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FINGER PROXIMAL PHALANX FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Finger Proximal Phalanx Fracture 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 Proximal Phalanx Fracture Pediatric, the historical and specifically named fractures include:

Salter-Harris type II and juxta-epiphyseal fractures of the proximal phalanx base

MP joint dislocation with volar plate 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.

The prevalence of hand fractures is extremely high in children, and the proximal phalanx is the most commonly fractured hand bone in the pediatric population. These fractures are twice as common as fractures of the other phalanges, and the base of the proximal phalanx is the most frequently fractured site, primarily due to Salter-Harris type II and juxta-epiphyseal fractures, usually in the little finger. Fractures of the proximal phalanx neck—which are practically exclusive to children—head/condyle, and shaft are less common but also occur in certain situations. The mechanism of injury for these fractures varies depending on the child’s age and may include crushing forces, falls, and sports participation. Although these injuries share some similarities with their counterparts in the adult population, the presence of physes and other developmental changes in children and adolescents warrants careful consideration of these factors to ensure appropriate diagnosis and management.1-5

Definitions

  • A pediatric proximal phalanx fracture is a disruption of the mechanical integrity of the proximal phalanx.
  • A pediatric proximal phalanx fracture produces a discontinuity in the proximal phalanx contours that can be complete or incomplete.
  • A pediatric proximal 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.6-8
  • 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 proximal phalanx fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • In the pediatric population, even most displaced fractures are easily reduced closed and often quite stable.3

P - Pattern

  • Proximal phalanx head: oblique, transverse, or comminuted; can involve the proximal interphalangeal (PIP) joint; these are intra-articular fractures that usually affect one or both condyles of the proximal phalanx head with or without displacement; displaced fractures can affect joint congruity.
  • Proximal phalanx neck: fractures of the neck of the phalanges occur almost exclusively in children and are most common in the proximal phalanx; these fractures occur distal to the collateral ligament recess of the proximal phalanx, and presenting patients typically have apex volar angulation with associated sagittal and subcondylar malalignment.3,9,10
  • Proximal phalanx shaft: transverse, oblique, or comminuted, with or without shortening; these fractures are less common than other proximal phalanx fractures, and clinical examination is necessary because very innocuous-looking injuries can have substantial rotational deformities that can lead to gripping problems.2,11
  • Proximal phalanx base: the base is the most common site of injury, and these fractures typically occur when the finger is abducted past the normal range of the metacarpophalangeal (MP) joint (Nellans); these are usually either Salter-Harris type II or juxta-epiphyseal base fractures, but the MP joint can also be involved.9,12
    • These fractures may be intra- or extra-articular and usually involve the dorsal or volar lip of the proximal phalanx base.10

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 proximal phalanx require antibiotics with surgical irrigation and wound debridement.6,13,14

R - Rotation

  • Pediatric proximal phalanx fracture deformity can be caused by rotation of the distal fragment on the proximal 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 proximal phalanx.
  • Radial or ulnar deviation and malrotation of pediatric proximal phalanx neck fractures are also possible, and radiographs can underestimate the degree of clinical deformity.3
  • Oblique fractures of the little finger are often malrotated, although physeal, transverse, intra-articular, and minor fractures by radiographic appearance can all be malrotated and lead to a rotated malunion.15
  • Some pediatric proximal phalanx fractures will have substantial rotational deformities that can only be detected through clinical evaluation.11
  • The MP joint is particularly prone to rotational injuries due to its mobility and the lever arm of the digit acting at the base of the proximal phalanx.16

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: pediatric proximal phalanx neck fractures usually have apex volar angulation with associated sagittal and subcondylar malalignment.9
  • Significant ulnar angulation can also result when the base of the little finger’s proximal phalanx is fractured.12
  • Physeal arrest can result in difficult-to-treat angular deformities and joint malalignment due to continued growth in adjacent bones.11

