximal phalanx closed reduction can be carried out in ED. Depending on the age and preference of the child, closed reduction can be performed using a ring block +/- procedural sedation. The proximity of the physis assures a high degree of remodelling. The ED practitioner’s thumb or a cylindrical object such as a pen or pencil can be used to achieve adequate reduction. Post reduction stability is maintained by buddy tapping +/- splinting.

Operative: Severely displaced, unstable or open fractures require evaluation by a hand surgeon.

X-ray shows a displaced Salter-Harris type II fracture to the base of Patrick’s proximal phalanx. There is a rotational deformity on clinical exam. You reduce the fracture in ED using a ring block and Nitrous Oxide. On reassessment post reduction the clinical deformity is corrected and check X-rays are satisfactory. You discharge Patrick home with his finger buddy taped and arrange follow up in an outpatient clinic.  

Phalangeal shaft, neck and condylar fractures

Phalangeal shaft fractures

Treatment for fractures along the shaft of the phalanges is dictated by the orientation of the fracture as well as the degree of angulation on initial presentation. Clinical exam is also extremely important as even innocuous appearing fractures along the phalangeal shaft can be clinically significant if they cause a rotational deformity of the injured digit. A rotational deformity must be corrected as failure to do so can lead to long term functional impairments for the child.

Non operative: For length stable fractures with minimal displacement, buddy taping to an adjacent finger for support and to allow early range of motion can be an effective treatment for approximately 3-4 weeks.

Operative: Oblique or spiral fractures requiring closed reduction need more rigid immobilisation such as an ulnar or radial guttar splint or cast. Alignment of these fractures can be difficult to maintain and fixation is often required; surgical opinion is advised.

Surgery is also indicated in cases of open or severely displaced fractures or where there is instability post-reduction.

X-ray of long oblique proximal phalanx shaft fracture Courtesy of Orthobullets: https://www.orthobullets.com/hand/6114/phalanx-fractures

Phalangeal neck fractures

Neck fractures of the proximal and middle phalanges are classic paediatric injuries, rarely seen in adults. They typically result from a crush injury to the finger such as a child getting the finger caught in a closing door.

Non operative: Non-displaced fractures to the neck of the proximal or middle phalanges can usually be managed safely by immobilizing the digit for 3-4 weeks.

Operative: Surgical consultation is recommended for any displaced neck fractures as these are inherently unstable and require close follow up.

Condylar fractures

The condyles are a pair of tuberosities that form the distal articular surfaces of the proximal and middle phalanges. Condylar fractures are intra-articular fractures and can be unstable, therefore surgical consultation is recommended as these fractures require meticulous reduction to ensure proper joint congruity.

Volar plate avulsion injuries

Tori is a 14-year-old girl and a talented soccer goalie. She reports that while trying to save a penalty, her right middle finger was forcefully hyperextended and is now very painful. She shows you her right middle finger which is swollen and bruised at the PIPJ.

An overview of volar plate injuries

The volar plate lies between the flexor tendons and the palmar PIPJ capsule. It originates from the proximal phalanx and inserts into the middle phalanx. The volar plate contributes to the stability of the PIPJ by preventing hyperextension of the PIPJ.  Volar plate injuries encompass a spectrum of soft tissue injuries and can occur with an avulsion fracture at the volar base of the middle phalanx.  Subluxation or dislocation of the PIPJ may also occur.

Mechanism

Volar plate injuries are commonly caused by forced, sudden hyperextension injuries of the PIPJ, seen typically in older children/adolescents involved in hand/contact sports. Occasionally volar plate injuries can be caused by a crush injury to the digit.

Presentation

Diagnosis of a volar plate injury is based on history and clinical examination. Typically, there is swelling of the PIPJ. Bruising to the volar surface of the PIPJ is sometimes observed. Maximal tenderness on palpation is over the volar PIPJ and the patients may report pain on passive hyperextension of the PIPJ. The collateral ligaments should be tested as with collateral ligament injuries to check stability of the PIPJ.

 X-rays may reveal an avulsion fracture at the base of the volar surface of the middle phalanx and can help identify PIPJ subluxation or dislocation.

Case courtesy of Dr Mohammad A. ElBeialy, Radiopaedia.org. From the case rID: 46050

Treatment

Non- operative: A stable joint without a large avulsion fracture (<40% of articular segment) and/or a reducible fracture with 30 degrees of flexion is usually managed conservatively with splinting. In less severe injuries the injured finger can be buddy taped.

