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FINGER MIDDLE PHALANX FRACTURE PEDIATRIC

Introduction

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

PIP joint volar plate avulsion fracture

PIP joint central slip avulsion fracture

Middle phalanx base epiphyseal 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 hand is the most common site of fracture in the pediatric population. The majority of these fractures occur in the phalanges, and the middle phalanx is least frequently affected of these bones, behind the distal and proximal phalanges, respectively. Mechanism of injury for pediatric middle phalanx fractures varies by age and includes falls, crushing forces, and sports participation. Although these fractures share some similarities with their counterparts in adults, special consideration must be given to key differences between the populations that will alter the diagnosis and management of middle phalanx fractures in children and adolescents.1-6

Definitions

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

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

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

S - Stability (stable or unstable)

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

  • Middle phalanx head: oblique, transverse, or comminuted; can involve the distal interphalangeal (DIP) joint; these are intra-articular fractures that usually affect one or both condyles of the middle phalanx head with or without displacement; displaced fractures can affect joint congruity.
  • Middle phalanx neck: fractures of the neck of the phalanges occur almost exclusively in children and are most common in the proximal phalanx, but can also occur in the middle phalanx; these fractures occur distal to the collateral ligament recess of the phalanx.1,3,10
  • Middle phalanx shaft: transverse, oblique, or comminuted, with or without shortening.
  • Middle phalanx base: can involve the proximal interphalangeal (PIP) joint; may be intra- or extra-articular and usually involve the dorsal or volar lip of the middle phalanx base;10 pediatric middle phalanx base fractures can also extend through the physis or metaphysis.1

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 middle phalanx require antibiotics with surgical irrigation and wound debridement.7,11,12

R - Rotation

  • Pediatric middle phalanx fracture deformity can be caused by rotation of the distal fragment on the proximal fragment. Significant malrotation can affect the position of the fingertip during grip.
  • 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 middle phalanx.
  • Radial or ulnar deviation and malrotation of pediatric middle phalanx neck fractures are also possible, and radiographs can underestimate the degree of clinical deformity.3
  • Oblique fractures of the small 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.4

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

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
  • Example: pediatric middle phalanx neck fractures usually have apex volar angulation with associated sagittal and subcondylar malalignment.1

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: fracture line defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
  • Most pediatric middle phalanx neck fractures are displaced, with dorsal translation and extension angulation.3

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Pediatric middle phalanx fractures can have fragment involvement with the DIP or PIP 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 middle 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.7-9

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

PIP joint volar plate avulsion fracture

  • The common mechanism of injury is a “jammed finger” at the PIP joint secondary to a hyperextension force—such as in ball-handling sports like basketball and volleyball—which can result in an avulsion fracture of the volar surface of the middle phalanx epiphysis. 3,4,13
    • The avulsion fracture size can range from a tiny flank to a larger fragment.10
  • Volar plate avulsion fractures at the PIP joint are more common than central slip avulsion fractures.10
  • Although not common, volar dislocation of the PIP joint may also be concomitant with these volar plate avulsion fractures.
    • If a force is exerted on the middle phalanx from the dorsal to the volar side, the middle phalanx will dislocate to the volar side, and the lateral band can become interposed between the proximal and middle phalanges; this injury can also rupture the central slip when it crosses the dorsal head of the proximal phalanx.14

Imaging

  • A true lateral X-ray view is essential to demonstrate if an avulsion fragment is present.

Treatment

  • Despite the high incidence of these injuries in children and adolescents, specific treatment guidelines for the pediatric population are scarce.13
    • Utilizing the most effective treatment protocol is therefore difficult, as there are several options available. Some physicians adopt protocols from adults to pediatrics, while others tend to follow general recommendations for fractures in children, particularly when a chip avulsion is visible in the radiograph.13
  • Most PIP joint volar plate avulsion fractures should be treated with early motion after a short period of extension block splinting for up to 10 days. Bony union is never achieved, but a fibrous nonunion confers adequate joint stability.3,13
    • Prolonged immobilization must be avoided in most cases because it can result in joint stiffness and permanent flexion contracture.13
  • Some experts recommend early active mobilization with minimal or no splinting, but this has not yet been supported by the available evidence.13
  • Certain cases of volar plate avulsion fracture with dislocation may be irreducible for several reasons, such as a longitudinal tear in the extensor tendon between the central slip and lateral bands or interposition of a collateral ligament or fracture fragment in the PIP joint. In children, the entire epiphysis may even be displaced and block reduction.15

