Hand Surgery
1st Edition

14
Fractures and Joint Injuries of the Child’s Hand
Michelle A. James
“Children are not just small adults.” Mercer Rang (1).
“Do not children fall with impunity from heights which would cost their elders a broken leg or perhaps a fractured skull?” Galileo Galilei, 1638 (2).
The child explores the world with his or her hands, but not always with the impunity that was asserted by Galileo. Finger fractures are common childhood injuries, second only to distal forearm fractures in frequency (3). This chapter discusses the characteristics and patterns of injury that are unique to the growing hand.
Enchondral growth of the metacarpals and phalanges occurs through physes, which are also called growth plates or epiphyseal plates. Physes are located at the distal ends of the finger metacarpals and at the proximal ends of the thumb metacarpal and finger and thumb phalanges (Fig. 1). Physes remain open (radiolucent on x-ray) during growth and close (replaced with bone, showing bony bridging on x-ray) in a predictable chronologic pattern when growth is complete. The chronologic patterns of epiphyseal ossification and physeal closure in the hand form the basis for determination of skeletal age (4).
Physes are composed of cartilage and are structurally weaker than bone. In spite of this, only 15% of bony injuries in children involve the physis (5,6), although, in the hand, this proportion is higher (30% to 52%) (7). Fractures are more common than physeal injuries throughout childhood, except during perinatal and adolescent growth spurts (8). This low incidence of physeal injury, in spite of relative structural weakness, is probably because (a) the sturdy periosteum helps protect the physis (1), and (b) physes and epiphyses are most susceptible to less common injury forces, such as shearing and avulsion (9). Physes are also weaker than ligament or capsule, which explains why fractures and epiphyseal injuries are more common than sprains and dislocations in children (1). Twelve percent of physeal injuries occur in the phalanges (10).
Physes are composed of columns of cartilage cells that are divided, in an epiphyseal to metaphyseal direction, on the basis of physiologic function into zones of growth, maturation, transformation, and remodeling (Fig. 2) (11). The weakest area of the physis is within the zone of maturation (9). When an injury causes physeal separation, the cleavage plane of the physis is between the areas of hypertrophy and calcification within this zone, which leaves the germinal and resting zones with the epiphysis and the calcifying and terminal hypertrophic regions with the metaphysis (5). Most physeal injuries do not cause growth disruption.
Epiphyseal-physeal injuries have been divided into different types, depending on configuration (Fig. 3), which in turn provides prognosis by using the Salter-Harris system (6). This system is used to classify physeal injuries of long bones, including metacarpals and phalanges. In addition to the direction and magnitude of the injuring force, the skeletal maturity of the child plays a role in the cause of a specific type of injury. Physeal fractures occur most commonly in girls between 9 and 12 years of age and in boys between 12 and 15 years of age (5), although different ages have predilections for different types. Type 1 fractures are physeal separations, which are not usually significantly displaced, because the periosteal attachment remains intact. They tend to occur in younger children, are common in the hand, and do not usually cause growth disruption. Type 1 injuries in infants with unossified secondary ossification centers may be difficult to see on x-ray. Type 2 injuries are the most common type of physeal injuries in the hand and elsewhere. Instead of propagating across the physis, like type 1 injuries, they enter through the physis and exit through the metaphysis, leaving a small triangle of metaphysis attached to the epiphysis (the Thurston-Holland fragment). Type 2 injuries usually occur in children who are older than 3 years of age and are most common in children who are older than 10 years of age. They are caused by a combination of shearing and angulatory forces and are often significantly displaced. Types 3 and 4 are intraarticular fractures that involve the epiphysis. Type 3 injuries may occur as the physis is closing. The fracture passes through the physis and the epiphysis; in the hand, type 3 fractures
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are often associated with an avulsion injury that involves the volar plate or extensor tendon insertion. Type 4 fractures cross the physis, involve the epiphysis and the metaphysis, and are caused by an intraarticular compression force. Type 3 and 4 fractures are rare in the hand and require accurate reduction to restore articular congruency and, for type 4 fractures, to prevent growth arrest. Type 5 fractures are rare and difficult to diagnose and are especially uncommon in the hand. In this type, an axial loading force compresses the physis, thus causing growth arrest, without apparent injury on x-ray (5,6,8,9 and 10,12,13 and 14). A type 7 fracture in the hand refers to avulsion of an epiphyseal fragment (usually of the proximal phalanx) by the collateral ligament (12).
FIGURE 1. Locations of the physes and epiphyses of the meta-carpals and phalanges.
When the physeal injury is sufficient to cause growth disruption, the extent and type of deformity that is caused by growth disruption is determined by the location of the injury within the physis, the percentage of the physis that is injured, and the growth remaining. A peripheral growth disruption causes an angulatory deformity. Disruption of more than one-half of the physis causes complete growth arrest and consequent shortening. Treatment of growth disruption is discussed in the section Surgical Management.
