Advances in Hand Therapy: Best practice in conservative management of proximal phalangeal fractures in children.

INTERVENTION: Intervention: Splinting (group 1) vs no splinting (group 2) of proximal phalangeal fractures that have been clinically assessed as being healed at 3 weeks post injury. All face to face interventions will be delivered at The Children's Hospital at Westmead outpatient department. Visit 1, 30 minutes (within 2 weeks post fracture) ‐ Study information will be provided to potential participants. ‐ Fabrication of a thermoplastic splint and instructions given about full‐time wearing regime and precautions. Visit 2, 30 minutes (range 3 weeks to 4 weeks post immobilisation) ‐ Administration staff to obtain consent. ‐ Eligibility for stage 2 inclusion will be assessed by a senior hand therapist ‐ For those eligible envelope randomization will be used to determine study group ‐ All participants will have total active motion (TAM) measures recorded of their affected digit/s and the contralateral digit/s on the unaffected hand. TAM will be measured using a rolyan goniometer. ‐ Participants randomly allocated to Group 1 standard treatment will commence AROM exercises three times per day. Those with finger injuries will commence tendon gliding exercises x 10 repetitions and finger lifts x 10 repetitions. Those with thumb injuries will commence thumb finger touch x 10 repetitions and slides x 10 repetitions. Participants will be instructed to remove their splints for exercises and light functional use at home only. Splints must be worn overnight, for school and for high risk activities. ‐ Participants allocated to the Group 2 new protocol group will commence the same exercises as those who receive standard treatment, as outlined above. Participants will be instructed to cease splinting from this appointment. They are able to resume light activities and will be advised not to participate in sports or high risk activities. Therapists will advise the participant to buddy tape the affected finger to the adjacent finger if there is concern about the CONDITION: Finger fracture ; ; Finger fracture; Injuries and Accidents ‐ Fractures Musculoskeletal ‐ Other muscular and skeletal disorders Physical Medicine / Rehabilitation ‐ Other physical medicine / rehabilitation ; ; [5 and 8 weeks post commencement of intervention (immobilisation) or 2 weeks and 5 weeks post randomisation. ] The secondary outcome measures are: ; • Myometry ; ; Myometry will be measured in both groups at 5 weeks post injury. Myometry of each hand will be assessed for all participants by measuring power grip for fingers and thumb fractures and lateral pinch for thumb fractures using the CITEC dynamometer. This is a reliable method of recording grip strength in children (Molenaar et al, 2008). ; Participants will be required to sit with the elbow at 90 degrees and the wrist and forearm in a neutral position. Three measures for power will be taken and participants will be able to rest between each trial and can indicate when they are ready to continue. Grip and pinch strength is compared to the unaffected hand, taking into account hand dominance difference of 10% (Beenakkrel et al, 2001). We will compare grip and pinch strength for the two groups, with one being a control group and the other treatment group. ; [Myometry ‐ 5 weeks post intervention (immobilisation) or 2 weeks post randomisation.] INCLUSION CRITERIA: INCLUSION CRITERIA Stage 1: • Children aged between 5 to 16 years • Unaffected contralateral hand • Early diagnosis (within 2 weeks post fracture) Stage 2: • Assessed as being clinically healed at visit 2 by senior hand therapist PRIMARY OUTCOME: The primary outcome measure is total active motion (TAM), as compared to the contralateral digit. If TAM of the fractured finger at five weeks is no more than 20 degrees less than TAM of the contralateral digit, the range of motion will be defined to be “adequateâ€?. If TAM of the fractured thumb is no more than 15 degrees less than TAM of the contralateral thumb, the range of motion will be defined as ‘adequate’. TAM will be measured at both 3 and 5 weeks for all participants for both the affected digit and unaffected digit on the contralateral side. TAM will be measured using the dorsal method with a short arm Rolyan goniometer, following guidelines from the American Society for Surgery of the Hand, 1990. This method has been considered suitable for these fractures (Kato et el, 2007). Ellis and Bruten in 2002 reported that for finger goniometery intra‐rater reliability was within 5 degrees 95% of the time, and 7‐9 degrees 95% of the time for inter‐rater reliability. [TAM is measured at 3 weeks and 5 weeks post commencement intervention (immobilisation)] SECONDARY OUTCOME: The PRQ will be completed at 5 weeks within the final session and 8 weeks by phone, text or email. As there are no specific assessments to measure hand function in children following a traumatic hand injury, we will use a series of 5 questions requiring a yes/no answer. These questions will relate to function, pain and re‐injury. The PRQ data will be sought from both the participant and the parent/guardian at the 5 week follow‐up and the parent/guardian at the 8 week follow‐up. To encourage ethical reporting we will encourage parents/guardians to answer questions for the 8 week PRQ after consultation with the participant. Within the 5 week session the therapist will ask the 5 questions verbally and record the answers. The patient and parent will be asked how they would like the PRQ delivered for the 8 week follow‐up, with options being either over the phone, text or via email. Confirmed proximal phalanx fracture which is undisplaced or minimally displaced and stable that is being conservatively managed including closed reduction (performed in ED or in outpatient clinic (not in theatre)