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FINGER DISTAL PHALANX FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Finger Distal Phalanx Fractures Pediatric

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Finger Distal Phalanx Pediatric, the historical and specifically named fractures include:

Seymour fracture

Mallet finger fracture

FDP tendon avulsion fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Fractures of the hand are the most common type of fracture sustained by children, and the majority of these occur in the phalanges, with the proximal phalanx being most frequently affected, followed by the distal phalanx. The cause of these injuries varies and is largely dependent on the age of the child, with crush injuries being common in toddlers and sports participation often responsible in older children and adolescents. Although pediatric distal phalanx fractures share several similarities with their counterparts in the adult population, the presence of physes and other developmental changes necessitates special consideration. Thus, the diagnosis and management of certain pediatric distal phalanx fractures can differ substantially from that for adults.1-6

Definitions

  • A pediatric distal phalanx fracture is a disruption of the mechanical integrity of the distal phalanx.
  • A pediatric distal phalanx fracture produces a discontinuity in the distal phalanx contours that can be complete or incomplete.
  • A pediatric distal phalanx fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature.7-9
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable pediatric distal phalanx fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • In the pediatric population, even the displaced fractures can be easily reduced closed and often are stable.3

P - Pattern

  • Distal phalanx tuft: The oblique, transverse, and comminuted fractures are the most common distal phalanx fracture patterns.  Tuft fractures usually result from crush injuries, and they are often comminuted but stable and minimally displaced. Tuft fractures are nearly always associated with an injury to the nail matrix, digit pulp, or both.5,10,11
  • Distal phalanx shaft: transverse, oblique, or comminuted with or without shortening.
  • Distal phalanx base: can involve the distal interphalangeal (DIP) joint; may be intra- or extra-articular; intra-articular fractures are due to extensor digitorum tendon avulsion injury or flexor digitorum profundus (FDP) tendon avulsion injury. These fractures usually involve the dorsal or volar lip of the distal phalanx base.11

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the pediatric distal phalanx require antibiotics with surgical irrigation and wound debridement.7,12,13
  • Since Seymour fractures involve an associated nail bed laceration, most are technically considered open fractures.1

R - Rotation

  • Pediatric distal phalanx fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.   This is not a common type of fracture deformity in the pediatric distal phalanx.
  • Oblique fractures of the small finger are often malrotated, although physeal, transverse, intra-articular, and minor fractures by radiographic appearance can also be malrotated and lead to a rotated malunion.4

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
  • Example: Seymour fractures typically result from a volar force and a dorsal apex angulation of the diaphysis compared with the epiphysis.1

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: fracture line defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
  • Most pediatric distal phalanx fractures are nondisplaced, with support provided by the robust periosteum.3

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Pediatric distal phalanx fractures can have fragment involvement with the DIP joint.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or particularly if there is a step-off in the articular surface then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.
  • Pediatric fractures of the distal phalangeal condyles are intra-articular and can involve one or both condyles. Fracture patterns include lateral avulsion fractures, unicondylar or intracondylar fractures, bicondylar or transcondylar fractures, and a shearing fracture.3

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.7-9

Pediatric distal phalanx fractures: named fractures, fractures with eponyms and other special fractures

Seymour fracture

  • A “Seymour fracture” is a Salter-Harris I or II fracture of the distal phalanx physis, with concomitant avulsion of the proximal edge of the nail from the eponychial fold, flexion deformity at the fracture site, and frequently ungual subluxation. Some have suggested that a Seymour fracture can also occur in a juxta-epiphyseal position, 1-2 mm distal to the physis in the metaphysis.3,14
  • These displaced fractures typically occur from crush injuries to the distal phalanx, resulting from a volar force and the dorsal apex angulation of the diaphysis compared with the epiphysis. The commonly associated nail bed laceration technically makes most of them open fractures because the nail is avulsed and the germinal matrix is torn.1,14,15  This nail bed laceration is often not visible, but because the nail plate is typically superficial to the eponychial fold.  This makes the nail appear longer compared with the uninjured digits and hides the underlying nail bed laceration.1
  • The distal phalanx is typically in a flexed posture as a result of the imbalance between the terminal extensor and FDP tendons. Because of this flexed posture of the distal phalanx, Seymour fractures often are misinterpreted as DIP dislocations or bony mallet injuries, but displacement in Seymour fractures occurs at the site of the physis/fracture rather than the DIP joint.1,16
  • Posteroanterior radiograph views of the injured finger may appear normal. Therefore, lateral views are essential to confirm a Seymour fracture diagnosis.

