Chapter 10: Fractures and Dislocations of the Hand and Carpal Bones in Children

Nina Lightdale-Miric, Scott H. Kozin

Chapter Outline

Introduction to Fractures and Dislocations of the Hand and Carpal Bones in Children

Incidence

The pediatric hand is exposed and especially vulnerable to injury as the curious child explores the surrounding world. Young children are often unaware of dangers and place their hands in susceptible situations.14,86,204,217,218 Hand injuries account for up to 25% of pediatric fractures (Table 10-1).72,86 The reported annual incidence is approximately 26.4 fractures per 10,000 children.217 
 
Table 10-1
Incidence of Pediatric Hand Injuries
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Table 10-1
Incidence of Pediatric Hand Injuries
Peak age: 13 years
Annual incidence: 26.4 per 10,000 children
Percentage of all pediatric emergency patients: 1.7%
Right side incidence equals left
Male incidence is greater than female incidence
Most common fracture types
  •  
    Nonphyseal: Distal phalanx (crush)
  •  
    Physeal: Proximal phalanx
  •  
    Index and small fingers most commonly injured
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Pediatric hand fractures occur primarily in a biphasic age distribution: The toddler and the adolescent. In toddlers, the injury occurs most often secondary to a crush10,57,110,204; for example, a finger caught in a closing door. In teenagers, however, the mechanism is more commonly from a torque, twist, or axial load sustained during contact activities and athletics.29,60,68,121,165,212,220 
A higher incidence of pediatric upper extremity fractures is associated with certain youth sports, such as snowboarding, football, basketball, and skateboarding.123 In one study, overweight adolescents were found to have poorer balance, which may explain a propensity for fracture.71 Hand fractures in children peak around age 13, coinciding with active participation in organized contact sports, attempted daredevil maneuvers, as well as the occasional emotional outburst (e.g., punching a wall).15,27,60 
The two most common pediatric hand fractures are distal phalanx crush injuries and Salter–Harris (S-H) II fractures of the proximal phalanx.72,86,119,158,217,218 The border digits (thumb and small fingers) are the most vulnerable rays.14,86,119,158,217,218 Dislocations are relatively uncommon in children. Lateral bending forces are more often transmitted through the physis rather than the collateral ligaments in a child‘s hand because the growth plate is the path of least resistance.86,110,121,180,217,218 Proximal phalanx S-H II fractures account for nearly 33% of all hand fractures in children. Although rare, the thumb metacarpophalangeal (MCP) joint is the most commonly dislocated joint in the skeletally immature hand.38,67,113 The proximal interphalangeal (PIP) joint is the most commonly injured articular surface, involving volar plate or collateral ligament avulsion fractures. 
Fractures and dislocations about the child‘s carpus are rare compared to injuries of the adjacent physis of the distal radius.135,218 The scaphoid is the most frequently injured carpal bone in children.11,30,76 Pediatric scaphoid fractures have a peak incidence between the ages of 12 and 15 years.53 Scaphoid fractures are extremely rare during the first decade of life.16,59,76,107,154,165,180,185,203 Only a few reported cases involve children younger than 8 years of age, and the youngest patient reported is 4 years of age.53 
Carpal ligament dissociation and tears of the triangular fibrocartilage complex (TFCC) rarely occur in children.198 These tears are usually associated with distal radial fractures, radial growth arrest, ulnar overgrowth, and ulnar carpal impaction. Most often these children present late after acute trauma with activity-related pain. Rotational forces with axial loading cause tearing of the carpal ligaments or TFCC. In children with a positive ulnar variance, the TFCC is thinner and more susceptible to injury. Similarly, hypertrophic unions and nonunions of the ulnar styloid increase the risk of TFCC injuries. 

Applied Anatomy of Hand and Carpal Bones

Adults and children have distinct patterns of hand injury because of age-specific patterns of use as well as differences in underlying skeletal and soft tissue composition. Knowledge of the architecture of the physis, the soft tissue origins and insertions, and the surrounding periosteum is essential for recognition and treatment of children‘s hand fractures. 

Osseous Anatomy of Hand and Carpal Bones

Potential epiphyses exist at both the proximal and distal ends of all the tubular bones. Secondary ossification centers, however, develop only at the distal ends of the metacarpals of the index, long, ring, and small rays, and at the proximal end of the thumb. Conversely, the epiphyses are present only at the proximal ends of the phalanges in all digits.77,121 

Secondary Ossification Centers

In boys, the secondary ossification centers within the proximal phalanges appear at 15 to 24 months and fuse by bone age of 16 years (Fig. 10-1).77,196 In girls, the appearance and closure occur earlier, at 10 to 15 months and bone age of 14 years, respectively. The secondary ossification centers of the middle and distal phalanges appear later in both girls and boys, usually by 6 to 8 months. Fusion of the secondary ossification centers, however, occurs first distally then proximally with maturity. 
Figure 10-1
Appearance of secondary ossification centers (A).
 
Fusion of secondary centers to the primary centers (F).
Fusion of secondary centers to the primary centers (F).
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Figure 10-1
Appearance of secondary ossification centers (A).
Fusion of secondary centers to the primary centers (F).
Fusion of secondary centers to the primary centers (F).
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Within the metacarpal, the secondary ossification centers appear at 18 to 27 months in boys and at 12 to 17 months in girls. The proximal thumb metacarpal secondary ossification center appears 6 to 12 months after the fingers. The secondary centers within the metacarpals fuse between 14 to 16 years of age in girls and boys. Carpal bones classically ossify in a pattern moving counterclockwise when looking at the back of your right hand, starting with the capitate and hamate by 1 year of age. 
The pattern of carpal bone ossification and appearance of secondary ossification sites in the metacarpals and phalanges is often used to predict the skeletal bone age and years of remaining growth in children (Fig. 10-2).77,196 The fetal wrist begins as a single cartilaginous mass. By the 10th week of gestation, the carpus transforms into eight distinct entities with definable intercarpal separations. Although these precursors display minor differences in contour, the anatomical elements greatly resemble the individual carpal bones in their mature form.111 
Figure 10-2
The age at the time of appearance of the ossific nucleus of the carpal bones and distal radius and ulna.
 
The ossific nucleus of the pisiform (not shown) appears at about 6 to 8 years of age.
The ossific nucleus of the pisiform (not shown) appears at about 6 to 8 years of age.
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Figure 10-2
The age at the time of appearance of the ossific nucleus of the carpal bones and distal radius and ulna.
The ossific nucleus of the pisiform (not shown) appears at about 6 to 8 years of age.
The ossific nucleus of the pisiform (not shown) appears at about 6 to 8 years of age.
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The capitate is the first bone to ossify, usually within the first few months of life. The pattern of ossification proceeds stepwise from the distal row to the proximal row in a circular fashion. The hamate appears next, usually at about 4 months of age. The triquetrum appears during the second year, and the lunate begins ossification around the fourth year. The scaphoid begins to ossify in the fifth year, usually slightly predating the appearance of the trapezium.107 Scaphoid ossification begins at the distal aspect and progresses in a proximal direction.145 The trapezium and trapezoid ossify in the fifth year, with the trapezoid lagging slightly behind. The ossification pattern usually concludes with the pisiform in the ninth or tenth year. The scaphoid, trapezoid, lunate, trapezium, and pisiform may demonstrate multiple centers of ossification.116,145 Although these variations are well recognized, they may be confused with acute trauma by the inexperienced observer. 
The ossific nucleus of each carpal bone is cloaked in a cartilaginous cover during development, which is thought to provide a unique shelter from injury.11,72 This observation is supported by epidemiologic studies of scaphoid fractures that highlight the infrequent incidence in children younger than 7 years of age and the marked increase in teenagers.76,107 The detection of injuries to the immature carpus is problematic because of the difficulties in examining an injured child and the limited ability of radiographs to detail the immature skeleton; therefore, the incidence may be underappreciated.11,140,167 

Physeal Anatomy of Hand and Carpal Bones

The physis (growth plate) of the long bones of the hand provides longitudinal digital growth. Pediatric hand fracture geometry is the direct result of the histologic anatomy of the physis.137 The physis is divided into four distinct zones: Germinal, proliferative, hypertrophic, and provisional calcifications (zones I, II, III, and IV, respectively). The zone of chondrocyte hypertrophy (zone III) is the least resistant to mechanical stresses. This zone is devoid of the collagen that provides inherent stabilizing properties. Collagen is present in zones I and II, and the calcium present in zone IV provides similar structural strength.72,202 Therefore, the fracture often propagates through zone III as the path of least resistance. High-energy injuries, however, may undulate through all four zones of the physis.137,184 
The irregularity of the physeal zones in the phalanges and metacarpals increases near skeletal maturity.21 Thus, a fracture line may more often be transmitted through several zones in adolescents. This variable path through irregular topography may contribute to increased risk of partial growth arrest following adolescent fractures that involve the physis.184 Physeal irregularity also explains the differing patterns of physeal injuries dependent on age: S-H I and II fractures tend to occur in younger patients compared to the rarer S-H III or IV fractures that are more prevalent in children close to skeletal maturity. 

Pseudoepiphyses, Double Epiphyses, and Periphyseal Notching of Hand and Carpal Bones

A persistent expression of the distal epiphysis of the thumb metacarpal is called a pseudoepiphysis.80 The pseudoepiphysis appears earlier than the proximal epiphysis and fuses rapidly. By the sixth or seventh year, the pseudoepiphysis is incorporated within the metacarpal and is inconspicuous. Pseudoepiphyses also have been noted at the proximal ends of the finger metacarpals, usually of the index ray. The only clinical significance is radiologic differentiation from an acute fracture in the setting of incidental injury (Fig. 10-3). 
Figure 10-3
Abnormal epiphyseal appearance.
 
A: Double epiphysis. B: Pseudoepiphysis. C: Notched epiphysis.
A: Double epiphysis. B: Pseudoepiphysis. C: Notched epiphysis.
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Figure 10-3
Abnormal epiphyseal appearance.
A: Double epiphysis. B: Pseudoepiphysis. C: Notched epiphysis.
A: Double epiphysis. B: Pseudoepiphysis. C: Notched epiphysis.
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Double epiphyses can be present in any bone of the hand, but these anomalies are more common in the metacarpals of the index finger and thumb. There are variable expressions of double epiphyses, but the true entity is considered only when a fully developed growth mechanism is present on both ends of a tubular bone. Double epiphyses are usually seen in children with other congenital anomalies, but their presence does not appear to influence overall bone growth. When fractures occur in bones with double epiphyses, growth of the involved bone appears to be accelerated.216 
Periphyseal “notching” should not be confused with double epiphyses, pseudoepiphyses, or fracture.46,80,206,216 The location of the notches can coincide with the physis or may be slightly more distant from the epiphysis. Notching is a benign condition that does not influence the structural properties of the bone.216 
Clinical examination and x-rays of the contralateral noninjured hand are often critical to clarify what is unique individual osseous anatomy versus an acute injury. 

Soft Tissue Anatomy of Hand and Carpal Bones

The tensile strength of a younger child‘s soft tissues usually exceeds that of the adjacent physis and epiphysis.18,137 For this reason, tendon or collateral ligament avulsions are less common compared to physeal or epiphyseal fractures in the skeletally immature hand.18,84 

Tendons

The terminal tendon of the digital extensor mechanism and the extensor pollicis longus insert on the epiphyses of the distal phalanx. The central slip of the extensor mechanism inserts onto the epiphysis of the middle phalanx. The extensor pollicis brevis inserts onto the epiphysis of the proximal phalanx of the thumb. The abductor pollicis longus has a broad-based insertion onto both the epiphysis and metaphysis of the thumb metacarpal. The extensor digitorum communis for index through small finger connects into the sagittal band at the MCP joint, which in turn lifts the proximal phalanx into extension by its insertion along the volar plate. These extensor tendinous insertions are broad to the thick periosteum, which predisposes bony avulsion injuries. 
The long digital flexor tendons (the flexor digitorum profundus [FDP] and the flexor pollicis longus [FPL]) insert along the metadiaphyseal, not epiphyseal, region of their respective terminal phalanges of the fingers and thumb.84 The flexor digitorum superficialis (FDS) inserts onto the central three-fifths of the middle phalanx. 

Collateral Ligaments

The collateral ligaments at the interphalangeal joint originate from the collateral recesses of the phalangeal head, span the physis, and insert onto both the metaphysis and epiphysis of the middle and distal phalanges (Fig. 10-4). The collaterals also insert onto the volar plate to create a three-sided box that protects the physes and epiphyses of the interphalangeal joints from laterally directed forces.38,84 This configuration explains the rarity of S-H III injuries at the interphalangeal joints. In flexion, the collateral ligaments are stretched because of the shape of the proximal phalanx head. Condyle fractures of the proximal phalanx are therefore at increased risk for displacement with finger motion. 
Figure 10-4
Anatomy of the collateral ligaments at the distal (A) and proximal (B) interphalangeal joints.
 
The collateral ligaments at the interphalangeal joints originate in the collateral recesses and insert into both the metaphyses and epiphyses of their respective middle and distal phalanges. Additional insertion into the volar plane (arrows) is seen at the interphalangeal joints.
The collateral ligaments at the interphalangeal joints originate in the collateral recesses and insert into both the metaphyses and epiphyses of their respective middle and distal phalanges. Additional insertion into the volar plane (arrows) is seen at the interphalangeal joints.
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Figure 10-4
Anatomy of the collateral ligaments at the distal (A) and proximal (B) interphalangeal joints.
The collateral ligaments at the interphalangeal joints originate in the collateral recesses and insert into both the metaphyses and epiphyses of their respective middle and distal phalanges. Additional insertion into the volar plane (arrows) is seen at the interphalangeal joints.
The collateral ligaments at the interphalangeal joints originate in the collateral recesses and insert into both the metaphyses and epiphyses of their respective middle and distal phalanges. Additional insertion into the volar plane (arrows) is seen at the interphalangeal joints.
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In contrast, the collateral ligaments about the MCP joints originate from the metacarpal epiphysis and insert almost exclusively onto the epiphysis of the proximal phalanx (Fig. 10-5). This anatomic arrangement accounts for the frequency of S-H III injuries at the MCP joint level. The ligamentous anatomy about the thumb MCP joint more closely resembles that of the PIP joints, which mirrors the arrangement of the adjacent physes. 
Figure 10-5
The collateral ligaments at the MCP joint originate and insert almost exclusively on the epiphyseal regions of the metacarpal and the proximal phalanx.
Flynn-ch010-image005.png
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Volar Plate

The volar plate is a stout stabilizer of the interphalangeal joint and MCP joints and resists hyperextension forces. The volar plate originates from the metaphysis of the respective proximal digital segment and inserts onto the epiphysis of the distal segment (Fig. 10-4B). The plate receives insertional fibers from the accessory collateral ligaments to create a three-sided box that protects the joint. Hyperextension of the finger joints often results in avulsion injuries of the epiphysis or S-H III at the volar plate insertion site. 

Periosteum

The periosteum is robust in a child‘s hand and can act as a considerable asset or liability in fracture management. On the positive side, the periosteal sleeve can minimize fracture displacement and aid in fracture reduction. On the negative side, the periosteum can shear off, become interposed between displaced fracture fragments, and prevent reduction. 

Nail Matrix

The skin, nail elements, soft tissues, and bone of the distal digit are closely related (Fig. 10-6). The dorsal periosteum of the distal phalanx is the underlying nutritional and structural support for the sterile matrix and nail bed. The germinal matrix is responsible for generating the nail plate. The volar aspect of the distal phalanx anchors the pulp through tough, fibrous septae that stabilize the skin against shear forces. 
Figure 10-6
Anatomy about the distal phalanx.
 
A: The skin, nail, and extensor apparatus share a close relationship with the bone of the distal phalanx. Specific anatomic structures at the terminal aspect of the digit are labeled. B: This lateral view of the nail demonstrates the tendon insertions and the anatomy of the specialized nail tissues.
A: The skin, nail, and extensor apparatus share a close relationship with the bone of the distal phalanx. Specific anatomic structures at the terminal aspect of the digit are labeled. B: This lateral view of the nail demonstrates the tendon insertions and the anatomy of the specialized nail tissues.
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Figure 10-6
Anatomy about the distal phalanx.
A: The skin, nail, and extensor apparatus share a close relationship with the bone of the distal phalanx. Specific anatomic structures at the terminal aspect of the digit are labeled. B: This lateral view of the nail demonstrates the tendon insertions and the anatomy of the specialized nail tissues.
A: The skin, nail, and extensor apparatus share a close relationship with the bone of the distal phalanx. Specific anatomic structures at the terminal aspect of the digit are labeled. B: This lateral view of the nail demonstrates the tendon insertions and the anatomy of the specialized nail tissues.
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Remodeling of Hand and Carpal Bones

A young child‘s ability to remodel displaced fractures in the hand and carpus must be incorporated into injury management decision making. Factors that influence remodeling potential include the patient‘s age, the proximity of the fracture to the physis, the plane of motion of the adjacent joint, and the presence of malrotation.17 The remodeling capacity is greater in younger children, fractures that are closer to the physis, and deformity in the plane of motion.72,73,134,159 Several clinicians have observed remodeling between 20 to 30 degrees in the sagittal plane in children under 10 years of age and up to 10 to 20 degrees in older children.36,134 Remodeling potential in the coronal or adduction–abduction plane is rarely quantified but is likely greater than or equal to 50% of the remodeling potential in the sagittal plane. Rotational deformity remodeling never occurs and is an absolute indication for fracture management. 
The speed of healing in children is remarkable. In the skeletally immature hand, most fractures become clinically stable within 2 weeks. Although this rapid healing potential may allow earlier range of motion and decreased stiffness, delay in treatment of 7 to 10 days may limit a surgeon‘s ability to perform a successful reduction without osteoclasis. 

Assessment of Hand and Carpal Bone Fractures

Hand and Carpal Bone Fracture Injury Mechanisms

Pediatric hand and carpal bone fracture patterns correlate with mechanism of injury. Assessment of each child with a hand fracture should include detailed description of the injury itself (if witnessed), timing of the injury, treatment prior to presentation, history of previous injuries to the same hand, and identification of potential penetrating or embedded materials such as glass, metal, or teeth. 
Axial load injuries nearly always occur through the metacarpals or carpometacarpal (CMC) joints. Digital torsion or lateral bending forces most often propagate through the physis of the phalanx into an S-H II injury or may result in avulsion fractures. Crush injuries can occur in any hand or carpal bone and may involve the nail matrix or articular surface. 

Injuries Associated with Hand and Carpal Bone Fractures

Pediatric hand and carpal bone fractures and dislocations overwhelmingly occur in isolation. Children involved in motor vehicle accidents, contact sports, and falls from a height can sustain hand trauma in the setting of head, cervical spine, wrist, elbow, or shoulder girdle injuries, such as clavicular fractures. In these polytrauma cases, treatment decision making may be driven by a need for earlier stabilization to allow the child the ability to use crutches or prevent fracture displacement during rehabilitation of other injuries. 
Children who have sustained hand and carpal bone fractures and dislocations from crush injuries, penetrating trauma, mechanical equipment entrapment, or motor vehicle accidents may also have injuries to the soft tissue envelope of the fingers and hand. Nerve, artery, and tendon repair as well as flap or skin graft coverage may dictate the need for hand fracture stabilization in trauma with associated injuries. 

Signs and Symptoms of Hand and Carpal Bone Fractures

The evaluation of a child‘s hand, especially traumatized infants and toddlers, can be more challenging than that of an adult. The child frequently is noncompliant, unable to understand instructions, and fearful of the physician. The examiner must be patient, engage the child, and often employ the parents to comfort the child as needed. Observation, bribery, and play are the tricks of the trade. The child‘s hand use, posture, and movements provide clues about the location and severity of the injury as the child interacts with toys, parents, and the environment in the examining area. A hurried examination or a frightened child can lead to an erroneous or missed diagnosis. 
Fracture is diagnosed by swelling, ecchymosis, deformity, or limited movement of the fingers or hand. Fracture malrotation is noted by digital scissoring during active grasp or passive tenodesis. Tendon integrity is observed by digital posture at rest and during active grasp around objects of varying size. Passive wrist examination with finger flexion tenodesis is a critical part of the evaluation to accurately diagnose fracture malrotation. 
The history, physical examination, and clinical suspicion are the essential elements to diagnosis of a scaphoid or carpus fracture.153 Although the findings are similar in adults and children, they are more difficult to elicit in children. The relative infrequency of this injury and the difficulty in interpreting radiographs of the immature wrist increase the likelihood of missing a pediatric scaphoid fracture. A distal pole fracture presents with swelling or tenderness over the scaphoid tuberosity. A scaphoid waist fracture presents with pain to palpation within the anatomic snuffbox, scaphoid tubercle, and/or with axial compression of the thumb ray. 
For TFCC and carpal ligamentous injuries, pain is localized to the distal ulna and ulnar carpal region. Forearm rotation may be limited and usually reproduces the pain, particularly at the extremes of supination and/or pronation. Compression and ulnar deviation of the carpus against the ulna may reproduce the pain with crepitus. The stability of the distal radioulnar joint should be compared to the contralateral side.141,198 
After the child is relaxed, the physician may palpate areas of tenderness and move injured joints to assess their integrity. Stress testing should be gentle, and joint stability should be recorded in the anteroposterior (AP) and lateral directions. Neurologic injuries are especially difficult to detect in a young child. The proper digital artery is dorsal to the proper digital nerve within the finger. Therefore, pulsatile bleeding indicative of a digital artery injury and laceration usually indicates a concomitant digital nerve laceration. 
Sensory function is particularly difficult to determine in a young child. Normal discriminatory sensibility does not occur until 5 to 7 years of age. Therefore, meaningful objective data are difficult to obtain in the very young. A clinical clue to sensory impairment is that children often bypass a painful or anesthetic digit during grasp and pinch. A helpful examination maneuver is the wrinkle test. Immersion of an innervated digit in warm water for 5 minutes usually results in corrugation or wrinkling of the volar skin of the pulp. Wrinkling is often absent in a denervated digit. If there is doubt about the integrity of the nerve, operative exploration is imperative. 
Comparison to the uninjured hand is invaluable in all aspects of pediatric hand and carpal bone fracture assessment. A thorough upper extremity and whole child examination driven by history and mechanism of injury should be completed for associated injuries. A workup for suspected child abuse or benign neglect may be indicated if the history places a child in a high-risk environment or home alone. 

Radiographic Examination of Hand and Carpal Bone Fractures

A careful clinical evaluation is a prerequisite for conducting a proper radiographic examination. Localization of areas of tenderness or deformity directs a focused radiographic assessment. Several pediatric imaging factors complicate interpretation of plain radiographs, including not yet ossified segments and normal variations. Lack of understanding of normal ossification pattern of the immature hand creates problems with the detection of fractures and also promotes false interpretation of ligamentous injuries. Accurate interpretation may require comparison to the uninjured hand or consultation with a pediatric atlas of child development and normal radiographic variants.77,196 
Complete evaluation of the injured hand or digit requires AP, lateral, and oblique views. The phalangeal line test is useful in recognizing displaced fractures and joint malalignment. A line drawn from the center of the phalangeal neck through the center of the phalangeal metaphysis at the level of the physis, should pass through the exact center of the metacarpal or phalangeal head in a normal finger, regardless of joint flexion (Fig. 10-7).26 Oblique views are particularly useful for assessing displacement and intra-articular extension. A common radiographic pitfall is failure to obtain a true lateral radiograph of the injured digit. Isolation of the affected digit on the film or splaying of the fingers projects a true lateral view. Stress views are rarely used for fracture evaluation. If the injury can be clinically isolated to a single digit, individual finger x-rays will demonstrate more detail than a zoomed out image of the entire hand. 
Figure 10-7
The straight method of assessing alignment about the MCP joint.
 