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
  • Pediatric proximal phalanx neck fractures are prone to proximal displacement, and most are displaced with dorsal translation and extension angulation.3,12
  • Pediatric proximal phalanx shaft fractures tend to displace apex volarly.12

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Pediatric proximal phalanx fractures can have fragment involvement with the PIP or MP joints.
  • 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 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 proximal 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 shearing fractures.3

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.6-8

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

Salter-Harris type II and juxta-epiphyseal fractures of the proximal phalanx base

  • Salter-Harris type II and juxta-epiphyseal fractures represent two of the most common hand fractures in children, and the majority involves the proximal phalanx.1
    • Salter-Harris II fractures are physeal, while in juxta-epiphyseal fractures, the fracture line is entirely metaphyseal and 1-2 mm distal to the physis. 17
    • Several similarities exist between these two types of fractures, and there is ongoing debate as to which is more common.
  • In one study of 100 boys and girls with proximal phalanx base fractures, the most common type of fracture was the juxta-epiphyseal type II fracture (53%) followed by the Salter-Harris II fracture (26%). This suggests that many of the pediatric proximal phalanx base fractures thought to be Salter-Harris II may actually be juxta-epiphyseal.17
    • Both fractures appear to follow the same injury pattern: sudden ulnar or radial angulation of the finger and excessive abduction of the MP joint that separates a small fragment at the base of the proximal phalanx on the side of the angulation; the fracture line consequently either continues transversely through the physis or the metaphysis 1–2 mm distal to the physis.11,17
  • The little finger is the most frequently involved digit of these fractures, followed by the ring finger. Fractures of the base of the little finger result from forced abduction and are termed “extra-octave” fractures to describe the extreme ulnar deviation that is typically present.12,17,18

Imaging

  • PA, lateral, and oblique X-ray views are recommended.

Treatment

  • Most mildly displaced Salter-Harris II and juxta-epiphyseal fractures are stable and can be treated with closed reduction.
    • Reduction can be accomplished with the “pencil technique,” in which a pencil is placed within the web space adjacent to the fractured digit to serve as a fulcrum, and then pressure is applied to the proximal fragment while the shaft is brought radially. This maneuver will not correct sagittal malalignment, but in patients with ≥2 years of skeletal growth, sagittal malalignment remodels well.11,12
    • Another option for closed reduction is to flex the MP joint to 90°, which tightens the collateral ligaments and thus stabilizes the proximal fragment. Reduction is then accomplished by pushing the distal fragment across into the correct alignment. In this technique, the MP joint is locked in 90° of flexion during manipulation, which helps correct any extension deformity.18
    • Whichever technique of closed reduction is used, over-correction is generally recommended. The periosteal sleeve is usually intact on the side of the angulation and generally prevents over-reduction and provides stability in the reduced position.18
    • Once the fracture is reduced, the finger should be splinted to the adjacent uninjured finger before an ulnar gutter splint is applied. This is especially important in ‘‘extra-octave’’ fractures, in which the pull of the abductor digiti minimi muscle tends to redisplace the fracture.18
  • In severely displaced fractures, closed reduction and splinting can result in residual deformity and other long-term complications. Entrapment of flexor tendons—particularly the flexor digitorum profundus—is also associated with these fractures, which makes them additionally irreducible. Surgical intervention may therefore be necessary in these cases or when there is a disruption of the collateral ligaments or fracture comminution.1,11,12
    • Open reduction and pinning is the preferred method of treatment in these cases, and an anatomic and stable reduction of the involved phalanx is very important in order to allow a proper gliding of the tendon.
    • K-wire fixation may be needed in fractures that are extremely unstable.1

