25 Fractures of the Pediatric Hand

James S. Lin and Julie B. Samora


Hand fractures are common injuries in children and adolescents. There are unique management considerations in skeletally immature patients. Clinical examination may be difficult in anxious children with varying capacities to communicate. Open physes and incomplete carpal ossification may make fracture identification challenging on radiographs. Smaller anatomy also contributes to the challenges in diagnosis and treatment. Fortunately, the robust periosteum and skeletal healing potential of children usually allow for excellent outcomes oftentimes without need for operative intervention. However, the robust healing potential also necessitates prompt identification and man-agement of pediatric hand fractures to prevent skeletal deformities in those injuries that require more than conservative intervention. Furthermore, adherence to rehabilitation and immobilization protocols may also be a concern for children. In this section, common pediatric hand fracture patterns and management principles are reviewed.

25 Fractures of the Pediatric Hand

I. Extra-octave Fractures

A. Background

  • Juxta-epiphyseal Salter-Harris type II fracture.

  • Transverse fracture through the proximal phalanx physis or metaphysis of the small digit.

  • Most common fracture pattern of the proximal phalanx in children. 1

B. Presentation

  • Injured digit is typically abducted and angulated (► Fig. 25.1):

    • Usually in ulnar deviation. 2

Fig. 25.1 Extra-octave fracture of right hand of a 12-year-old male sustained when a football had direct impact of the small finger. Note the abduction deformity of the injured small digit.

C. Mechanism of Injury

  • Forced abduction of the small finger from direct impact or sporting activities.

D. Treatment

1. Closed Reduction and Immobilization+ /- Kirschner-Wire (K-Wire) Fixation

  • Indications

    • Most fractures can be treated with closed reduction and casting or splinting:

      • Proximity of the fracture to the physis allows for significant remodeling. 3

    • Pin fixation may be required to hold reduction if unstable.

  • Techniques

    • Reduction may be aided by the “pencil technique”

      • Involves placing a pencil (or other long thin instrument such as a freer elevator) deep within the fourth web space.

      • Helps control the proximal segment of the fracture and provide a lever arm.

      • Distal finger can be directed radially over the lever arm. 4

    • Immobilization for 3 weeks with splinting or casting typically required.

    • Buddy taping after immobilization until full range of motion is achieved (► Fig. 25.2).

Fig. 25.2 Extra-octave fracture noted on the plain anteroposterior (AP) radiographs of a 6-year-old girl following a trampoline injury (a). 11 days post reduction, with radiographic evidence of healing already present (b).

2. Open Reduction and Immobilization + /– K-Wire Fixation

  • Indications

    • Fractures unable to be close reduced, possibly due to:

      • Comminution

      • Soft tissue entrapment (i.e., flexor tendons)

      • Associated collateral ligament disruption

II. Phalangeal Neck Fractures

A. Background

  • Predominantly pediatric injuries. 4

B. Presentation

  • Affected interphalangeal joint is typically hyperextended.

  • Flexion is blocked due to obliteration of the subcondylar fossa. 3

  • Fractures usually dorsally displaced and highly unstable:

    • Complication rates higher than all other pediatric hand fractures. 5 , 6 , 7

C. Mechanism of Injury

  • Commonly when digit is entrapped in a closing door, and the child reflexively withdraws his or her hand.

    • This imposes a rotational force that displaces the distal fragment.

  • Sports and falls are also common etiologies. 8

D. Evaluation Considerations

  • Three radiographic views (anteroposterior [AP], lateral, and oblique).

  • Assess malrotation and radial/ulnar deviation on clinical examination.

