The hand and fingers are incredibly complex… and tremendously important to all of us (that opposable thumb is what helps us be classified alongside the other super cool primates like gorillas!). They also seem to be frequently involved in injuries. We have previously discussed the importance of metacarpal fractures and problematic issues like flexor tenosynovitis. Recently, a fantastic colleague of ours, Ashley Strobel (@AStrobelMD) pointed out that PedEM Morsels is missing an important aspect of hand injuries – Finger Fractures! While we have discussed Subungal Hematoma before, this entity deserves our caution. So, let’s digest a quick morsel of information on Finger Fractures in Children:

Finger Fractures: Basics

• The hand is the most often injured part of a child’s body. [Cornwall, 2012]

• Of hand fractures, finger fractures are the most common. [Abzug, 2016; Cornwall, 2012]
  • Young children – Household-related injuries (ex, closing doors)
  • Older children – Sports-related injuries

• Most finger fractures are treated conservatively and do well. [Cornwall, 2012]
  • Buckle fractures of the phalanges are stable.
  • Even displaced fractures can often be treated with closed reduction and immobilization.
    • The thick periosteal sleeve helps maintain reduction position.
    • “Buddy taping” can, however, also lead to problems. [Won, 2014]

• Some are prone to be more problematic though. [Cornwall, 2012]
  • Age matters.
    • Younger children typically do better.
  • Location of fracture and fracture pattern matter.
    • The growth plates are only at the proximal end of each individual phalanx.
    • Fractures that involve the physis lead to complications associated with growth plate injuries.
  • Local soft tissue involvement matters.
    • Fractures can entrap local connective tissue (ex, volar plate).
    • Open fractures may be concealed by an intact nail plate.

Finger Fractures: Evaluation

• While most finger fractures will do well with conservative management, this is predicated on the lack of concerning features. [Cornwall, 2012]

• The physical exam of an injured child can be difficult (child may not want to flex/extend actively).
  • “Passive” tests can be helpful: [Abzug, 2016; Cornwall, 2012]
    • Passive extension of wrist will flex fingers.
    • Compression of the forearm flexors will accentuate this.
    • Evaluate the resting cascade of the digits.
  • Evaluate for rotational deformities as well as angulation.

• Imaging is important! [Cornwall, 2012]
  • Often finger fractures can be seen on “hand” films…
  • Subtle finger fractures are easily missed on “hand” films!
    • The overlapping digits on the lateral film make appreciation of displacement difficult.
  • Always get a dedicated finger x-ray of the affected digit. [Cornwall, 2012]

Finger Fractures: Pitfalls

• Distal phalanx physeal / juxtaphyseal fracture (Seymour Fracture) [Cornwall, 2012]
  • Associated with laceration of the nail matrix.
  • Often has avulsion of the proximal nail plate (although not always apparent).
  • Distal nail plate is typically still attached.
  • The associated nail bed injury and disruption in eponychial fold and cuticle seal makes this an OPEN FRACTURE.
  • If Seymour fracture is suspected, the nail plate needs to be removed to assess the nail bed integrity.
  • If nail bed is lacerated, treat like open fracture.
    • Give antibiotics.
    • Needs gentle, but copious irrigation.
    • The torn nail matrix needs to be gentle removed from wound, as it will interfere with fracture reduction.
    • Younger children often need percutaneous pinning (by our Orthopaedic friends). Older children may not.
    • Nail bed will need to be repaired and nail plate replaced and sutured to the lateral nail folds.
  • These are distinct from distal tuft fractures – as tuft fractures don’t involve the physis.
  • Seymour fracture complications from delayed diagnosis:
    • Osteomyelitis
    • Growth arrest
    • Cosmetic deformity

• Phalangeal Neck Fractures [Cornwall, 2012]
  • Extra-articular transverse or oblique fracture.
  • Similar in supracondylar humerus fracture.
  • Occur almost exclusively in children.
  • Angulation and rotation are common.
  • Since growth plate is proximal to the injury, remodeling is limited.
  • Malunion, rotational deformity, and avascular necrosis may result. [Qattan, 2010]
  • Displaced fractures are unstable and require percutaneous pinning.
  • Reduced fractures still need close follow-up as stability may not be definitive. [Vonlanthen, 2019; Abzug, 2016]

• Phalangeal Condyle Fractures [Cornwall, 2012]
  • Intra-articular fracture.
  • Similar to lateral condyle fracture of distal humerus.
  • May appear minor on initial images.
  • Remodeling does not occur so anatomic reduction is imperative.
  • Can lead to intra-articular malunion.
  • Will require pinning or possible open reduction.

• Volar Plate Fractures [Cornwall, 2012]
  • Proximal Interphalangeal Joint has an avulsion of the insertion of the volar plate at the base of the middle phalanx.
  • Caused by hyperextension injury.
  • May have reported history of dorsal dislocation.
  • X-ray may only show a very small “fleck” of bone at the avulsed site.
  • Typically do well with 1 week of splinting or buddy taping and then 2 weeks of active range-of-motion exercises!
  • Prolonged immobilization may result in permanent loss of range-of-motion.

Moral of the Morsel

• Fingers are important! Don’t be cavalier with their injuries!
• Do NOT under appreciate that small fracture! It may appear like a small “chip,” but location may indicate a more ominous condition.
• Get dedicated finger films! Don’t make poor decisions based on poor information.
• Think about more than the bones! The connective tissues and soft tissues are very important also!

References