The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
 
(Courtesy of Robert MC, MD and Campbell Jr, MD.)
The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
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The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
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Figure 10-7
The straight method of assessing alignment about the MCP joint.
The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
(Courtesy of Robert MC, MD and Campbell Jr, MD.)
The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
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The long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand (A). If there is a fracture in the proximal phalanx, as in this patient‘s opposite or injured hand (B, C), the axes will not be colinear (arrows).
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To radiographically assess the pediatric carpus, AP, lateral, and scaphoid views in ulnar deviation of the wrist are routine. Middle third scaphoid fractures may or may not be evident on initial radiographs. Distal pole fractures are best seen on the lateral view. A pronated oblique view further highlights the CMC joint and distal pole fracture pattern. A scaphoid view places the scaphoid parallel to the film and reveals the scaphoid in its full size. One must be aware of the pseudo-Terry Thomas sign.109 The scaphoid ossifies from distal to proximal, so the distance between the ossified lunate and scaphoid decreases as the child develops and approaches adolescence. Thus, the distance between the scaphoid and lunate ranges from the relatively larger 9 mm in a 7-year-old child to 3 mm in a 15-year-old child.98,109 Failure to appreciate these normal radiographic variants may lead to an erroneous diagnosis of scapholunate dissociation when the apparent gap is filled with normal cartilage and unossified bone. Comparison to contralateral wrist radiographs is extremely useful in distinguishing abnormal from normal patterns; however, one must keep in mind that carpal ossification is not always symmetric. Magnetic resonance imaging (MRI) or computed tomography (CT) scans are usually diagnostic. 
If the clinical picture is consistent with a scaphoid fracture but the radiographs are negative, the patient should be immobilized. The child should either be instructed to return in 2 weeks for repeat examination and radiographs, or advanced image studies may be ordered. The use of MRI can help to detect scaphoid fractures that are not visualized on the initial radiographs.22,35,49,96,118 Johnson et al.96 evaluated 56 children (57 injuries) with MRI within 10 days of injury. All children had a suspected scaphoid injury but negative radiographs. In 33 (58%) of the 57 injuries, the MRI was normal, and the patients were discharged from care. In 16 cases (28%), a fractured scaphoid was diagnosed, and treatment was initiated. Sedation is required for a young child having MRI, and the modality may be overly sensitive in identifying bone edema that never develops into a fracture.22,120 
Other advanced imaging studies, such as bone scan, CT, and ultrasound have also been shown to be effective in detecting occult fracture (Fig. 10-8).53 The role of bone scan has been nearly supplanted by MRI. In the assessment of fracture displacement for operative indications and in the determination of union CT scans are most valuable. For viewing the carpus, CT images must be made along the longitudinal axis of the scaphoid, which is different from CT imaging of the wrist.169 
Figure 10-8
A CT scan of 16-year-old male with negative radiographs but persistent pain.
 
Sagittal image reveals waist fracture without displacement.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Sagittal image reveals waist fracture without displacement.
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Figure 10-8
A CT scan of 16-year-old male with negative radiographs but persistent pain.
Sagittal image reveals waist fracture without displacement.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Sagittal image reveals waist fracture without displacement.
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If plain radiographs reveal an ulnar styloid fracture, a TFCC tear may be suspected. An acute displaced fracture at the base of the styloid suggests the likelihood of a TFCC tear. Arthrograms and MRI scans will help in the diagnosis.28,79 
Minifluoroscopy portable units are invaluable and allow a real-time assessment of articular congruity and joint stability. These units have considerable advantages, including the ability to obtain multiple angles, live images, and stress views with low-radiation exposure for the patient and physician. We utilize minifluoroscopy in the child that requires dynamic imaging for accurate diagnosis or when the x-ray technician is having difficulty obtaining orthogonal x-rays. 

Differential Diagnosis of Hand and Carpal Bone Fractures

The differential diagnosis in a child who presents with hand trauma includes nontraumatic entities that may be interpreted as acute injuries. These diagnoses are uncommon but may cause swelling, deformity, or decreased motion. 

Congenital/Acquired

A Kirner deformity is a palmar and radial curving of the terminal phalanx of the small digit. This deformity occurs spontaneously between the ages of 8 and 14 years and may be confused with an acute fracture or epiphyseal separation (Fig. 10-9).103 A Kirner deformity, however, is usually bilateral and not associated with trauma.50 A trigger thumb in a young child is sometimes mistaken for an interphalangeal joint dislocation. This is caused by the fixed flexion posture, near equivalent clinical feel of “joint reduction” with manipulative digital extension, and triggering of the nodule in the FPL through the A1 pulley. The key diagnostic feature or sine qua non of a trigger thumb is the palpable nodule in the FPL over the A1 pulley. Familial camptodactyly or clinodactyly presents predominantly in adolescents when they bump the fifth finger in sports or just notice it is crooked. X-rays consistent with irregular trapezoidal or delta phalanges (a.k.a. longitudinal epiphyseal bracket) and hypoplastic middle phalanx condyles may be hard to distinguish from old or new trauma. Examination of the contralateral side as well as the parents‘ hands often guides the clinician toward a congenital etiology of the finger deformity. 
Figure 10-9
 
A–B: A 9-year-old girl with incurving of the tip of the right small finger. Similar findings are noted in family members. The AP and lateral radiographs show radial and palmar incurving of the distal phalanx characteristic of Kirner deformity.
A–B: A 9-year-old girl with incurving of the tip of the right small finger. Similar findings are noted in family members. The AP and lateral radiographs show radial and palmar incurving of the distal phalanx characteristic of Kirner deformity.
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Figure 10-9
A–B: A 9-year-old girl with incurving of the tip of the right small finger. Similar findings are noted in family members. The AP and lateral radiographs show radial and palmar incurving of the distal phalanx characteristic of Kirner deformity.
A–B: A 9-year-old girl with incurving of the tip of the right small finger. Similar findings are noted in family members. The AP and lateral radiographs show radial and palmar incurving of the distal phalanx characteristic of Kirner deformity.
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Thermal Injury

Thermal injury to the growing hand (e.g., frostbite, burns from flame or radiation) may cause unusual deformities from altered appositional and interstitial bone growth. Ischemic necrosis of the physes and epiphyses may occur (Fig. 10-10). The clinical result may yield altered bone width, length, or angulation secondary to the unpredictable thermal effect on the growing elements that make interpretation of subsequent trauma difficult.81,142 
Figure 10-10
An 11-year-old girl sustained a frostbite injury to the right hand.
 
Radiograph reveals premature fusion of the physis of the distal and proximal phalanges with irregularity of the bases of the shortened phalanges.
Radiograph reveals premature fusion of the physis of the distal and proximal phalanges with irregularity of the bases of the shortened phalanges.
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Figure 10-10
An 11-year-old girl sustained a frostbite injury to the right hand.
Radiograph reveals premature fusion of the physis of the distal and proximal phalanges with irregularity of the bases of the shortened phalanges.
Radiograph reveals premature fusion of the physis of the distal and proximal phalanges with irregularity of the bases of the shortened phalanges.
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Osteochondrosis (Thiemann Disease)

Osteochondrosis of the phalangeal epiphyses may cause epiphyseal narrowing and fragmentation, which are characteristic of Thiemann disease. This hereditary entity usually involves the middle and distal phalanges and typically resolves without treatment, though some permanent joint deformity has been reported.40,173 

Tumors

A tumor may be discovered after fracture of the weakened bone or confused with fracture secondary to swelling and pain. An enchondroma of the proximal phalanx is the classic benign tumor that may fracture after trivial trauma (Fig. 10-11). Malignant bone, cartilage, or muscle tumors are rare. Radiographs reveal intrinsic destructive bony changes in an osteogenic sarcoma or extrinsic compression with adjacent periosteal reaction secondary to an adjacent rhabdomyosarcoma. 
Figure 10-11
 
A, B: A 14-year-old girl with multiple enchondromas (Ollier disease), which weaken the bone and increase the susceptibility to fracture.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A, B: A 14-year-old girl with multiple enchondromas (Ollier disease), which weaken the bone and increase the susceptibility to fracture.
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Figure 10-11
A, B: A 14-year-old girl with multiple enchondromas (Ollier disease), which weaken the bone and increase the susceptibility to fracture.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A, B: A 14-year-old girl with multiple enchondromas (Ollier disease), which weaken the bone and increase the susceptibility to fracture.
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Inflammatory and Infectious Processes

Dactylitis from sickle cell anemia can masquerade as a traumatic injury. The affected digit(s) present(s) with fusiform swelling and decreased motion. The medical history usually is positive for sickle cell disease. The inflammatory arthropathies (e.g., juvenile rheumatoid arthritis, psoriatic arthritis, scleroderma, systemic lupus) may be confused with trauma. A joint effusion and tenosynovitis are findings that require further diagnostic evaluation. Aside from standard laboratory testing, MRI is important for diagnosis of an inflammatory synovitis or tenosynovitis. An infectious process often can be mistaken for injury, though local and systemic evaluation usually ascertains this diagnosis. Advanced skeletal maturity of the involved carpus is a diagnostic finding consistent with inflammatory arthritis. 

Hand and Carpal Bone Fracture Outcomes

Outcomes assessment for the results of treatment of pediatric hand and carpal bone fractures include subjective measurements such as stiffness, pain, and the ability to perform activities of daily living. Outcomes instruments such as the Disabilities of the Arm, Shoulder and Hand (DASH), Pediatric Outcomes Data Collection Instrument (PODCI), and Michigan Hand Outcomes Questionnaire (MHQ) can be completed by parents or adolescent children to survey a broad spectrum of long- and short-term results. Newer instruments also try to include assessment of the child‘s ability to text, type on a computer, and play video games. Objective clinical outcome measurements include rates of complications such as infection, finger or nail deformity, loss of range of motion, and malrotation and shortening. Functional evaluations such as pinch and grip strength, peg board test, in-hand manipulation, and Jebsen–Taylor timed testing are examples of validated instruments in the assessment of hand function in children. 
Radiographic outcomes include malunion, nonunion, articular congruity, degenerative joint changes, shortening, and malrotation. Missed days of school, return to sports, and performance of writing activities in the classroom are more elusive but critical outcomes to be considered in the care of pediatric hand and carpal bone fractures. Cost-effectiveness of treatment options can be considered in pediatric hand fractures. Total cost will certainly increase as treatment progresses from “bedside” clinical procedures, to emergency room care, and ultimately to the operating room with general anesthesia. 

Fractures of the Distal Phalanx

Distal Phalanx Fracture Classification

Fractures of the distal phalanx in children can be classified into extraphyseal and physeal injuries (Table 10-2). Extraphyseal fractures are common and range from a simple distal tuft fracture to an unstable diaphyseal fracture underlying a nail bed laceration. The extraphyseal fracture pattern can be divided into three types: Transverse, longitudinal split, or comminuted (Fig. 10-12). A transverse fracture (Fig. 10-12A) may occur either at the distal extent of the terminal phalanx or through the diaphysis. Displaced transverse fractures through the diaphysis are almost always associated with a considerable nail bed injury that requires repair. A longitudinal splitting type fracture, much less common, is the result of excessive hoop stress within the tubular distal phalanx at the time of a crush injury (Fig. 10-12B). The “cloven-hoof” appearance of the fracture is characteristic (Fig. 10-13). This type of distal phalanx fracture may be contained within the shaft or can propagate through the physis and even into the joint.10 Comminuted or stellate fractures of the distal diaphysis also can occur and usually are accompanied by extensive soft tissue injury (Fig. 10-14). 
 
Table 10-2
Classification of Distal Phalangeal Fractures
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Table 10-2
Classification of Distal Phalangeal Fractures
Extraphyseal
  •  
    Transverse diaphysis
  •  
    Longitudinal splitting
  •  
    Comminuted separations
  •  
    Avulsion of flexor digitorum profundus tendon with bone (Jersey finger)
Physeal
  •  
    Dorsal mallet injuries
  •  
    Salter–Harris I or II
  •  
    Salter–Harris III or IV
  •  
    Salter–Harris I or II joint dislocation. Avulsion of extensor tendon and Salter–Harris fracture
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Figure 10-12
Three types of extraphyseal fractures of the distal phalanx.
 
A: Transverse diaphyseal fracture. B: Cloven-hoof longitudinal splitting fracture. C: Comminuted distal tuft fracture with radial fracture lines.
A: Transverse diaphyseal fracture. B: Cloven-hoof longitudinal splitting fracture. C: Comminuted distal tuft fracture with radial fracture lines.
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Figure 10-12
Three types of extraphyseal fractures of the distal phalanx.
A: Transverse diaphyseal fracture. B: Cloven-hoof longitudinal splitting fracture. C: Comminuted distal tuft fracture with radial fracture lines.
A: Transverse diaphyseal fracture. B: Cloven-hoof longitudinal splitting fracture. C: Comminuted distal tuft fracture with radial fracture lines.
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Figure 10-13
 
A, B: Extraphyseal fracture of the distal phalanx: The cloven-hoof longitudinal splitting fracture. In this patient, the fracture line (arrow) does not appear to extend across the physis.
A, B: Extraphyseal fracture of the distal phalanx: The cloven-hoof longitudinal splitting fracture. In this patient, the fracture line (arrow) does not appear to extend across the physis.
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Figure 10-13
A, B: Extraphyseal fracture of the distal phalanx: The cloven-hoof longitudinal splitting fracture. In this patient, the fracture line (arrow) does not appear to extend across the physis.
A, B: Extraphyseal fracture of the distal phalanx: The cloven-hoof longitudinal splitting fracture. In this patient, the fracture line (arrow) does not appear to extend across the physis.
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Figure 10-14
 
A, B: Stellate or comminuted extraphyseal fractures and clinical findings.
A, B: Stellate or comminuted extraphyseal fractures and clinical findings.
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Figure 10-14
A, B: Stellate or comminuted extraphyseal fractures and clinical findings.
A, B: Stellate or comminuted extraphyseal fractures and clinical findings.
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Physeal fractures clinically resemble a mallet finger. There are four basic fracture patterns, and all result in a flexed posture of the distal interphalangeal (DIP) joint (Fig. 10-15). An S-H I or II fracture with flexion of the distal fragment, known as a Seymour fracture, occurs predominantly in young patients less than 12 years of age. The unopposed FDP flexes the distal fragment. The injury is often open and associated with a very proximal nail bed or plate injury.177 The proximal nail plate may lie on top of the dorsal nail fold, whereas the distal nail plate remains intact. Closed reduction may be blocked by interposition of the nail bed in the dorsal physis deep to the nail plate. Rarely, an S-H I or II fracture causes extrusion of the epiphyseal fragment.129,207 This “epiphyseal dislocation” is challenging to diagnose with an “invisible” not yet ossified epiphysis. The remaining distal phalanx stays colinear with the axis of the digit, whereas the displaced unossified epiphysis is dorsally dislocated by traction produced by the extensor tendon. A dorsal S-H III fracture of the distal phalanx, “bony mallet finger” occurs in teenagers and results in an extension lag at the DIP joint. Rarely, the epiphysis may also separate from the terminal extensor tendon.172 
Figure 10-15
 
A–D: Mallet-equivalent fracture types.
A–D: Mallet-equivalent fracture types.
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Figure 10-15
A–D: Mallet-equivalent fracture types.
A–D: Mallet-equivalent fracture types.
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Distal phalanx fractures can also be described by mechanism of injury including crush, hyperflexion, and hyperextension. A crush injury creates a spectrum of damage from minor tissue disruption with little need for intervention to severe tissue trauma that requires bony fixation, meticulous nail bed repair, and skin coverage (Fig. 10-16). A flexion force applied to the extended tip of the finger results in a malletlike injury to the terminal tendon insertion or physeal separation with nail bed injury as described above. The DIP joint remains flexed whereas active extension is not possible in both types. A hyperextension force can produce a bony avulsion injury of the volar articular surface or rupture of the insertion of the FDP tendon (Jersey finger) (Fig. 10-17).108,213 
Figure 10-16
 
A, B: Crush injury to the fingers of a 4-year-old child with multiple fingernail bed lacerations requiring meticulous repair with absorbable suture.
A, B: Crush injury to the fingers of a 4-year-old child with multiple fingernail bed lacerations requiring meticulous repair with absorbable suture.
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Figure 10-16
A, B: Crush injury to the fingers of a 4-year-old child with multiple fingernail bed lacerations requiring meticulous repair with absorbable suture.
A, B: Crush injury to the fingers of a 4-year-old child with multiple fingernail bed lacerations requiring meticulous repair with absorbable suture.
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Figure 10-17
An FDP avulsion fracture of the distal phalanx (Jersey finger).
 
This bony avulsion is apparent on radiographs, indicating the extent of proximal migration.
This bony avulsion is apparent on radiographs, indicating the extent of proximal migration.
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Figure 10-17
An FDP avulsion fracture of the distal phalanx (Jersey finger).
This bony avulsion is apparent on radiographs, indicating the extent of proximal migration.
This bony avulsion is apparent on radiographs, indicating the extent of proximal migration.
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Finally, fractures can be classified into open or closed injuries. A nail bed injury or a subungual hematoma greater than 50% creates a high index of suspicion for an open bony injury and displaced nail bed laceration (Fig. 10-18).221 
Figure 10-18
 
A: A crush injury to the thumb of a 4-year-old child with a stellate nail bed laceration and fracture of the tuft. B: Radiograph reveals a comminuted tuft fracture.
A: A crush injury to the thumb of a 4-year-old child with a stellate nail bed laceration and fracture of the tuft. B: Radiograph reveals a comminuted tuft fracture.
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Figure 10-18
A: A crush injury to the thumb of a 4-year-old child with a stellate nail bed laceration and fracture of the tuft. B: Radiograph reveals a comminuted tuft fracture.
A: A crush injury to the thumb of a 4-year-old child with a stellate nail bed laceration and fracture of the tuft. B: Radiograph reveals a comminuted tuft fracture.
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Distal Phalanx Fracture Treatment Options

Nonoperative Treatment of Distal Phalanx Fractures

Distal phalanx fractures in children are associated with nail bed lacerations. The soft tissue repair may be at the bedside or in the operating room, depending upon the emergency room facilities, operating room availability, and surgeon‘s preference. Any substantial nail bed laceration requires irrigation, debridement, and repair to prevent nail deformity and osteomyelitis. The pediatric distal phalangeal fracture is assessed for risk of infection, nail deformity, growth arrest, malalignment, and instability. An unstable fracture that cannot support the nail bed necessitates stabilization (Table 10-3). 
 
Table 10-3
Fractures and Dislocations of the Hand and Carpal Bones
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Table 10-3
Fractures and Dislocations of the Hand and Carpal Bones
Nonoperative Treatment
Indications Relative Contraindications
Stable Unstable
Closed Open
Low risk of infection, nail deformity, joint instability or growth plate arrest High risk of infection, nail deformity, joint instability, or growth plate arrest
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Nonoperative Techniques

Immobilization
Most distal phalangeal fractures can be treated with nonoperative measures using a splint or cast. Mild and moderate displacement of extraphyseal fractures will heal without difficulty. Even physeal injuries with mild displacement of the dorsal epiphyseal fragment, “bony mallet finger,” have favorable results with hyperextension splinting. Using buddy tape to secure the injured digit to a longer finger or applying plastic bandages for the young child with a crush injury may provide enough immobilization while enabling early range of motion and close monitoring for infection in stable fracture patterns. 
Hematoma Evacuation
Indications for a hematoma evacuation, or trephination, include subungual hematoma involving more than 50% of the nail plate or painful pressure under the nail.41 Decompression can be done with a sterile hypodermic needle or a heated paper clip or cautery tip, but the heat can cause further nail bed injury if penetration is too deep. After 12 to 24 hours, the effectiveness of trephination decreases as the blood coagulates. The use of oral antibiotics in the setting of trephination, although theoretically protective against infection, has not been proven in case series.43 
Nail Bed Repair
A nail bed repair can be performed at bedside, in a clinical procedure room, or in an emergency room under digital block and/or conscious sedation. A digital tourniquet is often used and needs to be removed after repair. Nail bed repair is required for overt nail bed lacerations and potentially for subungual hematomas that involve more than 50% of the nail plate. After adequate anesthesia and an ideal sterile field are achieved, a blunt Freer elevator is used to remove the nail plate to avoid additional nail bed injury. Curved clamps or snaps should not be used as they can cause further nail matrix injury. Partial nail removal is rarely indicated for nail bed repair in children. Proximal exposure of the germinal matrix may require scalpel incisions along the eponychial folds and proximal retraction of the eponychial flap. The nail bed is repaired with interrupted 6-0 chromic or equivalent absorbable sutures under loupe magnification. Following repair, the nail bed is supported, and the dorsal nail fold is kept open using the previously removed nail plate or another substitute, such as the foil from the suture pack.55,171,221 

Operative Treatment of Distal Phalanx Fractures

Unstable extraphyseal fractures with wide displacement require stabilization. Open injuries with severe displacement or irreducible fractures require reduction and stabilization (Fig. 10-19).4,26 The Seymour fracture represents an irreducible fracture that requires open reduction. The sterile matrix must be extricated from the fracture site and repaired beneath the eponychium. Epiphyseal dislocations also require operative intervention to both restore joint congruity and reestablish extensor tendon continuity. Physeal fractures with a dorsal fragment larger than 50% of the epiphysis or considerable DIP joint subluxation may require operative intervention.38,82 An avulsion of the FDP is an indication for open tendon reinsertion. Surgery should be done as soon as possible to limit tendon ischemia and shortening. Delay in diagnosis may prohibit tendon reattachment. 
Figure 10-19
 
A: An irreducible distal phalangeal fracture that required extrication of the nail bed from within the fracture site. B: Stabilization of the fracture fragments with a longitudinal K-wire across the DIP joint.
A: An irreducible distal phalangeal fracture that required extrication of the nail bed from within the fracture site. B: Stabilization of the fracture fragments with a longitudinal K-wire across the DIP joint.
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Figure 10-19
A: An irreducible distal phalangeal fracture that required extrication of the nail bed from within the fracture site. B: Stabilization of the fracture fragments with a longitudinal K-wire across the DIP joint.
A: An irreducible distal phalangeal fracture that required extrication of the nail bed from within the fracture site. B: Stabilization of the fracture fragments with a longitudinal K-wire across the DIP joint.
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Amputations of the fingertip are often open distal phalangeal fractures. The injury may involve skin, nail tissue, and bone. Support for nail growth is a primary consideration. Minimal loss of tissue can be treated with local wound care and healing through secondary intention. A small amount of exposed bone does not preclude spontaneous healing in children. The likelihood of nail deformity (hook nail or “parrot‘s beak”) is high for amputations that involve more than 50% of the distal phalanx. Primary nail ablation may be indicated in children with less than 50% remaining distal phalanx to avoid a sometimes painful, more often aesthetically disconcerting, hook nail deformity (Fig. 10-20). 
Figure 10-20
A hook nail can become symptomatic and require revision nail ablation.
 
Adequate primary management can prevent this sequelae.
Adequate primary management can prevent this sequelae.
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Figure 10-20
A hook nail can become symptomatic and require revision nail ablation.
Adequate primary management can prevent this sequelae.
Adequate primary management can prevent this sequelae.
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Soft tissue coverage varies depending on the degree of tissue loss and direction of injury. Simple healing by primary closure is preferred for most volar oblique fingertip amputations. Dorsal oblique amputations are complicated by nail bed injury and are more difficult to cover. Composite grafts of skin and subcutaneous tissue from the amputated part have been used in young children <3 years of age with variable results. Local flaps are another option for coverage of large volar or dorsal oblique amputations. Options include a variety of flaps, such as a V–Y volar advancement, a thenar flap, a cross-finger flap, a pedicled flap, or a neurovascular island flap (Figs. 10-21 and 10-22).7,100 Fortunately, coverage issues are rare in children. An amputation of the distal thumb can also be covered with a bipedicle (Moberg volar advancement flap) or a unipedicle neurovascular flap.136 The choice of coverage depends on the degree and direction of soft tissue loss, age of the patient, and preference of the surgeon. 
Figure 10-21
Volar V–Y advancement flap for coverage.
 
A: A volar oblique tissue loss of the ring finger with intact nail bed. B: Flap designed with apex at the DIP joint and mobilized to cover the fingertip. The defect is closed proximal to the flap creating the Y. C: Satisfactory result with good durability and sensibility.
A: A volar oblique tissue loss of the ring finger with intact nail bed. B: Flap designed with apex at the DIP joint and mobilized to cover the fingertip. The defect is closed proximal to the flap creating the Y. C: Satisfactory result with good durability and sensibility.
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Figure 10-21
Volar V–Y advancement flap for coverage.
A: A volar oblique tissue loss of the ring finger with intact nail bed. B: Flap designed with apex at the DIP joint and mobilized to cover the fingertip. The defect is closed proximal to the flap creating the Y. C: Satisfactory result with good durability and sensibility.
A: A volar oblique tissue loss of the ring finger with intact nail bed. B: Flap designed with apex at the DIP joint and mobilized to cover the fingertip. The defect is closed proximal to the flap creating the Y. C: Satisfactory result with good durability and sensibility.
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Figure 10-22
Cross-finger flap in a 17-year-old male with open distal phalangeal injury and tissue loss.
 
A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
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A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
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Figure 10-22
Cross-finger flap in a 17-year-old male with open distal phalangeal injury and tissue loss.
A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
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A: Extensive volar and distal soft tissue loss with preservation of the bone and nail bed. B: A cross-finger flap of skin and subcutaneous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the index finger. C: The vascular epitenon is preserved on the donor digit to support a skin graft. The flap is transferred to the volar aspect of the index finger to recreate the tuft. D: Satisfactory coverage and functional result.
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Surgical Treatment of Distal Phalanx Fractures

Preoperative Planning
Operating room and table setup for surgical treatment of hand fractures in children can be successfully accomplished using the checklist below (Table 10-4). 
 