Operative: Surgical opinion should be sought if there is instability of the PIPJ or there is a large avulsion fracture.

When you examine Tori’s hand there is an isolated injury to Tori’s right middle finger as evidenced by swelling, bruising and tenderness to the PIPJ. Although active ROM is painful, Tori is able to fully extend and flex the finger. X-ray demonstrates a small avulsion fracture to the volar base of the middle phalanx on her right middle finger and you correctly diagnose her with a volar plate injury. Tori’s injury is stable and suitable for buddy taping to allow for early range of motion and prevent stiffness.

Distal Phalangeal Fractures

Distal tuft fracture

Khalid is a 2-year-old boy. He is brought to ED by his Mum as he caught his right index finger in the hinge side of a closing door. You examine his hands and note swelling and erythema to the distal phalanx of his right index finger. There is no nail bed injury or open wounds and he is moving the finger freely as you observe him playing with a toy tractor which was kindly supplied by the PED play specialist. His Mum appears more upset than he is, so you calmly reassure her that a serious finger injury is unlikely but an X-ray is required to rule out a fracture.

Mechanism

Distal tuft fractures are common in the toddler or pre-school age groups and typically occur as a result of direct crush injuries such as getting little fingers caught in a closing door.

Presentation

A concomitant nail bed laceration or pulp laceration may be present in children who have a distal tuft fracture. In this case the fracture is classed as an open fracture and opinion should be sought from Plastic Surgery Team. Check out the DFTB post on fingertip injuries for more information related to the assessment and management of nail bed injuries. Be alert for injury to flexor/extensor tendons.

Treatment

Non-Operative: Most children who have a closed distal tuft fracture are treated conservatively with splinting or buddy taping.

Operative: Surgical treatment is reserved for patients with distal tuft fractures who have nail bed injuries, subtotal/total amputations, or an unstable transverse fracture pattern.

X-ray demonstrates an un-displaced tuft fracture. You buddy tape Khalid’s fingers and reassure Mum that the fracture is small and unlikely to cause Khalid any functional problems.

Seymour fractures

Jordan is a 12-year-old boy who is brought to the PED with an injury to his left thumb. During a rugby match he was tackled to the ground and an opposition player stood on his thumb. He shows you a swollen, bruised partially flexed thumb. There is blood at the proximal nail fold and the nail plate is partially avulsed. The finger is visibly contaminated with dirt and soil from the rugby pitch, so you irrigate it with saline prior to X-ray and check that Jordan’s vaccination status is up to date.

Mechanism

A Seymour fracture is an injury unique to children. This fracture pattern is usually caused by a crush injury and results in an angulated Salter-Harris type I or Salter-Harris type II fracture with an associated nail bed injury. It is important to recognise this fracture pattern as early referral to a hand surgeon is important to avoid complications.

Presentation

The typical presentation is a swollen, bruised, and painful finger flexed at the DIPJ. There may be blood under the nail or the nail plate can be completely avulsed proximally causing it to sit superficial to the eponynchial fold (aka proximal nail fold). Soft tissue (often the germinal matrix of the nail) can become interposed in the fracture which prevents fracture reduction and healing.

Imaging

PA X-ray views of the injured finger often appear normal. Lateral view X-ray are used to confirm the diagnosis.

Pro tip! Because of the flexed appearance at the DIPJ, a Seymour fracture can be misinterpreted as bony mallet injury; however a mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not enter DIPJ).

Treatment

Non-Operative: Closed injuries are managed with closed reduction and splinting. The child may be followed up with a weekly X-ray to ensure maintenance of fracture reduction.

Operative: Substantive injuries require open reduction and nail bed repair.

Bottom Line

It is important to seek surgical opinion regarding the management of Seymour fractures as if left untreated possible complications include osteomyelitis, malunion, and pre-closure of the physis.

Jordan’s x-ray shows an angulated Salter-Harris type II fracture to the distal phalanx and you correctly diagnose a Seymour fracture. You refer Jordan to the plastic surgery team who decide to take Jordan to theatre to ensure a thorough washout and repair of the nail bed injury.