Complications

  • Swelling
  • Boutonniere deformity
  • Joint stiffness
  • Permanent flexion contracture

Outcomes

  • In one study, patients with stable volar plate avulsion fractures treated with dorsal extension block splinting for 10 days experienced positive outcomes with no need for subsequent supplementary immobilization at the follow-up.13
    • Of the 33 patients with a complete follow-up, 31 (94%) had an excellent result and 2 (6%) had a good result.13
    • This demonstrates that the extension block splinting intervention is effective and well tolerated, and results seemed to be superior to those in adults; however, questions remain as to whether these injuries can be treated in an even less invasive way and whether any treatment is needed at all.13
  • Another study reported that stable PIP joint volar plate avulsion fractures were adequately managed with only minimal splinting or no treatment.16
  • Central slip avulsion fractures at the PIP joint are rare compared to volar plate avulsion fractures, and it is important to differentiate the two injuries.3
  • These types of avulsions result from hyperflexion, and similarly to volar plate avulsions, the most common injury mechanism is a jammed finger. This can tear the central slip from its insertion into the proximal portion of the middle phalanx.10

PIP joint central slip avulsion fracture

Typically, there is also injury to the extensor tendon that inserts into the middle phalanx, and a small avulsed bony fragment is often seen originating from the dorsal rim of the middle phalanx base.10

Imaging

  • AP and lateral X-ray views are recommended.
  • MRI and ultrasound may be needed to assess healing from these injuries if surgery is needed.

Treatment

  • Small flecks avulsed from the dorsal rim of the middle phalanx can be treated like volar plate avulsion fractures as long as an Elson test indicates intact central slip function.3
  • Larger, nondisplaced fragments should be treated with splint or cast immobilization to keep the PIP joint extended, thus allowing bony healing and restoration of the central slip insertion.
    • Displaced fractures or those associated with PIP joint subluxation require open reduction and internal fixation (ORIF).3
  • If the radial lateral band becomes interposed between the head of the proximal phalanx and base of the middle phalanx and the central slip ruptures, reduction is often needed.
    • One method to accomplish this is to pull out the radial lateral band upward from the joint space by anchoring the ruptured central slip to the base of the middle phalanx and also repairing the collateral ligament.
    • Three weeks of immobilization followed by active range of motion (ROM) exercises are recommended.14

Complications

  • Swelling
  • Stiffness
  • Contracture

Outcomes

  • Fixation of the central slip using the anchor system has been associated with good outcomes, but it is difficult to decide the most suitable anchoring position with a suture anchor since the original attachment of the central slip is on the epiphysis.14 

Middle phalanx base epiphyseal fracture

  • Epiphyseal fractures are prevalent in pediatric patients, and the phalangeal epiphyses are one of the most common locations for these injuries in children and adolescents.17
  • Epiphyseal fractures of the middle phalanx base occur almost exclusively in elite adolescent sport climbers. The long and ring fingers are most commonly affected, and the fracture pattern is usually Salter-Harris type III.18
    • These injuries typically result from excessive strain on the PIP joint, which is primarily a consequence of clinging to small handholds while climbing.18
    • Salter-Harris type III fractures appear to be fatigue fractures caused by repetitive stress and microtrauma, and a possible injury mechanism is chronic microfractures of the dorsal part of the epiphysis.19
    • Phalangeal epiphyseal fractures are becoming more common in skeletally immature patients as the sport of climbing is growing in popularity and young athletes are pushing their physical limits. It currently appears to be the most common injury among these athletes.18
    • There is a greater risk of injury to the epiphysis when the growth plate cartilage is beginning to close in developing athletes.17
    • The extensor mechanism of the PIP joint is attached by a median band to the dorsal articular capsule and is only attached to the middle phalanx at the epiphysis. Therefore, Salter-Harris type III fractures are also usually associated with injuries to the median band of the extensor mechanism.17