Complications

  • “Pseudo-claw” deformity
  • Residual deformity
  • Stiffness

Outcomes

  • If an anatomic and stable reduction is achieved through surgery, good functional and radiologic outcomes may be achieved.1
  • Remodeling after juxta-epiphyseal fractures of the base of the proximal phalanx depends on several factors, including the age of the patient and degree and type of deformity.
    • Remodeling is less likely to occur in adolescents than young children, and angulation in the same plane as the joint movement will usually correct with growth. Whereas if the angulation is in the opposite plane, or is rotational, it will not correct.18
  • In one study of patients with juxta-epiphyseal fractures of the proximal phalanx base, 18 mildly displaced fractures were treated with closed reduction and splinting. This led to successful outcomes with no complications.
    • In the 16 patients with severely displaced fractures, however, it was difficult to obtain an adequate reduction by closed techniques, and complications occurred. K-wire fixation was therefore necessary to maintain the reduction in 5 of these patients.18
    • MP joint dislocation is not very common in the pediatric population, but it can be a serious injury that is typically associated with significant trauma. The index finger and thumb are the most commonly involved digits.19

MP joint dislocation with volar plate avulsion fracture

  • These injuries are often the consequence of hyperextension and falls on an outstretched hand (FOOSH), and outdoor activities and sports are frequently responsible.20
  • MP dislocations can be classified as simple or complex, with the latter involving soft tissue interposition between the articular surfaces of the joint.19
  • Volar plate avulsion fractures are most commonly responsible for complex MP dislocations.20
  • The volar plate attaches to the proximal phalangeal epiphysis in children, and when a finger is hyperextended, the proximal metacarpal attachment of the volar fibrocartilage ruptures away from the periosteal continuity, while the proximal phalanx is forced dorsally. This causes the metacarpal head to be displaced towards the palm, while the volar plate remains attached to the proximal phalanx and slips into the joint and becomes entrapped.20,21

Imaging

  • AP, lateral, and oblique X-ray views are required to confirm the diagnosis. The lateral view is most helpful.

Treatment

  • Most simple dorsal MP dislocations can be managed conservatively with closed reduction that includes distal traction and volar pressure on the dislocated bone, followed by splinting the joints in flexion.19
  • Complex MP dislocations are often irreducible due to the soft tissue (eg, volar plate) that is trapped between the articular surfaces. Therefore, surgery is typically needed in these cases and whenever attempted closed reduction fails.19,21
    • The surgical approach utilized can be dorsal, volar, or combined, and there is ongoing debate as to the optimal strategy. Surgeons must be mindful of the presence of osteochondral fragments that may require fixation or excision, depending on their size and location. 20,22
  • The advantage of the volar approach is that it allows direct access to the lesion and repair of the volar plate, which decreases the risk of subsequent instability. The dorsal approach provides excellent exposure of the volar plate and access to the osteochondral fragments of the metacarpal head, but its main disadvantage is the longitudinal splitting of the volar plate to reduce the MP joint, which is irreparable.22
  • The volar plate is incised to achieve reduction in the dorsal approach, while both the volar plate and natatory ligament are incised in the volar approach.20
  • Incision of the volar plate releases tension in the accessory collateral ligament and allows the remainder of the volar plate to be reduced along the side to which the flexor tendons have shifted.21
  • Extensive soft tissue release may not be necessary in pediatrics because of normally increased laxity of ligamentous structures. Only enough fibrocartilagenous plate or ligament should be incised to accomplish the reduction.21
    • After surgery, early protected mobilization of the MP joint with a dorsal splint preventing full extension is needed.21
    • Another surgical option for complex dorsal MP dislocations is arthroscopic reduction.22
    • Internal fixation is unnecessary in these injuries, and it has been suggested that K-wires crossing the physis may be harmful in skeletally immature patients.21

Complications

  • Premature physis closure
  • Posttraumatic osteoarthritis
  • Osteonecrosis
  • Stiffness
  • Loss of motion

Outcomes

  • One study suggested that closed reduction is successful in about 50% of cases.19
  • Findings from another study on patients ranging in age from 13-22 years showed that complex dorsal MP dislocations treated on the day of injury with dorsal or volar open reduction techniques can achieve good outcomes with no functional deficit, no pain, and minimal arthritis.20