Physes can be injured by mechanisms other than trauma. Frostbite, electrical injuries, burns, and irradiation can all cause physeal injury and growth impairment (5,12). Frostbite may cause complete physeal arrest or partial disruption that results in angulatory deformities (15,16,17,18 and 19). Burns (12,19,20 and 21) tend to injure the peripheral physis, thus causing partial arrest and angulatory deformities with growth. This type of peripheral physeal injury may be termed type 6 (5).
FIGURE 2. Schematic representation of the growth plate (physis). Traumatic separation (at junction of opposite arrows) occurs through the zone of cartilage transformation.
Some characteristics of children’s hands protect them from injury and contribute to improved healing, as compared to adults, whereas other characteristics make them more prone to complications when they are fractured. Children’s bone can tolerate a greater degree of deformation without fracturing than adult bone can. The more porous nature of children’s bone prevents extension of a fracture line, thus causing traumatic bowing or buckle or greenstick fractures in response to lower-energy trauma (1). Unossified cartilage may have superior shock-absorbing properties, which contributes to the lower incidence of carpal injuries in children (5,22), although some authors have hypothesized that the change in material composition between an ossific nucleus and surrounding cartilage may render this area susceptible to injury (23). Remaining growth provides enhanced remodeling capacity for children. In addition to the remodeling that is caused by periosteal resorption on the convex side and growth on the concave side of a malunion, physeal remodeling occurs, with asymmetric growth of the physis serving to reorient the articular surface (1). Remodeling is especially effective for metaphyseal fractures with deformity in the plane of
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joint motion; as much as 30 degrees of motion in this direction of angulation can be accepted (24,25). Nonunion is rare in children, especially in the hand. Children’s bones heal faster than those of adults, which can be an advantage and a disadvantage; immobilization periods are shorter, but, as Rang points out, “the orthopaedic surgeon does not have as long to deliberate over a fracture in a child as he does in an adult” (1). Joint stiffness is uncommon after extraarticular fractures in children (24).
FIGURE 3. A: Type 1 physeal injury with separation of the epiphysis through the physis. B: Type 2 physeal injury with a metaphyseal (Thurston-Holland) fragment. C: Type 3 physeal injury with fracture of part of the epiphysis (intraarticular injury). D: Type 4 physeal injury with fracture of the metaphysis and epiphysis (intraarticular injury). E: Type 5 physeal injury with compression of the physis. F: Type 6 physeal injury (peripheral injury). G: Type 7 physeal injury (avulsion injury). Arrows represent force lines.
The injured child may be more difficult to examine than an adult. Children’s hands are chubbier, which may hide clinical deformities. A child in pain may be less cooperative with clinical and x-ray examinations than an adult. Although dislocations are rare in the child’s hand, forcible attempts at closed reduction may cause a physeal injury (12). The child’s injured hand requires more extensive and sturdier immobilization than the adult’s (13). Splinting of a single finger in the child is likely to cause angulation of a fracture (26), and children are better able to wiggle out of a splint or cast. A long arm cast with the elbow flexed to 90 degrees may be necessary, even for a fingertip injury. As in adults, malrotation does not remodel (26). Limited remodeling occurs in the radioulnar direction, except at the base of the proximal phalanx, where remodeling in this direction occurs more reliably owing to the nature of metacarpophalangeal joint (MCPJ) motion (25). Malunions of fractures of the phalangeal neck, at the opposite end of the bone from the physis, rarely remodel in children (27). Diaphyseal malunions usually do not remodel (25). Older children (those with less than 2 years of growth remaining) have diminished remodeling potential compared to younger children.
One final characteristic that is unique to children’s hands is the unfortunate fact that the child’s hand may be a target of abuse or may be injured when the child is trying to protect him- or herself from abuse. Findings characteristic of abuse include hand burns in a glovelike immersion pattern, dorsal-only hand burns, banding injuries around the wrists (from hands tied together, to restrain the child), hand fractures in children younger than 1 year of age, and any hand injury that the child is developmentally too immature to have caused himself or herself (28,29,30,31,32 and 33).
SURGICAL ANATOMY
If possible, surgery on the child’s hand should be planned to avoid exposure or transfixion of the physes, which are easily seen on x-ray (Fig. 1). Transfixion of the physis is discussed in the section Surgical Management.
The locations of the attachments of the extrinsic extensor and flexor tendons, collateral ligaments, and volar plate relative to the physis may contribute to the unique configurations of some children’s hand fractures (Fig. 4). The flexor digitorum profundus (FDP) and flexor pollicis longus tendons attach to the distal phalanx, distal to the physis. The terminal portions of the extensor digitorum communis and the extensor pollicis longus insert into the epiphysis of the distal phalanx, proximal to the physis (34). Thus, when forced flexion of the extended distal interphalangeal joint (DIPJ) occurs in a child or adolescent, the resulting injury may be physeal or bony, rather than tendinous, as in an adult mallet injury (8,35,36 and 37). The collateral ligaments of the DIPJ and proximal interphalangeal joint (PIPJ) attach to epiphyses and metaphyses, whereas the collateral ligaments of the MCPJ attach almost entirely to the epiphyses (38). The volar plates of the DIPJ and PIPJ attach distally to the epiphyses of the distal phalanx and middle phalanx, respectively, and the volar plate of the MCPJ links the epiphysis of the metacarpal to the epiphysis of the phalanx (34). The clinical significance of these findings is not known.