Metacarpal Fractures

Katie is a 15-year-old girl who presents to your ED with her father. Her father reports that she had an argument with her Mum and punched a wall at home, he also reports that this is not the first time an incident like this has occurred. Katie shows you her right hand which is grossly swollen and bruised over the dorsal surface. There are no open wounds and she reports focal tenderness on palpation to her 5th metacarpal bone. There is an obvious loss of knuckle height and rotational deformity to her little finger. During the exam she is visibly withdrawn and quiet and you are suspicious that there is more than a hand injury bothering Katie.  

Mechanism

Metacarpal fractures are common in adolescent athletes. The most common type of metacarpal fracture is the so-called ‘‘boxer’s fracture’’, which involves the neck of the ring or small finger metacarpal. This injury usually occurs as a result of direct bony trauma when the child/adolescent strikes a fixed object such as a wall with a closed fist or is struck on a fisted hand with an object such as a bat/hurl/hockey stick for example.

Presentation

The child/adolescent will usually present with bruising, swelling and diffuse pain over the dorsum of the hand. There may be loss of knuckle prominence. Be vigilant for rotational deformity; no degree of malrotation is acceptable.

Ensure to evaluate skin integrity over the injured area, check for and document the presence of open wounds; consider the possibility that these could be so-called ‘’fight bites’’ and will require antibiotics. Substantial injuries or infected open wounds require a surgical opinion as these may require admission for IV antibiotic cover and washout in theatre. Check integrity of flexor/extensor tendons in the presence of open wounds. Remember to check Tetanus vaccination status.

A child/adolescent who presents to the PED with a hand injury because of a fight or an injury mechanism such as puching a wall requires special attention- screening for mental health and/or social problems is paramount. Involvement of medical social worker teams or mental health teams may be necessary. The HEEADSSS screening tool may be useful to guide this line of inquiry.  

Treatment

Treatment is generally based on the level of injury (e.g. head, neck, shaft and base) and clinical findings (rotational deformities, open wounds, fracture stability).  

Un-displaced stable fractures of the neck or shaft (2nd-5th metacarpals)

Non-operative: Can be treated in rest volar splint/back -slab and followed up in clinic

Angulated neck of metacarpal fractures

Most common is fracture of 5th metacarpal or  ‘‘Boxer’s fracture’’

Treatment guided by degree of angulation. Seek surgical opinion

Non-operative: Closed reduction in PED using nerve block +/- procedural sedation and immobilisation in cast

Operative: Surgery may be required in the presence of open wounds, suspected tendon injuries or if angular deformity is substantial and/ or there is a rotational deformity on clinical exam.

Case courtesy of Dr Benoudina Samir, Radiopaedia.org. From the case rID: 23848

Displaced intra articular, unstable, comminuted or unstable fractures

Operative: These fractures all require surgical referral

Metacarpal head fracture (intra-articular) Courtesy of Orthobullets: https://www.orthobullets.com/hand/6037/metacarpal-fractures

Thumb metacarpal fractures

Thumb metacarpal base fractures require surgical opinion. Disruption of carpometacarpal (CMC) joint congruity can result in significant functional impairments for a child/adolescent particularly loss or limitation of pincer or power grip.

Specific names are given to fractures of the base of the 1st metacarpal

  • Bennett fracture: defined as an intra-articular 2-part fracture of the base of 1st metacarpal bone *(see also Reverse Bennett fracture below)
  • Rolando fracture: similar to Bennett fracture but prognosis is worse. Defined as a comminuted intra-articular fracture of the 1st metacarpal, producing at least 3 parts.

X-ray demonstrates a severely angulated fracture to the neck of Katie’s 5th metacarpal bone. Taking this into consideration and the presence of rotational deformity, you refer her to the hand surgery team for management. They decide to admit her for manipulation under anaesthetic (MUA). While awaiting admission you get the opportunity to establish a rapport and talk to Katie about her mental health. You use the HEEADSSS screening tool to guide your inquiry. She reveals information about difficulties at home related to her mother’s substance abuse and reports that she has been missing a lot of school due to bullying. Katie agrees that she needs help dealing with these issues and you refer her to the inpatient mental health team with her permission. Her dad is also informed.

*Reverse Bennett fracture dislocation

An intra-articular fracture dislocation of the base of 5th metacarpal bone is called a reverse Bennett fracture. This fracture pattern is inherently unstable and referral to hand specialist is essential.