Imaging

  • Routine AP and lateral X-rays

Treatment

  • Since these are nearly always open injuries, the optimum treatment for Seymour fractures requires early recognition and surgical management.4
  • Treatment of open Seymour fractures requires surgical intervention and should consist of the following: nail removal, thorough irrigation and debridement of the fracture, gentle removal of the incarcerated nail bed from the fracture site, reduction of the fracture with or without pinning, repair of the nail bed if a substantial proximal flap exists, replacement of the nail plate underneath the eponychial fold, and splinting or casting.3  Small oblique incisions that are directed proximally toward the DIP joint at the junction of paronychial and eponychial folds may be necessary to allow eponychal fold reflection in order to provide adequately visualize and expose of the nail bed laceration.3  Hyperflexion of the digit also aids in visualization and allows for thorough irrigation and debridement of the fracture site.1  Seymour fractures are usually unstable, and reduction should therefore be maintained by K-wire fixation. Fluoroscopy is used for placement of a K-wire.  K-wire fixation will cause minimal iatrogenic damage to the epiphysis.16  Postoperative parenteral antibiotics should also be administered, followed by a short course of oral antibiotics for approximately 5-7 days.3,15
  • The rare case of a closed Seymour fracture can be managed with closed reduction and a splint; however, since children may not be compliant with splint wear, even these fractures are often managed surgically.1
  • Fracture instability tends to occur if the nail plate is completely removed and not replaced, and the avulsed nail therefore should always be replaced. Malunion with residual pseudomallet or flexion deformity can occur in Seymour fractures treated without fixation.3

Complications

  • Infection
  • Osteomyelitis
  • Premature physeal closure
  • Nail bed deformity
  • Dorsal rotation of the epiphysis
  • Articular deformity
  • Extensor mechanism dysfunction
  • Nail growth disturbance
  • Loss of DIP joint flexion
  • Malunion

Outcomes

  • In one study, open fractures were managed surgically with thorough debridement, nail removal, and open reduction, with K-wire fixation if necessary, and closed fractures with a splint. No infections were noted, and the fractures healed with no significant deformity at an average follow-up of 18 months.16
  • In another study on 24 patients with Seymour fractures, nine had closed injuries and were treated with closed reduction and splinting using a standardized forearm-based finger splint in intrinsic-plus position.  Fifteen underwent surgical management.  Debridement, open reduction, nailbed repair, and splinting were performed on 9 patients.  Open reduction, debridement, and K-wire fixation across the DIP joint was performed on 5 patients due to instability.  After surgery, the same forearm-based splint was used to immobilize the affected digit. Clinical results revealed that 23 of the 24 patients had re-established full motion in comparison with the corresponding digit of the opposite side, with a mean motion range of 80°. No infections were reported.  At the 1-year follow-up, no patients complained of pain, and patient satisfaction was primarily good or excellent.14

Mallet finger fracture

  • Mallet finger fractures in children are somewhat similar to those occurring in adults, but there are several important distinctions between the two, and they consequently must be considered separately:1,14,17
    • In children the terminal extensor tendon inserts on the epiphysis and the volar FDP inserts on the metaphysis.4
    • The distal phalanx physis is either still open or gradually closing in pediatric patients, approximately around 13–16 years of age.18
    • In adult patients, mallet finger deformities result from an injury or laceration to the extensor tendon with or without an associated fracture, but in skeletally immature children it typically occurs due to an avulsion fracture of the extensor tendon of the distal phalangeal epiphysis.1,17
    • This avulsion results in an intra-articular fracture, which may extend to or through the metaphysis of the distal phalanx, resulting in a Salter-Harris type III or type IV fracture, respectively.1
    • Although a Salter-Harris I or II fracture of the distal phalanx mimics the appearance of an adult mallet finger on clinical exam, it does not involve the DIP joint surface as in adults.3
  • Typically, bony mallet injuries occur as a result of an axially-directed load or flexion force applied to on an extended fingertip, which drives the tip volarly faster than the extensor can relax. These injuries are particularly common in pre-teens and teenagers, and often result from sports participation.1,3
  • Active ROM exam demonstrates an active extension lag. The collateral ligaments and volar plate are stable. FDP tendon function is intact with normal sensation and normal capillary refill.
  • Soft tissue swelling is commonly noted over the dorsum of the DIP joint in these injuries, and the avulsed bone fragment is dorsally displaced to a varying degree.11
  • In young children, delayed diagnosis of mallet finger is common, likely because of the rarity of this injury and the fact that functional impairment often is not immediately noted.17
  • Bony pediatric mallet fractures can be classified into three types:
    • Type I: No DIP joint subluxation
    • Type II: DIP joint subluxation
    • Type III: Injury to epiphysis and physis1