FIGURE 4. A: Attachments of collateral ligaments at the interphalangeal joints. B: Attachments of collateral ligaments at the metacarpophalangeal joints.
PATHOPHYSIOLOGY
The cause of hand injuries varies with age. In toddlers, fingertip crush injuries from doors (39,40) and exercise equipment (41,42) are common, whereas, in older children, falls (25) and sports injuries (3,20,43,44,45,46,47,48,49,50 and 51) are more common etiologies. Gunshot wounds (52) and blast injuries (21,53) are less common, but important, causes of hand injuries in children and adolescents from a prevention perspective.
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After the toddler years, boys sustain hand fractures more frequently than girls (3,25,54,55). The incidence of left and right hand fractures is approximately equal in some series (20,55); in others, right-sided hand fractures predominate (7,25); and in one series of upper extremity fractures, there was a large majority of left-sided fractures (56). Fractures of nonborder digits should prompt the clinician to look for additional hand injuries, because, in one series, analysis of multiple synchronous digit fractures showed an increased relative proportion of fractures of nonborder digits compared to border digits (7).
Physeal and epiphyseal injuries are classified by the Salter-Harris system (see the previous discussion in the introduction). Other classification systems that are used to describe individual fractures are discussed in the following sections.
Triangular Fibrocartilage Complex
Pediatric triangular fibrocartilage complex (TFC) injuries may be more common than previously was supposed (57,58). One review of 29 children and adolescents with ulnar wrist pain that was associated with surgically documented TFC tears showed an average age of 13 years and common coexistent pathology, including distal radioulnar joint instability, ulnar styloid nonunions, ulnocarpal impaction, and distal radius deformity (58). In this same series, 79% of TFC tears were classified as Palmer type 1B (see Chapter 20), and delay in diagnosis was prolonged, perhaps because symptoms were relatively mild.
Carpus
Carpal injuries in children are uncommon (12,59,60 and 61). Instead of injuring the carpus, the stress of a fall on an outstretched hand is usually absorbed by the child’s flexible joints or unossified cartilage, or the distal radius, forearm, or distal humerus is injured.
The scaphoid is the most commonly injured carpal bone in children (22,23,62,63,64,65,66 and 67). The changing composition of the scaphoid during growth (as ossification occurs) may be associated with changing vulnerability to fracture (60). Unlike scaphoid fractures in adults (see Chapter 22), pediatric scaphoid fractures usually involve the distal one-third of the scaphoid (possibly due to eccentric ossification) (59) and are most commonly avulsion type fractures (62,63,65,66 and 67). In adolescents, scaphoid fractures are not uncommon in sports injuries (43,45,49), and waist fractures are more common than in children.
Fractures of carpal bones other than the scaphoid are rare in children. Case reports of capitate, lunate, trapezoid, and hamate fractures have been published, along with reports of avulsion fractures of the triquetrum and dislocation of the pisiform (59,60 and 61). Capitate and scaphoid fractures may occur together (60). Intercarpal instability is rare and difficult to diagnose in children (60,68).
Metacarpals
The small finger metacarpal is one of the most commonly fractured bones in the hand and usually is injured at the level of the neck in adolescent boys during fist fights or sports (20,57). Thumb metacarpal fractures are also common; this bone is usually injured at the base, and the most common type of injury is Salter-Harris type 2; the metaphyseal fragment can be medial or lateral (55,69). Pediatric Bennett’s fractures may occur; these are Salter-Harris type 3 (45,69). Metacarpal fractures of the fingers are rarely physeal injuries (70), unlike thumb metacarpal fractures (34% epiphyseal in one series; all Salter-Harris type 2) (7). Salter-Harris type 3 or 4 metacarpal head fractures are occasionally seen in adolescents; these are difficult to diagnose and treat (50,70,71).
Metacarpophalangeal Joint
The incidence of MCPJ dislocation is underestimated in children (72), and children are more likely than adults to sustain an osteochondral fracture of the head of the meta-carpal when the MCPJ is dislocated, usually in the palmar direction (12,72,73 and 74). The index is the most common finger to sustain this injury. Palmar dislocation of the thumb MCPJ also occurs in children (12).
Pediatric gamekeeper’s injuries are different from adults. Injury to the MCPJ ulnar collateral ligament is rare in children. In younger children, a Salter-Harris type 1 or 2 injury to the proximal phalangeal physis may occur; in adolescents, a characteristic Salter-Harris type 3 avulsion fracture of the palmar ulnar base of the proximal phalanx may be seen (7,71) (Fig. 5).
Proximal and Middle Phalanges
In one large series of children’s phalangeal fractures, the most commonly fractured phalanx was the proximal phalanx, followed by the middle and distal. The most commonly fractured finger was the small finger, followed by long and ring fingers (with equal frequency), and then index finger, with thumb fractures the least frequent. Regarding location of the fracture within the phalanx, epiphyseal and metaphyseal injuries were the most common, followed by diaphyseal, intraarticular, and phalangeal neck fractures (75).