Imaging

  • AP and lateral X-ray views
  • Ultrasound
  • MRI

Treatment

  • Conservative treatment consisting of activity avoidance and gentle finger ROM exercises until fracture healing is recommended when a timely diagnosis is made and the fracture is nondisplaced, but surgery—such as ORIF—may be necessary when athletes present long after the initial injury with a displaced fracture and/or established nonunion.17,18
  • A percutaneous spot drilling epiphysiodesis technique may be used for epiphyseal fracture nonunion, which is minimally invasive and easy to perform.18
  • Extended activity avoidance may be sufficient for patients with Salter-Harris type II injuries.19

Complications

  • Osteonecrosis
  • Stiffness
  • Angular deformity

Outcomes

  • One study found that conservative management of nondisplaced middle phalanx base epiphyseal fractures was associated with excellent outcomes when the diagnosis was made early, but was more likely to fail in cases of delayed presentation, displaced fracture, and/or established nonunion.18
  • Another study identified good outcomes with conservative treatment in patients who presented early, but worse outcomes with a longer interval between the onset of symptoms and the start of therapy. Researchers suggested that ORIF may therefore be needed in these patients.19

Related Anatomy

  • The pediatric middle phalanx consists of a distal phalangeal head that articulates at the PIP joint with the distal phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the PIP joint with the proximal phalanx. In developing children and adolescents, the physeal plate is located at the base of the middle phalanx, which has a dorsal and volar lip.1
  • The ligaments associated with the middle phalanx at the DIP and PIP joints are the dorsal capsule, the proper and accessory collateral ligaments, and the volar plates, which stabilize the IP joints. The retinacular ligament, which runs obliquely along the middle phalanx, is also associated with this bone.
  • Tendon attachments of the middle phalanx include the flexor digitorum superficialis tendon, which is inserted by two slips on either side of the base of the middle phalanx, and the extensor digitorum tendons. The central slip of the extensor tendon attaches at the dorsal epiphysis of the middle phalanx, and the terminal extensor tendon attaches at the dorsal epiphysis of the distal phalanx.1
  • 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.20

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for 21% of all pediatric fractures, and the phalanges are the most commonly injured bones of the hands in this population.1,10
  • The annual incidence of phalangeal fractures in children and adolescents up to 19 years old is approximately 2.7%.21
  • Studies have shown that the proximal phalanx is the most frequently fractured phalangeal bone in the pediatric population, followed by the distal phalanx and the middle phalanx, respectively.5,6
  • The incidence of phalangeal fractures is highest in children aged 10-14 years, which coincides with the time that most children begin playing contact sports. About two-thirds of these injuries occur in males, which is likely due to their participation in contact sports.1
  • One study found that in the middle phalanx, fractures at the base of the bone were most common, followed by metaphyseal fractures.5
  • Another study found that the older the child, the more proximal the fracture that was sustained, and despite more patients being right-hand dominant, the distribution of phalangeal fractures was similar in both the right and left hands.2
ICD-10 Codes

  • PIP CENTRAL SLIP AVULSION FRACTURE PEDIATRIC

    Diagnostic Guide Name

    PIP CENTRAL SLIP AVULSION FRACTURE PEDIATRIC

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

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PIP CENTRAL SLIP AVULSION FRACTURE PEDIATRIC    
    - INDEX S62.621_S62.620_ 
    - MIDDLE S62.623_S62.622_ 
    - RING S62.625_S62.624_ 
    - LITTLE S62.627_S62.626_ 

    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 and tenderness
Loss of finger ROM
Typical History

A classic patient is a 15-year-old, left-handed girl who plays on her high school’s volleyball team. During practice, she attempted to “dig” a spiked ball—which is essentially volleying it before it hits ground—but was unable to assume the proper position with her hands clenched together in time. By the time the volleyball arrived, her fingers were still extended, and the ball struck her left ring finger. The traumatic force jammed her finger and resulted in an avulsion fracture of the PIP joint volar plate, which led to pain, swelling, tenderness, and a loss of finger ROM.