E. Classification

  • Al-Qattan classification system based on displacement and bony contact (► Fig. 25.3): 9

    • Type I

      • Nondisplaced

      • Relatively stable

    • Type II

      • Any degree of displacement

      • Bone-to-bone contact at the fracture site remains

      • Unstable fractures

    • Type III

      • Displaced

      • Bony apposition at the fracture site is lost entirely. 9

  • Types II and III can both be subclassified into four subtypes based on fracture configuration and rotation/location of the phalangeal head, respectively. 10

Fig. 25.3 Classification of phalangeal neck fractures based on displacement and bony contact. Used, with permission, from: Al-Qattan MM. Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg Br. 2001;26 (2):112-121.

F. Treatment

  • Splinting or casting alone:

    • Indications

      • Completely nondisplaced (type I) fractures. 9

    • Close (weekly) radiographic follow-up is required to detect late displacement.

  • Closed reduction and percutaneous pin fixation

    • Indications

      • Most phalangeal neck fractures are displaced and therefore treated operatively.

      • Anatomic reduction is imperative for good functional outcomes.

      • Pin fixation usually required to prevent redisplacement. 8 , 9 , 11

      • Type IIa (transverse fracture line at the phalangeal neck) most common. 10

    • Techniques

      • Closed reduction attempted in the operating room.

      • Subsequent K-wire fixation to maintain the reduction once confirmed by fluoroscopy (► Fig. 25.4).

      • Patient should then be cast immobilized until pin removal at approximately 4 weeks; motion can be initiated at this point.

  • Percutaneous reduction (osteoclasis technique) and pin fixation.

    • Indications.

      • Above indications, if closed reduction is inadequate, or for subacute fractures.

    • Use a K-wire to manipulate the fracture fragment to its anatomic position. 8 , 10 , 12 , 13

  • Open reduction and pin fixation:

    • Indications.

      • Above indications and if closed and percutaneous reduction is inadequate.

      • Sometimes required for type III fractures.

    • Care should be taken to protect collateral ligament attachments.

      • Preserve collateral ligaments to preserve blood supply.

      • Risk of avascular necrosis becomes greater with an open technique. 8 , 14

Fig. 25.4 Anteroposterior (AP) and lateral radiographs of displaced middle phalangeal neck fracture of the long finger in a 13-year-old male (a, b). Clinical examination demonstrating malrotation of the long finger (c), with elimination of the deformity after a closed reduction is performed (d). Intraoperative fluoroscopic AP (e) and lateral (f) images demonstrating reduction with two K-wires placed in oblique retrograde fashion.

G. Complications

1. Osteonecrosis

  • High rates with type III fractures. 10 , 15

2. Persistent Deformity, Malunion, Nonunion

  • Remodeling potential is limited due to the great distance from the phalangeal neck to the physis at the proximal phalangeal metaphysis. 7 , 9 , 10

3. Malunions

  • Established (as opposed to incipient 12 ) malunions.

  • Treatment.

  • Some propose delaying surgical reconstruction to wait for fracture remodeling if:

    • Malunion occurs only in the sagittal plane.

    • The adjacent joint is congruent.

    • Significant growth potential remains.

    • Family is willing to wait. 16

  • Subcondylar fossa reconstruction may be required if the above criteria are not met:

    • Incipient malunions, or partially healed malaligned fractures.

      • Treatment: Osteoclasis with percutaneous reduction and K-wire fixation. 8 , 12

4. Nonunions

  • Treatment:

    • Removal of sclerotic bone, reduction, and K-wire fixation with or without bone grafting may be required. 10

III. Condyle Fractures

A. Background

  • Intra-articular

  • May present with various patterns, including:

    • Unicondylar/intracondylar fractures

    • Bicondylar/transcondylar fractures

    • Lateral avulsion fractures

    • Shearing fractures

      • Separate the articular surface and subchondral bone from the remaining phalanx. 2

  • Most fractures are displaced.

  • Subluxation or dislocation of the associated interphalangeal joint is also common. 17

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Jun 20, 2021 | Posted by in Hand surgery | Comments Off on 25 Fractures of the Pediatric Hand

Full access? Get Clinical Tree

Get Clinical Tree app for offline access