Reverse Bennett fracture dislocation Case courtesy of Dr Alborz Jahangiri, https://radiopaedia.org/cases/reverse-bennett-fracture-dislocation-1

References

Andy Neill. AFEM 033 | Hand: Lingo and soft tissues. Retrieved from https://litfl.com/bscc/clinical-anatomy/hand-anatomy/

Abzug, J. M., Dua, K., Bauer, A. S., Cornwall, R., & Wyrick, T. O. (2016). Pediatric phalanx fractures. Journal of the American Academy of Orthopaedic Surgeons24(11), e174-e183.

Sullivan, M. A., Cogan, C. J., & Adkinson, J. M. (2016). Pediatric hand injuries. Plastic Surgical Nursing36(3), 114-120.

Wahba, G., & Cheung, K. (2018). Pediatric hand injuries: Practical approach for primary care physicians. Canadian Family Physician64(11), 803-810.

Weber, D. M., Seiler, M., Subotic, U., Kalisch, M., & Weil, R. (2019). Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. Journal of Hand Surgery (European Volume)44(6), 640-647.

A New Way To Teach

Cite this article as:
Team DFTB. A New Way To Teach, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28420

At DFTB we are very excited to be able to present the DFTB Modules – a set of free, open access teaching modules which are mapped to the UK and Australasian Paediatric Emergency curriculum that you can pick up and run in your own organisation.

This is a project that has been developed by our DFTB Fellows at the Royal London Hospital – Rebecca Paxton, Helena Winstanley, Chris Odedun, and Michelle Alisio. The DFTB Modules would not have been possible without our wonderful community of writers and contributors from around the world who have spent time crafting and reviewing the modules over the past year.

We’ve prioritized flexibility in creating the modules with cases and discussions with both basic and advanced trainees in mind. This way you can adapt them to your learners and existing resources. The first 15 modules have been released and we have another 30 in the pipeline. These will be published over the next few months. We would love to get your feedback or comments at fellows@dontforgetthebubbles.com

Why did we create the project?

The DFTB mission is about taking a “World recognized leadership role in making meaning of information in paediatric medicine, for clinicians“. Our principles are structured around being collaborative, pioneering, community-focused, and evidence-based.

Opportunities for teaching and learning across the curriculum in paediatrics, particularly in paediatric emergency, are variable between hospitals often due to access to useful resources. Whilst there are many fantastic educators in hospitals, many fill clinical roles. This means that their time to prepare for teaching is limited. For trainees, who often rotate from hospital to hospital, having access to structured resources and an opportunity for case-based discussion of a wide range of topics will help strengthen their learning.

By collaborating, as a group of medical professionals across the world, in writing these modules – we are working together as an international community to support thoughtful, evidence-based sessions.

Access the DFTB Modules here

A beginners guide to remote learning

Cite this article as:
Edward Snelson. A beginners guide to remote learning, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27341

Many of us are finding that we are being thrust into the world of remote medical education without the training or the experience to feel that we are likely to do this effectively.  There is a huge lack of adequate training for non-experts in this field that is designed to be pragmatic and useful for those of us who are more comfortable delivering face to face medical education.  I have looked for resources that might facilitate learning for a clinician who considers themselves a novice in remote or online medical education and have found none.

To help get people started, I’ve to put together some of the things I have learned about being an effective educator in the world of online and remote medical education.

Core Principles

You are the most important educational resource.  If you are delivering the education, your learners haven’t come to get a textbook or a list of facts.  They want to know what you know and what they don’t.  Forget some of the habits of traditional medical education.  Bring more of your experience and less of what you can find in a textbook.

Online and remote medical education has many advantages.  It is more accessible and has benefits for many people’s learning styles.  You can get a greater diversity of learners involved which can also be a powerful tool.  The educator can have more control of the virtual classroom.  

Online and remote medical education also carries many risks.  IT failures and audience disengagement are probably the greatest risks.  Preparation, planning and rehearsal are key elements in overcoming these challenges.

ProblemsSolutions
IT failure (connectivity, software limitations)Good signal (WiFi or mobile data) Educator’s device must be up to the task Choose the best software application for the job
Lack of connection from the audience to the educator.  Educator less able to read the audience.Where possible, have the audience visible (e.g. all on video) Maximise interactive content Have questions via audio as well as via chat
Audience disengagement and loss of attentionMaximal interactive content Chunks of delivered education should be brief and broken up by interactive elements Use of breakout rooms Polls Virtual flipcharts Injections of humour Changes of pace Music
Educator’s unfamiliarity with online teaching as a modalityRehearsal Visual aids (session map) Repetition of session to multiple audiences
Learner’s unfamiliarity with online learningPre-session briefing and joining instructions Start meeting with an explanation of what the session will involve and explain the functions
SecurityUse of required password for Zoom sessions Link to meeting sent with clear ground rules for whether it can be shared and with whom

A Step by Step Guide

Choosing a software application

There are various packages that are available.  The decision as to which to use will depend on various factors including ease of access, user friendliness, functions available, familiarity and permissions within an organisation.