Salter-Harris type 2 fractures of the thumb and small finger proximal phalanx are the most common types of proximal and middle phalangeal fractures (25). At the base of the small finger, this is called an extraoctave fracture, when it is displaced into abduction (26,76). Salter-Harris type 1 and 3 fractures of the proximal phalanx may displace rotationally; this is difficult to diagnose and does not remodel (77,78).
Metaphyseal fractures of these bones remodel in the planes of motion (flexion/extension for both if the apex is
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palmar, and radial/ulnar for the proximal phalanx), if enough growth remains (12,25). As in adults, phalangeal shaft fractures may be difficult to treat owing to the deforming forces that are created by tendon insertions (see Chapter 8).
Phalangeal neck fractures (also called subcondylar, supracondylar, and cartilaginous cap fractures) are almost unique to children (7,12,25,27,55,79,80,81,82,83 and 84). These are often caused by entrapment in a door, with rotationally displacement as the child tries to extricate the finger. They have been classified into three types: type 1 (undisplaced), type 2 (displaced with some bone-to-bone contact), and type 3 (displaced with no bone-to-bone contact; four subtypes, depending on position of articular surface) (79) (Fig. 6). These treacherous fractures are difficult to diagnose and tend to displace after reduction. They do not remodel with growth. Distal unicondylar fractures may occasionally occur in children (85).
FIGURE 5. Pediatric gamekeeper’s injury (adolescent; type 3). Arrow represents force line.
Proximal Interphalangeal Joint
PIPJ dislocations are more common than DIPJ dislocations in children, but both are unusual (20), because the forces that dislocate these joints in adults are more likely to cause physeal injuries in children (12). In adolescents, however, dorsal PIPJ dislocations (jammed finger) are frequently associated with sports, when ball contact causes direct axial compression of the fingertip (45). Complete dorsal dislocation of the middle phalangeal epiphysis has been reported, which is analogous to a boutonnière injury in adults (55,86).
FIGURE 6. Classification of phalangeal neck fractures. The distal fragment is mostly composed of cartilage. The shaded ossified portion is seen on x-ray.
Distal Interphalangeal Joint, Distal Phalanges, and Fingertips
Because the extensor digitorum communis inserts into the epiphysis, and the FDP inserts into the metaphysis (34) (see the section Surgical Anatomy), and because the FDP insertion is stronger than the bone and physis, children have characteristic skeletal age-related mallet injury configurations, when they are subjected to forced DIPJ flexion. Unlike mallet injuries in adults, these injuries are more likely to involve the physis and the joint in children and adolescents, with Salter-Harris type 1 or 2 injuries occurring in children and type 3 injuries in adolescents (7,45,55,71,87) (Fig. 7).
Forced DIPJ extension may cause FDP avulsion along with an intraarticular fracture; this is most commonly seen in the ring finger and is incurred while playing football (51,71). DIPJ dislocations are rare in children (88).
Distal phalangeal fractures due to crush injuries (usually from doors) are common in children (39,87). In one large series, 40% of distal phalangeal fractures were physeal, and more than 50% of these were Salter-Harris type 2 (7).
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These fractures are commonly open and are frequently undertreated, because the extent of injury is missed by the primary practitioner. Avulsion of the base of the fingernail with a nailbed laceration should arouse suspicion of an open distal phalanx fracture (7,12,3,36,39,55,71,89,90,91 and 92).
FIGURE 7. Child and adolescent mallet fractures.
Amputations
Finger and fingertip replantation have broader indications in children, because the prognosis is usually better than it is in adults. The most common level of amputation in children is through the distal phalanx, and crush and avulsion are common mechanisms (12,93,94). In one series, 80% of growth was maintained after replantation (94).
EVALUATION
Evaluation of the child’s hand may be tricky. The child who is in pain is a poor historian and is less likely than an adult to be cooperative with physical examination. Imaging studies may be unreliable or misleading, if the child is unable to remain motionless while the studies are obtained. The child is more likely to cooperate with evaluation when pain relief is adequate and a comforting parent is present.
X-ray does not reveal nondisplaced Salter-Harris type 1 or type 5 fractures (see the previous discussion in the section introduction) or displacement of unossified epiphyses (92). As in adults, x-rays do not show malrotation (77). Evaluation of partial physeal arrest to determine the presence and location of a bony bar is probably best done by fine-cut computed tomography (19).
The examiner should keep in mind the possibility of child abuse when evaluating the child’s injured hand. Skeletal surveys for possible abuse should include the hand (see the previous discussion in the section introduction).
Triangular Fibrocartilage Complex and Carpus
Diagnosis of TFC injuries is frequently delayed in children and adolescents. Diagnosis is probably best made by arthroscopic examination (58).
The normal ossification centers of the carpal bones appear on x-ray and complete ossification at predictable skeletal ages for girls and boys (4,23,60,95) (Table 1). Multiple ossification centers may be present within a single carpal bone, but this is uncommon, and coalescence is rapid (23,96). Thus, a persistent bipartite carpal bone (such as the scaphoid) probably represents a fracture nonunion, which is also uncommon in children (96).