Table 10-4
Distal Phalanx Fractures
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Table 10-4
Distal Phalanx Fractures
Preoperative Planning Checklist
  •  
    OR table: Hand table
  •  
    Position: Supine
  •  
    Fluoroscopy location: Minifluoro unit
     
    Perpendicular or opposite the surgeon
  •  
    Equipment: Hand tray instruments, wire driver
  •  
    Tourniquet (sterile/nonsterile): Nonsterile or Esmark at approximately 200 mm Hg in small children
  •  
    Hardware: 0.027, 0.035, or 0.045 K-wires, limited role for other fixation devices
  •  
    Suture: 6-0 chromic for nail bed in all patients
     
    5-0 chromic skin closure in young children; in older children, nonabsorbable monofilament (Prolene, Monocryl, or nylon suture) can be used for soft tissue laceration or incision closure
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Surgical Approach and Technique.
Closed manipulation and percutaneous K-wire fixation is usually effective treatment of displaced distal phalanx physeal fractures. One or two smooth 0.35 or 0.45 K-wires can be inserted retrograde through the tip of the finger and across the fracture for stabilization. A hypodermic needle can be used as an emergency substitute for smooth wires.128 The assistance of joystick K-wires, tenaculums, or forceps can be applied as external temporary fixation while final fixation is placed. After the fracture is stabilized, the nail may be repaired in the technique described previously. 
In open injuries or fractures that will not reduce with closed technique, a dorsal or midlateral approach is used for most extraphyseal and physeal fractures (Fig. 10-23). The dorsal fragment is isolated and reduced (Fig. 10-24). A small portion of the collateral ligaments may be recessed to enhance exposure; however, soft tissue dissection should be limited to prevent osteonecrosis of small bony fragments. Open fracture fixation can be accomplished with a smooth wire, pull-out wire, tension band, or heavy suture.72,82,86,104,145 Fixation across the DIP joint with a small diameter, smooth wire is usually necessary to maintain joint and physeal congruity. A volar approach is only used for avulsion of the FDP tendon. In acute Jersey fingers, the FDP is identified at the level of retraction and repaired to the distal phalanx with transosseous sutures or wires (Fig. 10-25). The transosseous sutures or wires must avoid the growth plate in young children (Table 10-5). 
Figure 10-23
Exposures to the DIP joint.
 
A: H-type flap with the transverse limb over the DIP joint. B: S-shaped exposure of the DIP joint. C: An extended exposure of the DIP joint. All exposures must avoid injury to the germinal matrix, which is located just proximal to the nail fold.
A: H-type flap with the transverse limb over the DIP joint. B: S-shaped exposure of the DIP joint. C: An extended exposure of the DIP joint. All exposures must avoid injury to the germinal matrix, which is located just proximal to the nail fold.
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Figure 10-23
Exposures to the DIP joint.
A: H-type flap with the transverse limb over the DIP joint. B: S-shaped exposure of the DIP joint. C: An extended exposure of the DIP joint. All exposures must avoid injury to the germinal matrix, which is located just proximal to the nail fold.
A: H-type flap with the transverse limb over the DIP joint. B: S-shaped exposure of the DIP joint. C: An extended exposure of the DIP joint. All exposures must avoid injury to the germinal matrix, which is located just proximal to the nail fold.
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Figure 10-24
 
A: Displaced mallet fracture with considerable articular involvement and dorsal prominence. B: Open reduction through a dorsal approach reveals the articular fragment attached to the terminal tendon.
A: Displaced mallet fracture with considerable articular involvement and dorsal prominence. B: Open reduction through a dorsal approach reveals the articular fragment attached to the terminal tendon.
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Figure 10-24
A: Displaced mallet fracture with considerable articular involvement and dorsal prominence. B: Open reduction through a dorsal approach reveals the articular fragment attached to the terminal tendon.
A: Displaced mallet fracture with considerable articular involvement and dorsal prominence. B: Open reduction through a dorsal approach reveals the articular fragment attached to the terminal tendon.
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Figure 10-25
A 17-year-old athlete with an avulsion fracture from the FDP tendon.
 
The fracture extends through the epiphysis and into the joint (large arrow). The FDP tendon with its attached bony fragment has retracted to the level of the A4 pulley (small arrow).
The fracture extends through the epiphysis and into the joint (large arrow). The FDP tendon with its attached bony fragment has retracted to the level of the A4 pulley (small arrow).
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Figure 10-25
A 17-year-old athlete with an avulsion fracture from the FDP tendon.
The fracture extends through the epiphysis and into the joint (large arrow). The FDP tendon with its attached bony fragment has retracted to the level of the A4 pulley (small arrow).
The fracture extends through the epiphysis and into the joint (large arrow). The FDP tendon with its attached bony fragment has retracted to the level of the A4 pulley (small arrow).
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Table 10-5
Distal Phalanx Fractures
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Table 10-5
Distal Phalanx Fractures
Surgical Steps
  •  
    Attempt closed reduction of displaced or open fractures after irrigation and debridement of foreign bodies or contamination
  •  
    If alignment adequate, place one or two K-wires from fingertip, across physeal or extraphyseal fracture
  •  
    Use “joystick” smaller K-wires, towel clip, or small fragment reduction forceps to enhance the closed reduction
  •  
    If necessary, open skin in H-shape or transversely over physeal fracture
    •  
      Preserve extensor and collateral soft tissue attachments
    •  
      Avoid dissection of smaller bone fragments
  •  
    Reduce incarcerated, rotated, or extruded fragments and proceed with K-wire or rare screw fixation
  •  
    Remove nail plate and repair nail lacerations as indicated; replace plate or foil under dorsal nail fold
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Author‘s Preferred Techniques

Extraphyseal Fractures

Simple closed stable fractures are treated with nonoperative immobilization for 3 to 4 weeks. Clinical union precedes complete radiographic healing by about 1 month. Protected range of motion should begin as soon as the patient has clinical union and painless range of motion to avoid stiffness. Uncommonly, in our practice, an unstable, displaced distal phalangeal fracture requires percutaneous pinning with a smooth K-wire. The DIP joint and physis are transfixed to provide additional stability. The pin is removed approximately 3 to 4 weeks after injury, followed by early protected range of motion. 
Distal phalanx fractures with a nail bed laceration require adequate anesthesia, removal of the nail plate, and nail bed repair. The parents and patient are told that it takes several cycles of nail growth (3 to 6 months) before the final morphology of the nail is known. Fortunately, in properly treated nail bed injuries, chronic deformity is rare. 

Physeal Fractures

Most closed pediatric S-H III physeal fractures, or bony mallet fingers, are treated in situ or by closed reduction and splinting. Placement of the DIP joint into neutral or mild hyperextension reduces most fractures. A splint is applied, and radiographs are taken to assess the degree of reduction. Adequate healing usually requires full-time splinting for 4 to 6 weeks depending on the age of the child, size of the fracture fragment, and amount of bony apposition. The DIP joint is positioned in neutral to 15 degrees of extension. Extreme hyperextension is contraindicated because dorsal skin hypoperfusion and necrosis may result.161 Careful instructions regarding skin monitoring are given to parents and patients to avoid splint pressure necrosis. Radiographs are taken weekly for the first 2 weeks and then every 2 weeks thereafter to monitor for loss of reduction or volar joint subluxation. Adolescent mallet fingers with soft tissue terminal tendon disruption are treated similarly to adults with 4 to 6 weeks of dorsal DIP joint splint immobilization. Operative repair of soft tissue or bony mallet fingers is rarely indicated, even for a delay in presentation. Most acute and delayed presentation mallet injuries will heal with splint immobilization. The loss of digital flexion associated with surgery can be more disabling than a minor extension lag after an untreated injury. 
Surgery is indicated for fractures that are open, grossly unstable, irreducible, or have unacceptable alignment (Fig. 10-24). Closed reduction and percutaneous fixation is preferred. Additional fixation of the dorsal fragment can be accomplished with a 0.028-in smooth K-wire placed parallel to the epiphysis. An irreducible fracture requires open reduction. Fixation techniques vary depending on the age of the child and the fracture configuration. Smooth wires, however, are the principal means of fixation. Entrapped soft tissue, osteochondral fragments, or epiphyseal dislocations require open reduction. 
Physeal fractures with dorsal entrapment of the germinal matrix (Seymour fractures) require nail plate removal, extrication of the nail bed, and repair. Axial alignment after nail bed repair is maintained with a splint if stable or K-wire fixation if unstable for 3 to 4 weeks (Fig. 10-26). 
Figure 10-26
 
A: A 13-year-old boy sustained an open S-H type II fracture. B: The wound was cleansed, and acceptable alignment was obtained with closed reduction.
A: A 13-year-old boy sustained an open S-H type II fracture. B: The wound was cleansed, and acceptable alignment was obtained with closed reduction.
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Figure 10-26
A: A 13-year-old boy sustained an open S-H type II fracture. B: The wound was cleansed, and acceptable alignment was obtained with closed reduction.
A: A 13-year-old boy sustained an open S-H type II fracture. B: The wound was cleansed, and acceptable alignment was obtained with closed reduction.
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Jersey Finger

Avulsion injuries of the FDP require open repair (Fig. 10-25). Bone-to-bone fixation is preferred using pull-out wires or suture. Fragments that are too small for fixation require bone removal and repair of the tendon directly to the fracture bed. This usually requires transosseous sutures from volar to dorsal, avoiding injury to the germinal nail bed and growth plate. Repair of long-standing profundus avulsions is controversial and is usually not recommended with an intact and functioning FDS tendon. 

Amputations

Mild to moderate loss of skin, subcutaneous tissue, and bone is best treated by wound cleansing, dressing changes, and healing by secondary intention. Acceptable functional and aesthetic results are uniform. Skin or composite grafts are rarely necessary for coverage in children and are associated with donor site morbidity, hyperpigmentation, and lack of sensibility. Extensive soft tissue loss with exposed bone requires more innovative coverage. A volar oblique injury can usually be treated with a variety of local flaps, including a V–Y advancement flap, cross-finger flap, or thenar flap (Figs. 10-21 and 10-22). 
Dorsal tissue loss is more difficult to reconstruct. The nail bed injury adds additional complexity. Mild loss can be treated by local wound care. Moderate to severe loss may require a reverse cross-finger flap or a more distant flap. Unfortunately, nail bed replacement techniques often result in considerable nail deformity (Fig. 10-27). 
Figure 10-27
Author‘s preferred treatment algorithm for distal phalanx fractures.
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Postoperative Care and Rehabilitation

Children younger than 4 or 5 years of age are immobilized with long-arm mitten strapping, soft casts (3M, St. Paul, Minnesota), or casts. As the child ages, the degree of immobilization is decreased. An adolescent with a simple distal phalangeal fracture or nail bed repair can usually be treated similar to an adult with only DIP joint immobilization. The use of adjunctive antibiotics and tetanus prophylaxis should be utilized in contaminated cases. Nonabsorbable suture should be removed after 2 weeks, but, whenever possible, chromic suture is used in a child to avoid the trauma of suture removal. Percutaneous fixation is removed in the office 3 to 4 weeks after surgery. The replaced dorsal nail plate or foil under the nail fold will loosen and fall off as the new nail grows in a distal direction. Formal hand therapy is usually not required, though a home instruction program with an emphasis on DIP joint motion is useful. To regain full joint movement, DIP blocking exercises are particularly helpful. Formal therapy is reserved for patients who fail to regain motion and strength after 3 to 4 weeks on a home program (Table 10-6). 
 
Table 10-6
Distal Phalanx Fractures in Children
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Table 10-6
Distal Phalanx Fractures in Children
Potential Pitfalls and Preventions
Pitfalls Preventions
Osteomyelitis Irrigation, debridement
Nail bed laceration repair
Monitor and treat infection signs early with repeat irrigations and antibiotic coverage
Premature physeal closure Smooth wires
Minimize reduction attempts
Hook nail Ablate nail plate when less than 50% distal phalanx amputated
Quadregia Do not oversew extensors or flexors to tip of amputated finger
Extensor lag Neutral or 15-degree extension splint
Continue night, school, and sports splint use for additional 4 to 6 weeks after full-time day splint use discontinued
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Treatment-Specific Outcomes

Decision making in the treatment of distal phalanx fractures in children must be individualized to the exact injury and needs of the child. Crush mechanisms cause fractures and soft tissue injuries that range widely in severity. The number of studies that have sought to assess outcomes in distal phalanx fractures in children is limited. The cost-effectiveness of trephination and observation versus removal of the nail plate in nondisplaced nail lacerations over distal phalanx fractures has been studied in several case series.43,166 These authors concluded that osteomyelitis and nail deformity were equivalent; however, trephination and observation were more cost-effective. All studies emphasize the need for a prospective randomized trial; however, a study of this kind is difficult to perform in the setting of emergent care of children. 

Management of Expected Adverse Outcomes and Unexpected Complications

Prognosis

The overall results following distal phalangeal fractures are favorable. A small loss of motion has little functional impact. A small extensor lag or minor longitudinal nail ridge is well tolerated by most patients. Considerable nail irregularity or deformity is a frequent source of dissatisfaction. 

Complications

Bony complications from distal phalangeal fractures are uncommon. Potential problems include nonunion, malunion, and osteomyelitis. Nonunion and malunion are exceedingly rare, except in open injuries that result in avascular fracture fragments or untreated widely displaced fractures. Osteomyelitis can result from open fractures and requires application of the basic tenets for the treatment of infected bone. Debridement, removal of any sequestrum, and intravenous antibiotics are required to resolve the infection. Additional tissue coverage is necessary in digits with a marginal soft tissue envelope. These infections are rare because of the robust vascularity of a child‘s hand. 
Soft tissue complications are more prevalent than bony problems. Difficulties may involve the skin, subcutaneous tissue, nail, and tendons. An inadequate soft tissue envelope can be reconstructed with replacement using a variety of local flaps. 
Nail problems depend on the location and degree of nail bed injury. Damage to the germinal matrix produces deficient nail growth and nail ridging. Injury to the sterile matrix causes poor nail adherence or nail ridging. Treatment options are limited and usually involve resection of the damaged segment and replacement with a full-thickness or split-thickness skin or nail bed graft.31,178,222 Adjacent digits or toes are potential sources of nail bed transfers. The results in children have been superior to those in adults.105,178,179,222 The hook nail or “parrot‘s beak” nail is a nail plate complication related to the underlying bony and soft tissue deficit. The nail plate curves over the abbreviated end of the distal phalanx (Fig. 10-28). Treatment requires restoring length to the shortened distal phalanx and creation of an adequate soft tissue envelope to support the nail plate (Fig. 10-29).7 In these situations, a thenar flap or composite graft is typically used to provide improved support for the nail bed. 
Figure 10-28
A hook-nail deformity of the small finger after a distal fingertip amputation.
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Figure 10-29
 
A, B: Postoperative photographs of the patient shown in Figure 10-21 after the antenna procedure. The procedure involved a volar V–Y advancement flap to cover the distal tip, elevation of the sterile matrix, and the nail supported using three K-wires. C: Line drawings demonstrating technique of elevation and support of the sterile matrix with wires.
 
(A, B: Courtesy of William B. Kleinman, MD. C: Reprinted from Atasoy E, Godfrey A, Kalisman M. The “antenna” procedure for the “hook-nail” deformity. J Hand Surg [Am]. 1983; 8:55, with permission.)
A, B: Postoperative photographs of the patient shown in Figure 10-21 after the antenna procedure. The procedure involved a volar V–Y advancement flap to cover the distal tip, elevation of the sterile matrix, and the nail supported using three K-wires. C: Line drawings demonstrating technique of elevation and support of the sterile matrix with wires.
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Figure 10-29
A, B: Postoperative photographs of the patient shown in Figure 10-21 after the antenna procedure. The procedure involved a volar V–Y advancement flap to cover the distal tip, elevation of the sterile matrix, and the nail supported using three K-wires. C: Line drawings demonstrating technique of elevation and support of the sterile matrix with wires.
(A, B: Courtesy of William B. Kleinman, MD. C: Reprinted from Atasoy E, Godfrey A, Kalisman M. The “antenna” procedure for the “hook-nail” deformity. J Hand Surg [Am]. 1983; 8:55, with permission.)
A, B: Postoperative photographs of the patient shown in Figure 10-21 after the antenna procedure. The procedure involved a volar V–Y advancement flap to cover the distal tip, elevation of the sterile matrix, and the nail supported using three K-wires. C: Line drawings demonstrating technique of elevation and support of the sterile matrix with wires.
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A mild DIP joint or extensor tendon lag can occur after pediatric mallet fracture care. No further treatment is warranted. Severe DIP joint deformities are uncommon but may result in swan-neck positioning of the finger. Reconstruction options are similar to methods used in adults, such as a spiral oblique retinacular ligament reconstruction or central slip tenotomy.200 In a young child, untreated lacerations proximal to the terminal tendon insertion may result in an extensor lag that can be repaired successfully with a tenodermodesis repair (Table 10-7).44,101 
 
Table 10-7
Distal Phalanx Fractures in Children
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Table 10-7
Distal Phalanx Fractures in Children
Common Adverse Outcomes and Complications
Osseous: Nonunion, malunion, osteomyelitis
Soft tissue: Scar, stiffness, extensor tendon insufficiency with extensor lag
Nail: Split or hook-nail deformity, rides, ingrown lateral or dorsal nail fold
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Middle and Proximal Phalanx Fractures in Children

Middle and Proximal Phalanx Fracture Classification

Classification of middle and proximal phalanx fractures in children is based on anatomic location and mechanism of injury. There are four locations: The physis, shaft, neck, and condyles (Table 10-8). The fracture pattern varies with the direction and amount of force incurred. Most fractures of the proximal and middle phalanges result from a torsional or angular force combined with an axial load, such as catching a ball, falling on an outstretched hand, or colliding in sports. Crush injuries are less common in the proximal and middle phalanges than in the distal phalanx. The thumb proximal phalanx and MCP joint are subject to greater lateral bending forces. 
 
Table 10-8
Classification of Proximal and Middle Phalangeal Fractures
Physeal
Shaft
Phalangeal neck
Intra-articular (condylar)
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Every fracture must be carefully examined for malrotation and rotational deformity regardless of classification, mechanism of injury, or radiographic appearance. Active finger flexion will produce deviation of the plane of the nails or overt digital scissoring (Fig. 10-30). Passive wrist extension will cause long finger flexor tenodesis, and malrotation is evident from an abnormal digital cascade. 
Figure 10-30
 
A: An AP radiograph of an S-H II fracture at the long finger proximal phalanx. The radiogaph reveals slight angulation and can appear benign. Clinical examination must be done to assess the digital cascade for malrotation. B: Tenodesis of the wrist with passive extension reveals unacceptable malrotation as evident by the degree of overlap of the middle finger on the ring finger.
A: An AP radiograph of an S-H II fracture at the long finger proximal phalanx. The radiogaph reveals slight angulation and can appear benign. Clinical examination must be done to assess the digital cascade for malrotation. B: Tenodesis of the wrist with passive extension reveals unacceptable malrotation as evident by the degree of overlap of the middle finger on the ring finger.
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Figure 10-30
A: An AP radiograph of an S-H II fracture at the long finger proximal phalanx. The radiogaph reveals slight angulation and can appear benign. Clinical examination must be done to assess the digital cascade for malrotation. B: Tenodesis of the wrist with passive extension reveals unacceptable malrotation as evident by the degree of overlap of the middle finger on the ring finger.
A: An AP radiograph of an S-H II fracture at the long finger proximal phalanx. The radiogaph reveals slight angulation and can appear benign. Clinical examination must be done to assess the digital cascade for malrotation. B: Tenodesis of the wrist with passive extension reveals unacceptable malrotation as evident by the degree of overlap of the middle finger on the ring finger.
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Physeal Fractures

Physeal fractures of the proximal phalanx are reported in several series as the most common pediatric hand fracture.10,73,86,110,202 Extra-articular S-H II fractures are more prevalent, and intra-articular S-H III and IV fractures are less common. A common fracture pattern is the S-H II fracture along the ulnar aspect of the proximal phalanx of the small digit. The small digit is angulated in an ulnar direction. This fracture has been termed the “extra-octave” fracture to denote its potential benefit to the span of a pianist‘s hand (Fig. 10-31).159 Physeal fractures about the middle phalanx can involve the lateral, dorsal, or volar aspects of the physis. A lateral force across the PIP joint may cause an S-H III or IV fracture. Similarly, a flexion force may produce a dorsal S-H III fracture indicative of a central slip avulsion fracture (pediatric boutonniere injury). A hyperextension injury produces small avulsion fragments from the middle phalangeal epiphysis associated with damage to the volar plate. 
Figure 10-31
 
A: An extra-octave fracture in a 12-year-old girl. B: The fracture was reduced with the MCP joint in full flexion.
A: An extra-octave fracture in a 12-year-old girl. B: The fracture was reduced with the MCP joint in full flexion.
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Figure 10-31
A: An extra-octave fracture in a 12-year-old girl. B: The fracture was reduced with the MCP joint in full flexion.
A: An extra-octave fracture in a 12-year-old girl. B: The fracture was reduced with the MCP joint in full flexion.
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The thumb proximal phalanx is particularly susceptible to injury. An ulnar collateral ligament (UCL) avulsion injury at the base of the thumb proximal phalanx is similar to the adult gamekeeper‘s or skier‘s thumb. The mechanisms of injury, clinical findings of UCL laxity at the MCP joint, and physical symptoms of instability with grip and pinch will be similar to the adult soft tissue UCL injury. However, the fracture pattern is usually an S-H III injury, as the ligament typically remains attached to the epiphyseal fracture fragment (Fig. 10-32). Displaced injuries with articular incongruity or joint instability require open reduction and internal fixation (ORIF) to restore articular alignment and joint stability.191 
Figure 10-32
Bony gamekeeper‘s or skier‘s thumb is an S-H III fracture of the base of the thumb proximal phalanx attached to the UCL of the MCP joint.
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Children rarely sustain comminuted intra-articular fractures of the PIP joint, the so-called “pilon” fractures or fracture–dislocations.192 These injuries can occur in adolescent athletes and result from an axial load sustained while attempting to catch a ball or physically contacting an opponent. Fracture lines often propagate into the physis. The fracture fragment from the volar side may have the volar plate attached, whereas the dorsal fragment is likely to have the central slip attached. The central aspect of the joint may be depressed and comminuted. The joint can be unstable and incongruent, requiring careful treatment. 

Shaft Fractures

Shaft fractures in children are less common. The fracture configuration may be transverse, spiral, or spiral oblique. The fracture may be comminuted. Proximal and middle phalangeal fractures are usually angulated in an apex volar pattern because the distal fragment is extended by the central slip and lateral band, and the proximal fragment is flexed by the FDS in the middle phalanx and by the intrinsic musculature in the proximal phalanx (Fig. 10-33). Oblique fractures often rotate and shorten. Careful clinical evaluation of rotational alignment is critical. Comminution is secondary to a high-energy injury or direct trauma to the phalanx (Fig. 10-34). 
Figure 10-33
 
A, B: Radiographs of transverse middle and proximal phalangeal fractures which demonstrate the characteristic apex velar deformity.
A, B: Radiographs of transverse middle and proximal phalangeal fractures which demonstrate the characteristic apex velar deformity.
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Figure 10-33
A, B: Radiographs of transverse middle and proximal phalangeal fractures which demonstrate the characteristic apex velar deformity.
A, B: Radiographs of transverse middle and proximal phalangeal fractures which demonstrate the characteristic apex velar deformity.
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Figure 10-34
Comminuted fractures secondary to a crush injury with longitudinal splitting into the physis.
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Neck Fractures

Neck fractures of the phalanx are problematic with regard to treatment and functional outcome. Displaced neck fractures are also referred to as subcondylar fractures and often occur in young children as a result of finger entrapment in a closing door (Fig. 10-35). The head fragment remains attached to the collateral ligaments and tends to rotate into extension.47 This displacement disrupts the architecture of the subcondylar fossa, which normally accommodates the volar plate and base of the phalanx during interphalangeal joint flexion. Malunited neck fractures, therefore, result in a mechanical block to interphalangeal joint flexion. Frequently, these fractures are inadequately imaged, underappreciated, or misinterpreted as trivial and referred late for care. 
Figure 10-35
 
A: Phalangeal neck fractures are often unstable and rotated. These fractures are difficult to reduce and control by closed means because of the forces imparted by the volar plate and ligaments. B, C: Fixed with a closed reduction and hyperextension maneuver across the DIP joint as well as a derotational wire.
A: Phalangeal neck fractures are often unstable and rotated. These fractures are difficult to reduce and control by closed means because of the forces imparted by the volar plate and ligaments. B, C: Fixed with a closed reduction and hyperextension maneuver across the DIP joint as well as a derotational wire.
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Figure 10-35
A: Phalangeal neck fractures are often unstable and rotated. These fractures are difficult to reduce and control by closed means because of the forces imparted by the volar plate and ligaments. B, C: Fixed with a closed reduction and hyperextension maneuver across the DIP joint as well as a derotational wire.
A: Phalangeal neck fractures are often unstable and rotated. These fractures are difficult to reduce and control by closed means because of the forces imparted by the volar plate and ligaments. B, C: Fixed with a closed reduction and hyperextension maneuver across the DIP joint as well as a derotational wire.
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Intra-Articular (Condylar) Fractures

Condylar fractures involve the joint and represent a constellation of fracture patterns, including small lateral avulsion fractures, unicondylar or intracondylar fractures, bicondylar or transcondylar fractures, and a rare shearing injury of the entire articular surface and its underlying subchondral bone from the distal aspect of the phalanx (Fig. 10-36). Condylar fractures can be associated with subluxations or dislocations of the joint. Many of these fractures are initially misdiagnosed as sprains.86,110 Restoration of articular alignment and joint stability is critical to a successful outcome. 
Figure 10-36
 
A: An AP radiograph reveals an intra-articular fracture of the small finger. B: Lateral view demonstrates the double density sign indicative of displacement (arrows).
A: An AP radiograph reveals an intra-articular fracture of the small finger. B: Lateral view demonstrates the double density sign indicative of displacement (arrows).
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Figure 10-36
A: An AP radiograph reveals an intra-articular fracture of the small finger. B: Lateral view demonstrates the double density sign indicative of displacement (arrows).
A: An AP radiograph reveals an intra-articular fracture of the small finger. B: Lateral view demonstrates the double density sign indicative of displacement (arrows).
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Treatment of the Middle and Proximal Phalanx Fractures

The treatment of middle and proximal phalangeal fractures varies greatly with the type of injury. Nonoperative treatment is predictable management for most physeal and shaft fractures. Operative treatment is common for neck and condylar fractures, especially fractures that are displaced or unstable (Table 10-9). 
 