Imaging

  • Plain anteroposterior and lateral X-ray views will usually confirm the diagnosis.

Treatment

  • Limited information is available on the management of pediatric bony mallet injuries, but many surgeons treat these pediatric patients with the same management principles used for adults. Many mallet finger fractures can be treated conservatively, and the ultimate goal treatment is to achieve adequate joint stability and prevent extensor lag and swan neck deformities.1
  • Conservative treatment is generally indicated for patients with bony mallet injuries that involve less than one-third of the articular surface.1
    • This should include full-time splint or cast immobilization of the DIP joint in full extension for 6-8 weeks, followed by 2-4 weeks of nighttime splinting.1
    • A major issue with conservatively treating mallet fractures in children is compliance with splinting, as some patients cannot maintain the splint for behavioral reasons or an improper fit. In these situations, a transarticular K-wire may need to be placed through the DIP joint and cast the hand to protect the pin from breakage.3
  • Surgical management of bony mallet injuries is generally indicated when conservative treatment fails or the injury results in joint incongruence, fails to maintain cortical bony contact after attempted reduction, has persistent volar subluxation of the distal phalanx, or involves more than one-third of the articular surface.1
    • Reduction of the fracture fragment or DIP subluxation is typically performed with percutaneous K-wire fixation and may involve multiple pins to reduce the fracture and the DIP joint in extension.3
    • Extension block pinning can be used to percutaneously reduce and stabilize the fracture and DIP joint.1,3
    • Other surgical techniques include tension band wiring, hook plating, internal suturing, pin fixation, and the use of bone anchors. If the patient is near skeletal maturity, a screw, tension band, pullout wire, or suture anchor may be used for fixation but are rarely needed.1,3
    • The Ishiguro method, which involves extension block pinning in the reduced position with the DIP joint pinned in neutral, has also been proposed as an easier and less invasive procedure to treat mallet fractures when compared with other currently available operative methods.
  • This method facilitates closed reduction and permits indirect anatomical reduction of the fracture, and may therefore be applied to cases of displaced pediatric mallet fractures.18
  • Aggressive physical and/or occupational therapy should be considered in children who do not regain flexion appropriately after surgery.18

Complications

  • Infection
  • Swan neck deformity
  • Postraumatic osteoarthritis
  • Skin necrosis
  • Nail deformity
  • Loss of fixation
  • Refracture
  • Extensor lag

Outcomes

  • In a large review of adult and pediatric mallet finger injuries and mallet fractures, outcomes were uniformly good, with surgical treatment offering no advantage over conservative treatment.3
  • In another study of 17 pediatric patients who underwent operative fixation of bony mallet fractures, 12 were treated with closed reduction and extension block pinning, 2 with open reduction followed by extension block pinning, and 3 with open reduction with intrafocal pinning.
    • At the follow-up, only one patient reported pain, full extension was restored in most patients, and complications were minimal.
    • The authors concluded that closed reduction and extension block pinning appeared to be an effective and minimally invasive option for these injuries.18

FDP tendon avulsion fracture

  • Also known as “jersey finger,” these are uncommon injuries in the pediatric population that occur from sudden hyperextension of an actively contracted FDP tendon, which avulses the tendon from its insertion.4
  • Jersey finger typically occurs in young athletes, and the nickname comes from the common injury pattern in which the athlete grasps at an opponent’s jersey, and when the jersey is rapidly pulled away, the FDP tendon is avulsed from the distal phalanx because the finger is actively flexing while being hyperextended by the jersey.4,11,20
  • The ring finger is the most commonly involved digit, in part because it extends slightly beyond the other digits when the hand grasps.20
  • Diagnosis of jersey finger is often missed in the pediatric population due to either lack of awareness, delay in recognition, or being mistaken for a jammed or sprained finger due to the fusiform swelling in the flexor tendon sheath. Flexion of the DIP joint and isolated profundus tendon function must be tested in order to properly diagnose these injuries.4,20