Most scaphoid fractures in children are harder to diagnose than to treat (64). In one study, plain x-rays failed to reveal 13% of these fractures until 2 weeks after injury (62).
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Scaphoid views help to show the older adolescent’s fracture, when its configuration is more similar to adult fractures (45). The distal avulsion fractures that are most commonly seen in the incompletely ossified scaphoid of children and younger adolescents are best visualized on tangential lateral oblique supination views (60,63) or pronation views (66).
If the clinician suspects a scaphoid fracture, but the initial x-rays are negative, and 2 weeks of immobilization followed by repeat x-rays is contraindicated, magnetic resonance imaging (MRI) may be obtained. MRI has a 100% negative predictive value for scaphoid fractures (97) and is more reliable than bone scan (98). Marrow edema on MRI does not indicate occult fracture (97). MRI might also help with the earlier diagnosis of scaphoid stress fracture in gymnasts (49).
When the capitate fractures (an unusual occurrence in children), the proximal fragment tends to rotate, which makes its position difficult to assess on plain x-rays. Computed tomography may be required to adequately visualize a fractured capitate (60).
The carpal bones appear on x-ray as ossific nuclei that are surrounded by radiolucent cartilage. Although the distance between the scaphoid and lunate ossific nuclei in 7-year-old children averages 9 mm (68), this is the normal appearance of the immature carpus and should not be mistaken for scapholunate dissociation.* MRI is required to document true diastasis (60).
Metacarpals and Metacarpophalangeal Joint
The extended MCPJ disguises malrotation and angulation of metacarpal fractures, and inadequate lateral x-rays may further confuse the clinician. The position of the reduction should be checked clinically in MCPJ flexion before immobilization (55).
A widened joint on anteroposterior (AP) x-ray suggests a complex MCPJ dislocation (12). Children with this injury are likely to have an osteochondral fracture (73); the presence of this on x-ray should not be confused with an as-yet unossified sesamoid bone (72). At the thumb MCPJ, children are more likely to sustain a bony gamekeeper’s injury than an injury to the ulnar collateral ligament. The bony fragment may be nondisplaced and difficult to view on x-ray, thus requiring stress views for diagnosis (12).
Proximal and Middle Phalanges and Proximal Interphalangeal Joint
The true lateral view of the finger (not the hand) is the most important x-ray of the child’s injured finger and is probably the most difficult to obtain (12). Epiphyseal fractures of the phalanges are best seen on the lateral view (24). Several unusual types of children’s phalangeal fractures also have x-ray pitfalls. For Salter-Harris type 3 fractures of the proximal phalanx, x-rays underestimate the size of the fragment and the degree of rotation (78). Phalangeal neck fractures may be missed on the AP view; a true lateral x-ray is critically important to diagnose these fractures (80,81,83,84) (Fig. 6). Adequate evaluation of intraarticular fractures of the phalanges requires four views (AP, lateral, and two obliques) (71,99).
Distal Interphalangeal Joint, Distal Phalanges, and Fingertips
In children, an extension lag after a forced flexion injury requires a true lateral x-ray to diagnose a bony mallet injury (12,36). A lateral x-ray after a reverse mallet injury (forced extension injury that causes FDP avulsion) is also useful, as a small bony fleck may indicate the level of retraction of the FDP (51).
X-rays should be obtained after a nailbed injury or traumatic avulsion of fingernail, or both, to check for a distal phalanx fracture as the cause of the soft tissue injury (90,91). Distal phalangeal fractures with overlying soft tissue injury are open fractures, making the diagnosis imperative for appropriate treatment. Radiographic diagnosis of distal phalangeal physeal separations is particularly challenging in toddlers, when the injury occurs before the ossific nucleus appears (55,92).
Supporting the injured fingertip with another finger or an object, such as a pencil, while obtaining x-rays may inadvertently reduce a distal phalanx fracture, thus making it less visible on x-ray and causing the diagnosis to be missed (100).
NONOPERATIVE TREATMENT
The majority of children’s hand fractures are treated nonoperatively (7,12,71,75). The clinician has the luxury of relying on remodeling to correct residual angulation in selected cases. Remodeling occurs reliably in the plane of joint motion for metaphyseal fractures with adequate growth remaining. Remodeling is less reliable for shaft fractures and does not occur in fractures at the end of the bone that is opposite the physis, in malrotation, or in children near the end of growth (25,26 and 27).
Three to 4 weeks of immobilization is adequate for most metacarpal and phalangeal fractures, before allowing active range of motion (12). X-ray evidence of union lags behind the absence of tenderness, which is the best clinical evidence of union; thus radiographic union is not a prerequisite to mobilization (55). Postimmobilization stiffness is rare in children (55).