Table 10-9
Treatment of Middle and Proximal Phalanx Fractures
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Table 10-9
Treatment of Middle and Proximal Phalanx Fractures
Nonoperative Indications Operative Indications
Stable initially or after closed reduction Unstable
Closed, isolated Open, polytrauma
Normal tenodesis Malrotation
Joint congruity and stability Joint incongruity (S-H III, neck, or condylar fractures)
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Nonoperative and Operative Techniques of Middle and Proximal Phalanx Fractures

Physeal Fractures

Most physeal fractures of the proximal and middle phalanges can be managed by simple immobilization. Displaced fractures often require closed reduction. Minimal displacement is treated with splinting in the safe position for 3 weeks. Moderate displacement requires closed reduction with local anesthesia or conscious sedation. Placing the MCP joint into flexion to tighten the collateral ligaments and angulating the digit into radial deviation for a fracture displaced in an ulnar direction reduces the fracture. In the “extra-octave” fifth proximal phalanx fracture, placing a pencil or digit in the fourth web space and using it as a fulcrum to assist reduction has been recommended.215 Minimal force is necessary to restore alignment.5,52 Buddy taping and cast immobilization will maintain alignment until healing (Fig. 10-31). The age and compliance of the patient determines if buddy tape or casting is indicated. Minimally displaced S-H III epiphyseal fractures at the base of the middle phalanx associated with volar plate avulsion can be treated with early buddy tape or extension block splint. “Pediatric boutonniere” fractures or dorsal S-H III epiphyseal fractures can be treated with a PIP extension splint and early DIP range of motion exercises just as in the adult. 
Irreducible fractures of the physis have been reported.10,37,85,110 Any surrounding soft tissue structures, including periosteum and tendons, may prevent reduction. Open treatment with removal of the impeding tissue and fracture reduction is required for these rare injuries (Fig. 10-37). In addition, some S-H II fractures may be reducible but unstable after reduction. These fractures tend to result from higher-energy mechanisms of injury that cause more disruption of the supporting soft tissues. Insertion of a smooth K-wire after reduction is required to maintain fracture alignment.85,175 Another indication for operative management is a displaced S-H III fracture of the proximal phalangeal base with a sizable (more than 25%) epiphyseal fragment. Closed or open reduction may be required to restore articular congruity.86,175 Small K-wires can be inserted parallel to the joint surface, avoiding the physis. Tension-band wiring187 techniques can be used for S-H III and IV fractures in older children. Operative exposure and fixation techniques are challenging with nonborder digit proximal phalangeal S-H III fractures. 
Figure 10-37
Displaced S-H II fracture of the proximal phalanx that was irreducible.
 
The distal fragment was herniated through a rent in the periosteum and extensor mechanism that prohibited reduction.
The distal fragment was herniated through a rent in the periosteum and extensor mechanism that prohibited reduction.
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Figure 10-37
Displaced S-H II fracture of the proximal phalanx that was irreducible.
The distal fragment was herniated through a rent in the periosteum and extensor mechanism that prohibited reduction.
The distal fragment was herniated through a rent in the periosteum and extensor mechanism that prohibited reduction.
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Classically in teenagers, a bony gamekeeper‘s or skier‘s thumb is an S-H III fracture of the proximal phalanx that requires closed reduction and percutaneous pinning (CRPP) or ORIF with K-wire or modular screw fixation if the fragment is large enough. Open visualization may be necessary for visualization of the articular reduction and reduction of the UCL. The approach is similar to the operative steps of an adult gamekeeper‘s thumb surgery with incision of the adductor fascia for exposure followed by later repair after fracture reduction (Fig. 10-38). 
Figure 10-38
 
A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
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A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
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Figure 10-38
A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
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A–H: Open reduction and K-wire fixation of a bony gamekeeper‘s thumb. Taking care to repair the UCL, articular surface, and adductor aponeurosis.
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Beware of the “flipped physis” of the middle or proximal phalanx in younger children. The findings on x-ray may be subtle and only visible on the lateral view. Treatment most often requires open “flipping” of the physis, attempting to keep any collateral ligaments or capsule intact. Surprisingly, appropriate management rarely results in growth arrest (Fig. 10-39). 
Figure 10-39
 
A–D: Beware of the “flipped” epiphysis. Requires open reduction and fixation, but in younger children may not even cause growth arrest. Higher risk of infection and growth arrest than other epiphyseal fractures.
 
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A–D: Beware of the “flipped” epiphysis. Requires open reduction and fixation, but in younger children may not even cause growth arrest. Higher risk of infection and growth arrest than other epiphyseal fractures.
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Figure 10-39
A–D: Beware of the “flipped” epiphysis. Requires open reduction and fixation, but in younger children may not even cause growth arrest. Higher risk of infection and growth arrest than other epiphyseal fractures.
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A–D: Beware of the “flipped” epiphysis. Requires open reduction and fixation, but in younger children may not even cause growth arrest. Higher risk of infection and growth arrest than other epiphyseal fractures.
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Shaft Fractures

Shaft fractures that are nondisplaced and stable can be treated with simple immobilization. Safe position splinting for 3 to 4 weeks should be adequate for clinical union. Displaced or angulated fractures require closed reduction. The amount of acceptable angulation in the plane of motion is controversial.180 In children less than 10 years of age, 20 to 30 degrees may be acceptable. In children older than 10 years, 10 to 20 degrees of angulation is acceptable. Less angulation is acceptable in the coronal plane. Malrotation is unacceptable. 
Fractures that are unstable after reduction or irreducible by closed methods require operative intervention. A shaft fracture that is unstable after reduction is managed primarily by closed reduction and percutaneous K-wire fixation in either a longitudinal or horizontal direction, depending on the obliquity of the fracture (Fig. 10-40).189 Open reduction is indicated for fractures that cannot be reduced. A dorsal approach is usually used for exposure. The extensor tendon is split for proximal phalangeal fractures and elevated for middle phalangeal fractures. The choice of implant depends on the age of the patient and the fracture configuration. Smooth wires, tension bands, or modular set screws are preferable to plates to avoid extensor mechanism adherence.92 Bone grafting alone has been described to provide rigid fixation to proximal phalangeal base fractures.194 All malrotated fractures require reduction and fixation. 
Figure 10-40
 
A, B: Closed reduction, percutaneous pinning of a proximal phalanx spiral oblique shaft fracture.
 
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A, B: Closed reduction, percutaneous pinning of a proximal phalanx spiral oblique shaft fracture.
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Figure 10-40
A, B: Closed reduction, percutaneous pinning of a proximal phalanx spiral oblique shaft fracture.
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A, B: Closed reduction, percutaneous pinning of a proximal phalanx spiral oblique shaft fracture.
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Phalangeal Neck Fractures

Closed treatment of fractures of the phalangeal neck is difficult because these fractures are often unstable (Fig. 10-35A). Closed manipulation is done with digital distraction, a volar-directed pressure on the distal fragment, and hyperflexion of the DIP or PIP joint depending on the phalanx fractured. Percutaneous pinning is usually necessary to maintain the reduced position.47 Under fluoroscopy, K-wires are inserted through the collateral recesses and across the fracture. These wires should engage the contralateral cortex proximal to the fracture site. 
An alternative technique with a small distal fragment is to insert the pins through the articular surface of the phalanx in a longitudinal fashion, crossing the fracture to engage the proximal fragment. For example, in the middle phalanx neck fracture, a longitudinal wire can be placed distal to proximal, across the physis of the distal phalanx with the DIP in hyperextension to engage the distal fragment and condyles of the middle phalanx. Then the finger is flexed at the fracture site and the pin driven into the proximal middle phalanx with restoration of bony alignment (Fig. 10-35B, C). 
Recent publications have drawn attention to the remodeling potential of shallow neck fractures in a child under the age of 2 years. Remarkable reforming of the anatomic condyles can occur, despite being so far from the epiphysis. If very young children present late, waiting out their remodeling potential may obviate the need for any management (Fig. 10-41).157 
Figure 10-41
 
A–C: Remodeling potential of the subcondylar fracture in a very young child.
A–C: Remodeling potential of the subcondylar fracture in a very young child.
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Figure 10-41
A–C: Remodeling potential of the subcondylar fracture in a very young child.
A–C: Remodeling potential of the subcondylar fracture in a very young child.
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Intra-Articular Fractures
Nondisplaced fractures can be treated by immobilization. Weekly radiographs are necessary to ensure maintenance of reduction. Displaced intra-articular fractures require closed or open reduction.175 Closed or percutaneous reduction can be accomplished with traction and use of a percutaneous towel clip or reduction clamp to obtain provisional fracture reduction. Percutaneous fixation is used for definitive fracture fixation. Fractures not appropriate for closed manipulation require ORIF (Fig. 10-42). A dorsal, lateral, or rare volar incision is used for direct inspection of the fracture and articular surface. Care is taken to preserve the blood supply of the fracture fragments entering through the collateral ligaments. Fracture stabilization is either by K-wires or miniscrews. 
Figure 10-42
 
A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
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A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
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Figure 10-42
A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
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A: A 10-year-old girl with a displaced unicondylar fracture of the ring finger proximal phalanx. B: Clinical examination reveals malrotation of the digit. C: Dorsal exposure with incision between lateral band and central slip. D: Exposure of displaced fracture fragment. E: Fracture reduced with K-wire fixation. F: Postoperative radiograph shows restoration of articular surface.
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Certain unusual intra-articular fractures are especially difficult to treat. Shear fractures and osteochondral slice fractures are difficult to recognize. Treatment is open reduction and smooth wire fixation. Osteonecrosis, especially of small fragments, is a concern. Some of these fractures require a volar surgical approach. Avoidance of extensive soft tissue dissection lessens the risk of osteonecrosis. 
Comminuted pilon fracture–dislocations of the PIP joint are uncommon in children. Operative intervention is usually required to restore articular congruity. Anatomic reduction is preferred whenever possible (Fig. 10-43).193 Bone grafting may be necessary for stable reduction. Extreme joint comminution may preclude anatomic reduction, and alternative treatment options, such as dynamic traction, may be necessary.2,174 
Figure 10-43
 
A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
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A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
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Figure 10-43
A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
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A: A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint. B: Traction radiograph helps define fracture components. C: Dorsal exposure revealed ulnar condyle outside of joint requiring incision of extensor tendon for reduction. D: Reduction of joint surface and K-wire fixation. E: Postoperative AP radiograph shows restoration of articular surface. F: Lateral radiograph shows sagittal alignment of condyles.
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Complex Injuries
Combined injuries that affect several tissue systems are common in the digits. Skin, tendon, neurovascular structures, and bone may all be injured in the same digit (Fig. 10-44). Open fracture care is mandatory, followed by establishment of a stable bony foundation. Markedly comminuted fractures or injuries with bone loss may require external fixation followed by delayed bony reconstruction. Neurovascular and tendon reconstruction in children follows the same principles as for adults. Rehabilitation of complex injuries in children can be complicated by a lack of cooperation. Vascular injuries can affect subsequent growth (Tables 10-10 and 10-11). 
Figure 10-44
 
A: A 14-year-old boy sustained a near-amputation of his ring digit with severe soft tissue injury. B: Use of 90-90 intraosseous wiring was supplemented with K-wire fixation to provide a stable base for soft tissue repair.
A: A 14-year-old boy sustained a near-amputation of his ring digit with severe soft tissue injury. B: Use of 90-90 intraosseous wiring was supplemented with K-wire fixation to provide a stable base for soft tissue repair.
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Figure 10-44
A: A 14-year-old boy sustained a near-amputation of his ring digit with severe soft tissue injury. B: Use of 90-90 intraosseous wiring was supplemented with K-wire fixation to provide a stable base for soft tissue repair.
A: A 14-year-old boy sustained a near-amputation of his ring digit with severe soft tissue injury. B: Use of 90-90 intraosseous wiring was supplemented with K-wire fixation to provide a stable base for soft tissue repair.
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Table 10-10
Orif of Middle and Proximal Phalanx Fractures
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Table 10-10
Orif of Middle and Proximal Phalanx Fractures
Preoperative Planning Checklist
  •  
    OR table: Hand table
  •  
    Position: Supine
  •  
    Fluoroscopy location: Perpendicular or opposite the surgeon
  •  
    Equipment: Hand tray instruments, wire driver
  •  
    Tourniquet (sterile/nonsterile): Nonsterile or Esmark at approximately 200 mm Hg in small children
  •  
    Hardware: 0.027, 0.035, or 0.045 K-wires. Tension-band wires, modular screw set
  •  
    Suture: Nonabsorbable or absorbable suture for incision closure
X
 
Table 10-11
Orif of Middle and Proximal Phalanx Fractures
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Table 10-11
Orif of Middle and Proximal Phalanx Fractures
Surgical Steps
  •  
    Attempt closed reduction of displaced or open fractures after irrigation and debridement of foreign bodies or contamination
  •  
    If alignment adequate, place one or two K-wires parallel or crossed at fracture site, across physeal or extraphyseal fracture. Limit crossing of PIP joint
  •  
    Use “joystick” smaller K-wires, Freer elevator, dental pick, towel clip, or small fragment reduction forceps to enhance the closed reduction, osteoclasis
  •  
    If necessary, open skin through a direct lateral approach or expose the articular surface through the open fracture wound
    •  
      Preserve extensor and collateral soft tissue attachments
    •  
      Avoid dissection of smaller bone fragments
  •  
    Reduce incarcerated, rotated, or extruded fragments and proceed with K-wire or lag screw fixation
X

Author‘s Preferred Treatment

Physeal Fractures

Nondisplaced fractures are treated with simple immobilization for 3 weeks. Most displaced S-H I and II fractures can be treated with closed reduction (Fig. 10-45). Alignment and rotation are verified clinically, and reduction is assessed with radiographs. The hand is immobilized in a safe-position splint, and a radiograph is obtained 5 to 7 days later to ensure maintenance of reduction. When there is doubt about anatomic alignment, the cast is removed for more thorough clinical and radiographic examinations. Immobilization is continued for 3 to 4 weeks. Physeal fractures that are unstable after closed reduction require percutaneous pin fixation. Small smooth wires are used to secure the reduction. Irreducible fractures require open reduction, removal of any interposed tissue, and fixation. 
Figure 10-45
 
A: An S-H II fracture of the proximal phalanx of the thumb. B: Gentle closed reduction under fluoroscopic control obtained an anatomic reduction.
A: An S-H II fracture of the proximal phalanx of the thumb. B: Gentle closed reduction under fluoroscopic control obtained an anatomic reduction.
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Figure 10-45
A: An S-H II fracture of the proximal phalanx of the thumb. B: Gentle closed reduction under fluoroscopic control obtained an anatomic reduction.
A: An S-H II fracture of the proximal phalanx of the thumb. B: Gentle closed reduction under fluoroscopic control obtained an anatomic reduction.
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Displaced S-H III fractures of either the middle or proximal phalanges are difficult to reduce and maintain by closed methods. Dorsal S-H III or IV fractures of the middle phalangeal base often require open reduction and fixation to avoid the development of a boutonniere deformity (Fig. 10-46). A dorsal approach, with an incision between the central tendon and the lateral band, is preferred. The PIP joint may require supplemental pin fixation for 3 weeks to permit healing. Lateral S-H III fractures that are displaced more than 1.5 mm or involve more than 25% of the articular surface may also require ORIF. This fracture pattern is especially common in the proximal phalanx of the thumb. 
Figure 10-46
 
A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
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A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
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Figure 10-46
A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
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A, B: A 16-year-old male sustained a dorsal S-H IV fracture of the middle phalanx. C: Open reduction and internal screw fixation was accomplished through a dorsal approach. Radiographs show reduction of joint subluxation and fixation of fracture fragment. D, E, F: Postoperative extension and flexion with near normal motion.
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Shaft Fractures

Nondisplaced fractures are treated with immobilization for 3 to 4 weeks. Displaced fractures are treated with CRPP fixation.74 Reduction is accomplished with longitudinal traction and rotation of the distal fragment to approximate the proximal fragment. For a proximal phalangeal fracture, the MCP joint is flexed to relax the intrinsic muscle pull and to stabilize the proximal fragment. The fracture orientation dictates the angle of pin insertion (Fig. 10-39). Optimal pin placement is perpendicular to the fracture line. Placement of the pins in the midaxial line prevents iatrogenic injury of the neurovascular structures or entrapment of the extensor mechanism by the pin. Open reduction is reserved for irreducible fractures. 

Neck Fractures

Neck fractures usually require operative intervention. If closed reduction is obtainable, then percutaneous pin fixation is performed. The pin(s) are placed through the collateral recesses to engage the proximal fragment in a crossed fashion. If closed reduction is unsuccessful, open reduction with preservation of the collateral ligaments and similar percutaneous pinning are indicated. However, open reduction should be avoided whenever possible to decrease the chances of osteonecrosis. 
Late presentation of a neck fracture requires consideration of the time from injury, age of the patient, and fracture displacement. Considerable displacement requires treatment to regain joint flexion (Fig. 10-47). If the fracture line is still visible, a percutaneous pin osteoclasis may be possible. Under fluoroscopy, one or two smooth K-wires are inserted into the fracture site to break up any callus. These K-wires are used to “joystick” the distal fragment into a reduced position.209 The fracture is then stabilized with additional percutaneous pins. This approach may decrease the risk of osteonecrosis associated with late open reduction. A nascent or established malunion that cannot be reduced by osteoclasis can be treated by late open reduction (Fig. 10-48). The callus is gently removed and the fracture aligned. The risks of osteonecrosis must be weighed against acceptance of the malunion. Mild loss of the condylar recess can be treated with recession of the prominent volar bone rather than risk osteonecrosis associated with extensive fracture mobilization.181,197 In addition, slow remodeling is feasible in very young children without rotational malalignment and with a family that is willing to wait up to 2 years for remodeling.36,87 
Figure 10-47
Displaced phalangeal neck fracture of the proximal phalanx revealing loss of subchondral fossa at the PIP joint.
 
If this is not corrected to anatomic alignment, there will be a mechanical block to flexion.
If this is not corrected to anatomic alignment, there will be a mechanical block to flexion.
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Figure 10-47
Displaced phalangeal neck fracture of the proximal phalanx revealing loss of subchondral fossa at the PIP joint.
If this is not corrected to anatomic alignment, there will be a mechanical block to flexion.
If this is not corrected to anatomic alignment, there will be a mechanical block to flexion.
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Figure 10-48
 
A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
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A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
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Figure 10-48
A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
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A: A 14-year-old girl with incipient malunion of right thumb proximal phalanx neck fractures that impede flexion. B: Lateral radiograph reveals loss of the subchondral fossa. C: An AP view after open reduction and K-wire fixation. D: Oblique view reveals restoration of subchondral fossa. E, F: Postoperative flexion and extension compared to the other side.
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Intra-Articular Fractures

Intra-articular fractures of the phalanges usually require percutaneous or open reduction. Unicondylar fractures that are mildly displaced can be treated with CRPP. Widely displaced unicondylar and bicondylar fractures require open reduction (Fig. 10-41). A dorsal approach is preferred. Fixation is usually obtained with smooth wires. Placement and direction of the wires are dictated by the fracture configuration. Rotational control of the fragment may require multiple wires. The fixation device must avoid tethering of the collateral ligament, which will limit PIP joint motion. Usually, a pin is placed parallel to the joint to maintain articular alignment, followed by oblique pins to stabilize the articular fragment(s) to the shaft. In adolescents, miniscrew fixation can be used, though these screws must avoid impingement of the collateral ligaments that will impede flexion. 
Pilon fractures or intra-articular fracture–dislocations present a management dilemma.193 Open reduction is worthwhile when the fragments are large and the joint surface can be reconstructed. Bone grafting may be necessary for stable reduction. Severe articular damage and comminution is best treated with dynamic traction (Fig. 10-49). 
Figure 10-49
Author‘s preferred treatment algorithm for middle and proximal phalanx fractures in children.
Flynn-ch010-image049.png
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Postoperative Care

The duration of immobilization after surgical intervention for phalangeal fractures is usually 3 to 4 weeks. Percutaneous pins are removed at that time and motion instituted. Formal hand therapy usually is not required, though the child must be encouraged to reestablish a normal usage pattern to improve motion and flexibility. Periarticular fractures are monitored closely for persistent loss of motion that would benefit from formal hand therapy. Patients with complex fractures or replantations are more prone to develop stiffness. In these instances, therapy is routinely prescribed to regain motion. Therapy is directed at both flexion and extension of the injured digit. Static or dynamic splinting may be required after fracture healing. Persistent stiffness may require tenolysis and/or joint release to regain motion (Table 10-12; Fig. 10-50). 
 
Table 10-12
Middle and Proximal Phalanx Fractures
View Large
Table 10-12
Middle and Proximal Phalanx Fractures
Potential Pitfalls and Preventions
Pitfalls Preventions
Malrotation
  •  
    Check tenodesis intraoperatively
  •  
    Use lateral view to establish if radial and ulnar condyles of middle or proximal phalanx are overlapping
Osteonecrosis Minimize open procedures and soft tissue stripping of fragile blood supply to condyles
Pin tract infection Bicortical fixation, relax tension on wire on skin
Stiffness Allow early range of motion as soon as clinically stable; radiographic union will lag behind clinical union
X
Figure 10-50
A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint depicted in Figure 10-33 with healed fracture but limited motion after therapy.
 
A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
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A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
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Figure 10-50
A 16-year-old girl with a severe intra-articular pilon fracture of the small finger PIP joint depicted in Figure 10-33 with healed fracture but limited motion after therapy.
A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
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A: Passive extension. B: Passive flexion. C: Dorsal exposure and tenolysis under local anesthesia with sedation. D: Joint release. E: Passive extension. F: Passive flexion. G: Active flexion.
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Prognosis

The overall results following proximal and middle phalangeal fractures are positive. Considering the frequency of these fractures, the occurrence of complications and functional impairment is low. Despite appropriate treatment, however, some children have permanent loss of motion, malunion, or growth disturbance. The major concern is to avoid rotational, articular, or periarticular malunion caused by the inappropriate diagnosis or treatment. 