Treatment Options
Treatment Goals
  • When treating closed pediatric middle phalanx fractures, the treating surgeon has 4 basic goals:7,12
    1. A finger with a normal appearance. The X-ray may not need to be perfect but the finger should have no obvious deformity (ie, the finger looks normal!)
    2. Avoid finger stiffness by maintaining a normal functional ROM (ie, the finger works!)
    3. The finger is not painful (ie, the finger does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the joint does not develop early post-traumatic arthritis!)
    5. Fracture care should minimize the risk for infection and osteomyelitis.
  • One additional goal is mandatory for open fractures:
Conservative
  • The majority of pediatric middle phalanx fractures can be treated without surgical treatment.12 Most of these fractures are nondisplaced, and even most of those that are displaced are easily reduced closed and often quite stable.3
  • Vertically oriented oblique and spiral middle phalanx shaft fractures cannot be adequately immobilized with the use of buddy taping and a splint, and a more rigid type of immobilization—such as plaster or fiberglass cast—is often necessary.1
  • 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 for maintenance of reduction or protection of pins.3
  • The typical closed, nondisplaced, minimally angulated, middle 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.1
  • Even middle 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.
Operative
  • Surgical treatment of pediatric middle phalanx fractures must always be an individualized therapeutic decision. However, surgical middle 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 middle phalanx fracture involving the PIP joint, surgical fracture care may be required.
    3. Open middle 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 middle phalanx shaft fracture, and surgical fixation is often required in these cases.1
  • Displaced and angulated middle phalanx neck fractures are inherently unstable in the sagittal plane and therefore 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.1
    • 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.1
    • 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.3,4
  • CRPP techniques are also the preferred treatment for pediatric patients with acute middle phalanx condyle fractures; however, pinning of anatomically reduced fractures does occur with resultant intra-articular malunion, and open reduction and pin or screw fixation may be required to avoid complications.1,4
    • When repairing middle 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
  • In rare cases, ORIF may be necessary in pediatric patients with middle phalanx base fractures in which the flexor tendon or 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
  • All malrotated digits require anatomic reduction and operative stabilization. These are usually oblique middle 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.4
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 middle phalanx fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can be mobilized after 4 weeks.
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics (eg, cephalosporin, penicillin), and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.22
  • 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).
Complications
  • Adjacent joint stiffness is common after healing of displaced middle 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 the pediatric population. This makes cast immobilization of a finger or entire hand a more feasible option when treating pediatric middle phalanx fractures.3
  • Malunion and fingertip deformity after pediatric middle phalanx fractures is rare but can occur, especially in open, severe, unstable fractures.23 Oblique, intercondylar middle phalanx fractures are also at a high risk for malunion.4
  • Posttraumatic osteoarthritis can occur in the PIP joint after some pediatric middle phalanx fractures.
  • Chronic osteomyelitis of the finger middle phalanx is rare but can occur in open fractures, especially in patients with diabetes or in patients whose immune system is compromised.
Outcomes
  • Most outcomes after pediatric middle phalanx fractures are good.13,14,17,18 Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because the metacarpophalangeal and DIP joints of the finger can be mobilized while the PIP joint and middle phalanx are splinted.
  • In one study of 61 children with a displaced phalangeal neck fractures, 49 were treated with CRPP and 12 were treated with percutaneous reduction and pinning. Results indicated that 92% of patients had good to excellent outcomes, including fracture union, range of motion >50° at the DIP joint and >90° at the PIP joint, no residual deformity, and good to normal digit function.24
    • However, in another study of 37 children with displaced phalangeal neck fractures, outcomes were similar between patients in whom fracture reduction was achieved and maintained with buddy taping and a short arm splint and those who underwent CRPP.25
  • 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.3
Key Educational Points
  • Pediatric middle phalanx fractures must be immobilized before radiographic fracture healing is complete to avoid disabling stiffness.
  • Immobilization of pediatric middle phalanx fractures for >4 weeks is rarely needed.1
  • Today, as in ancient times, most pediatric middle phalanx fractures can be treated without surgery.9,22
  • 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 years in males and 14.5 years in females, and knowledge of these growth centers is important because iatrogenic physeal arrest may occur in patients with physeal injuries or those who undergo multiple fracture reduction attempts.1
  • An unmineralized physis is biomechanically weaker than the surrounding ligamentous structures and mature bone, which makes fractures of the physes more likely compared with ligamentous injuries or diaphyseal fractures.1
  • Pediatric middle 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.1,3
  • Despite the general ease of treatment and good outcomes of many pediatric middle phalanx fractures, it is essential to carefully and thoroughly evaluate each injury to consider the possibility of any special fractures that may require a more intense course of treatment. Most complications in treating these pediatric patients occur because the severity of the injury is underestimated on initial evaluation.3
References