Related Anatomy

  • The pediatric proximal phalanx consists of a distal phalangeal head that articulates at the PIP joint with the middle phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the MP joint with the metacarpal. In developing children and adolescents, the epiphyseal plate is located at the base of the proximal phalanx, which has a dorsal and volar lip.9
  • The ligaments associated with the proximal phalanx at the PIP and MP joints are the joint capsule, the proper and accessory collateral ligaments, the volar plates, the natatory ligament, and the transverse and oblique bands of the retinacular ligament. The oblique band originates on the lateral volar aspect of the proximal phalanx and attaches dorsally to the common extensor, while the transverse band originates and attaches closer to the joint line and inserts on the lateral border of the proximal phalanx.
  • Tendon attachments of the proximal phalanx include the extensor digitorum tendon, the flexor digitorum superficialis, and a flexor sheath that attaches to the sides of the proximal phalanx.
  • There is a basic anatomical difference between pediatric proximal and middle phalanges: the proximal phalanges have a longer, wider intramedullary canal with more cancellous bone, whereas the middle phalanges have a shorter, narrower intramedullary canal with more cortical bone. In general, fractures through cortical bone heal slower than fractures in cancellous bone.23

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for about 21% of all pediatric fractures, and the phalanges are the most commonly injured hand bones in this population.9,10
  • The annual incidence of phalangeal fractures in children and adolescents up to 19 years old is approximately 2.7%.24
  • The proximal phalanx is the most frequently fractured phalangeal bone in the pediatric population. These fractures are about twice as common as those of the distal and middle phalanges.1,4,25
  • The incidence of all phalangeal fractures is highest in children aged 10-14 years, which coincides with the time that most children begin playing contact sports.9
    • Studies have also suggested that the older the child, the more proximal the fracture that is sustained, with proximal phalanx fractures being most common in adolescents. In addition, despite the fact that most patients are right-hand dominant, the distribution of phalangeal fractures is generally found to be similar in both the right and left hands.4,26
  • Physeal injuries account for 15-30% of all pediatric fractures, and significant growth disturbance may occur in approximately 10% of cases. These types of injuries are most common during the adolescent growth spurt between ages 10-16, and are more common in boys than in girls.19
ICD-10 Codes

  • FINGER PROXIMAL PHALANX

    Diagnostic Guide Name

    FINGER PROXIMAL PHALANX

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

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (IF AVAILABLE)
    INDEX PROXIMAL PHALANX    
    - DISPLACED S62.611_S62.610_ 
    - NONDISPLACED S62.641_S62.640_ 
    MIDDLE PROXIMALPHALANX    
    - DISPLACED S62.613_S62.612_ 
    - NONDISPLACED S62.643_S62.642_ 
    RING PROXIMAL PHALANX    
    - DISPLACED S62.615_S62.614_ 
    - NONDISPLACED S62.645_S62.644_ 
    LITTLE PROXIMAL PHALANX    
    - DISPLACED S62.617_S62.616_ 
    - NONDISPLACED S62.647_S62.646_ 

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

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    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
History of finger trauma
Pain, swelling, and ecchymosis
Finger deformity
Tenderness and Loss of finger ROM
Typical History