Imaging

  • Standard three-view radiographs of the hand should be obtained to look for associated fracture or other injuries, and a true lateral radiograph may show the avulsed fracture fragment and thus and location of the proximally displaced tendon.
  • Ultrasound can also assist in diagnosing these injuries.

Treatment

  • Immediate splinting of the injured finger in a comfortable position is recommended initially for jersey finger injuries diagnosed acutely. If the injury is not addressed within 7-10 days, contracture and poor outcome may result, so a timely referral is critical.20
  • Surgery is generally required unless the patient is unable or unwilling to comply with postoperative therapy, or the injury is not diagnosed acutely.21
  • Acute repair involves reinsertion of the FDP tendon or attached bony fragment into the volar distal phalanx. This may require repair over a dorsal button.4  A number of surgical techniques are used to treat jersey finger, including the Bunnell pull-out suture technique, suture anchor repair, and repair of the FDP tendon with incorporation of the volar plate.21
  • Injuries that present 3-4 weeks after injury are considered chronic, and treatment should be guided by a combination of patient factors and technical considerations.  If the DIP joint is supple, and the patient’s main concern is loss of dexterity, staged FDP reconstruction may be a reasonable option.  DIP joint arthrodesis with FDP excision and FDS tenolysis may be used to treat a painful or unstable joint.21

Complications

  • Contracture
  • Adhesion formation

Outcome

  • Since jersey finger is a zone I injury, acute repair usually has excellent results, while late reconstruction is much more complicated and outcomes are less certain.4
  • Despite the inherent risks of the pull-out suture technique, excellent outcomes are obtainable when the surgical technique and post-operative rehabilitation are executed appropriately.21

Related Anatomy

  • The pediatric distal phalanx consists of a distal bony tuft, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the DIP joint with the middle phalanx. In developing children and adolescents, the physeal plate is located at the base of the distal phalanx, which has a dorsal and volar lip.1
  • Ligaments that attach to the distal phalanx include the volar plate of the DIP joint and the radial and ulnar collateral ligaments (proper and accessory collaterals) of the DIP joint.
  • Tendon attachments include the insertion of the terminal extensor tendon into the epiphysis of the distal phalanx’s dorsal lip, the insertion of the FDP into the volar proximal third of the distal phalanx at the metaphysis-diaphysis, and the insertion of the flexor pollicis longus (FPL) in the same metadiaphyseal region of the thumb distal phalanx.1,3
  • The pediatric distal phalanx is further stabilized by fibrous septae in the pulp of the finger and ulnar and radial lateral interosseous ligaments between the base and tuft of the distal phalanx.

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for 21% of all pediatric fractures.  The phalanges are the most commonly injured bones in the hands of this population.1,11
  • The annual incidence of phalangeal fractures in children/adolescents up to 19 years old has been reported as 2.7%.22
  • Reports have shown that the proximal phalanx is fractured most frequently in the pediatric population, followed by the distal phalanx.5,6
  • The incidence of phalangeal fractures is highest in children aged 10-14 years, which coincides with the time that most children begin playing contact sports. About two-thirds of these injuries occur in males, which is likely due to their participation in contact sports.1
  • Toddlers and preschool-aged children are more likely to sustain distal tuft fractures in the home setting as a result of crush and laceration injuries.1
  • One study found that the older the child, the more proximal the fracture that was sustained, with the median age for distal phalanx fractures being 9 years. This study also found that despite more patients being right-hand dominant, the distribution of phalangeal fractures was similar in both the right and left hands.2
  • Salter-Harris II fractures are the most common of their type in pediatrics, accounting for 75% of all physeal fractures.20
  • Subungual hematomas are a common related injury.
ICD-10 Codes