Triangular Fibrocartilage Complex and Carpus
TFC injuries are diagnosed by arthroscopy and are treated operatively (58). Scaphoid fractures in children are usually distal one-third fractures or distal avulsion injuries (60,67), and the majority of these fractures heal with cast immobilization (62,64),
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as long as treatment is not delayed (65). Transverse distal one-third scaphoid fractures should be immobilized for 4 to 8 weeks in a short arm-thumb spica cast (60); avulsion fractures probably heal faster. Even if treatment of a transverse fracture is delayed, a trial of cast immobilization is more likely to be successful than in adults, as long as the fracture is not displaced. Immobilization is also sufficient treatment of fractures of other carpal bones.
Metacarpals and Metacarpophalangeal Joint
Most metacarpal fractures in children are treated nonoperatively. In the thumb, as much as 30 degrees of angulation and 1 mm of intraarticular displacement can be accepted in fractures of the base of the metacarpal, and the periosteal sleeve may support a closed reduction of a Salter-Harris type 2 Bennett’s fracture, thus obviating the need for pinning (12,69). In particular, Salter-Harris type 2 fractures with a medial metaphyseal-epiphyseal corner tend to do well with closed reduction and casting (69). Closed reductions of thumb MCPJ dislocations are usually successful (12). Bony gamekeeper’s injuries can be treated closed, as long as the avulsed fragment is not significantly displaced or rotated (55).
Fractures of the small finger metacarpal neck may angulate as much as 40 degrees without significant limitation of function; this malunion does not remodel in the older teenager, and more than 40 degrees of angulation may cause a painful lump in the palm (12). Intraarticular metacarpal head fractures are not suitable for closed treatment (55,70).
Repeated attempts at closed reduction of a finger MCPJ dislocation are contraindicated, as the dislocation may be complex and requires open reduction (71,72 and 73). Hyperextension of the MCPJ should be avoided during attempted reduction of MCPJ subluxation, as this maneuver may convert this injury to a complex dislocation (72).
Proximal and Middle Phalanges and Proximal Interphalangeal Joint
The majority (80% to 90%) of children’s phalangeal fractures are treated closed (12,71). It is easy to underestimate the displacement of physeal fractures through the base of the proximal phalanx, before the epiphysis is completely ossified (71). Closed reduction is frequently required for ulnar angulation of proximal phalangeal base fractures of the small finger (extraoctave fracture) (26,76). This type of fracture is frequently a greenstick fracture, which requires fracture completion as part of the reduction maneuver (12). A pencil or similar object that is placed between the ring and small fingers can be used as a fulcrum for reduction (26) but should not be left in place in the cast. Closed reduction of displaced phalangeal physeal and shaft fractures is usually successful, although several cases of interposition of soft tissue, such as flexor tendon (101,102), lumbrical and interosseous tendon (103), and volar plate (104), have been reported.
Similarly, closed reduction of PIPJ dislocation is usually successful, and reports of soft tissue interposition that blocks reduction are the exception rather than the rule (74,105). If gentle attempts at closed reduction are unsuccessful, force should not be applied, as forcible attempts to reduce a PIPJ can cause physeal fractures (74).
Closed reduction is usually inadequate for displaced phalangeal neck fractures or intraarticular fractures. Even when they are nondisplaced, it is difficult to maintain the position of these two types of fractures in a cast (71,79,99).
Distal Interphalangeal Joint, Distal Phalanges, and Fingertips
As in the PIPJ, if a DIPJ dislocation is irreducible, the clinician should suspect soft tissue interposition, which precludes closed treatment. Interposition of the volar plate has been reported in a DIPJ dislocation in a child (88).
Most bony mallet injuries in children can be treated with extension splinting. The position in the splint should be at less than 50% of available passive DIPJ hyperextension (71); these injuries require longer immobilization than most pediatric hand fractures (7). The Salter-Harris type 3 bony mallet in the adolescent usually requires operative treatment (71), although some authors prefer to accept the dorsal bump that may result from closed treatment (24).
Fractures of the distal phalanx due to crush injuries are frequently open and therefore should be irrigated and débrided (71). If available, the avulsed nail may be reinserted under the eponychium to splint the fracture (7). Cast immobilization for younger children or splint immobilization for older children is usually sufficient.
Children with a subungual hematoma from a crush injury but no disruption of the nail margin can be treated with trephination for pain relief instead of nail removal and nailbed exploration; this treatment has good results, regardless of the size of the subungual hematoma (106).
SURGICAL MANAGEMENT
Most pediatric hand fractures that require open reduction and internal fixation are best treated with Kirschner wire fixation. Placement of Kirschner wires across a physis is often necessary to obtain adequate fixation. On rare occasions, this can cause a bony bridge across the physis, which results in a physeal arrest (71). In general, based on experimental work in skeletally immature dogs, pins that are placed across a physis are less likely to cause damage, if they are smooth and centrally placed and have a small diameter relative to the physis. Peripherally placed pins may cause a peripheral bony bridge and a resulting angulatory deformity, but the physis continues to grow around a small, centrally located bony bridge. Growth disturbance consistently results when a large bony bridge forms or if a screw is placed across a physis. Both
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serve to mechanically fix the epiphysis to the metaphysis (107) (see the section Complications).