A classic patient is a 13-year-old, left-handed boy who was injured in a fight with another child at school. During the fight, the boy threw a hook with his left fist, which connected with the other boy’s jaw. The impact caused sudden ulnar deviation of the little finger’s proximal phalanx and resulted in a juxta-epiphyseal fracture at the base of this bone. The boy experienced severe pain immediately after the injury, and inflammation in the form of swelling and tenderness developed soon thereafter, which led him to seek out medical attention.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric proximal phalanx fractures, the treating surgeon has 4 basic goals:6,14
    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 posttraumatic arthritis!)
    5. Fracture care should minimize the risk for infection and osteomyelitis.
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • The majority of pediatric proximal phalanx fractures can be treated without surgical treatment.14 Most of these fractures are nondisplaced, and even most of those that are displaced are easily reduced closed and often quite stable.3
  • Even proximal phalanx fractures that require a reduction to correct fracture-related deformity can usually be held in anatomic or near-anatomic alignment with a splint without internal or external surgical fixation.
  • The typical closed, nondisplaced, minimally angulated, proximal phalanx fracture without significant malrotation can be managed with buddy taping and an aluminum, plaster, fiberglass, or custom splint for 3-4 weeks, followed by initiation of active ROM.9
    • Displaced injuries can lead to deformity that compromises hand function, and surgical intervention such as open reduction and internal fixation (ORIF) may be needed to correct these cases and when closed reduction fails.2
    • Closed reduction may also not be possible in proximal phalanx neck fractures that are more that 1-2 weeks old on account of the rapid healing in children.11
  • Treatment for fractures along the proximal phalanx shaft is dictated by the orientation of the fracture and the degree of initial displacement. Vertically oriented oblique and spiral fractures cannot be adequately immobilized with the use of buddy taping and a splint and typically need more rigid immobilization, such as an ulnar or radial gutter splint or cast. These fractures must be monitored vigilantly for displacement, which can be difficult to see through casting material.11
    • Up to 10° of angulation is acceptable when treating proximal phalanx shaft fractures, but rotational malalignment is not. If acceptable alignment cannot be maintained, surgery is indicated.12
  • Most active children will remove their splint and start playing sports long before the fracture heals if not closely monitored. Therefore, casts are preferable to splints when immobilization is truly important to maintain reduction or protect the pins.3
Operative
  • Surgical treatment of pediatric proximal phalanx fractures must always be an individualized therapeutic decision. However, surgical proximal 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 proximal phalanx fracture involving the MP joint, surgical fracture care may be required.
    3. Open proximal 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 proximal phalanx shaft fractures, and surgical fixation is often required in these cases.9
  • Displaced and angulated proximal phalanx neck fractures are inherently unstable in the sagittal plane and typically require surgical management. Closed reduction and percutaneous pinning (CRPP) is often regarded as the optimal strategy in these cases, as it decreases the risk for malunion and nonunion compared to patients who undergo closed reduction.9
    • For patients in whom CRPP is unsuccessful, percutaneous reduction and pinning should be performed with the use of a temporary intrafocal K-wire as a joystick for reduction and osteoclasis as necessary. For patients in whom percutaneous reduction and pinning is unsuccessful, open reduction and percutaneous pinning may be needed.9
    • Pins are usually left in place for 4 weeks to allow for complete healing of the fracture, and the hand and involved finger(s) are immobilized in a cast while the pins are in place. After removal, postoperative rehabilitation is necessary to reduce the risk of flexion contracture.3,15
  • CRPP techniques are also the preferred treatment for pediatric patients with acute proximal phalanx condyle fractures; however, pinning of anatomically reduced fractures with resultant intra-articular malunion does occur, and open reduction and pin or screw fixation may be required to avoid complications.9,15
    • When repairing proximal phalanx condyle fractures, 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
  • CRPP is indicated for most displaced pediatric proximal phalanx base fractures as well, but open reduction and internal fixation (ORIF) may be necessary in rare cases when soft tissue becomes interposed at the fracture site, severe fracture comminution is present, and/or collateral ligament disruption occurs; however, this procedure should only be performed if absolutely necessary, because there is a high risk for osteonecrosis and extensor tendon injury.1,3,9
    • If K-wires are used, they should be gently inserted into the fracture site to create leverage for reduction once any interposed tissue is removed. Ideally, the pins should diverge at the fracture site to optimize stability, but this can be difficult to achieve in very small children.11
    • Once K-wires are in place, they must be protected at all times with a cast or brace if left outside the skin for later removal, and rarely do these wires need to stay in place longer than 3-4 weeks.11
  • All malrotated digits require anatomic reduction and operative stabilization. These are usually oblique proximal 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 is by percutaneous smooth pin stabilization or less commonly, ORIF.15
CPT Codes for Treatment Options