  • FINGER DISTAL PHALANX PEDIATRIC FRACTURE

    Diagnostic Guide Name

    FINGER DISTAL PHALANX PEDIATRIC FRACTURE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DIP, PIP, MCP VOLAR PLATE (RUPTURE, AVULSION FRACTURE)    
    - INDEX S63.431_S63.430_ 
    - MIDDLE S63.433_S63.432_ 
    - RING S63.435_S63.434_ 
    - LITTLE S63.437_S63.436_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Finger trauma
Pain, swelling and ecchymosis of the fingertip
Subungual pain (hematoma)
Pain, swelling and ecchymosis of the finger tip
Finger tip deformity after injury
Loss of range of motion
Typical History

A classic patient is a 10-year-old, right-handed youth baseball player. During a game, he attempted to catch a fast-moving groundball with his bare right hand, but miss judged the ball’s height. As a result, the ball connected directly with the tip of his right long finger, causing a tuft fracture of the distal phalanx. This led to immediate pain, swelling, ecchymosis, and eventually a subungual hematoma.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Distal Phalanx Salter I fracture (possible closed Seymour fracture). Note widening (arrow) of the physis (arrow)
    Distal Phalanx Salter I fracture (possible closed Seymour fracture). Note widening (arrow) of the physis (arrow)
  • Distal Phalanx Tuft fracture (arrow)
    Distal Phalanx Tuft fracture (arrow)
  • Distal Phalanx Mallet fracture in young teenager with open growth plates (arrow)
    Distal Phalanx Mallet fracture in young teenager with open growth plates (arrow)
Treatment Options
Treatment Goals
  • When treating closed pediatric distal phalanx fractures, the treating surgeon has 4 basic goals:7.13
    1. A finger with a normal appearance. The X-ray may not need to be perfect but the finger should have no obvious deformity (ie, the finger looks normal!)
    2. Avoid finger stiffness by maintaining a normal functional ROM (ie, the finger works!)
    3. The finger is not painful (ie, the finger does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the joint does not develop early post-traumatic arthritis!)
    5. For open fractures, fracture care should minimize the risk for infection and osteomyelitis.
  • Phalangeal shaft fractures are generally less common in the pediatric population compared with other phalangeal fracture patterns, and the principles of managing these injuries should be based on initial fracture displacement and orientation.1
Conservative
  • The majority of pediatric distal phalanx fractures can be treated without surgical treatment.13 Most of these fractures are nondisplaced, and even most of those that are displaced are easily reduced closed and often quite stable.3
  • Treatment is also dependent on the location of the fracture in the distal phalanx:
  • The typical closed, nondisplaced, minimally angulated, distal phalanx fracture without significant malrotation can be managed with buddy taping and an aluminum plaster or fiberglass or custom splint for 3-4 weeks, followed by initiation of active ROM.1
    • Closed tuft fractures only require pain relief and a mitten cast or short volar splint that covers the injured area and restricts DIP joint motion but leaves the PIP joint free for 2-3 weeks. Active ROM of the DIP joint is initiated afterwards.1
    • Open tuft fractures should be also copiously irrigated and treated with prophylactic antibiotics for 3-5 days.20
    • Vertically oriented oblique and spiral phalangeal shaft fractures cannot be adequately immobilized with the use of buddy taping and a splint, and a more rigid type of immobilization—such as plaster or fiberglass cast—will be necessary.1
    • Distal phalanx base fractures should be treated with splinting in extension if there is minimal or no displacement, but more serious injuries may require surgical pinning.20
  • Pediatric distal phalanx fractures usually do not require that the finger be included in a short-arm cast.
  • Even distal phalanx fractures that require a reduction to correct fracture-related deformity usually can be held in anatomic or near-anatomic alignment with a splint without internal or external surgical fixation.
  • Most active children remove their splint and start playing sports long before the fracture heals if left to their own devices. Therefore, casts are preferable to splints when immobilization is truly important for maintenance of reduction or protection of pins.3
Operative
  • Surgical treatment of pediatric distal phalanx fractures must always be an individualized therapeutic decision. However, surgical distal phalanx fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced base of distal phalanx fracture involving the DIP joint, surgical fracture care may be required (eg, displaced mallet finger injuries).
    3. Open distal phalanx fractures require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Acceptable alignment may be difficult to maintain in patients who have an oblique, spiral, or comminuted phalangeal shaft fracture, and surgical fixation is often required in these cases.1
  • Closed reduction and percutaneous pin fixation techniques are the preferred treatment for pediatric patients with acute distal phalangeal condyle fractures; however, pinning of anatomically reduced fractures does occur with resultant intra-articular malunion, and open reduction and pin or screw fixation may be required to avoid complications.1,4
  • ORIF should only be performed if it is absolutely necessary, because there is a high risk for osteonecrosis due to the blood supply of the condyles entering through the collateral ligament.1
  • Pin or screw placement through the collateral ligaments should be avoided to prevent tethering on these structures that may limit motion. Cast protection is important during healing, especially when pins are used for fixation because stiffness is easier to correct than a loss of fixation leading to malunion.3
  • All malrotated digits require anatomic reduction and operative stabilization. These are usually oblique distal phalanx fractures of the border digits, although physeal, transverse, intra-articular, and minor fractures by radiographic appearance can all be malrotated and lead to a rotated malunion. Acute treatment usually is done with percutaneous smooth pin stabilization or less commonly, ORIF.4