Management of Expected Adverse Outcomes and Unexpected Complications (Table 10-13)

 
Table 10-13
Middle and Proximal Phalanx Fractures
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Table 10-13
Middle and Proximal Phalanx Fractures
Common Adverse Outcomes and Complications
Malunion, malrotation, finger deformity
Growth arrest
Stiffness
Osteonecrosis
Degenerative joint changes
Pin tract infection, osteomyelitis
X
Complications associated with proximal and middle phalangeal fractures begin with failure to recognize the injury (Fig. 10-51). Radiologic AP and lateral views of the injured digit must be made correctly and scrutinized for subtle abnormalities. Questionable findings warrant additional views or advanced imaging studies. A common misdiagnosis is failure to recognize a displaced phalangeal neck fracture because of inadequate lateral radiographs of the finger. 
Figure 10-51
 
A: A 3-year-old girl sustained a fracture of the neck of the proximal phalanx of the index and middle fingers. The displaced fracture in the middle finger appears similar to an epiphysis at the distal end of the phalanx. B: No true lateral radiograph of the injured finger was obtained. Close scrutiny of this lateral view shows a dorsally displaced neck fracture, rotated almost 90 degrees (arrow). C: A lateral radiograph taken 18 months later reveals malunion with hyperextension of the PIP joint and loss of flexion.
A: A 3-year-old girl sustained a fracture of the neck of the proximal phalanx of the index and middle fingers. The displaced fracture in the middle finger appears similar to an epiphysis at the distal end of the phalanx. B: No true lateral radiograph of the injured finger was obtained. Close scrutiny of this lateral view shows a dorsally displaced neck fracture, rotated almost 90 degrees (arrow). C: A lateral radiograph taken 18 months later reveals malunion with hyperextension of the PIP joint and loss of flexion.
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Figure 10-51
A: A 3-year-old girl sustained a fracture of the neck of the proximal phalanx of the index and middle fingers. The displaced fracture in the middle finger appears similar to an epiphysis at the distal end of the phalanx. B: No true lateral radiograph of the injured finger was obtained. Close scrutiny of this lateral view shows a dorsally displaced neck fracture, rotated almost 90 degrees (arrow). C: A lateral radiograph taken 18 months later reveals malunion with hyperextension of the PIP joint and loss of flexion.
A: A 3-year-old girl sustained a fracture of the neck of the proximal phalanx of the index and middle fingers. The displaced fracture in the middle finger appears similar to an epiphysis at the distal end of the phalanx. B: No true lateral radiograph of the injured finger was obtained. Close scrutiny of this lateral view shows a dorsally displaced neck fracture, rotated almost 90 degrees (arrow). C: A lateral radiograph taken 18 months later reveals malunion with hyperextension of the PIP joint and loss of flexion.
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Another early complication is false interpretation of a “nondisplaced” fracture that is malrotated. All children with phalangeal fractures require careful examination for rotational alignment. The clinical examination is the mainstay for determining fracture rotation. Digital scissoring is indicative of fracture malrotation and requires reduction. Regardless of radiographic appearance, rotational alignment should be evaluated by active finger flexion and passive tenodesis. 
Most phalangeal fractures can be maintained in satisfactory alignment after closed reduction. Certain fractures, however, have a propensity for redisplacement (Fig. 10-52). Oblique shaft fractures, unicondylar articular fractures, and neck fractures are prime examples. Early follow-up to ensure maintenance of reduction is paramount if closed treatment is chosen. Displacement requires repeat manipulation and pin fixation. When in doubt, the digit should be examined out of cast carefully for malalignment and blocks to motion because of the fracture displacement. Most of these unstable fractures do best with pin fixation after acceptable reduction. 
Figure 10-52
 
A, B: An 8-year-old girl with a mildly displaced fracture of the neck of the middle phalanx. C: Closed reduction was successful on the day of injury and a plaster splint was applied. D: Two weeks later, the fracture had markedly redisplaced.
A, B: An 8-year-old girl with a mildly displaced fracture of the neck of the middle phalanx. C: Closed reduction was successful on the day of injury and a plaster splint was applied. D: Two weeks later, the fracture had markedly redisplaced.
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Figure 10-52
A, B: An 8-year-old girl with a mildly displaced fracture of the neck of the middle phalanx. C: Closed reduction was successful on the day of injury and a plaster splint was applied. D: Two weeks later, the fracture had markedly redisplaced.
A, B: An 8-year-old girl with a mildly displaced fracture of the neck of the middle phalanx. C: Closed reduction was successful on the day of injury and a plaster splint was applied. D: Two weeks later, the fracture had markedly redisplaced.
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Late complications include rare nonunion, malunion, osteonecrosis, growth disturbance, and arthritis. Nonunion is rare except in combined injuries with devascularization of the fracture fragments. Bone grafting is usually successful for union. Malunion can result in angulation or limited motion. Extra-articular malunion can cause angulation or rotational abnormalities. The treatment depends on the child‘s age and ability to remodel according to fracture location, plane of malunion, and degree of deformity (Fig. 10-53). Considerable deformity may require osteotomy to realign the bone.69 A subcondylar or intra-articular malunion is particularly difficult to treat. Early diagnosis within the first month offers the possibility of fracture realignment through the site of deformity. Treatment of a late diagnosis must include consideration of the risks and benefits associated with extensive surgery. Successful late osteotomies can restore normal tenodesis and return to full function, but risk nonunion, stiffness, and painful functional recovery (Fig. 10-54). 
Figure 10-53
 
A: A 13-year-old boy with malunion of the ring finger middle phalanx articular surface. B, C: Radiographs reveal slight malunion of the radial condyle with mild intra-articular incongruity. The lateral view suggests a double density shadow (arrow). The flexion and extension motion of the digit was normal, and reconstruction was not recommended.
A: A 13-year-old boy with malunion of the ring finger middle phalanx articular surface. B, C: Radiographs reveal slight malunion of the radial condyle with mild intra-articular incongruity. The lateral view suggests a double density shadow (arrow). The flexion and extension motion of the digit was normal, and reconstruction was not recommended.
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Figure 10-53
A: A 13-year-old boy with malunion of the ring finger middle phalanx articular surface. B, C: Radiographs reveal slight malunion of the radial condyle with mild intra-articular incongruity. The lateral view suggests a double density shadow (arrow). The flexion and extension motion of the digit was normal, and reconstruction was not recommended.
A: A 13-year-old boy with malunion of the ring finger middle phalanx articular surface. B, C: Radiographs reveal slight malunion of the radial condyle with mild intra-articular incongruity. The lateral view suggests a double density shadow (arrow). The flexion and extension motion of the digit was normal, and reconstruction was not recommended.
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Figure 10-54
 
A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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Figure 10-54
A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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A–K: A 12-year-old girl with malunion of the small finger shaft proximal phalanx fracture. Operative steps for fixation and correction of tenodesis.
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Osteonecrosis is usually related to extensive fracture comminution, soft tissue injury, or surgical dissection of an intra-articular fracture. In severe cases, reconstruction is limited to some form of joint transfer. Growth disturbance can result from any injury that involves the physis. A shortened or angulated digit may result. It is fortunate that this complication is rare because reconstruction options for children with remaining growth in the fingers are limited. Angulation must be addressed by corrective osteotomy. 
Posttraumatic degenerative joint disease is rare in children, but intra-articular injury and sepsis may result in arthrosis. Treatment is directed toward the child‘s symptoms and not the radiographic findings. Minimal pain and excellent function often accompany considerable arthritic changes on radiographs and warrant no treatment. Pain and functional limitations require treatment; options include a vascularized joint transfer, interposition or distraction arthroplasty, hemi-hamate osteochondral transfer, prosthetic joint replacement, and arthrodesis.182 Arthrodesis in the most functional position is considered the most reliable procedure. 

Metacarpal Fractures in Children

Metacarpal Fracture Classification

Metacarpal fractures are classified by location in the epiphysis, physis, neck, shaft, or base (Table 10-14). The metacarpals are surrounded by soft tissue and are relatively protected within the hand. Considerable variation exists in the relative mobility of the metacarpals through the CMC joints. The index and long rays have minimal CMC joint motion (10 to 20 degrees). In contrast, the ring and small rays possess more motion (30 to 40 degrees), and the thumb CMC joint has universal motion. Every metacarpal fracture must be examined for rotation. Malrotation will result in digital scissoring during active flexion or an abnormal digital cascade with passive tenodesis. Direct trauma, rotational forces, and axial loading may all cause fractures of the metacarpal. Contact sports and punching are the most common mechanisms of injury. Pediatric thumb metacarpal fractures have unique anatomy and characteristic patterns and are discussed in a separate section. 
 
Table 10-14
Classification of Finger Metacarpal Fractures
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Table 10-14
Classification of Finger Metacarpal Fractures
Epiphyseal and physeal fractures
Neck fractures
Shaft fractures
Metacarpal base fractures
X

Epiphyseal and Physeal Fractures

Epiphyseal and physeal fractures of the metacarpal head are rare but occur most often in the small ray.11,26,86,112 Physeal S-H II fractures of the small metacarpal occur among patients 12 to 16 years of age and are prone to partial closure of the physis.112,126,145 Intra-articular, head-splitting fractures at the metacarpal epiphysis and physis consistent with S-H III and IV patterns seldom occur at the metacarpal level but are problematic when displaced (Fig. 10-55). There is an increased risk of head avascular necrosis after an epiphyseal fracture. 
Figure 10-55
 
A: An S-H type II fracture of the metacarpal head. B: Head-splitting fracture of the metacarpal epiphysis.
 
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A: An S-H type II fracture of the metacarpal head. B: Head-splitting fracture of the metacarpal epiphysis.
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Figure 10-55
A: An S-H type II fracture of the metacarpal head. B: Head-splitting fracture of the metacarpal epiphysis.
(Courtesy of Children‘s Hospital Los Angeles, CA.)
A: An S-H type II fracture of the metacarpal head. B: Head-splitting fracture of the metacarpal epiphysis.
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Metacarpal Neck Fractures

The metacarpal neck is the most frequent site of metacarpal fractures in children. The metacarpal geometry and composition predispose the metacarpal neck to injury. The distal metacarpal neck angles as it approaches the MCP joint, and the cortical bone within the subcondylar fossa is relatively thin, making it vulnerable to injury. Neck fractures in children are analogous to boxer‘s fractures in adults (Fig. 10-56). Neck fractures are more common in the small and ring fingers. Fortunately, these injuries are juxtaphyseal and have considerable remodeling potential. 
Figure 10-56
 
A: A true boxer‘s fracture of the metacarpal neck of the fifth ray. B: This fracture is more in the diaphysis and should not be considered a boxer‘s fracture.
A: A true boxer‘s fracture of the metacarpal neck of the fifth ray. B: This fracture is more in the diaphysis and should not be considered a boxer‘s fracture.
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Figure 10-56
A: A true boxer‘s fracture of the metacarpal neck of the fifth ray. B: This fracture is more in the diaphysis and should not be considered a boxer‘s fracture.
A: A true boxer‘s fracture of the metacarpal neck of the fifth ray. B: This fracture is more in the diaphysis and should not be considered a boxer‘s fracture.
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Metacarpal Shaft Fractures

Metacarpal shaft fractures are relatively common. Torsional forces combined with axial load cause long oblique and spiral fractures whereas direct trauma (being stepped on or a heavy object dropping onto the hand) produces short oblique or transverse fractures. An isolated shaft fracture of a central ray is suspended by the inter-metacarpal ligaments, which limit displacement and shortening. In contrast, the border digits (index and small) displace more readily. 

Metacarpal Base Fractures

Metacarpal base fractures are uncommon in children. The base is protected from injury by its proximal location in the hand and the stability afforded by the bony congruence and soft tissue restraints. The small finger CMC joint is the most prone to injury. Fracture–dislocations of the small finger CMC joint are often unstable because of the proximal pull of the extensor carpi ulnaris (reverse Bennett fracture). 

Metacarpal Fracture Treatment Options

Nonoperative and Operative Treatment of Metacarpal Fractures (Table 10-15)

 
Table 10-15
Metacarpal Fractures
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Table 10-15
Metacarpal Fractures
Nonoperative Operative
Nondisplaced Multiple metacarpals
Closed Open or extensive soft tissue injury
Reducible Displaced articular
Stable Unstable
Irreducible
Malrotation
Excessive shortening
X
The treatment of metacarpal fractures varies with the location, extent, and configuration of the fracture. Nonoperative or closed treatment is the primary mode of management for most fractures. Operative intervention is used for multiple metacarpal fractures, extensive soft tissue injury, intra-articular head-splitting fractures, malrotated fractures, and irreducible fractures. 

Epiphyseal and Physeal Fractures

A metacarpal head-splitting fracture may be difficult to detect and requires special views. The Brewerton view is helpful and is performed with the dorsum of the hand against the cassette and the MCP joints flexed about 65 degrees. The central beam is angled 15 degrees to the ulnar side of the hand.106 This projection focuses on the metacarpal heads and may highlight subtle bony abnormalities. An MRI scan to assess articular alignment is diagnostic in complex injuries. 
Management is based on the amount of articular or fracture fragment displacement and stability detected on imaging studies, at times including MRI. Many of these fractures can be treated by closed methods. Gentle reduction under metacarpal or wrist block anesthesia is followed by application of a splint in the safe position. If the fracture is reducible but unstable, percutaneous pin fixation is recommended. If the Thurston Holland fragment is large enough, the wire can secure the metaphyseal piece and avoid the physis. Otherwise, the wire must cross the physis to obtain stability. A small-diameter smooth wire is advocated, and multiple passes should be avoided. 
Displaced intra-articular head-splitting fractures require ORIF to restore articular congruity. Many of these fractures have unrecognized comminution that complicates internal fixation. Wire or screw fixation is used, depending on the age of the patient and size of the fragments. Transosseous suture repair may be necessary. Bone grafting may be necessary for stable reduction. The primary goal of surgical treatment is anatomic reduction of the joint. A secondary goal is stable fixation to allow early motion. 

Neck Fractures

Metacarpal neck fractures are usually treated by closed methods. The amount of acceptable apex dorsal angulation in children as in adults is controversial. Greater angulation is allowable in the mobile ring and small rays compared to the index and long. Another consideration is the effect of remodeling over time, which is dependent on the age of the child. In general, 10 to 30 degrees of angulation greater than the corresponding CMC joint motion is acceptable. Radiologic AP and lateral views may be supplemented by an oblique view to assess fracture configuration. 
Considerable angulation can be treated with closed reduction with local anesthesia or conscious sedation and splint or cast application. The Jahss maneuver is commonly recommended and involves initial flexion of the MCP joint to 90 degrees to relax the deforming force of the intrinsic muscles and tighten the collateral ligaments.95 Subsequently, upward pressure is applied along the proximal phalanx to push the metacarpal head in a dorsal direction whereas counterpressure is applied along the dorsal aspect of the proximal metacarpal fracture. Jahss95 suggested immobilization with the MCP and PIP joints flexed, but this type of immobilization is no longer advocated for fear of stiffness and skin breakdown. Immobilization in the intrinsic plus or safe position is the appropriate approach. A well-molded splint or ulnar gutter or outrigger cast is necessary. Three-point modeling over the volar metacarpal head and proximal dorsal shaft is recommended. The PIP joints may or may not be included in the immobilization depending on the status of the reduction and reliability of the patient. 
Uncommonly, a neck fracture may be extremely unstable and require percutaneous pinning (Fig. 10-57). Pins can be inserted in a variety of configurations. Extramedullary techniques include crossed pinning or pinning to the adjacent stable metacarpal. Intramedullary techniques can also be used, similar to those used for metacarpal shaft and neck fractures in adults.58,70 Intramedullary techniques are reserved for patients near physeal closure. Prebent K-wires or commercially available implants are inserted through the metacarpal base in an antegrade fashion. The wires can be used to assist in fracture reduction. Stability is obtained by stacking several wires within the canal and across the fracture site. 
Figure 10-57
 
A, B: A 14-year-old boy with a dorsally angulated fracture of the second metacarpal. C: Closed reduction was unstable, and percutaneous K-wire fixation was performed.
 
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:715–716, with permission.)
A, B: A 14-year-old boy with a dorsally angulated fracture of the second metacarpal. C: Closed reduction was unstable, and percutaneous K-wire fixation was performed.
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Figure 10-57
A, B: A 14-year-old boy with a dorsally angulated fracture of the second metacarpal. C: Closed reduction was unstable, and percutaneous K-wire fixation was performed.
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:715–716, with permission.)
A, B: A 14-year-old boy with a dorsally angulated fracture of the second metacarpal. C: Closed reduction was unstable, and percutaneous K-wire fixation was performed.
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Open reduction of metacarpal neck fractures is seldom required in children and is reserved for irreducible fractures, unstable fractures in skeletally mature children, multiple metacarpal fractures, and combination injuries that require a stable bony platform. 

Shaft Fractures

An isolated long or ring metacarpal fracture is often minimally displaced because the metacarpals are suspended by the intermetacarpal ligaments. Immobilization for 4 weeks is usually all that is necessary. In contrast, the index and small digits may require additional treatment, such as closed reduction and immobilization. Percutaneous pinning is reserved for unstable shaft fractures (Fig. 10-58). Pins can be inserted with extramedullary or intramedullary techniques. Diaphyseal fractures are slower to heal and more prone to malunion than neck fractures. 
Figure 10-58
A 14-year-old boy with a reducible, but unstable, ring finger metacarpal shaft fracture.
 
A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
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A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
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Figure 10-58
A 14-year-old boy with a reducible, but unstable, ring finger metacarpal shaft fracture.
A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
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A: The injury on an AP radiograph appears reduced. B: Lateral radiograph shows persistent apex dorsal angulation. C: An AP radiograph after CRPP. D: Lateral radiograph reveals anatomic alignment. E: Full extension after pin removal and home therapy. F: Full flexion with normal digital cascade.
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An ORIF approach to a metacarpal shaft fracture is rarely indicated in children unless there are multiple fractures or extensive soft tissue damage or the child is skeletally mature. However, a long spiral-oblique fracture with substantial malrotation and shortening may require miniscrew fixation to reestablish alignment. 

Metacarpal Base Fractures

Fractures of the metacarpal base or fracture–dislocations at the CMC joint are usually high-energy injuries with substantial tissue disruption. Assessment for signs of compartment syndrome and careful neurovascular assessment are mandatory. Isolated fracture–dislocations of the small ray CMC joint are the most common metacarpal base fractures. Use of CT scan may better define articular congruity and comminution. A CRPP approach is usually sufficient to restore alignment and to resist the deforming force of the extensor carpi ulnaris.170 The pins can be placed transversely between the small and ring metacarpals and/or across the CMC joint. 
Open reduction may be necessary to achieve reduction and ensure stable fixation in high-energy injuries. A transverse or longitudinal incision can be used for exposure. Longitudinal incisions are recommended in patients with concomitant compartment syndrome to allow for simultaneous decompression. Fixation options are numerous, depending on the fracture configuration. Supplemental bone graft may be necessary for substantial comminution. Late presentation is especially difficult. Treatment often requires open reduction or CMC arthrodesis (Tables 10-16 and 10-17; Fig. 10-59). 
 
Table 10-16
Orif of Metacarpal Fractures in Children
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Table 10-16
Orif of Metacarpal Fractures in Children
Preoperative Planning Checklist
  •  
    OR table: Hand table, radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: Parallel or perpendicular to the patient‘s hands
  •  
    Equipment: Hand instrument set, small tenaculums, bone clamps, or towel clips, rare pediatric use of modular screw and plate tray
  •  
    Tourniquet (sterile/nonsterile): Nonsterile, upper arm, not elevated unless converted to open procedure
X
 
Table 10-17
Orif of Metacarpal Fractures
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Table 10-17
Orif of Metacarpal Fractures
Surgical Steps
  •  
    Expose longitudinally and dorsally with incision directly over metacarpal or in the case of multiple fractures, in interval between the two broken metacarpals
  •  
    Protect the extensor tendons and their juncturae. Handle with care, as increased manipulation may lead to postoperative adhesions
  •  
    Split the periosteum over the metacarpl shaft
  •  
    Use towel clips, bone clamps or tenaculums to reduce fracture and pin with longitudinal crossed pattern, proximal to distal or distal to proximal
  •  
    Transverse traction pinning of the distal fragment to the intact neighboring metacarpal may help with shortening in oblique fractures, but beware of overdistraction and malrotation
  •  
    Reduce joint component and provisionally stabilize with K-wires.
  •  
    In Bennett fractures, reduce displaced lateral metacarpal to intact ulnar fragment that is attached to the volar beak ligament
  •  
    Reduce metacarpal neck component, provisionally stabilize with wires
    •  
      Rarely, pin placement through the base of the proximal phalanx and MCP joint may help capture very distal head fragments
  •  
    Restore rotation; check tenodesis after wire fixation
X
Figure 10-59
A 15-year-old boy with crush injury of the right hand requiring compartment release.
 
He presented 6 weeks later with persistent pain and limited motion. A: An AP radiograph shows overlapping long, ring, and small CMC joints. B: Lateral radiographs reveal fracture–dislocations of long, ring, and small CMC joints. C: Postoperative AP radiograph after reduction and CMC fusion using miniplates. D: Lateral radiograph after reduction and CMC fusion.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
He presented 6 weeks later with persistent pain and limited motion. A: An AP radiograph shows overlapping long, ring, and small CMC joints. B: Lateral radiographs reveal fracture–dislocations of long, ring, and small CMC joints. C: Postoperative AP radiograph after reduction and CMC fusion using miniplates. D: Lateral radiograph after reduction and CMC fusion.
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Figure 10-59
A 15-year-old boy with crush injury of the right hand requiring compartment release.
He presented 6 weeks later with persistent pain and limited motion. A: An AP radiograph shows overlapping long, ring, and small CMC joints. B: Lateral radiographs reveal fracture–dislocations of long, ring, and small CMC joints. C: Postoperative AP radiograph after reduction and CMC fusion using miniplates. D: Lateral radiograph after reduction and CMC fusion.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
He presented 6 weeks later with persistent pain and limited motion. A: An AP radiograph shows overlapping long, ring, and small CMC joints. B: Lateral radiographs reveal fracture–dislocations of long, ring, and small CMC joints. C: Postoperative AP radiograph after reduction and CMC fusion using miniplates. D: Lateral radiograph after reduction and CMC fusion.
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X

Author‘s Preferred Treatment

Epiphyseal and Physeal Fractures

Nondisplaced epiphyseal and S-H II metacarpal neck fractures with up to 30 to 35 degrees of sagittal angulation in adolescents are treated with immobilization as long as there is no rotation and sufficient growth remaining. A widely displaced fracture that is reducible requires percutaneous pinning to maintain the reduction. Displaced epiphyseal fractures with considerable intra-articular displacement require ORIF through a dorsal approach and splitting of the extensor apparatus over the MCP joint. Anatomic reduction of the articular surface is the objective, and fixation devices vary according to the patient and fracture configuration. Even external fixation may be required for severely comminuted fractures (Fig. 10-60). Rarely, pinning across the base of the proximal phalanx with a smooth wire may be necessary to stabilize a small distal metacarpal fragment. 
Figure 10-60
A 15-year-old boy with a punching injury causing (A) an articular, multifragmented metacarpal head fracture.
 
B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
 
(Courtesy of Children‘s Hospital Los Angeles, CA.)
B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
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B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
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Figure 10-60
A 15-year-old boy with a punching injury causing (A) an articular, multifragmented metacarpal head fracture.
B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
(Courtesy of Children‘s Hospital Los Angeles, CA.)
B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
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B: Fragments were pinned together with 0.035 and 0.028 K-wires. A mini ex fix was utilized to provide distraction across the joint and alignment for collateral ligaments during healing. C: Final results at ex fix removal.
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X

Metacarpal Neck Fractures

Nonoperative and closed methods are the mainstays of treatment. Considerable sagittal angulation is acceptable, especially in the ring and small digits. Small finger angulation up to 30 degrees does not usually necessitate closed reduction as long as there is no malrotation and there is sufficient growth remaining. Greater angulations are treated with closed reduction and cast application. Index and ring finger angulations of more than 20 degrees are treated by closed reduction. Pin fixation is used for unstable fractures that have a tendency to redisplace. Open reduction is rarely necessary. 

Metacarpal Shaft Fractures

The number, configuration, and location of the metacarpal shaft fracture(s) dictate treatment. Isolated fractures that are minimally displaced require only immobilization. Isolated fractures that are displaced or malrotated require closed reduction and percutaneous fixation. Rotation is carefully assessed to ensure adequate reduction. An irreducible fracture or multiple fractures usually require open reduction (Fig. 10-58). The fixation technique varies according to the age of the child and fracture pattern. If open fixation is necessary, stable fixation is the goal. Miniplate and screw fixation is preferred to restore alignment and to allow early mobilization of tendons and soft tissue. The physis should be avoided during plate application to prevent growth disturbance. The operative approach and internal fixation principles are similar in children and adults. Long oblique fractures are managed with interfragmentary screw fixation. Short oblique and transverse fractures require a neutralization plate with purchase of four cortices proximal and distal to the fracture. Transverse wire fixation to the surrounding metacarpals is used sparingly because of the risk of metacarpal nonunion secondary to distraction. For transverse wiring, use large K-wires such as 0.062 in or 0.20 mm to avoid risk of breakage. 

Metacarpal Base Fractures

Metacarpal base fractures are often displaced or unstable. Extra-articular fractures can be treated by closed reduction with or without percutaneous pinning. Intra-articular fracture–dislocations are more challenging. Percutaneous pinning is often required to stabilize the fracture and to reduce CMC joint subluxation. The wires are placed between the bases of the adjacent metacarpals or across the CMC joint in isolated injuries. Irreducible or multiple fracture–dislocations require open reduction. Late presentation with symptomatic degenerative changes requires CMC arthrodesis (Fig. 10-59). 

Postoperative Care

Most metacarpal fractures managed by closed treatment are immobilized for 4 weeks. Subsequently, a home program of range of motion exercises is started and formal therapy is not needed. In active children and young athletes, a light splint can be worn for protection and as a peer warning signal for an additional few weeks. If percutaneous pin fixation is used, the wires are removed in the office 4 weeks after surgery. 
Rehabilitation of open fracture reduction depends on the stability of the fixation and the reliability of the patient to postoperative recommendations. Older and reliable patients with stable internal fixation are mobilized earlier, usually 5 to 7 days after surgery. A removable splint for protection between exercise sessions is used for 4 to 6 weeks (Table 10-18). 
 
