Pediatric Phalanx Fractures

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1 Pediatric Phalanx Fractures Julie Balch Samora, MD/PhD/MPH March 1,

2 Disclosures Board/committee member: AOA, AAOS, ASSH, RJOS, POSNA Globus (spouse)

3 Goals To identify the most common phalanx fractures in the pediatric population To understand indications for non-surgical and surgical treatment of common injuries To recognize the bad players....

4 Outline Mallet fingers Tuft/SHII Phalanx Fractures Seymour fractures Phalangeal neck fractures Condyle fractures Thumb bony UCL injuries....

5 Physical Exam Integrity of the skin Neurovascular exam Deformity/malrotation/cascade Tenderness ROM Hand and forearm compartments

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8 Can utilize warm water to assess nerve function. Soak for 5 min. If wrinkling of skin pulp, digital nerves are intact.....

9 Bony injury Radiographs Proximity to growth plate Gas in soft tissues Glass - usu. radiopaque 2mm - 99% visible with 2 views 1mm - 80% 0.5mm - 65%....

10 Mallet Finger Disruption of terminal extensor tendon distal to DIP Can be either bony or tendinous Mechanism usually traumatic impaction to tip of finger in extended position PE: Extensor lag (resting position in flexion) and lack of active DIP extension

11 Mallet Finger treatment Splinting, splinting, splinting!!!

12 Pediatric Mallet Fingers Retrospective review of 99 mallet fingers, all but one treated with extension splinting 80% were bony mallet fractures Acutely treated patients (<28 days) had residual extension lag in 12% of patients and complications in 9% Chronic patients had higher rates of extension lag (25%) and complications (19%) 67% of nonadherent patients had lag and 50% had complications Lin JS, Samora JB. Outcomes of splinting in pediatric mallet finger. J Hand Surg Am

13 12 year old male who presented with an acute bony mallet finger due to a football injury

14 Goal is to prevent swan deformity!

15 Phalanx Fractures Check for skin integrity, malrotation, and instability Unstable: Oblique Spiral Comminuted Neck fractures P1 condyles

16 Distal Phalanx Tuft Fractures Most commonly fractured bone in the hand The majority can be treated conservatively

17 Salter Harris II fractures and phalanx shaft fractures Vast majority can be treated with closed reduction and casting Look for comminution/unstable features, which would preclude conservative mgmt

18 Extra Octave Fractures Al-Qattan et al. The diaphysial axis-metacarpal head angle in the management of fractures at the base of the proximal phalanx in children. JHS Eur, 2013.

19 Phalanx shaft fracture in 13 year old female

20 Closed reduction and casting in the ED

21 1 st week follow-up

22 2 nd week follow-up- some appreciable radial deviation of thumb, offered repeat closed reduction or CRPP. Patient declined.

23 4 week follow-up: Obvious clinical deformity

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25 Osteoclasis technique

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29 8 year old female with crush injury from desk falling onto left hand

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31 Phalangeal neck fractures (proximal/middle phalanges) Almost entirely a pediatric phenomenon 3 radiographic views Usually displaced These are HIGHLY unstable!!! Need anatomic reduction or else subcondylar fossa obliterated reduced flexion capability Must be operated on in an expeditious fashion

32 Al-Qattan MM, Al-Qattan AM. A review of phalangeal neck fractures in children. Injury, Int J Care Injured. 2015;46: Al-Qattan Extended Classification System of phalangeal neck fractures

33 Stepwise algorithm for phalangeal neck fractures 61 consecutive children treated according to the proposed algorithm CRPP PRPP ORPP No fracture required an open reduction All fx treated after 13 days required percutaneous pinning 45 excellent, 4 good (92% total), 1 fair, 3 poor results Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of Type II displaced pediatric phalangeal neck fractures. J Hand Surg. 2014;39(3):

34 Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of Type II displaced pediatric phalangeal neck fractures. J Hand Surg. 2014;39(3):

35 Obtain at least Two Views!

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37 13 year old female. Original x-rays, obvious deformity- was casted in situ

38 Presented in delayed fashion (4 months later) with clinical deformity and desire for improvement

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40 Phalangeal Condylar Fractures Type I (unicondylar, nondisplaced)- splint Type II (unicondylar, displaced)- surgery Type III (bicondylar)- surgery Poor prognosis, stiffness, DJD

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44 17 year old presenting 3.5 weeks from injury. Radiographs performed 2 weeks into injury at outside facility Painful, stiff, crooked finger

45 JHS Br 2002 Teoh Technique

46 Careful to preserve soft tissue attachments to condyle fragment

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49 8-year-old, right-hand-dominant male, playing in the basement with his brother when a cinder block fell and landed on his right thumb. Open injury treated with Keflex at outside hospital. Presents for definitive treatment.

50 Surgery-- one day after clinic visit. Simple I&D and CRPP.

51 4 week Follow-up- Placed Back in cast

52 ~9 weeks

53 5 months postop Thumb is completely non-painful but next to no motion at IP joint. Motion: Kapandji 10

54 11 months postop

55 11 months postop

56 Seymour Fracture Displaced physeal or juxtaphyseal distal phalanx fracture Lin, Popp, Samora. Treatment of acute Seymour fractures. JPO, 2019.

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60 Summary Hand injuries are extremely common in the pediatric population Thorough history, physical examination and imaging are critical Tenodesis is a great exam in children Mallet fingers can be treated with splinting alone Recognize problem fractures among seemingly minor finger injuries

61 Julie Balch Samora, MD/PhD/MPH