Treatment depends on the underlying diagnosis but always includes pain control and rest from activity. Classic Little Leaguer’s elbow refers to medial humeral epicondyle apophysitis. These athletes benefit from rest, ice, anti-inflammatory medication, and a physical therapy program aimed at upper body strengthening. Throwing mechanics and the pitching guidelines published by Little League Baseball/Softball should be reviewed with these players. Switching players to a lower throwing position (e.g., first base) after rehabilitation, to avoid pitching for the remainder of the season, is often recommended.
Multiple small joints, a delicately balanced intrinsic muscle system, a powerful extrinsic muscle system, dense sensory innervation, and specialized skin combine to make the hand a highlymobile and sensitive yet powerful anatomic part. The extrinsicmuscles originate in the forearm and the intrinsic muscles arelocated in the hand and coordinate small, delicate movements. The movements of opening the hand, extending and spreading the fingers, and then clenching the hand into a fist requirescoordinated function of the intrinsic and extrinsic muscles. Tenderness of direct palpation of the bones raises the concern for fracture. Scaphoid fracture is the most common carpal bonefracture in the pediatric population. It requires immobilizationin a thumb spica cast, whereas displaced fractures require surgical intervention. Salter-Harris fractures of the distal radius are also very common. In young gymnasts, there is increased riskfor injury at the distal radial physis from repetitive impact andupper extremity weight bearing. This is commonly called gymnast’s wrist and requires absolute rest from impact and weightbearing to prevent premature closure of the growth plate.
Ganglion cysts are synovial fluid-filled cysts about the wrist. The most common location is the dorsum of the wrist near the radiocarpal joint, followed by the volar radial aspect of the wrist. The defect is in the joint capsule, which allows synovial fluid into the soft tissues with wrist use, where it can become walled off with fibrous tissue. Often, in skeletally immature patients, the process is benign and disappears over time. Large ganglion cysts or cysts that are painful and interfere with function may require more aggressive therapy. Aspiration and steroid injection into the cyst may be helpful, but many will recur. Surgical excision will remove the tract that attaches to the wrist joint, so it is usually curative.
Polydactyly (extra digits) occurs in simple and complex varieties (see Table 201-2). Skin tags and digit remnants that occur near the metacarpophalangeal joint of the fifth digit and thumb that do not have palpable bones or possess voluntary motion are simple varieties. These may be excised or ligated in the nursery. Complex deformities should be referred to a pediatric orthopedist for amputation. Syndactyly (fused digits) are concerning because of the possibility of shared structures and the tethering effects on bone growth (see Table 201-2). All patients with syndactyly should be referred for treatment options.
Trigger thumb and trigger finger are secondary to isolated thickening of the flexor tendons. As the thickened nodule enlarges, it may catch in a bent position, then snap or triggerstraight as it passes through the first pulley that anchors the tendon. Ultimately, as it enlarges, it cannot pass through at all and produces a flexion deformity at the interphalangeal joints. The nodule may be palpable near the metacarpophalangeal joint. These children should be referred for surgical correction.