Table 10-18
Metacarpal Fractures in Children
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Table 10-18
Metacarpal Fractures in Children
Potential Pitfalls and Preventions
Pitfalls Preventions
Malrotation Check tenodesis
After each K-wire or reduction maneuver recheck tenodesis
Malunion Stable fixation
Allow shaft metacarpals an extended healing time, as the diaphysis may be slower to consolidate than the neck
Osteonecrosis of metacarpal head Consider joint aspiration
Avoid dissection of fragments during open repair
X

Management of Expected Adverse Outcomes and Unexpected Complications

Most metacarpal fractures heal without substantial sequelae. Mild deformity in the plane of motion is tolerated and may correct with remodeling. Considerable angulation or rotation creates a functional impairment that requires treatment. 
Bony complications include malunion and osteonecrosis (Table 10-19). Nonunion is rare.94,145 Even a small amount (less than 10 degrees) of rotational malalignment may create overlap of the digits during flexion and a functional disturbance (Fig. 10-61). Corrective osteotomy to realign the digit is often necessary. The osteotomy for rotational correction can be made at the site of fracture or anywhere along the metacarpal. The proximal shaft or base has certain advantages. This area provides ample bone for healing and offers the opportunity for internal fixation using wires or a plate. Diaphyseal malunions with symptomatic flexion deformity into the palm require a dorsal wedge osteotomy and internal fixation. 
 
Table 10-19
Adverse Factors for Finger Metacarpal Fractures
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Table 10-19
Adverse Factors for Finger Metacarpal Fractures
Epiphyseal and physeal fractures
Osteonecrosis, malreduction/malunion
Neck fractures
Excessive apex dorsal angulation, malrotation
Shaft fractures
Malrotation, soft tissue interposition, nonunion
Metacarpal base fractures
Loss of reduction, malreduction of articular fragments, late instability
X
Figure 10-61
 
A, B: A 15-year-old boy with severe overlapping of the ring finger on the little finger secondary to rotatory malunion of a spiral fracture of the ring metacarpal. C: Distal osteotomy through the deformity stabilized with pin fixation to correct the malrotation.
 
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:731, with permission.)
A, B: A 15-year-old boy with severe overlapping of the ring finger on the little finger secondary to rotatory malunion of a spiral fracture of the ring metacarpal. C: Distal osteotomy through the deformity stabilized with pin fixation to correct the malrotation.
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Figure 10-61
A, B: A 15-year-old boy with severe overlapping of the ring finger on the little finger secondary to rotatory malunion of a spiral fracture of the ring metacarpal. C: Distal osteotomy through the deformity stabilized with pin fixation to correct the malrotation.
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:731, with permission.)
A, B: A 15-year-old boy with severe overlapping of the ring finger on the little finger secondary to rotatory malunion of a spiral fracture of the ring metacarpal. C: Distal osteotomy through the deformity stabilized with pin fixation to correct the malrotation.
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Osteonecrosis of the metacarpal head may occur after an intra-articular fracture. Factors include the degree of injury and the intracapsular pressure caused by the hemarthrosis.39,126,156 Theoretically, early joint aspiration may diminish the intra-articular pressure. Fortunately, partial osteonecrosis in a growing child incites remarkable remodeling of the adjacent articular surface and often results in a functional joint. Part-time splint protection during the remodeling phase is recommended. Considerable joint incongruity is rare, and reconstruction options are limited.182 

Fractures of the Thumb Metacarpal in Children

Thumb Metacarpal Fracture Classification

Fractures of the thumb metacarpal can occur at the epiphysis, physis, neck, shaft, or base. Fractures of the neck and shaft and their treatment principles are similar to those of the fingers (Table 10-20). Thumb metacarpal base fractures that involve the physis or epiphysis require unique considerations (Fig. 10-62). 
 
Table 10-20
Classification of Thumb Metacarpal Fractures
View Large
Table 10-20
Classification of Thumb Metacarpal Fractures
Fractures of the head
Fractures of the shaft
Fractures of the thumb metacarpal base
Fractures distal to the physis
S-H II fractures—metaphyseal medial
S-H II fractures—metaphyseal lateral
Intra-articular S-H III or IV fractures
X
Figure 10-62
Classification of thumb metacarpal fractures.
 
Type A: Metaphyseal fracture. Types B and C: S-H type II physeal fractures with lateral or medial angulation. Type D: an S-H type III fracture (pediatric Bennett fracture).
Type A: Metaphyseal fracture. Types B and C: S-H type II physeal fractures with lateral or medial angulation. Type D: an S-H type III fracture (pediatric Bennett fracture).
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Figure 10-62
Classification of thumb metacarpal fractures.
Type A: Metaphyseal fracture. Types B and C: S-H type II physeal fractures with lateral or medial angulation. Type D: an S-H type III fracture (pediatric Bennett fracture).
Type A: Metaphyseal fracture. Types B and C: S-H type II physeal fractures with lateral or medial angulation. Type D: an S-H type III fracture (pediatric Bennett fracture).
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The adductor pollicis, abductor pollicis longus, and thenar muscles play a role in fracture mechanics and can displace metacarpal fractures. The muscles‘ directions of pull dictate the direction of fracture displacement and deformity. The adductor pollicis inserts onto the proximal phalanx and into the extensor apparatus through the adductor aponeurosis. Epiphyseal fractures of the proximal phalanx base with the attached UCL can displace outside the adductor aponeurosis.191 This pediatric “Stener lesion” prohibits healing and requires open reduction. The abductor pollicis longus inserts onto the metacarpal base and is the primary deforming force in most fracture–dislocations about the thumb CMC joint (Bennett fractures or pediatric equivalents). 
Direct trauma, rotational forces, and axial loading may all cause thumb metacarpal fractures. Sporting endeavors are the prime events causing fractures. A valgus force to the MCP joint usually produces an epiphyseal fracture. Skiing, biking, and playing baseball catcher are specific activities that place the thumb MCP joint and metacarpal shaft in a vulnerable position. Adduction forces, such as direct trauma to a soccer goalie or basketball player during a fall or ball injury, place the thumb CMC joint and base of thumb metacarpal at risk. 

Thumb Metacarpal Base Fractures

Fractures of the base of the thumb metacarpal are subdivided according to their location. Type A fractures occur between the physis and the junction of the proximal and middle thirds of the bone. The fractures are often transverse or slightly oblique. There is often an element of medial impaction, and the fracture is angulated in an apex lateral direction (Fig. 10-63). 
Figure 10-63
Metaphyseal thumb metacarpal fracture that does not involve the physis.
 
Treatment consisted of closed reduction and cast immobilization.
Treatment consisted of closed reduction and cast immobilization.
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Figure 10-63
Metaphyseal thumb metacarpal fracture that does not involve the physis.
Treatment consisted of closed reduction and cast immobilization.
Treatment consisted of closed reduction and cast immobilization.
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Type B and C fractures are S-H II fractures at the thumb metacarpal base. Most patterns have the metaphyseal fragment on the medial side (type B) (Fig. 10-60). The shaft fragment is adducted by the pull of the adductor pollicis and shifted in a proximal direction by the pull of the abductor pollicis longus. Although this pattern resembles a Bennett fracture with respect to the deforming forces, there is no intra-articular extension.13 Type C fractures are the least common and have the reverse pattern, with the metaphyseal fragment on the lateral side and the proximal shaft displacement in a medial direction. This pattern often results from more substantial trauma and does not lend itself to closed treatment. 
A type D fracture is an S-H III or IV fracture that most closely resembles the adult Bennett fracture.17,62,72,175 The deforming forces are similar to a type B injury with resultant adduction and proximal migration of the base-shaft fragment. 
Biplanar x-rays including a hyperpronated view of the thumb accentuate the view of the CMC joint. Examination under live fluoroscopy or CT scan may also be necessary for preoperative planning and classification of fracture severity. 

Operative and Nonoperative Treatment Options of Thumb Metacarpal Fractures

Thumb Metacarpal Base Fractures

Type A
Type A fractures can usually be treated by closed methods. Although swelling about the thenar eminence limits manipulation of the fracture and diminishes the effectiveness of immobilization, most fractures can still be treated successfully by closed reduction and immobilization. Because the CMC joint has near universal motion and the physis is proximal in the metacarpal, remodeling is extensive in young patients. If reduction is attempted, pressure is applied to the apex of the fracture to effect reduction. Anatomic reduction is not required because remodeling is plentiful.104,145 Unstable fractures with marked displacement require percutaneous pin fixation to maintain alignment (Fig. 10-64). 
Figure 10-64
A 13-year-old boy fell down stairs and injured his right thumb.
 
A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
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A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
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Figure 10-64
A 13-year-old boy fell down stairs and injured his right thumb.
A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
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A: An AP radiograph shows displaced fracture base of the thumb metacarpal. B: Lateral radiograph shows considerable angulation. C: At time of reduction, fracture was very unstable. D: Closed reduction under fluoroscopy. E: Percutaneous pin fixation to maintain alignment.
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Types B and C
Closed reduction is more difficult for type B and C fractures. The mobility of the metacarpal base and the swelling make closed reduction difficult. Comminution, soft tissue interposition, or transperiosteal “buttonholing” in type C fractures may further complicate reduction.215 If closed reduction is accomplished and stable, then short-arm thumb spica splint or cast immobilization is possible. Repeat radiographic evaluation should be obtained 5 to 7 days later to ensure maintenance of reduction.11 
If closed reduction is possible but the reduction is unstable, percutaneous pinning is recommended (Fig. 10-65). There are multiple options for pin configuration including direct fixation across the fracture, pinning across the reduced CMC joint, and pinning between the first and second metacarpals. Open reduction is indicated for irreducible fractures. Type C fractures may require open reduction to remove any interposed periosteum that blocks reduction (Fig. 10-66).25,215 
Figure 10-65
 
A: An 8-year-old boy with reducible, but unstable, fracture. B: A single percutaneous pin was placed to maintain alignment.
A: An 8-year-old boy with reducible, but unstable, fracture. B: A single percutaneous pin was placed to maintain alignment.
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Figure 10-65
A: An 8-year-old boy with reducible, but unstable, fracture. B: A single percutaneous pin was placed to maintain alignment.
A: An 8-year-old boy with reducible, but unstable, fracture. B: A single percutaneous pin was placed to maintain alignment.
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Figure 10-66
 
A: Fracture of the thumb metacarpal base with small lateral metaphyseal flag that appears innocuous on radiograph (arrow). B: However, additional images revealed marked displacement of the distal fragment. C: Closed reduction was unsuccessful, because of interposed tissue. After open reduction, K-wires were used to stabilize the fracture.
A: Fracture of the thumb metacarpal base with small lateral metaphyseal flag that appears innocuous on radiograph (arrow). B: However, additional images revealed marked displacement of the distal fragment. C: Closed reduction was unsuccessful, because of interposed tissue. After open reduction, K-wires were used to stabilize the fracture.
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Figure 10-66
A: Fracture of the thumb metacarpal base with small lateral metaphyseal flag that appears innocuous on radiograph (arrow). B: However, additional images revealed marked displacement of the distal fragment. C: Closed reduction was unsuccessful, because of interposed tissue. After open reduction, K-wires were used to stabilize the fracture.
A: Fracture of the thumb metacarpal base with small lateral metaphyseal flag that appears innocuous on radiograph (arrow). B: However, additional images revealed marked displacement of the distal fragment. C: Closed reduction was unsuccessful, because of interposed tissue. After open reduction, K-wires were used to stabilize the fracture.
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Type D
Type D fractures are unstable and require closed or open reduction to restore physeal and articular alignment.62,78 An acceptable closed reduction is maintained by percutaneous pin fixation. An unacceptable closed reduction is rare but requires open reduction and fixation.175 A hyperpronated view of the thumb accentuates the view of the CMC joint. The choice of implant must be individualized, though smooth wires are favored to minimize potential injury to the physis and articular cartilage (Fig. 10-67).72,175 Skeletal traction is an alternative treatment for complex injuries with severe bony or soft tissue damage.23,186 
Figure 10-67
 
A: A 14-year-old boy sustained an S-H type III fracture of the proximal thumb metacarpal with lateral subluxation of the carpometacarpal joint. B: Open reduction and K-wire fixation to restore joint alignment and congruity.
 
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:769, with permission.)
A: A 14-year-old boy sustained an S-H type III fracture of the proximal thumb metacarpal with lateral subluxation of the carpometacarpal joint. B: Open reduction and K-wire fixation to restore joint alignment and congruity.
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Figure 10-67
A: A 14-year-old boy sustained an S-H type III fracture of the proximal thumb metacarpal with lateral subluxation of the carpometacarpal joint. B: Open reduction and K-wire fixation to restore joint alignment and congruity.
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988:769, with permission.)
A: A 14-year-old boy sustained an S-H type III fracture of the proximal thumb metacarpal with lateral subluxation of the carpometacarpal joint. B: Open reduction and K-wire fixation to restore joint alignment and congruity.
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Author‘s Preferred Treatment

Type A

Type A fractures can usually be treated with closed reduction and cast application. Residual angulation between 20 and 30 degrees is acceptable depending on the age of the child and clinical appearance of the thumb. The multiplanar motion of the CMC joint combined with the potential for remodeling makes this degree of angulation inconsequential. Fractures that are reducible, but unstable, require percutaneous pinning (Fig. 10-64). 

Types B and C

Treatment varies with the amount of displacement and degree of periosteal disruption. Mild angulation requires only cast application without reduction. Moderate angulation is treated with closed reduction and immobilization. Severe angulation is usually combined with displacement and requires reduction. A successful closed reduction is often augmented with percutaneous pin fixation because of the fracture instability. An unsuccessful closed reduction requires open reduction and fixation. 

Type D

Displaced S-H III and IV fractures are rare and require closed or open reduction and internal fixation. The goal is anatomic alignment of the joint and physis. If an open reduction is required, the preferred approach is through a gently curved incision overlying the CMC joint along the glabrous border of the skin. The cutaneous nerves are protected. The origins of the thenar eminence muscles are reflected. A CMC joint arthrotomy is made, and the articular surface is exposed. The fracture joint surface is reduced and fixed with pins or miniscrews. Additional percutaneous pin fixation of the first to the second metacarpal is used to protect the fracture fixation. 

Postoperative Care

Closed treatment requires immobilization for 4 to 6 weeks, depending on the fracture severity and degree of soft tissue damage. A home program for range of motion is started thereafter. Formal therapy is not instituted unless considerable soft tissue injury occurred. In active children and young athletes, a light splint may be worn for protection for an additional few weeks. 
Open fracture management depends on the stability of the fixation and the reliability of the patient. Young children or marginal fracture fixations require 4 to 6 weeks of immobilization. Fracture union with mild stiffness takes precedence over fracture nonunion with excessive motion. Adolescents with stable fixation can be mobilized earlier, usually 5 to 7 days after surgery, provided they are trustworthy in terms of activity restrictions. A removable splint is used for protection between exercise sessions until union. 

Management of Expected Adverse Outcomes and Unexpected Complications

Thumb metacarpal fractures usually heal without altering hand function. The remodeling capabilities of fractures near or involving the physis are extensive. The basilar thumb joint also allows multiplanar motion and can accommodate moderate fracture malunion. Residual deformity along the thumb metacarpal can be concealed through CMC joint motion, and the thumb tolerates malrotation better than the fingers (Fig. 10-68). 
Figure 10-68
A 14-year-old boy presents 3 weeks after injury with mild pain and deformity at the base of right thumb.
 
A: An AP radiograph shows a moderately displaced fracture at the base of the thumb metacarpal. B: Lateral radiograph shows mild angulation. C: Follow-up motion after splinting for an additional 2 weeks, and home therapy reveals excellent opposition. D: The thumb is able to touch the base of the small finger.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: An AP radiograph shows a moderately displaced fracture at the base of the thumb metacarpal. B: Lateral radiograph shows mild angulation. C: Follow-up motion after splinting for an additional 2 weeks, and home therapy reveals excellent opposition. D: The thumb is able to touch the base of the small finger.
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Figure 10-68
A 14-year-old boy presents 3 weeks after injury with mild pain and deformity at the base of right thumb.
A: An AP radiograph shows a moderately displaced fracture at the base of the thumb metacarpal. B: Lateral radiograph shows mild angulation. C: Follow-up motion after splinting for an additional 2 weeks, and home therapy reveals excellent opposition. D: The thumb is able to touch the base of the small finger.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: An AP radiograph shows a moderately displaced fracture at the base of the thumb metacarpal. B: Lateral radiograph shows mild angulation. C: Follow-up motion after splinting for an additional 2 weeks, and home therapy reveals excellent opposition. D: The thumb is able to touch the base of the small finger.
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Complications are uncommon. Nonunion, malunion, and articular incongruity are potential problems.78 Intra-articular incongruity may occur after incomplete reduction of intra-articular fractures or inadequate fixation after satisfactory reduction. Sequelae include pain, diminished motion, and arthrosis. Fortunately, the occurrence of articular malunion and the development of symptoms are uncommon. Available treatment options are limited and include intra-articular osteotomy, fusion, or interposition arthroplasty. 

Fractures of the Carpal Bones

Scaphoid Fractures in Children

The low incidence of scaphoid fracture in children is most likely related to the thick peripheral cartilage that covers and protects the ossification center. Therefore, fracture requires a considerable force to disrupt this cartilaginous shell and injure the underlying bone.42 The pattern of pediatric scaphoid injury differs from that of adults because of the evolving ossification center.53 During early stages of ossification, the scaphoid is more susceptible to avulsion fractures about the distal pole fracture.188,203 As the ossification progresses from distal to proximal, the fracture pattern mirrors the adult forms by early adolescence (Fig. 10-69). 
Figure 10-69
Three types of scaphoid fractures.
 
A: Distal third. B: Middle third. C: Proximal pole.
A: Distal third. B: Middle third. C: Proximal pole.
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Figure 10-69
Three types of scaphoid fractures.
A: Distal third. B: Middle third. C: Proximal pole.
A: Distal third. B: Middle third. C: Proximal pole.
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In children, fractures of the distal third of the scaphoid have traditionally been the most common injury pattern and often result from direct trauma.16,42,203 However, scaphoid waist fractures are increasing in frequency in younger children as participation in contact athletics begins earlier.65 Proximal pole fractures are rare in children and often represent an avulsion fracture of the scapholunate ligament. These fractures are at higher risk for nonunion and osteonecrosis. The scaphoid can also be fractured as a component of a greater arc perilunate injury.53 

Scaphoid Fracture Patterns and Classification (Table 10-21)

 
Table 10-21
Classification of Scaphoid Fractures
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Table 10-21
Classification of Scaphoid Fractures
Fractures of the Distal Pole
 Extra-articular distal pole fractures
 Intra-articular distal pole fractures
Fractures of the middle third (waist fractures)
Fractures of the proximal third
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Type A: Fractures of the Distal Pole

Distal pole fractures are often secondary to direct trauma or avulsion with a dorsoradial or dorsovolar fragment.203 The strong scaphotrapezial ligaments and capsular attachments produce mechanical failure through the bone (Fig. 10-70).33,203 The fracture line and size of the avulsion fragment vary from an isolated chondral injury that is barely visible on radiographs to a large osteochondral fragment. 
Figure 10-70
A 12-year-old boy fell on his right wrist and was tender over scaphoid tubercle.
 
Radiograph reveals small avulsion fracture of distal scaphoid that might easily be overlooked.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Radiograph reveals small avulsion fracture of distal scaphoid that might easily be overlooked.
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Figure 10-70
A 12-year-old boy fell on his right wrist and was tender over scaphoid tubercle.
Radiograph reveals small avulsion fracture of distal scaphoid that might easily be overlooked.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Radiograph reveals small avulsion fracture of distal scaphoid that might easily be overlooked.
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Type A1: Extra-Articular Distal Pole Fractures. The most important prognostic factor is the presence or absence of joint involvement. Extra-articular fractures may be either volar or dorsal avulsions (Fig. 10-71). A volar pattern is more common and is attributed to the stout scaphotrapezial ligaments. A dorsal fracture configuration is less common and is attributed to the dorsal intercarpal ligament. The fragments vary in size, and the radiographic appearance is age dependent. 
Figure 10-71
A 12-year-old boy fell playing ice hockey and complained of right wrist pain.
 
Radiograph reveals an extra-articular distal pole scaphoid fracture with slight comminution.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Radiograph reveals an extra-articular distal pole scaphoid fracture with slight comminution.
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Figure 10-71
A 12-year-old boy fell playing ice hockey and complained of right wrist pain.
Radiograph reveals an extra-articular distal pole scaphoid fracture with slight comminution.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
Radiograph reveals an extra-articular distal pole scaphoid fracture with slight comminution.
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Type A2: Intra-Articular Distal Pole Fractures. This type of fracture may be a variation of a type A1 fracture with an intra-articular extension (Fig. 10-72). Similar types (i.e., volar and dorsal) and mechanisms of injury are possible. 
Figure 10-72
Two variations of an A2 intra-articular fracture of the scaphoid distal pole.
 
A: The more prevalent type is on the radial aspect of the volar distal scaphoid. This fragment is attached to the radial portion of the scaphotrapezial ligament (arrows). B: The less common type is on the ulnar aspect of the volar distal scaphoid. This fragment is attached to the ulnar portion of the scaphotrapezial ligament (arrows). C: Radiograph of an intra-articular distal pole scaphoid fracture.
A: The more prevalent type is on the radial aspect of the volar distal scaphoid. This fragment is attached to the radial portion of the scaphotrapezial ligament (arrows). B: The less common type is on the ulnar aspect of the volar distal scaphoid. This fragment is attached to the ulnar portion of the scaphotrapezial ligament (arrows). C: Radiograph of an intra-articular distal pole scaphoid fracture.
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Figure 10-72
Two variations of an A2 intra-articular fracture of the scaphoid distal pole.
A: The more prevalent type is on the radial aspect of the volar distal scaphoid. This fragment is attached to the radial portion of the scaphotrapezial ligament (arrows). B: The less common type is on the ulnar aspect of the volar distal scaphoid. This fragment is attached to the ulnar portion of the scaphotrapezial ligament (arrows). C: Radiograph of an intra-articular distal pole scaphoid fracture.
A: The more prevalent type is on the radial aspect of the volar distal scaphoid. This fragment is attached to the radial portion of the scaphotrapezial ligament (arrows). B: The less common type is on the ulnar aspect of the volar distal scaphoid. This fragment is attached to the ulnar portion of the scaphotrapezial ligament (arrows). C: Radiograph of an intra-articular distal pole scaphoid fracture.
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Type B: Middle Third (Waist Fractures)

Middle third fractures do occur in skeletally immature patients. The mechanism of injury is usually a fall onto the outstretched hand and pronated forearm, which exerts tensile forces acting across the volar portion of the scaphoid as the wrist extends.32,53,211 Bony comminution may be present (Fig. 10-73). A careful scrutiny for other injuries about the carpus is mandatory.3,30 
Figure 10-73
 
A: A displaced midwaist scaphoid fracture with comminution, including a butterfly fragment from the volar radial aspect (arrow). B: A CT scan demonstrates the comminution. C: An ORIF was performed with two smooth wires and bone graft from the distal radius. D: Healing of fracture after pin removal.
A: A displaced midwaist scaphoid fracture with comminution, including a butterfly fragment from the volar radial aspect (arrow). B: A CT scan demonstrates the comminution. C: An ORIF was performed with two smooth wires and bone graft from the distal radius. D: Healing of fracture after pin removal.
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Figure 10-73
A: A displaced midwaist scaphoid fracture with comminution, including a butterfly fragment from the volar radial aspect (arrow). B: A CT scan demonstrates the comminution. C: An ORIF was performed with two smooth wires and bone graft from the distal radius. D: Healing of fracture after pin removal.
A: A displaced midwaist scaphoid fracture with comminution, including a butterfly fragment from the volar radial aspect (arrow). B: A CT scan demonstrates the comminution. C: An ORIF was performed with two smooth wires and bone graft from the distal radius. D: Healing of fracture after pin removal.
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Dividing the bone into thirds or delineating the area bounded by the radioscaphocapitate ligament defines the waist of the scaphoid. Waist fractures occur in many forms. Pediatric fractures are incomplete, minimally displaced, or complete with or without displacement. Comminuted fractures are rare and are associated with higher-energy injuries. 

Type C: Proximal Third

Proximal pole fractures are rare in children but have been reported in competitive adolescent athletes. The mechanism is often unclear and can be atypical, such as punching game machines or fighting.201 A proximal pole fracture may propagate through the interface between newly ossified tissue and the cartilaginous anlage, or the injury may be strictly through the cartilage. Proximal fractures may cause destabilization of the scapholunate joint, as the scapholunate interosseous ligament remains attached to the avulsed fragment (Fig. 10-74). 
Figure 10-74
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
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Figure 10-74
An AP radiograph of a 16-year-old male hockey player with a proximal one-third scaphoid fracture.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
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Proximal third fractures present diagnostic and therapeutic dilemmas. The proximal pole is the last to ossify, which further complicates diagnosis. The tenuous blood supply of this region presents the same problems in children as adults in terms of nonunion and risks of osteonecrosis. 