Triangular Fibrocartilage Complex
Adolescents with persistent ulnar wrist pain after a wrist injury should be evaluated for TFC injury. Concomitant injuries are the rule (86% of children and adolescents with TFC injury in one series had an ulnar styloid nonunion, distal radioulnar joint instability, ulnocarpal impingement, or distal radius deformity due to malunion or growth disturbance) (58). Diagnosis of TFC disruption is made arthroscopically. In most children and adolescents, the TFC injury is Palmer type 1B (108) (see Chapter 20). Good relief of pain can be expected, if the lesion is repaired (58).
Carpus
Scaphoid nonunion is rare in children and adolescents, probably because they tend to sustain distal one-third or avulsion fractures, which have a better prognosis than waist fractures (the most common type in adults) (96). When nonunion occurs in this population, standard treatment (bone graft and internal fixation) is successful (109) (see Chapter 21). One case report indicates that, in two children, scaphoid malunion remodeled spontaneously, thus precluding the need for surgical correction (110). Surgical treatment of fractures of carpal bones other than the scaphoid is rarely indicated.
True scapholunate ligament disruption is rare in children and adolescents, although the clinician may be deceived by the apparently abnormally large distance between the scaphoid and lunate, which is due to incomplete ossification of these bones, on x-rays of young children (68). Case reports of scapholunate ligament disruption have been published; one indicates that dorsal capsulodesis may be helpful in the surgical treatment of this condition (111,112) (see Chapter 25).
Metacarpals and Metacarpophalangeal Joint
There are few indications for surgical treatment of metacarpal fractures in children. Certain types of fractures of the base of the first metacarpal are likely to fail closed reduction and casting and to benefit from closed reduction and pinning. These include pure metaphyseal fractures and Salter-Harris type 2 fractures with a lateral metaphyseal-epiphyseal corner. Salter-Harris type 2 fractures with a medial metaphyseal-epiphyseal corner tend to do well with closed reduction and casting (69) (see Chapter 12). Displaced intraarticular fractures require surgery (55,70) (see Chapter 11).
Bony gamekeeper’s injuries (the child or adolescent version of avulsion of the metacarpal ulnar collateral ligament) may require reduction and pinning, if the bony fragment is displaced or rotated, or if there is a significant intraarticular step-off (55).
Children and adolescents may sustain complex dislocations of the finger MCPJ. In contrast to adults with this injury, they may be more likely to incur an osteochondral fracture at the time of dislocation, which is often difficult to visualize on x-ray. Better visualization of this fracture fragment is the basis for recommendation of the dorsal approach to a complex MCPJ dislocation in children or adolescents (71,73), although some authors have recommended a palmar approach (72). Children may not need a relaxing incision in the volar plate, owing to increased ligamentous laxity compared with adults (72) (see Chapter 11).
Proximal and Middle Phalanges and Proximal Interphalangeal Joint
In one large series, 10% of children’s phalangeal fractures required operative intervention for loss of joint congruency or for angulatory or rotational malposition that was unlikely to correct with remodeling (75). Salter-Harris type 1 and 2 fractures of the base of the proximal phalanx rarely require surgery, unless soft tissue interposition blocks reduction or the fracture is malrotated (7,71,101,102,103 and 104,113). Salter-Harris type 3 and 4 fractures are more likely to require surgery (71,78).
Phalangeal neck fractures (Fig. 6) commonly require operative reduction and fixation (55,71,79,80 and 81,83) through an extensor-splitting approach (84). They may require longer than 6 weeks of immobilization (71).
PIPJ dislocations do not require operative intervention, unless soft tissue blocks reduction, or they are associated with a displaced intraarticular fracture. Intraarticular fractures of the base of the middle phalanx (usually Salter-Harris type 3) require operative treatment (71). Condylar fractures also require surgery and are likely to cause joint stiffness, even if an anatomic reduction is obtained and maintained (24,85,99).
Distal Interphalangeal Joint, Distal Phalanges, and Fingertips
DIPJ fracture dislocations, such as bony mallet fractures (Fig. 7) may require surgery, especially Salter-Harris type 3 injuries (71). Crush injuries with open distal phalangeal fractures require irrigation and débridement and possible nailbed repair (see Chapter 63).
Although these fractures usually heal, a considerable number (as many as 50% in one series) (71) have residual functional disability. Diminished sensation and fine motor coordination, cold hypersensitivity, and problems with nail growth are all common after distal phalangeal crush fractures (89). Late treatment of crush injuries (as late as 2
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weeks postinjury) has been reported to be successful, but these are best treated promptly (91,92,100).
Amputations
In general, the prognosis for replantation in children is better than it is for adults, thus making the indications broader (see Chapter 90). One large series reported 88% revascularization survival and 63% replantation survival in children overall, with higher digit survival rates and better recovery of two-point discrimination in the youngest children (114). Another series reported even higher survival rates and a mean growth of 80% of the contralateral side (94).