New and Cited Articles

  1. Abzug JM, Dua K, Bauer AS, et al. Pediatric Phalanx Fractures. J Am Acad Orthop Surg 2016;24(11):e174-e183. PMID: 27755266
  2. Chew EM, Chong AK. Hand fractures in children: epidemiology and misdiagnosis in a tertiary referral hospital. J Hand Surg Am 2012;37(8):1684-8. PMID: 22763063
  3. Cornwall R, Ricchetti ET. Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res 2006;445:146-56. PMID: 16505727
  4. Waters PM. Problematic pediatric wrist and hand injuries. J Pediatr Orthop 2010;30; Suppl 2:S90-S5.
  5. Vadivelu R, Dias JJ, Burke FD, Stanton J. Hand injuries in children: a prospective study. J Pediatr Orthop 2006;26(1):29-35. PMID: 16439897
  6. Liu EH, Alqahtani S, Alsaaran RN, et al. A prospective study of pediatric hand fractures and review of the literature. Pediatr Emerg Care 2014;30(5):299-304. PMID: 24759492
  7. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  8. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
  9. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
  10. Sivit AP, Dupont EP, Sivit CJ. Pediatric hand injuries: essentials you need to know. Emerg Radiol 2014;21(2):197-206. PMID: 24158746
  11. 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
  12. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  13. Weber DM, Kellenberger CJ, Meuli M. Conservative treatment of stable volar plate injuries of the proximal interphalangeal joint in children and adolescents: a prospective study. Pediatr Emerg Care 2009;25(9):547-9. PMID: 19755884
  14. Nanno M, Sawaizumi T, Ito H. Irreducible palmar dislocation of the proximal interphalangeal joint of a finger evaluated by magnetic resonance imaging: a case report. Hand Surg 2004;9(2):253-6. PMID: 15810116
  15. Crick JC, Conners JJ, Franco RS. Irreducible palmar dislocation of the proximal interphalangeal joint with bilateral avulsion fractures. J Hand Surg Am;15(3):460-3. PMID: 2348065
  16. Bowers WH. The proximal interphalangeal joint volar plate. II: a clinical study of hyperextension injury. J Hand Surg Am 1981;6(1):77-81. PMID: 7204922
  17. Desaldeleer AS, Le Nen D. Bilateral fracture of the base of the middle phalanx in a climber: Literature review and a case report. Orthop Traumatol Surg Res 2016;102(3):409-11. PMID: 26993857
  18. El-Sheikh Y, Lutter C, Schoeffl I, et al. Surgical Management of Proximal Interphalangeal Joint Repetitive Stress Epiphyseal Fracture Nonunion in Elite Sport Climbers. J Hand Surg Am 2017. [Epub] PMID: 29146511
  19. Hochholzer T, Schöffl VR. Epiphyseal fractures of the finger middle joints in young sport climbers. Wilderness Environ Med 2005;16(3):139-42. PMID: 16209469
  20. 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
  21. 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
  22. 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.
  23. Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001
  24. Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II displaced pediatric phalangeal neck fractures. J Hand Surg Am 2014;39(3):467-73. PMID: 24495624
  25. Park KB, Lee KJ, Kwak YH. Comparison Between Buddy Taping With a Short-Arm Splint and Operative Treatment for Phalangeal Neck Fractures in Children. J Pediatr Orthop;36(7):736-42. PMID: 25955173

Reviews

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

Classics

  1. Jones NF, Jupiter JB. Irreducible palmar dislocation of the proximal interphalangeal joint associated with an epiphyseal fracture of the middle phalanx. J Hand Surg Am 1985;10(2):261-4. PMID: 3980941
  2. Keene JS, Engber WD, Stromberg WB Jr. An irreducible phalangeal epiphyseal fracture-dislocation. A case report. Clin Orthop Relat Res 1984;(186):212-5. PMID: 6723146
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