Bipartite Scaphoid Controversy: Traumatic Versus Developmental

A bipartite scaphoid probably exists but is uncommon and may be associated with Down syndrome 48,116 Criteria that must be met to diagnose a congenital bipartite scaphoid include the following: (a) Similar bilateral appearance, (b) absence of historical or clinical evidence of antecedent trauma, (c) equal size and uniform density of each component, (d) absence of degenerative change between the scaphoid components or elsewhere in the carpus, and (e) smooth, rounded architecture of each scaphoid component. A unilateral “bipartite scaphoid” should be viewed as a posttraumatic scaphoid nonunion (Fig. 10-75). 
Figure 10-75
 
A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
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A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
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Figure 10-75
A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
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A: A 9-year-old boy who fell on an outstretched wrist and had radial-sided pain and tenderness; original radiographs failed to reveal any bony abnormalities. B: About 1.5 years later, he had persistent radial-sided wrist pain, and radiographs revealed a midwaist scaphoid nonunion. This would not be considered a bipartite scaphoid but instead an injury that was sustained when the cartilaginous anlage was present. C: After 2 months of casting, early fracture union is present.
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Capitate Fractures

Isolated fractures of the capitate are rare and usually result from high-energy trauma.111 Capitate fractures may represent a form of greater arc perilunar injury (Fig. 10-76). The force can propagate completely around the lunate and cause a perilunate or lunate dislocation.30,34,151 The injury can also halt within the capitate and produce a scaphocapitate syndrome.6,205 
Figure 10-76
Progressive perilunar instability.
 
The greater arc (black arrow) is associated with fractures of the carpal bones, which may include the scaphoid, lunate, capitate, hamate, and triquetrum. The red arrow depicts the lesser arc, in which forces are transmitted only through soft tissue structures.
 
(Reprinted from Mayfield JK, Johnson RP, Kilcoyn RK. Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980; 5:226–241, with permission.)
The greater arc (black arrow) is associated with fractures of the carpal bones, which may include the scaphoid, lunate, capitate, hamate, and triquetrum. The red arrow depicts the lesser arc, in which forces are transmitted only through soft tissue structures.
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Figure 10-76
Progressive perilunar instability.
The greater arc (black arrow) is associated with fractures of the carpal bones, which may include the scaphoid, lunate, capitate, hamate, and triquetrum. The red arrow depicts the lesser arc, in which forces are transmitted only through soft tissue structures.
(Reprinted from Mayfield JK, Johnson RP, Kilcoyn RK. Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980; 5:226–241, with permission.)
The greater arc (black arrow) is associated with fractures of the carpal bones, which may include the scaphoid, lunate, capitate, hamate, and triquetrum. The red arrow depicts the lesser arc, in which forces are transmitted only through soft tissue structures.
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Excessive dorsiflexion of the wrist is the most common mechanism. The waist of the capitate abuts the lunate or dorsal aspect of the radius. The fracture occurs through the waist with variable displacement. The wrist is usually markedly swollen and painful to palpation. The clinical presentation varies with the associated carpal injuries. Median nerve paresthesias may be present secondary to swelling within the carpal tunnel. 
Standard AP and lateral views are usually adequate (Fig. 10-77). Careful scrutiny of the radiographs is necessary. The capitate fracture can be subtle, or the proximal capitate fragment can rotate 180 degrees. Either scenario can create a confusing image that often results in misinterpretation. Incomplete ossification further complicates radiographic diagnosis and degree of displacement. Small osteochondral fragments in the midcarpal region may indicate a greater arc injury or isolated capitate fracture. In these cases, advanced imaging studies, such as MRI or CT, may be useful (Fig. 10-78). 
Figure 10-77
A 12-year-old boy sustained multiple carpal fractures attributed to a crushing injury.
 
An established nonunion of the capitate is present 16 months later, which required bone grafting to obtain union.
 
(Courtesy of James H. Dobyns, MD.)
An established nonunion of the capitate is present 16 months later, which required bone grafting to obtain union.
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Figure 10-77
A 12-year-old boy sustained multiple carpal fractures attributed to a crushing injury.
An established nonunion of the capitate is present 16 months later, which required bone grafting to obtain union.
(Courtesy of James H. Dobyns, MD.)
An established nonunion of the capitate is present 16 months later, which required bone grafting to obtain union.
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Figure 10-78
A 13-year-old boy with persistent midcarpal pain after a fall.
 
An MRI scan shows a capitate fracture.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
An MRI scan shows a capitate fracture.
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Figure 10-78
A 13-year-old boy with persistent midcarpal pain after a fall.
An MRI scan shows a capitate fracture.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
An MRI scan shows a capitate fracture.
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Triquetrum Fractures

Avulsion fractures of the triquetrum are more common in adults than in children. The injury may occur in adolescents as carpal ossification nears completion. A fracture through the body of the triquetrum is rare and may occur with a perilunar injury as the path of the greater arc injury passes through the triquetrum.125 A fall on an outstretched wrist is the common event. The probable mechanism for a dorsal triquetrum fracture is a pulling force through the dorsal ligaments or abutment of the ulnar styloid. 
The wrist is mildly swollen and painful to palpation directly over the dorsal triquetrum. The clinical presentation is more severe with associated carpal injuries. 

Radiographic Findings

Radiologic AP and lateral views may not show the avulsion fracture. A pronated oblique view highlights the dorsum of the triquetrum and may reveal the avulsed fragment. At times, CT scans are necessary for accurate diagnosis (Fig. 10-79). 
Figure 10-79
A minimally displaced dorsal triquetral avulsion fracture (arrow) that was treated with short-term immobilization.
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Hamate, Pisiform, Lunate, and Trapezium Fractures

Pediatric fractures of the hamate, pisiform, lunate, and trapezium are rare. Hamate fractures are classified by their location in the hook, type 1, or in the body, type 2. Hook of the hamate fractures usually occur in adults but may occur in adolescents who play baseball or golf or sustain traumatic falls. If the fracture involved the distal third of the hook, it may occur from an avulsion injury. A CT scan may be necessary for diagnosis if the fracture is not visible on the carpal tunnel view (Fig. 10-80). Dorsal or body hamate fractures can occur with axial load or punching injuries, as the bases of the fourth and fifth metacarpals act like pistons and shear off large or small pieces of the hamate. 
Figure 10-80
 
A: A 15-year-old baseball player with chronic pain over hypothenar eminence while batting. B: A CT scan coronal view demonstrated a base of the hook of the hamate fracture. C: After 3 months of immobilization and rest from baseball, the patient is elected for fragment removal. Returned to baseball wearing a silicone gel patch in his batting glove over the hypothenar area.
A: A 15-year-old baseball player with chronic pain over hypothenar eminence while batting. B: A CT scan coronal view demonstrated a base of the hook of the hamate fracture. C: After 3 months of immobilization and rest from baseball, the patient is elected for fragment removal. Returned to baseball wearing a silicone gel patch in his batting glove over the hypothenar area.
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Figure 10-80
A: A 15-year-old baseball player with chronic pain over hypothenar eminence while batting. B: A CT scan coronal view demonstrated a base of the hook of the hamate fracture. C: After 3 months of immobilization and rest from baseball, the patient is elected for fragment removal. Returned to baseball wearing a silicone gel patch in his batting glove over the hypothenar area.
A: A 15-year-old baseball player with chronic pain over hypothenar eminence while batting. B: A CT scan coronal view demonstrated a base of the hook of the hamate fracture. C: After 3 months of immobilization and rest from baseball, the patient is elected for fragment removal. Returned to baseball wearing a silicone gel patch in his batting glove over the hypothenar area.
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Pisiform fractures are the result of direct trauma. Lunate fractures are associated with Kienbock disease,160 which is relatively uncommon in children. Trapezium fractures can occur with CMC joint injuries about the thumb. 

Soft Tissue Injuries about the Carpus

Ligamentous Injuries

Ligamentous injuries about the pediatric wrist are less common than osseous injuries.64,66,151 The immature carpus and viscoelastic ligaments are relatively resistant to injury. Fracture–dislocations and isolated ligamentous injuries are usually caused by high-energy trauma (Fig. 10-81).90 Motor vehicle accidents and sports-related injuries are potential causes of the rare fracture–dislocation. However, recurrent or chronic wrist pain is not uncommon in adolescents. Most recurrent ligamentous pain results from hypermobility and overuse during the adolescent growth spurt. This mechanism may result in joint subluxation, chondral impingement, or ligamentous tears similar to patellofemoral injuries in adolescents. 
Figure 10-81
 
Radiographic AP (A) and lateral (B) views of a dorsal perilunate dislocation in a 6-year-old boy.
 
(Courtesy of William F. Benson, MD.)
Radiographic AP (A) and lateral (B) views of a dorsal perilunate dislocation in a 6-year-old boy.
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Figure 10-81
Radiographic AP (A) and lateral (B) views of a dorsal perilunate dislocation in a 6-year-old boy.
(Courtesy of William F. Benson, MD.)
Radiographic AP (A) and lateral (B) views of a dorsal perilunate dislocation in a 6-year-old boy.
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A child with an acute traumatic injury avoids use of the wrist and hand. The wrist is swollen and painful to palpation, making isolation of the injured segment difficult except in extremely cooperative children. Provocative maneuvers for carpal instability usually are not possible because of pain in the injured wrist. 
Gross instability without pain on stress testing may indicate a hyperelasticity syndrome that is not related to trauma.152 However, recurrent pain does occur in children with hypermobility, overuse, and relative muscular weakness. These children complain of diffuse pain, generalized tenderness, and limited strength on examination. Diagnosis is difficult particularly because of concerns regarding emotional overlay and somatization. 
Radiologic AP and lateral views are routine. The incomplete ossification complicates radiographic interpretation, especially the assessment of carpal widening. Detection of slight widening or malalignment within the carpus is often difficult. Contralateral views are useful to compare ossification and carpal spacing.98 Suspicion of a fracture warrants advanced imaging studies, such as arthrography, stress radiograph, fluoroscopy, and MRI. Ligamentous injuries are diagnosed with MRI scans. 

Outcomes

As with the pediatric hand fractures, outcomes consist of union, alignment, and painless return to function and sports. Because of the vascular anatomy of the carpus, avascular necrosis is a rare but complicated outcome in proximal pole scaphoid fractures. Case series of children after carpal bone fractures and dislocations lack validated instrument scoring data. 

Fractures of the Carpal Bones Treatment Options (Table 10-22)

 
Table 10-22
Fractures and Dislocations of the Hand and Carpal Bones
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Table 10-22
Fractures and Dislocations of the Hand and Carpal Bones
Nonoperative vs. Operative Treatment
Nonoperative Operative
Nondisplaced Displaced
Avulsion fractures High risk of avascular necrosis or nonunion
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Scaphoid Fractures

Nondisplaced Scaphoid Fractures

Normal radiographs do not preclude the presence of a scaphoid fracture. Clinical suspicion in the presence of normal radiographs warrants immobilization and reevaluation in 2 weeks.30 The cast is removed, the wrist is examined, and repeat radiographs are obtained. Pain resolution and negative radiographs warrant discontinuation of immobilization and return to normal activities. Persistent pain with normal radiographs requires continued immobilization and advanced imaging studies. In this clinical setting, MRI scans have been shown to be diagnostically useful to avoid both misdiagnosis and overtreatment (Fig. 10-82).22,35,49,96,118 However, MRI may be overly sensitive in identifying bone edema that fails to develop into a fracture. 
Figure 10-82
An MRI scan of a minimally displaced healing scaphoid fracture not seen on radiograph.
Flynn-ch010-image082.png
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If radiographs reveal a fracture, immediate treatment is required. Most pediatric scaphoid fractures can be treated with cast immobilization because children possess a great ability to heal. In addition, most scaphoid fractures in children are either incomplete (disrupting only a single cortex) or nondisplaced. This principle is especially true for the distal pole, which is a frequent site of scaphoid fracture (Fig. 10-83).53 Therefore, cast immobilization is the standard of treatment for most nondisplaced or minimally displaced pediatric scaphoid fractures. For avulsion and incomplete fractures, a short-arm thumb spica cast for 4 to 6 weeks is recommended. In the young child, a long-arm cast is appropriate to prevent the cast from sliding off the arm. For complete distal third and waist fractures, immobilization consisting of up to 6 to 8 weeks of casting is recommended until healing. 
Figure 10-83
A 12-year-old boy depicted in Figure 10-69 after 8 weeks of casting.
 
A: Scaphoid view demonstrates healing of the fracture. B: Pronated oblique radiograph further confirms fracture union.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: Scaphoid view demonstrates healing of the fracture. B: Pronated oblique radiograph further confirms fracture union.
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Figure 10-83
A 12-year-old boy depicted in Figure 10-69 after 8 weeks of casting.
A: Scaphoid view demonstrates healing of the fracture. B: Pronated oblique radiograph further confirms fracture union.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: Scaphoid view demonstrates healing of the fracture. B: Pronated oblique radiograph further confirms fracture union.
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A longer period of immobilization (8 to 12 weeks) is recommended for proximal pole fractures, delayed diagnosis, or fractures with apparent bony resorption.53 Immobilization usually begins with 4 to 6 weeks of a long-arm thumb spica cast, followed by up to 6 weeks of a short-arm thumb spica cast. The exact cast position and the joints immobilized are a matter of individual preference.24,63,83 Most authors favor a long-arm thumb spica cast that permits thumb interphalangeal joint motion.63 

Displaced Scaphoid Fractures

Closed Reduction and Casting
Historically, closed reduction of a displaced scaphoid fracture has been described.24,83 Currently, ORIF is a more reliable method for restoring alignment and obtaining union. 
Percutaneous Screw Fixation
In adults, percutaneous screw fixation for displaced fractures has been advocated.1,219 However, the fracture must be reduced at the time of screw fixation. Fracture reduction can be accomplished with manipulation, joysticks, or arthroscopic assistance. This technique can be applied to adolescent patients with displaced scaphoid fractures. Screws can be placed under fluoroscopic control either volarly (distal to proximal) or dorsally (proximal to distal) depending on fracture patterns and surgeon preference (Fig. 10-84).20,183 This procedure is challenging in displaced scaphoid fractures. 
Figure 10-84
 
A: Nondisplaced proximal pole scaphoid fracture in a skeletally mature adolescent athlete. B: Treatment by percutaneous screw fixation led to healing.
A: Nondisplaced proximal pole scaphoid fracture in a skeletally mature adolescent athlete. B: Treatment by percutaneous screw fixation led to healing.
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Figure 10-84
A: Nondisplaced proximal pole scaphoid fracture in a skeletally mature adolescent athlete. B: Treatment by percutaneous screw fixation led to healing.
A: Nondisplaced proximal pole scaphoid fracture in a skeletally mature adolescent athlete. B: Treatment by percutaneous screw fixation led to healing.
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Open Reduction and Internal Fixation
Displacement of more than 1 mm or intrascaphoid angulation of more than 10 degrees on any image warrants ORIF. The implant choice is individualized according to the fracture and patient. Scaphoid screws are the primary fixation techniques, though K-wires can be used (Fig. 10-85).131 
Figure 10-85
 
A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
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A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
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Figure 10-85
A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
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A: A 16-year-old male with a right scaphoid nonunion with resorption at the fracture site. B: Volar approach and exposure of the fracture site. C: The fracture site was debrided of fibrous material, and the humpback deformity was corrected. D: The fracture site was packed with bone graft and a guide wire was placed for screw fixation. E: The screw was inserted over the guide wire. F, G: Radiographic AP and lateral views after fracture reduction, bone grafting, and screw placement.
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Smaller screws (mini and micro) may be necessary in the pediatric patient. Modern compression screws have been shown to speed healing.65 

Capitate Fractures

Treatment depends on the capitate fracture pattern, degree of displacement, and associated injuries. Distraction radiographs, MRI, or CT scans may be necessary to determine the exact pattern of injury. Nondisplaced fractures of the capitate and/or scaphoid can be treated with a long-arm cast for 6 to 8 weeks. Closed reduction of displaced fractures is not feasible.34 Displaced fractures require open reduction, especially the rotated proximal capitate pole. Associated perilunar injuries also require internal fixation and ligamentous repair. The anatomic relationships within the carpus must be restored. Wire or osseous screw fixation is appropriate stabilization after open reduction of fractures. Suture repair of ligamentous injuries is performed. 

Triquetral Fractures

An avulsion fracture is treated with a short period of immobilization (3 to 6 weeks) followed by motion and return to activities. A fracture through the body of the triquetrum with a perilunar injury requires ORIF. 

Hamate Fractures

Hook of the hamate, type 1, fractures are often missed in the acute setting unless a carpal tunnel view is ordered or a CT scan of the wrist obtained. Immobilization and avoidance of baseball batting, gymnastics, or golf may lead to complete union in children. After a period of casting, if imaging is consistent with a delayed union and the child is symptomatic, surgical ORIF or simple fragment excision may be pursued (Fig. 10-80). Careful protection of the ulnar nerve motor branch and ulnar artery anatomy is required, and subperiosteal dissection can minimize chances of injury. Postoperative return to sports that require direct pressure on the hypothenar eminence may be slow because of the hypersensitivity and require special silicone patches or glove padding. 
Dorsal body hamate, type 2, fractures may be part of a CMC dislocation or isolated. Reduction of the dislocation may be assisted by fixation of the hamate fracture. If the fragment is large enough, ORIF with a headless screw may be indicated (Fig. 10-86). 
Figure 10-86
 
A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
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A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
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Figure 10-86
A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
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A: A 16-year-old male sustained a large dorsal hamate fracture from punching a wall. B–E Dorsal exposure of fragment with cannulated headless screw fixation. F: Postoperative radiographs of healed fracture.
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Carpal Ligamentous Injury

General treatment recommendations for rare traumatic dislocation injuries are difficult. Decisive factors include the child‘s age, degree of clinical suspicion, and extent of injury. Minor injuries are treated with immobilization for 3 to 6 weeks and reexamination. Resolution of symptoms and signs allows return to normal activities. Persistent pain warrants further clinical and radiographic evaluation. Overt ligamentous injuries with static instability and malalignment require accurate diagnosis and appropriate treatment. A complete ligament tear (e.g., an adolescent with a scapholunate injury) is treated according to principles similar to those for adults. Open reduction, anatomic reduction, and ligament repair are the basic tenets of treatment. 
A child or adolescent with ligamentous laxity and persistent activity-related pain is especially difficult to treat. Discerning focal from nonfocal wrist pathology is imperative. Radiographs and MRI scans often are normal. Most of these children respond to therapeutic strengthening. Protective sports-specific wrist guards or taping may be appropriate (Fig. 10-87). A small subset of children have unresolved pain caused by chondral injuries or ligamentous tears that require arthroscopic treatment.51 
Figure 10-87
Wrist guards for gymnastics.
 
A: The “lion‘s paw” protector used mainly for the vault. B: Hand and wrist protectors used primarily for the uneven parallel bars.
A: The “lion‘s paw” protector used mainly for the vault. B: Hand and wrist protectors used primarily for the uneven parallel bars.
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Figure 10-87
Wrist guards for gymnastics.
A: The “lion‘s paw” protector used mainly for the vault. B: Hand and wrist protectors used primarily for the uneven parallel bars.
A: The “lion‘s paw” protector used mainly for the vault. B: Hand and wrist protectors used primarily for the uneven parallel bars.
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Preoperative Planning (Table 10-23)

 
Table 10-23
Fractures of the Scaphoid
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Table 10-23
Fractures of the Scaphoid
Preoperative Planning Checklist
  •  
    OR table: Hand table, radiolucent preferable
  •  
    Position/positioning aids: May consider wrist arthroscopy and completion of surgery on the tower with arthroscopic assistance
  •  
    Fluoroscopy location: Horizontal for dorsally placed screws, vertical for volarly placed screws or screws placed on the distal pole
  •  
    Equipment: Headless conical or compression screw, may require a miniversion if the child is smaller than adult size. Use x-ray of contralateral scaphoid to estimate length of screw
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
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Surgical Technique (Table 10-24)

 
Table 10-24
Orif of Fractures of the Scaphoid in Children
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Table 10-24
Orif of Fractures of the Scaphoid in Children
Surgical Steps
  •  
    Dorsal approach: Flex the wrist to identify screw starting point on the scaphoid, adjacent to scapholunate ligament. Aim guide wire down the thumb axis.
     
    Small incision and spread soft tissue with a snap or tenotomy to avoid dorsal radial sensory nerve and extensor pollicis longus during pin or screw placement.
  •  
    Volar approach: Hockey stick incision over flexor carpi radialis and scaphoid tubercle. Open sheath of flexor carpi radialis, protect radial artery, incision between the long radial scaphoid ligament and ligament. Expose fracture and clear of fibrous debris or loose fragments. Place pins or screws volar to dorsal. Aim guide wire toward Lister‘s tubercle.
     
    Joysticks: In fractures with substantial dorsal intercalated segmental instability, consider reducing the lunate and the transradius lunate pinning with K-wire to hold the lunate and the proximal pole in neutral during fixation. Remove after fixation completed.
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Author‘s Preferred Treatment

Immobilization of nondisplaced carpal bone fractures or suspected injuries without x-ray findings is the most common preferred treatment. The type of immobilization varies from patient to patient. Options range from long- or short-arm casts, with or without thumb spicas or ulnar gutter extensions, to removable splints. Because children and adolescents are rarely compliant, we tend to err on the side of more immobilization. Early use of MRI to diagnose and follow outcomes in children with carpal bone injuries can be helpful in children with mostly cartilaginous carpal bones.144 

Scaphoid Fractures

Almost all nondisplaced scaphoid fractures are treated with cast immobilization. 
For nondisplaced fractures, the preferred immobilization is a long-arm thumb spica cast for the initial 4 to 6 weeks, followed by a short-arm cast until clinical and radiographic union. Radiographs are obtained in the first 7 to 10 days to ensure alignment and then monthly until union. If in doubt regarding anatomic alignment or union, a CT scan is obtained. 
Proximal pole fractures are at high risk for osteonecrosis and nonunion. These injuries are unstable with motion because of the scapholunate ligament. Percutaneous or mini-open screw fixation stabilizes the fracture without further disruption of the precarious blood supply by operative exposure. Although technically challenging, percutaneous screw fixation of these fractures with protected immobilization until sufficient healing may lessen the risk of osteonecrosis, nonunion, and degenerative changes. 
Indications for open reduction and fracture fixation are a waist fracture with more than 1 mm of displacement or an angular deformity of more than 10 degrees. Trans-scaphoid perilunate injuries also require operative management. Fractures of the middle and distal thirds are exposed through a volar approach. Proximal third fractures are exposed through a dorsal approach.163 The implant depends on the fracture configuration and age of the child. Smooth wires may be necessary in young children. Wires are buried beneath the skin and removed after union. Scaphoid screw fixation is preferred in adolescents.65,88,89,133,138 Comminution is treated with bone graft obtained from the ipsilateral metaphysis of the distal radius, olecranon, or iliac crest. 

Postoperative Care and Rehabilitation

Nondisplaced fractures are treated with immobilization until union. After the cast is removed, a home therapy program is started. Formal therapy usually is not necessary. Displaced fractures treated with ORIF require variable periods of immobilization. Fixation with K-wires necessitates prolonged immobilization and may involve formal therapy for the recovery of motion. Stable screw fixation allows early motion 10 to 14 days after surgery with a short-arm thumb spica splint worn for protection during vigorous activity until union. However, many adolescents will not wear the splint dependably and require longer periods of nonremovable immobilization to prevent loss of screw fixation and nonunion. 

Prognosis of Scaphoid Fractures

Prompt treatment of a nondisplaced scaphoid fracture allows healing in most patients.30 Nondisplaced pediatric scaphoid fractures have a greater than 95% healing rate. A delay in treatment impedes healing and increases the possibility of displacement.76,175,203 Displaced fractures require prompt recognition and open reduction because adequate reduction and fixation result in predictable union.65 

Prognosis and Complications of Capitate Fractures

The rarity of this injury prevents broad generalizations. Early recognition and appropriate treatment lead to an acceptable outcome. Nonunion is rare and requires bone grafting (Fig. 10-76).130 Despite the considerable rotation of the proximal pole in displaced fractures, osteonecrosis of the capitate is rare. 

Prognosis and Complications of Triquetral Fractures

Avulsion fractures are relatively minor injuries. Treatment results in expedient and complete recovery. Body fractures associated with perilunate injuries have a guarded prognosis, depending on the extent of concomitant injuries and necessary treatment. 