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

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Hand Therapy
  • The care and precautions related to immobilization devices for the pediatric proximal 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.
  • 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).
    • If surgery is performed, early, self-directed, active ROM exercises of the injured finger are recommended after pin and cast removal.5
  • 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.27
Complications
  • Adjacent joint stiffness is common after healing of displaced proximal phalanx neck fractures, but is easier to overcome in children than in adults. Failure to protect the pins in a cast until fracture healing, conversely, could allow redisplacement and malunion of the fracture, which is much more difficult to address than stiffness in the pediatric population.3
  • In contrast to adults, stiffness is possible, but not as significant of a concern in pediatrics. This makes cast immobilization of a finger or entire hand a more feasible option when treating pediatric proximal phalanx fractures.3
  • Malunion and deformity after pediatric proximal phalanx fractures is rare but can occur, especially in open, severe, unstable fractures.28 Oblique, intercondylar proximal phalanx fractures have a high risk for malunion, while proximal phalanx neck fractures are also prone to both malunion and proximal displacement.12,15
  • Posttraumatic osteoarthritis can occur in the PIP or MP joint after some pediatric proximal phalanx fractures.
  • Chronic osteomyelitis of the proximal phalanx is rare but can occur in open fractures, especially in patients with diabetes or in patients whose immune system is compromised.
  • Conservative treatment of proximal phalanx neck fractures in the little finger can lead to avascular necrosis for reasons not well understood.11
Outcomes
  • Most outcomes after pediatric proximal phalanx fractures are good.2,11,18 Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because the PIP and distal interphalangeal (DIP) joints of the finger can be mobilized while the MP joint and proximal phalanx are splinted.
  • In one study, patients with a displaced proximal phalanx fracture and open physes were treated with closed reduction and percutaneous pinning.
    • At the final follow-up at a median of two years after surgery, overall outcomes were excellent for all patients without differences in subjective pain, function, or objective measures, and there were no complaints of pain, abnormal appearance, or functional limitations.
    • Outcomes were similar between subcondylar and phalangeal base fractures, but patients with subcondylar fractures were more likely to have stiffness early on and finger deviation at final follow-up.2
  • Another trial examined 66 children with phalangeal neck fractures.
    • Most nondisplaced fractures were treated with splinting and had excellent results.
    • Displaced fractures—including those that were only minimally displaced—generally had better outcomes if treated with K-wire fixation than if simply closed reduced, including decreased risk of malunion and nonunion.11
Key Educational Points
  • Pediatric proximal phalanx fractures must be immobilized before radiographic fracture healing is complete to avoid disabling stiffness.
  • Immobilization of pediatric proximal phalanx fractures for >4 weeks is rarely needed.1
  • Most pediatric proximal phalanx fractures can be treated without surgery.8,27
  • Underlying pathological conditions such as bone tumors like enchondromas and osteoporosis 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.9
    • These repeated attempts can crush and disrupt the layered order of the physis, which is why if a reduction cannot be accomplished in 1 or 2 attempts, it is better to consider open operative reduction to reduce the chance of arrest.11
  • 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.9
    • The physes are particularly vulnerable in younger children when shear forces are applied to the fingers, stressing the attachments of the chondrocytes at the zone of proliferation.11
  • Pediatric proximal phalanx 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.3,9
  • Despite the general ease of treatment and good outcomes of many pediatric proximal 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
  • Salter-Harris type I fractures, accounting for ~2% of all proximal phalanx injuries, must still be recognized. Radiographs of these injuries may not reveal any displacement, but deformity may still be detected in the clinical examination. If this fracture is identified early, treatment will be simple and residual deformity can be avoided.16
  • Minimally displaced and stable proximal phalanx fractures require minimal augmentation due to their inherent stability and rapid fracture healing. The periosteum can be a powerful tool for reduction in children, providing a “hinge” to lever the distal segment on the proximal portion of the bone to attain anatomic alignment.11
References

