10 Pediatric Hand Fractures Abstract The hand is the most frequently injured part of the body in the pediatric population and an injury will often result in a fracture. The treatment of pediatric hand fractures is in some way different from the treatment of fractures in the adult population. Pediatric hand fractures often involves the growth plate and in the treatment of the pediatric hand fractures it is essential to be aware of the growing potential of the bones in children. Most of the fractures can be treated conservatively, but some special fractures should be operated. The special fractures which requires early operative treatment include fractures of the neck of the proximal and medial phalanx and dislocation of the nail combined with an epiphyseal fracture of the distal phalanx. Keywords: pediatric hand fracture, Seymour’s fracture, distal tuft fracture, phalangeal neck fracture, proximal phalanx fracture, metacarpal fracture, scaphoid fracture Pediatric hand fractures are fractures in children who still have open physes and therefore have special considerations regarding immobilization, remodelling potential, and surgical indications. The fractures in children heal more quickly than in adults and the short healing time makes early diagnosis and fracture reduction essential. Especially if the fracture involves the physes, where 5 days are the limit for safe reduction. The frequency of hand fractures in children is in some studies shown to be the second most frequent fracture in children following distal forearm fractures.1,2 Several studies have shown that the frequency of fractures increases from 11 years of age and peaks at 14 to 15 years of age1–5 since the children at that age begin to participate in sport activities. The fractures are frequently seen in boys with a ratio of 3 boys to 1 girl except in the age group younger than 2 years where four out of six fractures are seen in girls. The fracture type and the injury pattern are different in different age groups. The most commonly involved ray is the fifth ray where the metacarpal is the most commonly fractured bone followed by the proximal phalanx.3,5 The injury pattern varies with age and in most of the children between 0 and 5 years of age it is a crush injury at the fingertip and in the children between 10 and 17 years of age it is sports-related trauma.6 Children aged 0 to 4 years mostly get tuft fractures, 5- to 8-year-olds get fracture of the distal phalanx (tuft and transverse fractures), 9- to 12-year-olds get fracture of the proximal phalanx in the small finger, and children between 13 and 16 years of age get metacarpal neck fractures.7 Many of the hand fractures in children can involve the physes and can be classified in relation to the Salter–Harris classification types 1 to 5 ( It is often a challenge to examine an injured child. Observation of the child and a gentle maneuver are mandatory to get the correct information needed for the diagnosis. Try to talk about other things and give the child something to play with. And then look for swelling, hematoma, and active motion. The tenodesis effect or a gentle pressure to the muscle bellies proximal for the injury can be helpful to evaluate a rotational deformity. A careful examination of the nail plate is also useful. Rotation greater than 10 degrees out of the plane of adjacent nail plates should alert the examiner of a rotational deformity. Nevertheless, the best way to examine for malrotation is, if it is possible, to get the child to make a fist and always compare with the not-injured hand. Table 10.1 Classification of types of Salter–Harris fractures
10.1 Introduction
Table 10.1) (see also Fig. 1.5). In the hand, the physes are in the proximal part of the phalangeal bones, in the proximal part of the first metacarpal bone, and in the distal part of the second to fifth metacarpal bone. The proximal phalangeal epiphyses ossify between 10 and 24 months of age and the epiphyses of the middle and distal phalanges will ossify 6 to 8 months later. The closure of the physeal goes from distal to proximal direction and the physes are closed in boys when they are 16.5 years old and in girls when they are 14.5 years old. Until the closure, the physes are not mineralized and are therefore weaker than the surrounding mature bone, and hence the physes are more often involved in fractures in children. The periosteum that surrounds the pediatric bone is highly vascularized and serves as the source for cell differentiation during fracture healing. Following a fracture in a pediatric bone, the growth in the physes and remodeling in the diaphysis can correct an initial fracture deformity. This correction is more effective in the sagittal plane and near the physes, and better in younger children, while the remodeling is less good in the coronal plane. Rotational deformities cannot be remodeled and will therefore always require treatment with reduction and possibly closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF). Even though one-third of all bone damage in the child’s hand involves the physes, epiphysiodesis is a rare consequence.8 However, in younger children, the physes are very sensitive and therefore multiple attempts to reduce physeal fractures may destroy the physeal plate thus resulting in an iatrogenic physeal arrest. If reduction is impossible in one or two trials, it is recommended to consider an open reposition to avoid growth arrest.9