ApplicationProsCons
ZoomGood range of functions including hand raising, chat, screen sharing, polling and breakout rooms User friendly Most people are familiar with Zoom Works well across a range of audience sizesBreakout rooms are only available in pro package (cost) Software is not permitted by some organisations, requiring users to access via personal devices People have to know how to use functions such as chat Basic and entry level package limit audience size to 100 but this can be increased at further cost Users need to set up Zoom on their device prior to the session (very straightforward)
Microsoft TeamsGood range of functions Permitted by organisationsFunctions are often clunky and poorly designed e.g. breakout rooms Less user friendly than many other packages Users need to set up Teams on their device prior to the session (more complicated)
Google MeetUse is possible within most organisations SimplicityVery limited functions – essentially it is a conferencing software package
Facebook roomsSimplicity Use is possible within most organisationsUsers may not have a Facebook account
SkypePermitted by organisationsLimited functions
YouTubeAble to reach an unlimited audienceUnable to see audience Interaction only possible via chat or third party applications (e.g. polling and virtual flipchart via mentimeter) Security and governance is more difficult to manage

There are many other software packages available.  It is worth trying the different packages to see what is the best fit for the teaching that you want to deliver.  I would recommend Zoom Pro for simplicity and functionality.

Every package will have settings that you should configure to your needs. For example, in Zoom, you can set defaults such as whether people are automatically muted when they join a meeting. Tutorials and guides for how to do configure settings are available online.

Hardware and connectivity

As the person delivering the session, you do not want to be let down by the tech on the day.  You need a device which is able to run the application smoothly.  Old or underpowered devices that let you down on the day need to be avoided.  You need to have a good broadband signal.  If you are using mobile data, you need a good signal.

The best way to make sure that it all works is to try out with the device you intend to use, in the place that you will be on the day, with the software that you will using.  Don’t assume that everything will work, make sure it will.

Time and Location

You should choose a time which is well protected.  You should have no other commitments that might encroach on the session.  You should be ready and set up about 30 minutes before the official start time so you need to build that into your schedule.

The space that you use for the session should be quiet and secure.  Think about what is in your background and aim to have nothing in view than yourself if possible.  Make sure that your lighting is in front of you and that you are not backlit.

The way that you intend to deliver the session will depend on the topic, the size of the audience and the teaching style.  A large audience lends itself to a webinar style.  A medium size group best suits a classroom style session and a small group session can be delivered more like a tutorial.

You should think about what resources and teaching aids you wish to use.  These are a really important part of your planning as they help with audience engagement. Many people will choose to use a PowerPoint presentation via the screen share facility in Zoom or Teams.  If you do use a PowerPoint, make sure that it is minimal.  The number of slides should be very few and the content very limited.  Remember that your audience may be viewing the session on a hand held device and thus wordy slides simply will not be easily readable.  If you have too many slides, this will lead you to talk too much and your audience will not be able to maintain interest.

There are a number of other ways to add dimensions and variety to your session.  Features within zoom and teams allow polling and breakout rooms (with zoom, breakout rooms is only available in the pro version).  It is also worth considering using external resources.

External resourcePossible uses
Mentimeter www.mentimeter.com Polling, Agenda setting, Idea sharing , Sharing learning outcomes
Fun Retro https://funretro.io/ Agenda setting, Idea sharing, Sharing learning outcomes
Google Docs https://drive.google.com Case studies, Handouts, Links


Using external resources is a great way of facilitating learning in a way that changes the pace and keeps the audience engaged.  For example, you could get your learners to go into a breakout room having first sent them a link to a google doc that has a case study and the tasks for that exercise.  You can also give them a link and code for the mentimeter that allows them to share what they think (virtual flipchart).  While they are in the breakout room, they are engaged in the learning in a different way and you get a few minutes to do whatever you need or want to do.

If you are using external resources, it is well worth putting together a list of links for your learners and sending these to your audience ahead of time.  Proactive learners will have those resources open and ready for the session.

