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
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
C. Mechanism of Injury
Forced abduction of the small finger from direct impact or sporting activities.
1. Closed Reduction and Immobilization+ /- Kirschner-Wire (K-Wire) Fixation
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.
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).
2. Open Reduction and Immobilization + /– K-Wire Fixation
Fractures unable to be close reduced, possibly due to:
Soft tissue entrapment (i.e., flexor tendons)
Associated collateral ligament disruption
II. Phalangeal Neck Fractures
Predominantly pediatric injuries. 4
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.
Al-Qattan classification system based on displacement and bony contact (► Fig. 25.3): 9
Any degree of displacement
Bone-to-bone contact at the fracture site remains
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
Splinting or casting alone:
Completely nondisplaced (type I) fractures. 9
Close (weekly) radiographic follow-up is required to detect late displacement.
Closed reduction and percutaneous pin fixation
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
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.
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:
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.
2. Persistent Deformity, Malunion, Nonunion
Established (as opposed to incipient 12 ) malunions.
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:
Removal of sclerotic bone, reduction, and K-wire fixation with or without bone grafting may be required. 10
III. Condyle Fractures
May present with various patterns, including:
Lateral avulsion 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