TABLE 1. AGE OF ONSET OF CARPAL OSSIFICATION
Bone Boys Girls
Mean onset (SD) Mean completion (SD) Mean onset (SD) Mean completion (SD)
Capitate 2.9 (1.7) 183 (12) 2.5 (1.8) 159 (10)
Hamate 4.2 (2.7) 183 (12) 3.1 (2.2) 159 (10)
Triquetrum 29.5 (16.2) 183 (12) 26.6 (14) 160 (9)
Lunate 43.5 (14.7) 183 (11) 36.1 (17.3) 160 (9)
Scaphoid 69.6 (15.4) 113 (17) 53.7 (15.8) 160 (9)
Trapezoid 72.0 (16.1) 111 (15) 51.8 (12.3) 160 (9)
Trapezium 72.7 (18.4) 110 (19) 51.6 (16.4) 160 (9)
SD, standard deviation.
Note: Means and standard deviations are expressed in months.
From Stuart HC, Pyle SI, Coroni J, et al. Onsets, completions, and spans of ossification in the 29 bone-growth centers of the hand and wrist. Pediatrics1962;29:237–249, with permission.
Replantation of fingertips also has better results in children than in adults. Fingertip amputations can be classified into four levels or zones, with different treatment recommendations and prognoses. Zone 1 injuries occur through soft tissue; zone 2 injuries are more proximal, but preserve more than one-half of the nailbed; zone 3 injuries preserve less than one-half of the nailbed; and zone 4 injuries are amputations that are proximal to the nail fold (115). Zone 1 injuries are repaired with a composite graft of the amputated tissue, if available; in zones 2 and 3, a single artery and, occasionally, a palmar vein can be repaired; and, in zone 4, artery and dorsal vein repairs are possible. Using these guidelines, authors in one large series achieved a greater than 50% success rate of replantation of fingertip injuries, with a success rate of 39% in adults. Reexploration of a failed fingertip amputation was unlikely to save the fingertip. Sensory recovery was good (115) (see Chapter 63).
COMPLICATIONS
Complications in children’s hand fractures are most commonly due to undertreatment. Parents may fail to appreciate the severity of their child’s hand injury and report late for care. The clinician may fail to establish or maintain reduction before malunion occurs (see the previous section Nonoperative Treatment) or fail to recognize an injury that requires operative intervention (see the previous section Surgical Management). Inadequate immobilization is a frequent cause of complications, as the child’s ability to wiggle out of a cast is often underestimated. Another source of complications is iatrogenic damage to the physis and, thereby, to the growth potential of the finger.
Metacarpals
One series of intraarticular distal metacarpal fractures included four teenagers who had avascular necrosis of the metacarpal head after injury, without obvious fracture. The authors recommended aspiration of traumatic MCPJ effusions in adolescents to possibly avoid this complication (50). As in adults, children with multiple closed hand fractures are at risk of the development of compartment syndrome (116), especially if they are obtunded from a head injury or under prolonged anesthesia (see Chapter 89).
Proximal and Middle Phalanges
A partial physeal arrest may be due to a peripheral physeal injury (Salter-Harris type 6) (Fig. 3) or iatrogenic damage from fracture fixation. The size of the metacarpal or phalangeal physis makes physeal bar resection, which is well described for partial physeal arrest in larger bones (19,117), a challenging undertaking. In the author’s experience, partial arrests are most commonly due to burns and respond well to epiphysiodesis (to prevent further deformity with growth) and osteotomy (to correct the deformity that has already occurred). In one reported case, a physeal bar, which formed following a Salter-Harris type 3 fracture, was treated in this fashion with good results (118).
Nonunion is uncommon in children’s hand fractures. Phalangeal neck fractures in which there is no bone-to-bone contact, owing to rotation of the distal fragment, are prone to nonunion, if they are not reduced (79).
Distal Phalanges
As in adults, overzealous dorsal splinting of a mallet injury in children can cause skin necrosis (71).
Metacarpophalangeal Joint, Proximal Interphalangeal Joint, and Distal Interphalangeal Joint
Posttraumatic arthritis is rare in children’s hands, and, when it occurs, pain is not usually a prominent complaint. Treatment options are limited, so, unless an arthritic joint is painful, operative management is probably not indicated (119,120).
If treatment is indicated, arthrodesis is the best treatment for the thumb carpometacarpal joint and MCPJ and the thumb and finger DIPJs and arguably is the best treatment for the finger MCPJs and PIPJs. Arthroplasty that uses distraction or resection has been attempted (119,121,122), with reported results that, although perhaps slightly better in children than adults, are underwhelming at best.
Joint transfer is another potential option for reconstruction of the isolated joint with posttraumatic arthritis. Nonvascularized joint transfers fail because of early joint degeneration (123). Free vascularized joint transfers have been recommended for the rarely indicated surgical treatment of the isolated MCPJ or PIPJ with traumatic arthritis (123,124,125,126,127 and 128). Although the joints reliably survive the transfer, and any transferred physes usually continue to grow, the
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reported results are unimpressive, as far as joint function is concerned, especially for the PIPJ. The toe MCPJ tends to hyperextend, when it is transferred to the hand MCPJ, and the toe PIPJ tends to have limited motion after transfer. Foot problems are uncommon. In general, this option has not proven as promising as it first appeared.
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*The normal scapholunate interval in the fully ossified adult wrist is 2 to 5 mm.