Post-treatment Management

  • The care and precautions related to immobilization devices for the pediatric distal phalanx fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can be mobilized after 4 weeks.
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics (eg, cephalosporin, penicillin), and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.10  Usually hardware removal will be needed after fracture healing.
  • Patients should be instructed to carefully exercise all joints in the injured hand that do not require immobilization. Patients usually can exercise on their own; however, signs of generalized finger or hand stiffness are indications for referral to hand therapy (PT or OT).
Treatment Photos and Diagrams
Distal Phalanx Fracture Treatment
  • Distal Phalanx splinted mallet fracture (arrow) with acceptable reduction
    Distal Phalanx splinted mallet fracture (arrow) with acceptable reduction
CPT Codes for Treatment Options

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Common Procedure Name
ORIF proximal phalanx
CPT Description
pen treatment phalangeal shaft fracture proximal/mid finger/thumb w/wo fixation each
CPT Code Number
26735
CPT Code References

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Complications
  • In contrast to adults, stiffness is possible, but not as major of a concern in the pediatric population. This makes cast immobilization of a finger or entire hand a more feasible option when treating pediatric distal phalanx fractures.3
  • Malunion and fingertip deformity after pediatric distal phalanx fractures is rare but can occur, especially in open, severe, unstable fractures.23
  • Posttraumatic osteoarthritis can occur in the DIP joint after some pediatric distal phalanx fractures (eg, large displaced mallet finger fracture).
  • Chronic osteomyelitis of the finger distal phalanx is rare but can occur in open fractures, especially in patients with diabetes or in patients whose immune system is compromised.
  • In one study, the highest complication rates were found in Seymour fractures (62%), Salter-Harris III/IV (50%), and mallet finger fractures (49%). Seymour fractures had a 23% infection rate, and DIP stiffness was the most common finding after mallet fractures (24%).24
  • Additional complications of distal tuft fractures that may occur include cold intolerance, hyperesthesia, and numbness.1
Outcomes
  • Most outcomes after pediatric distal phalanx fractures are very good.3,14,16,18 Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because the metacarpophalangeal (MP) and PIP joints of the finger can be mobilized while the DIP joint and distal phalanx are splinted. 
Key Educational Points
  • Pediatric distal phalanx fractures must be immobilized before radiographic fracture healing is complete to avoid disabling stiffness.
  • Immobilization of pediatric distal phalanx fractures for >4 weeks is rarely needed.1
  • Today, as in ancient times, most pediatric distal phalanx fractures can be treated without surgery.9,10
  • Underlying pathological conditions such as bone tumors (eg, enchondromas) should be expected in fractures that occur from trivial trauma.
  • The functional needs of each patient must be considered when recommending treatment for finger fractures.
  • The phalangeal physes remain open until approximately age 16.5 in males and 14.5 in females, and knowledge of these growth centers is important because iatrogenic physeal arrest may occur in patients with physeal injuries or those who undergo multiple fracture reduction attempts.1
  • An unmineralized physis is biomechanically weaker than the surrounding ligamentous structures and mature bone, which makes fractures of the physes more likely compared with ligamentous injuries or diaphyseal fractures.1
  • Phalangeal condyle fractures are often very difficult to manage because of delayed initial presentation and variability in interpretation of the injury on radiographs. Recognizing the true extent of this injury on original radiographs is important for long-term outcomes because articular congruity is essential.1,3
  • Seymour fracture is a problem fracture that can lead to substantial complications if missed.3
  • Despite the general ease of treatment and good outcomes of many pediatric distal phalanx fractures, it is essential to carefully and thoroughly evaluate each injury to consider the possibility of any special fractures that may require a more intense course of treatment. Most complications in treating these pediatric patients occur because the severity of the injury is underestimated on initial evaluation.3
References