If you deliver a really simple session, there is little risk that you will miss bits or find that elements get lost along the way.  If you have planned a more complicated session, giving yourself a visual aid-memoire in the form of a session map can be really useful.  Unless you are using a second device screen, you will need to have this on paper and placed just above your webcam for ease.  Even for simple sessions, having checklists can be really useful.  When you are thrown a curveball in an online session (someone having technical difficulties at the start) it can easily throw you and make you forget to do something essential such as introduce yourself.

You need to decide how you want your audience to be.  Will they have cameras on or off?  Will they be muted throughout and only use chat?  Will they be unmuting to speak and then muting themselves?  Will they be unmuted throughout because it’s a very small group?

It is essential that your learners know these parameters ahead of time.  If not you may find that they have assumed that they will be passive listeners and when you ask them to turn on video you see them five minutes later in a moderately damp dressing gown!

I would recommend that you send joining instructions which include the technical things like which platform and links will be needed, along with a few key bits of information such as the need to have video and audio for the session if that’s what you want.  You should ask if anyone has access or ability issues to let you know ahead of the session.

If your session is really high level, and particularly if you are doing complicated functions, consider having a second person supporting you.  This person does not have to be in the room with you but it does help if they are.  A second person can watch the session from another device and therefore sees what your audience sees.  They can therefore tell you when something isn’t going to plan.  The second person can also monitor chat, which can be difficult to do for the main facilitator when they are focused on delivering the session.

Rehearsal is really important.  You need to familiarise yourself with the software and by trying the different features, you will discover the potential glitches.  At the very least as preparation, have a meeting with friend or family using the platform that you intend to use and play with the different functions.

If your session is complicated or your audience is of high value in some way, you really want to run the whole session fully with a test audience.  This allows you to find out the time it takes and you are very likely to find that you need to crop something.  It also helps you to work out any practicalities that will make things run smoothly.

Setting up

Make sure that you are comfortable in every way.  Have some water available to drink.

Get everything set up and open the session before you expect people to join.  It is worth having a PowerPoint slide with some sort of greeting or session title so that people know that they are in the right place and that the video feed is working.  Your audience will also want to know that their audio is working.  A simple way of doing that is to play some music through your device and share that via the screen share function on the platform you are using.

You need to look at how you appear on video.  Check that you have optimal lighting.

Depending on the platform and settings that you have chosen, you may need to let people into the session.  If not, you can leave the session running and people can join and wait for the session to start.  If you have a second support person, brief them on what you want them to do.

About five minutes before the official start time, I recommend saying hello to your audience (so far) and letting them know that the session will start on time.  You can also remind them of any settings or preparation that they need to do.

Starting the session

At the beginning of the session it is important to cover some practical points.  Some of your audience may be unfamiliar with the software and despite having sent them specific instructions, people may not have read or understood these fully.

Things to tell your audience at the beginning of a session

  • Introduce yourself.
  • Tell people what you will be doing and how long the session will last.
  • Set ground rules as appropriate.
  • Tell people whether you want them to have video on or off.
  • Tell people how you want them to let you know when they have a question.  If you want them to use a “raise hand” function, tell them that you won’t always see their video feed so if they raise their hand on camera, you might not see that.
  • Explain any special functions that you want them to use.  That includes chat.
  • Tell your audience to let you know if something is wrong.

If you have any elements to your session other than your face and a PowerPoint, I find that it is good to start by giving the audience a low-level opportunity to practice using these features at the beginning so that they can try these out safely.  For example, if you plan to use breakout rooms with information on an online document and interactive software such as mentimeter you could do the following:

Explain these elements and ask them to open the menti.com site and the linked document.  The document could be instructions for a starter task such as “Find out what everyone wants to learn in this session” and the menti.com ideas board would be one where they will write their learning objectives for the session.  Then send them to breakout rooms to complete the task.

When they come back you can talk about their learning objectives but also deal with any user or technical difficulties encountered.

Even if you are delivering a bare-bones session, get your audience to use the simple features such as chat or hand raising right at the start.

The main event

Now go for it.  In order to be as effective as possible, you want to engage your audience and maintain their attention and enthusiasm.  There are lots of ways to help you achieve this.