Potential Pitfalls and Preventive Measures (Table 10-25)

 
Table 10-25
Fractures of Carpal Bones in Children
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Table 10-25
Fractures of Carpal Bones in Children
Potential Pitfalls and Preventions
Pitfalls Preventions
Nonunion Early diagnosis and treatment
Long-arm thumb spica nonremovable immobilization
Identify displaced fractures
Malunion Early recognition of lunate extension and dorsal intercalated segmental instability (DISI) deformity
Three-dimensional advanced imaging, such as CT scan
Avascular necrosis Early treatment of high-risk fractures, such as proximal pole of the scaphoid
Knowledge of the vascular supply to each carpal bone to avoid injury during dissection
Intercarpal instability Static and dynamic examination of entire wrist to identify greater or lesser arc injuries
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Management of Expected Adverse Outcomes and Unexpected Complications

Complications of Scaphoid Fractures

The most prevalent complications are missed diagnosis and late presentation.65 Scaphoid nonunions do occur in children, though the incidence is low.30,45,56,115,124,146,185 Late presentation occurs for a number of reasons, including children‘s reluctance to tell their parents about a mechanism of injury, moderate symptoms seemingly not severe enough to warrant medical attention, and a child‘s fear of losing his or her position on a sporting team.91 Open reduction, bone grafting, and internal fixation are the standard procedures for treatment of scaphoid nonunions (Fig. 10-88).56,91,133,201 The approach varies according to the location of fracture and vascularity of the fracture fragments. The principles of operative scaphoid nonunion treatment in children are similar to those in adults. Persistent scaphoid nonunion results in altered kinematics within the wrist and produces degenerative changes over time.117,210 The goal is to obtain union to prevent long-term arthrosis. 
Figure 10-88
 
A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
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A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
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Figure 10-88
A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
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A–C: Radiographs of a 12-year-old boy with scaphoid nonunion and lunate extension through the fracture seen on the lateral view. D: Volar approach through the wrist to correct the mild humpback and flexion deformity. E: Iliac crest bone graft in place and headless screw fixation. F–H: Final radiographs after integration of graft demonstrating correction of flexion deformity seen by lunate position on lateral.
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The long-term outcomes of treatment of nonunions of the scaphoid have been reported following treatment using both screws and K-wires. Masquijo and Willis reviewed 23 children, mean age 15.1 years old with scaphoid nonunions after bone grafting and fixation with a follow-up over 5 years. Scaphoid Outcome Scores were excellent in 66% and good in 33%.122 Reigstad et al.162 most recently reported 7-year outcomes in 11 adolescents with scaphoid waist nonunions treated with bone graft and K-wire fixation only. Range of motion, grip strength, key pinch strength, and subjective outcome scores were all excellent. No evidence of persistent nonunion or degenerative changes was evident on radiographs or from CT evaluation. 
Osteonecrosis may result from a scaphoid fracture. The proximal fragment is more prone to avascular changes. Avascular changes within the proximal fragment do not preclude union after internal fixation. The size of the fragment and the extent of avascularity dictate management. The treatment principles are similar in adults and children. Options to obtain union include conventional or vascularized bone grafting.208 With nonunion and osteonecrosis of the proximal pole, vascularized bone grafting from the distal radius has been successful.190,208 

Triangular Fibrocartilage Complex Tears in Children

Triangular Fibrocartilage Complex Tear Classification

The TFCC consists of the triangular fibrocartilage (TFC) and the volar ulnocarpal ligaments. The TFC spans the sigmoid notch of the radius to the fovea at the base of the ulnar styloid and provides stability to the distal radioulnar and ulnocarpal joints. The location of the tear determines the classification of TFCC tears.198 Peripheral tears (type B) are most common in adolescents. Tears from the radial insertion (type D) are next in frequency, whereas central (type A) and volar (type C) tears are rare.147,149 

Triangular Fibrocartilage Complex Tear Treatment

The initial approach to adolescents with chronic wrist pain without instability incorporates rest until symptoms subside followed by a strengthening program. If pain persists after regaining symmetric pinch and grip strength, then further evaluation is appropriate. If clinical examination is consistent with a TFCC tear or ulnar–carpal impaction, MRI and/or arthroscopy is appropriate. A partial TFCC tear or carpal chondromalacia is treated with arthroscopic debridement. Full thickness tears from the fovea (type 1B) require peripheral repair, usually arthroscopically, to restore stability. Tears from the radial insertion (type 1D) with instability are rarer but require a transradial repair. 

Dislocations of the Hand and Carpus

Dislocations of the Interphalangeal Joints

In children, the soft tissue stabilizers about the interphalangeal joints are stronger than the physis, which explains the propensity for fracture rather than dislocation. Occasionally, dislocations and fracture–dislocations occur about the interphalangeal and MCP joints, especially in adolescents (Fig. 10-89). 
Figure 10-89
A dorsal dislocation of the PIP joint with an S-H type II fracture of the middle phalanx in a 15-year-old boy.
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Distal Interphalangeal Joint

A hyperextension or lateral force may result in dorsal or lateral DIP joint dislocation. The collateral ligaments and volar plate typically detach from the middle phalanx. Most dislocations can be reduced by longitudinal traction, re-creation of the dislocation force, and reduction of the distal phalanx. The DIP joint reduction and congruity are confirmed by clinical motion and radiographs. Splinting of DIP joint for 2 to 3 weeks is sufficient, followed by a home program that focuses on DIP joint motion. 
Irreducible or complex dislocations of the DIP occur primarily in adults but can occur in pediatric patients.148,155,168,176,195 Open reduction through a dorsal approach is required for removal of the interposed tissue. The volar plate is often the offending agent, though the collateral ligaments and the FDP can block reduction.148,155 A stable DIP joint is treated with DIP joint splinting for 3 to 4 weeks. An unstable DIP joint requires pin fixation for 3 to 4 weeks. 

Proximal Interphalangeal Joint

Dislocation of the PIP joint may occur in a variety of directions. Dorsal dislocations are the most common, though lateral and volar dislocations also occur. The differential diagnosis includes adjacent bony and tendon injuries.54 Radiographs are required to assess the physis and to confirm joint alignment. The postreduction lateral radiograph must confirm concentric joint reduction. Persistent joint subluxation is detected by a slight offset between the proximal and middle phalanges along with a dorsal V-shaped space instead of smooth articular congruity. 

Dorsal PIP Joint Dislocations

The middle phalanx is displaced dorsal to the proximal phalanx. The collateral ligaments and volar plate are disrupted. Many dorsal dislocations are probably joint subluxations that retain some of the collateral ligament or volar plate integrity. Some subluxations are reduced by the patient or trainer on the field and never receive medical evaluation. 
Unreduced dorsal dislocations cause pain and obvious deformity. If necessary, anesthesia can usually be accomplished with a digital block. The dislocation is reduced with longitudinal traction, hyperextension, and palmar translation of the middle phalanx onto the proximal phalanx. The quality of the reduction and the stability of the joint must be assessed. Asking the patient to flex and extend the digit evaluates active motion. Most dislocations are stable throughout the normal range of motion, and radiographs confirm a concentric reduction. A stable joint requires a brief period (3 to 5 days) of splinting for comfort, followed by range of motion and buddy taping. Immediate motion may be started, though pain often prohibits movement and exacerbates swelling. Prolonged immobilization leads to PIP joint stiffness. 
An unstable reduction tends to subluxate or dislocate during PIP joint extension. The radiographs must be scrutinized for subtle dorsal subluxation and concomitant fracture of the middle phalangeal base. Unstable PIP joint dislocations, with or without small fractures of the middle phalangeal base, have a stable arc of motion that must be defined. This stable arc is typically from full flexion to about 30 degrees of flexion. This arc is used to determine the confines of extension block splinting.126 A short-arm cast is applied with an aluminum outrigger that positions the MCP joint in flexion and the PIP joint in 10 degrees less than the maximal extension that leads to joint subluxation. Reduction is verified by lateral radiographs. The aluminum splint is modified every 7 to 10 days to increase PIP joint extension by 10 degrees. A lateral view or dynamic fluoroscopy is used to confirm concentric reduction. This process is continued over 4 to 5 weeks. The cast and splint are then discontinued and a home therapy program is instituted. 
Extremely unstable injuries that dislocate in more than 30 degrees of flexion almost always involve considerable fracture of the middle phalanx. These injuries are regarded as pilon fractures or intra-articular fracture–dislocations. Treatment presents a management dilemma as discussed earlier.193 Options range from open reduction to dynamic traction. Long-term subluxation, stiffness, and arthrosis are concerns. 

Volar PIP Joint Dislocations

Volar PIP joint dislocations are uncommon in children,97,150 and the diagnosis is often delayed.150 Interposition of soft tissues or bony fragments can render the dislocation irreducible.97 The proximal phalangeal head may herniate between the lateral band and the central tendon. In contrast to dorsal dislocations, long-term results are often suboptimal. This outcome may be related to a delay in treatment or the degree of soft tissue involvement, especially the central slip. 
Volar dislocations require closed or open reduction. Reducible dislocations are treated with 4 weeks of full-time PIP joint extension splinting to promote healing of the central slip.199 Radiographs are necessary to confirm concentric reduction. An unstable reduction may require temporary pin fixation across the PIP joint. Irreducible dislocations require open reduction through a dorsal approach to extricate any interposed tissue. The central slip can be repaired to the middle phalanx. Postoperative immobilization consists of 4 weeks of full-time PIP joint extension splinting. 

Lateral PIP Joint Dislocations

Pure lateral dislocations are uncommon, though dorsal dislocations may have a lateral component.61 An isolated lateral dislocation represents severe disruption of the collateral ligament complex. The injury represents a spectrum of damage, beginning with the proper and accessory collateral ligaments and culminating in volar plate disruption.102 Bony avulsion fragments may accompany the ligamentous failure.37 Closed reduction is uniformly successful. A brief period (5 to 7 days) of immobilization followed by buddy taping to protect the healing collateral ligament complex is the customary treatment. 

Author‘s Preferred Treatment

Variables that affect treatment of PIP joint dislocations include the extent and anatomic location of soft tissue disruption, presence or absence of fracture, reducibility, and stability after reduction. The initial treatment of almost all PIP dislocations is an attempt at closed reduction followed by a stability assessment. A brief period of mobilization is important to prevent PIP joint stiffness. 

Dorsal Dislocation

A stable reduction is treated with brief immobilization followed by early motion. Coban wrap (3M, St. Paul, MN) buddy taping is used until full stable motion is achieved. Sports are restricted until the patient gains joint stability and full motion. An unstable reduction that can be held reduced in more than 30 to 40 degrees of flexion is treated with extension block splinting. Extremely unstable fracture–dislocations require open treatment, external fixation, or dynamic traction depending on the size of the fracture fragments. 

Volar Dislocation

A stable reduction is treated with immobilization for 4 weeks with the PIP joint in extension. Unstable reductions are treated with percutaneous pin fixation to maintain a concentric reduction. Irreducible dislocations require open reduction with repair of the central slip. 

Lateral Dislocations

Pure lateral dislocations are rare. Closed reduction is usually obtainable, followed by a brief period of immobilization. Irreducible dislocations require open reduction with or without collateral ligament repair. 

Metacarpophalangeal Joint Dislocations

The MCP joint is an uncommon site for dislocation in the child‘s hand.67,113 The dislocation may involve a finger or thumb. The gamekeeper‘s or skier‘s thumb can be considered a subset of subluxation or dislocation. 

Dorsal Metacarpophalangeal Dislocations of the Fingers

The most frequent dislocation of the MCP joint is dorsal dislocation of the index digit (Fig. 10-90), which results from a hyperextension force that ruptures the volar plate. The proximal phalanx is displaced dorsal to the metacarpal head. The diagnosis is readily apparent because the digit is shortened, supinated, and deviated in an ulnar direction. The interphalangeal joints are slightly flexed becuase of the digital flexor tendon tension. The volar skin is taut over the prominent metacarpal head. 
Figure 10-90
 
A: A 3-year-old boy with a complete complex dislocation of the index finger metacarpal joint. B: Note the parallelism in this lateral view. Open reduction was done through a volar approach.
A: A 3-year-old boy with a complete complex dislocation of the index finger metacarpal joint. B: Note the parallelism in this lateral view. Open reduction was done through a volar approach.
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Figure 10-90
A: A 3-year-old boy with a complete complex dislocation of the index finger metacarpal joint. B: Note the parallelism in this lateral view. Open reduction was done through a volar approach.
A: A 3-year-old boy with a complete complex dislocation of the index finger metacarpal joint. B: Note the parallelism in this lateral view. Open reduction was done through a volar approach.
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Dislocations of the MCP joint are classified as simple or complex. Complex dislocations are irreducible because of volar plate interposition in the joint. The injury can be open with the metacarpal head penetrating the palmar skin (Fig. 10-91). Simple dislocations are in a position of hyperextension on radiographs. Irreducible dislocations have bayonet apposition of the proximal phalanx dorsal to the metacarpal head. The sesamoid bone(s) of the index finger or thumb may be seen within the joint. The position of the sesamoid bones is indicative of the site of the volar plate.26,164 The most common irreducible dislocation is at the index MCP joint. Additional structures may impede reduction.99 The metacarpal head becomes “picture-framed” by the flexor tendon on the ulnar side and the lumbrical on the radial side. The superficial transverse metacarpal ligament and the natatory ligaments can also entrap the metacarpal neck. The collar of the restraining tissue is tightened by longitudinal traction, and this reduction maneuver may convert a dislocation from reducible to irreducible. 
(Courtesy of Joshua Ratner, MD.)
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Figure 10-91
A 17-year-old male after fall from height with open index and middle finger dorsal dislocations.
(Courtesy of Joshua Ratner, MD.)
(Courtesy of Joshua Ratner, MD.)
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Most simple dislocations can be reduced with distraction and volar manipulation of the proximal phalanx over the metacarpal head. Avoidance of hyperextension during reduction is important to prevent conversion of a simple to a complex dislocation. These reductions are usually stable. Reduction of a complex dislocation is problematic. The maneuver involves further hyperextension of the joint and palmar translation of the proximal phalanx. The goal is to extricate the volar plate with the proximal phalanx during palmar translation. Intra-articular infiltration of anesthetic fluid may assist reduction through joint distention and “floating” of the volar plate from its displaced position. The success rate for conversion of an irreducible dislocation to a reducible dislocation is low; open reduction is necessary in almost all patients. 

Open Reduction

Open reduction can be accomplished through a volar or dorsal approach. The volar approach provides excellent exposure of the metacarpal head and the incarcerated structures.9,12,67,75,99,113,127 However, the digital nerves are draped over the articular surface of the metacarpal head and precariously close to the skin. A deep skin incision can cut these nerves. The skin is gently incised and soft tissue is dissected. The first annular pulley is incised. The metacarpal head is extricated from between the flexor tendon and the lumbrical. The joint is evaluated for interposed structures, such as the volar plate, and then reduced under direct observation. 
The dorsal approach offers a less extensive exposure but avoids the risk of digital nerve injury.12 Through a dorsal incision, the extensor tendon is longitudinally split over the MCP joint. A transverse or longitudinal capsulotomy is made if the injury has not torn the capsule. A Freer elevator is placed within the joint to clear it of any interposed tissue. Often, the interposed volar plate needs to be split longitudinally to reduce the joint. If the flexor tendon is wrapped around the metacarpal, the Freer is used to extricate the metacarpal head. 
Regardless of the approach used, early motion is necessary to optimize outcome.99,127 The postoperative regimen is a 3- to 5-day immobilization period, followed by active motion. Rarely, a dorsal blocking splint is needed to prevent hyperextension that may foster repeat dislocation. 
Dorsal dislocations of the other fingers are uncommon (Fig. 10-92).8,143 Lateral fracture–dislocations are often S-H III fractures involving the base of the proximal phalanx (Fig. 10-93) and require ORIF of the displaced physeal fracture. 
Figure 10-92
A rare dorsal dislocation of the long finger that was irreducible by closed means.
 
A dorsal approach permitted inspection of the joint and extrication of the volar plate.
A dorsal approach permitted inspection of the joint and extrication of the volar plate.
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Figure 10-92
A rare dorsal dislocation of the long finger that was irreducible by closed means.
A dorsal approach permitted inspection of the joint and extrication of the volar plate.
A dorsal approach permitted inspection of the joint and extrication of the volar plate.
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Figure 10-93
 
A: A 9-year-old girl sustained this radial fracture–dislocation of the middle fingers. B: Closed reduction restored joint and fracture alignment.
A: A 9-year-old girl sustained this radial fracture–dislocation of the middle fingers. B: Closed reduction restored joint and fracture alignment.
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Figure 10-93
A: A 9-year-old girl sustained this radial fracture–dislocation of the middle fingers. B: Closed reduction restored joint and fracture alignment.
A: A 9-year-old girl sustained this radial fracture–dislocation of the middle fingers. B: Closed reduction restored joint and fracture alignment.
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Neglected Metacarpophalangeal Joint Dislocations

Early treatment is preferred for MCP joint dislocations,93 but delay of a few months may still result in an acceptable outcome. A delay of more than 6 months is associated with joint degeneration and a less predictable result. Late reduction may require a combined dorsal and volar approach for adequate exposure.9,114,139 Collateral ligament resection and temporary MCP joint pin fixation may be necessary. 

Dorsal Dislocation of the Thumb Ray

Thumb MCP joint dislocations are similar to those of the fingers, and hyperextension is the common mechanism. Thumb dislocations are classified according to the integrity and position of the volar plate, the status of the collateral ligaments, and the relative position of the metacarpal and proximal phalanx. The components of the classification are incomplete dislocation, simple complete dislocation, and complex complete dislocation (Fig. 10-94). 
Figure 10-94
Simple and complex dorsal dislocations of the thumb MCP joint.
 
Simple dislocations (A) are in extension and reducible. Complex dislocations (B) are in bayonet apposition and are irreducible because of the interposed volar plate.
Simple dislocations (A) are in extension and reducible. Complex dislocations (B) are in bayonet apposition and are irreducible because of the interposed volar plate.
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Figure 10-94
Simple and complex dorsal dislocations of the thumb MCP joint.
Simple dislocations (A) are in extension and reducible. Complex dislocations (B) are in bayonet apposition and are irreducible because of the interposed volar plate.
Simple dislocations (A) are in extension and reducible. Complex dislocations (B) are in bayonet apposition and are irreducible because of the interposed volar plate.
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Incomplete Thumb Metacarpophalangeal Joint Dislocation

An incomplete dislocation implies rupture of the volar plate with partial preservation of the collateral ligament integrity. The proximal phalanx perches on the dorsum of the metacarpal. Closed reduction is easily accomplished, and a 3-week course of immobilization is adequate. Return to sports requires protection for an additional 3 weeks. 
Simple Complete Thumb Metacarpophalangeal Dislocation
A simple complete dislocation implies volar plate and collateral ligament disruption. The proximal phalanx is displaced in a dorsal direction and is angulated 90 degrees to the long axis of the thumb metacarpal. Many of these dislocations can be reduced by closed means, though unnecessary longitudinal traction may convert a reducible condition into an irreducible situation (Fig. 10-95).75,127 A successful reduction requires thumb spica immobilization for 3 to 4 weeks to allow healing of the volar plate and collateral ligaments. 
Figure 10-95
A 9-year-old boy with a complete simple dorsal dislocation of the thumb MCP joint.
Flynn-ch010-image095.png
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Complex Complete Thumb Metacarpophalangeal Joint Dislocation
A complete or irreducible dislocation is the most severe form of this injury. The long axes of both the proximal phalanx and metacarpal are often parallel. Open reduction is usually required to extricate the volar plate from within the joint (Fig. 10-96).19 A dorsal or volar approach is suitable and raises concerns similar to those for irreducible index MCP joint dislocations.192 
Figure 10-96
 
A: Irreducible dorsal MCP dislocation in a 7-year-old boy. B: After open reduction through a volar incision.
A: Irreducible dorsal MCP dislocation in a 7-year-old boy. B: After open reduction through a volar incision.
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Figure 10-96
A: Irreducible dorsal MCP dislocation in a 7-year-old boy. B: After open reduction through a volar incision.
A: Irreducible dorsal MCP dislocation in a 7-year-old boy. B: After open reduction through a volar incision.
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Thumb Metacarpophalangeal Ulnar Collateral Ligament Injury (Gamekeeper‘s Thumb)

Injuries of the UCL are less prevalent in children than in adults. Forced abduction stress at a child‘s thumb MCP joint results in four types of injuries: (1) A simple sprain of the UCL, (2) a rupture or avulsion of the insertion or origin of the ligament, (3) a simple S-H I or II fracture of the proximal physis, or (4) an S-H III avulsion fracture that involves one-fourth to one-third of the epiphysis of the proximal phalanx (Figs. 10-97 and 10-98).132,214 
Figure 10-97
Ulnar instability of the thumb metacarpal joint.
 
A: Simple sprain. B: Rupture of the ligament. C: Avulsion fracture (S-H type III). D: Pseudo-gamekeeper‘s injury resulting from an S-H type I or II fracture of the proximal phalanx.
A: Simple sprain. B: Rupture of the ligament. C: Avulsion fracture (S-H type III). D: Pseudo-gamekeeper‘s injury resulting from an S-H type I or II fracture of the proximal phalanx.
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Figure 10-97
Ulnar instability of the thumb metacarpal joint.
A: Simple sprain. B: Rupture of the ligament. C: Avulsion fracture (S-H type III). D: Pseudo-gamekeeper‘s injury resulting from an S-H type I or II fracture of the proximal phalanx.
A: Simple sprain. B: Rupture of the ligament. C: Avulsion fracture (S-H type III). D: Pseudo-gamekeeper‘s injury resulting from an S-H type I or II fracture of the proximal phalanx.
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Figure 10-98
Spectrum of UCL injuries of the thumb.
 
A, B: On stress examination, a widening of the physis is seen. Varying sizes of fragments (B, C) may be associated with UCL avulsion fractures (arrows). The size of the fragment is important with respect to the congruity of the MCP joint.
A, B: On stress examination, a widening of the physis is seen. Varying sizes of fragments (B, C) may be associated with UCL avulsion fractures (arrows). The size of the fragment is important with respect to the congruity of the MCP joint.
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Figure 10-98
Spectrum of UCL injuries of the thumb.
A, B: On stress examination, a widening of the physis is seen. Varying sizes of fragments (B, C) may be associated with UCL avulsion fractures (arrows). The size of the fragment is important with respect to the congruity of the MCP joint.
A, B: On stress examination, a widening of the physis is seen. Varying sizes of fragments (B, C) may be associated with UCL avulsion fractures (arrows). The size of the fragment is important with respect to the congruity of the MCP joint.
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The injury is most common in preadolescents and adolescents. A history of trauma is customary, especially involving sports. The thumb is swollen about the MCP joint with ecchymosis, and tenderness to palpation is well localized over the UCL. Pain is exacerbated by abduction stress. A complete rupture or displaced fracture lacks a discrete endpoint during stress testing. Radiographic AP and lateral views are used to diagnose and delineate fracture configuration. Stress views may be needed if the diagnosis is questionable. An MRI scan can be used to evaluate ligament disruption in complicated injuries. 
Cast immobilization for 4 to 6 weeks is adequate for simple sprains, incomplete injuries, and nondisplaced fractures. A major concern is displacement of the ligament or fracture fragment behind the adductor aponeurosis known as a “Stener‘s lesion,” which prohibits healing.191,192 Complete ruptures, “Stener‘s lesion,” or displaced fractures usually require operative intervention. Distal insertion avulsion without bony fracture will require anchor fixation for repair (Fig. 10-99). 
Figure 10-99
 
A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
 
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
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A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
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Figure 10-99
A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
(Courtesy of Shriners Hospitals for Children, Philadelphia, PA.)
A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
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A: A 15-year-old boy with a UCL tear without fracture of the right thumb and valgus instability on stress testing. B: Exposure through an incision of the skin. C: Identification of the dorsal sensory nerve. D–E: Opening of the adductor aponeurosis and capsule; mobilization of the torn UCL. F: Placement of the bone anchor. G: Suture from the anchor passed through the ligament in a modified Kessler or similarly strong grasp technique. Tied in a figure-eight fashion. H: Knot buried under repair of the aponeurosis. I, J, K: Restoration of joint stability and maintenance of motion postoperatively.
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An S-H III fracture of the ulnar corner of the epiphysis of the proximal phalanx is the most common childhood gamekeeper‘s injury. A displaced fracture (fragment rotated or displaced more than 1.5 mm) requires ORIF to restore the integrity of the UCL and to obtain a congruous joint surface (Fig. 10-38). 
Chronic UCL injuries are more difficult to manage. Treatment depends on the length of time since original injury, age of the patient, and current level of function. Options range from UCL reconstruction to MCP joint fusion.182 

Author‘s Preferred Treatment

The treatment of dorsal MCP joint dislocations of the fingers and thumb should be stepwise and logical. The initial treatment for simple dislocations is usually closed reduction. This requires local anesthesia or conscious sedation to ensure comfort and eliminate resistance. Irreducible dislocations require open reduction. It is important to avoid multiple attempts at closed reduction of an irreducible dislocation. A dorsal or volar approach is used with removal of any interposed structure(s). The volar approach must respect the taut digital nerves overlying the prominent metacarpal head. Postoperative immobilization is used for 7 to 10 days, followed by active motion with splint protection. Athletic activities are restricted until healing is complete. 
Injuries of the UCL of the thumb are treated according to stability and displacement. Stable ligamentous injuries or minimally displaced fractures are treated with cast immobilization. Unstable complete ligamentous injuries or displaced fractures are treated with open reduction. 

References

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