Type 1 Widening of the epiphyseal plate |
Type 2 Fracture through the metaphysis |
Type 3 Fracture through the growth plate |
Type 4 Fracture through the epiphysis and metaphysis |
Type 5 Compression of epiphysis |
The treatment of pediatric hand fractures is in some areas different from the treatment of hand fractures in adults. About 80% of hand fractures in children can be treated nonoperatively with a normal functional and aesthetic result.6 The nonoperative treatment consists of plaster, splint, or buddy taping (
Fig. 10.1a,b). These treatments can be used for stable fractures, without dislocation or fractures reduced to an acceptable position. The use of tape requires that the children are cooperative and can therefore only be used when the children are from 7 to 8 years of age. In children who are noncompliant or younger than 7 to 8 years, a splint or a plaster cast should be used. Unstable fractures and irreducible fractures require CRPP or ORIF with K-wires or screws. In small children (< 5 years), it may often be necessary to use an above-elbow circular soft cast (
Fig. 10.2) or plaster cast bandage to prevent them from removing the bandage. Immobilization time is 3 to 4 weeks. After this, the child can start using the hand without restrictions. There is usually no need for occupational therapy. The children do their own occupational therapy by using their hand and fingers in the daily play and sporting activities.
The operative treatment is usually CRPP or, if not possible, ORIF. Closed reduction is impossible later than 1 to 2 weeks after the trauma due to the initial bone healing.
Internal fixation must be protected by a splint or a cast, since children are not compliant to early mobilization and since they will quickly regain mobility after immobilization.
There are specific pediatric fractures that require special attention.
Fig. 10.1 (a, b) Buddy taping of fingers.
10.2 Special Children Fractures
10.2.1 Seymour’s Fracture
A Seymour’s fracture is a juxta-epiphyseal fracture or a Salter–Harris types 1 to 2 fracture in the distal phalanx with nail bed laceration (
Fig. 10.3), flexion deformity on the fracture site, and often nail plate subluxation.10–13 It is an open fracture and should be treated as such. The fracture often occurs when the finger is crushed in a door and is therefore a frequent fracture in smaller children. Clinically, it looks like a mallet finger and often the proximal part of the nail lays superficially to the proximal nail fold (
Fig. 10.4).
Fig. 10.2 Above-elbow circular soft cast bandage.
The extensor tendon and the palmar plate inserts onto the epiphysis of the distal phalanx, while the flexor tendon inserts onto the palmar part of the met aphysis. This results in a dorsal displacement of the proximal fragment and a palmar displacement of the distal fragment. The bone between the metaphysis and the epiphysis is the weakest part of the bone because of the nonmineralized physes. The surgical treatment of a Seymour fracture consists of debridement, removal of any interposed soft tissue from the fracture line, reposition of fracture/epiphysiolysis, nailbed repair, and nail plate fixation. It may be necessary to remove the nail, suture the nailbed with absorbable sutures, and reattach the nail to give support for the fracture/epiphysiolysis. When the proximal part of the nail lays superficially to the proximal nail fold, it must be repositioned under the proximal nail fold. It is also advisable to transfix the distal interphalangeal (DIP) joint with a 0.8-mm K-wire. The K-wire is cut outside the skin, so it easily can be removed after 3 weeks without anesthesia. In the case of small children younger than 4 to 5 years, it is advisable to bandage them with an above-elbow circular plaster cast including the entire hand (
Fig. 10.2) to prevent them from removing the bandage. Children older than 5 years can often be immobilized in a finger splint depending on the child’s compliance. After removal of the bandage and K-wire, the children can use the hand and fingers freely.