  • Have your audience put their video feeds on. It can help you as a teacher to see people.  More importantly, it makes it less likely that they will be engaged in other tasks.  The classroom equivalent of an invisible online audience is a room full of people texting or checking emails while you talk.  
  • When your video feed is on, look at the webcam.  Eye contact is very important.  If you are looking anywhere else, your gaze is tangential which is subconsciously disengaging for your audience.  If you have a thumbnail of your own webcam feed on the screen, place this as close to the webcam as possible as your tendency will be to look at your own face much of the time.
  • Smile.
  • Be animated, including the use of hand gestures.
  • Use humour.
  • Limit the amount of time that you speak continually.  Even if you are going to continue speaking again, every few minutes ask the audience a question and leave time for them to think and answer.
  • Make your session about three quarters interactive in whatever way fits the modality.
  • Vary things as much as possible. You can switch from PowerPoint to webcam, then video.  Using interactive elements such as polling, breakout rooms or large group discussions are all possible ways to keep the session varied.

Managing the question and answer element

Q&A is one of the most basic yet effective means that is available for an educator to engage their audience and improve the depth of learning.  It helps the session facilitator to find the level needed for the teaching and meet the specific needs of the audience.  If you are delivering an online session with more than a few people, it is a very different experience from a face-to-face setting.

Q&A in a remote teaching session is often the element that requires the most management.  You should be prepared for the possibility that your audience has already become disengaged or distracted by other things.  It can be useful to give people a warning that a question is coming, “I hope you’re all paying close attention, because I’m going to ask you all a question in a moment.”  This might result in a few people putting away their phones (on which they were commenting on something on social media or answering an email) in time to be fully engaged when you need them to be interactive.

If your audience is muted when you ask a question, you can manage that in a number of ways.  Remember that regardless of audience size, it may be difficult to get your participants to answer, so encourage them as much as possible.

Method 1 – answer via chat

This is most likely to get responses as people won’t be worried about interrupting someone and they may feel safer in terms of constructing an answer when they can review and edit it before sending it.  The facilitator needs to allow enough time for people to do this, so don’t ask a question and assume that no-one is answering after a few seconds.

If you use chat as the means for answering questions, it can be a really good way of engaging people more if you invite individuals to expand their question verbally.  “Mohammed, you’ve put ‘what about POPs scores?’ in the chat.  Could you please unmute your mic and tell me what you’ve been told about POPs scores and how they are used?”

Method 2 – hand raising

Software such as Zoom allows participants to hit a button called “raise hand” which comes up as an alert to the host.  The facilitator can then invite that person to unmute their mic in order to ask their question.

Method 3 – Verbal free for all

Most platforms give the host the opportunity to unmute everyone’s microphones at once.  This can be used to create something closer to a classroom experience where people can just start talking.  There is a risk that more than one person will talk at once, which becomes greater with large groups.  There is also the risk that any background noise from other participants becomes audible.

It is worth trying different methods to see which works well.  Within any session, if you find that one method isn’t getting any or much response, you can see if a different method works better as all audiences are different.

Other Top Tips and Resources

Here’s a list of tips and tricks that may help:

  • Use headphones to avoid feedback and a microphone to reduce background noise.  A standard mobile phone microphone earpiece set works well.
  • If you have a second device logged into the same meeting in the same room, one of them must always be muted and have speakers off otherwise there will be an echo.
  • Remember that even when your video feed is off, people can hear you if you are not muted.
  • Remember to stop screen sharing when you have finished showing something to your audience.
  • Backgrounds are a fun way to inject humour into a session but you need to have a plain backdrop and there is a risk that it affects the applications function.
  • Your software may allow you to record the session which can then be used as a resource for you to review what went well and what could be improved.
  • Recordings of webinar or lecture-style sessions can be recorded and used as an educational resource.
  • Most conference software has multiple views to choose from.  Try using each view both in rehearsal and when delivering a session.
  • Each time you deliver a session, you will become more familiar with the technical and educational aspects of online learning.  Delivering the same session multiple times in a short period of time will help you to learn and improve.

DFTB are proud to share with you our first 15 remote education modules that you can pluck off the virtual shelf.

Finally, a short list of other resources that have explored the issue of becoming an effective educator in an online setting:

https://dontforgetthebubbles.com/teaching-virtually-anywhere/

https://www.aliem.com/teaching-age-covid19-real-time-video-conferencing/

https://icenetblog.royalcollege.ca/2020/03/17/teaching-remotely-in-response-to-covid-19-10-tips-to-improve-your-digital-classroom/

https://www.youtube.com/watch?v=HCK_1ydMhiE