New and Cited Articles

  1. Rodríguez-Vega V, Pretell-Mazzini J, Marti-Ciruelos R, et al. Simultaneous juxta-epiphyseal proximal phalanx fracture with flexor tendon entrapment in a child: a case report and review of literature. J Pediatr Orthop B 2013;22(2):148-52. PMID: 22561910
  2. Boyer JS, London DA, Stepan JG, Goldfarb CA. Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures. J Pediatr Orthop 2015;35(3):219-23. PMID: 24992352
  3. Cornwall R, Ricchetti ET. Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res 2006;445:146-56. PMID: 16505727
  4. 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
  5. Lee YK, Park S, Lee M. Flexor Tendon Entrapment at the Malunited Base Fracture of the Proximal Phalanx of the Finger in Child: A Case Report. Medicine (Baltimore) 2015;94(35):e1408. PMID: 26334897
  6. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  7. 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
  8. 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
  9. Abzug JM, Dua K, Bauer AS, et al. Pediatric Phalanx Fractures. J Am Acad Orthop Surg 2016;24(11):e174-e183. PMID: 27755266
  10. Sivit AP, Dupont EP, Sivit CJ. Pediatric hand injuries: essentials you need to know. Emerg Radiol 2014;21(2):197-206. PMID: 24158746
  11. Nellans KW, Chung KC. Pediatric hand fractures. Hand Clin 2013;29(4):569-78. PMID: 24209954
  12. Williams AA, Lochner HV. Pediatric hand and wrist injuries. Curr Rev Musculoskelet Med 2013;6(1):18-25. PMID: 23264097
  13. 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
  14. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  15. Waters PM. Problematic pediatric wrist and hand injuries. J Pediatr Orthop 2010;30; Suppl 2:S90-S5. Link
  16. Blagg SE, Giddins GE. Rotational Salter-Harris type 1 fracture of the proximal phalanx. J Hand Surg Br 1998;23(6):806-7. PMID: 9888688
  17. Al-Qattan MM, Al-Zahrani K, Al-Boukai AA. The relative incidence of fractures at the base of the proximal phalanx of the fingers in children. J Hand Surg Eur Vol 2008;33(4):465-8. PMID: 18687834
  18. Al-Qattan MM. Juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers in children and adolescents. J Hand Surg Br 2002;27(1):24-30. PMID: 11895341
  19. Menckhoff C. Pediatric Hand Injuries, Part I: Fractures and Dislocations. Ped Em Med Rep 2009. Link
  20. Rubin G, Orbach H, Rinott M, Rozen N. Complex Dorsal Metacarpophalangeal Dislocation: Long-Term Follow-Up. J Hand Surg Am 2016;41(8):e229-33. PMID: 27311864
  21. Light TR, Ogden JA. Complex dislocation of the index metacarpophalangeal joint in children. J Pediatr Orthop 1988;8(3):300-5. PMID: 3366889
  22. Kodama A, Itotani Y, Mizuseki T. Arthroscopic reduction of complex dorsal metacarpophalangeal dislocation of index finger. Arthrosc Tech 2014;3(2):e261-4. PMID: 24904773
  23. Dhamangaonkar AC, Patankar HS. Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures. J Hand Surg Am 2014;39(8):1517-23. PMID: 24855966
  24. 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
  25. 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
  26. 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
  27. 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.
  28. Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001

Reviews

  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. Waters PM. Problematic pediatric wrist and hand injuries. J Pediatr Orthop 2010;30; Suppl 2:S90-S5. Link
  3. Barton NJ. Fractures of the phalanges of the hand in children. Hand 1979;11(2):134-43. PMID: 488788
  4. 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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