New and Cited Articles

  1. Abzug JM, Dua K, Bauer AS, et al. Pediatric Phalanx Fractures. J Am Acad Orthop Surg 2016;24(11):e174-e183. PMID: 27755266
  2. Chew EM, Chong AK. Hand fractures in children: epidemiology and misdiagnosis in a tertiary referral hospital. J Hand Surg Am 2012;37(8):1684-8. PMID: 22763063
  3. Cornwall R, Ricchetti ET. Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res 2006;445:146-56. PMID: 16505727
  4. Waters PM. Problematic pediatric wrist and hand injuries. J Pediatr Orthop 2010;30; Suppl 2:S90-S5.
  5. Vadivelu R, Dias JJ, Burke FD, Stanton J. Hand injuries in children: a prospective study. J Pediatr Orthop 2006;26(1):29-35. PMID: 16439897
  6. Liu EH, Alqahtani S, Alsaaran RN, et al. A prospective study of pediatric hand fractures and review of the literature. Pediatr Emerg Care 2014;30(5):299-304. PMID: 24759492
  7. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  8. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
  9. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
  10. Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier; 2016, pp.231-77.
  11. Sivit AP, Dupont EP, Sivit CJ. Pediatric hand injuries: essentials you need to know. Emerg Radiol 2014;21(2):197-206. PMID: 24158746
  12. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12:119-26. PMID: 28344521
  13. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  14. Krusche-Mandl I, Köttstorfer J, Thalhammer G, et al. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am 2013;38(2):258-64. PMID: 23351909
  15. Abzug JM, Kozin SH. Seymour fractures. J Hand Surg Am 2013;38(11):2267-70. PMID: 24206995
  16. Ganayem M, Edelson G. Base of distal phalanx fracture in children: a mallet finger mimic. J Pediatr Orthop 2005;25(4):487-9. PMID: 15958901
  17. Forward KE, Yazdani A, Lim R. Mallet Finger in a Toddler: A Rare But Easily Missed Injury. Pediatr Emerg Care 2017;33(10):e103-e104. PMID: 28968312
  18. Chen AT, Conry KT, Gilmore A, et al. Outcomes Following Operative Treatment of Adolescent Mallet Fractures. HSS J 2018;14(1):83-87. PMID: 29399000
  19. Ota T, Itoh S, Matsuyama Y. Comparison of Treatment Results for Mallet Finger Fractures in Children Between Low-Intensity Pulsed Ultrasound Stimulation and Ishiguro's Method. Hand (N Y) 2018;13(1):80-85. PMID: 28719993
  20. Menckhoff C. Pediatric Hand Injuries, Part I: Fractures and Dislocations. Ped Em Med Rep 2009. Link
  21. Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med 2017;10(1):1-9. PMID: 28188545
  22. Naranje SM, Erali RA, Warner WC Jr, et al. Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop 2016;36(4):e45-8. PMID: 26177059
  23. Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001
  24. Lankachandra M, Wells CR, Cheng CJ, Hutchison RL. Complications of Distal Phalanx Fractures in Children. J Hand Surg Am 2017;42(7):574.e1-574.e6. PMID: 28465015

Reviews

  1. Nellans KW, Chung KC. Pediatric hand fractures. Hand Clin 2013;29(4):569-78. PMID: 24209954
  2. Goodell PB, Bauer A. Problematic Pediatric Hand and Wrist Fractures. JBJS Rev 2016;4(5). PMID: 27490217

Classics

  1. Barton NJ. Fractures of the phalanges of the hand in children. Hand 1979;11(2):134-43. PMID: 488788
  2. Hastings H, Simmons BP. Hand fractures in children. A statistical analysis. Clin Orthop Relat Res 1984;(188):120-30. PMID: 6467708
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