Fractures and Dislocations in the Hand

Assessment, Classification, Management, and Complications

The differences between pediatric and adult hand fractures lie in the elasticity of children’s bones and the potential disruption of their growth.

Children’s bones have increased water content and plasticity, and tend to fracture incompletely with trauma. Incomplete fractures are seen as bows (bending forces), buckle fractures (one cortex buckles with compression), or green-stick fractures (one cortex ruptures under tension, the other is intact or buckles). The plastic deformation may prevent complete reduction of the fracture when manipulated, but most fractures still do not require open operations, but can be managed with closed or percutaneous techniques, due to the remodeling potential.

The assessment of the fracture is clinical and radiological. The child will have point tenderness in the nondisplaced fracture over the physis, which should increase suspicion of a fracture. If plain X-rays in two, if not three planes, cannot explain pain or deformation, MRI or CT will. The tenodesis test adequately demonstrates any rotational deformity, as the fingers should all be pointing towards the scaphoid tubercle. If in doubt, compare with the other hand. Angular deformities in children may remodel, rotational will not and needs to be corrected.

Any fracture interfering with the growth-plate has a potential for disrupting normal growth. Pediatric fractures involving growth plates are classified according to Salter and Harris. Ogden expanded the classification in 1984 ( Table 56.1 ). ^,

TABLE 56.1

The Pediatric Fracture: Management and Potential Complications According to the Salter–Harris Classification, Including Later Additions

Figures redrawn after Salter RB, Harris R. Injuries involving the epiphyseal plate. J Bone Joint Surg Am . 1963;45:587–621.

Classification	Clinical	Configuration	Management	Complication
I: through physis, showing increased width of physis	Point tenderness only		Conservative	Possible shortening
II: through physis and metaphysis	Occurs >10 years old		Manipulation under anesthetic if displaced	Minimal shortening
III: through physis and epiphysis	>10 years old		Accurate surgical reposition	Can result in chronic disability as extending into joint
IV: metaphysis, physis and epiphysis	Any age, rare in hand		If displaced consider ORIF	Intraarticular so can result in chronic disability and can cause premature focal fusion of the joint
V: compression of the epiphyseal plate	Usually from axial loading		Conservative	Growth disturbances
VI: open fracture in which part of the physis is missing	Open fracture		Initial fat grafting to prevent physeal bar, later reconstruction with bone graft	Growth disturbances
VII: epiphyseal plate only			Requires accurate re-positioning as intraarticular fracture	No impact on growth
VIII: Isolated injury to the metaphysis			Usually can be manipulated under anesthetic or if necessary fixed with K-wire	Potential injury related to endochondral ossification
IX: Injury to the periosteum				May interfere with membranous growth

K-wire, Kirschner wire; ORIF, open reduction internal fixation.

The most common fracture pattern encountered in the fingers is a Salter–Harris II, which is satisfyingly corrected with a simple maneuver with a pen, over which the finger is manipulated ( Fig. 56.1 ).

Crush distal phalanx fractures and nailbed injuries are the most common pediatric fracture. These occasionally need a Kirschner-wire (K-wire) or an orange needle to pin a larger distal fragment in place, but often the fragment is too small. A special type of nailbed injury is the Seymour fractures, which are displaced distal phalanx Salter I or II fractures, with avulsion of the proximal edge of the nail from the eponychial fold and the germinal matrix often interposed in the fracture itself ( Fig. 56.2 ). Accurate and timely debridement and repositioning of all tissues is therefore paramount to allow adequate growth of both digit and nail. The clinical presentation can be confused with a mallet finger (because the extensor tendon inserts itself in the epiphysis whilst the flexor tendon inserts itself in the metaphysis), but a true lateral X-ray and a thorough examination under anesthetic should reveal the injury.

Fractures through the neck of the phalanges are usually only found in children and mostly involve some unfortunate interface between fingers and doors. Al-Qattan divided them into three categories, which determined prognosis and treatment: type I fractures are undisplaced, type II fractures are displaced, but maintain some bone-to-bone contact, whilst type III fractures have no bone-to-bone contact. Type III is furthermore subdivided according to the location of the distal fragment, type IIID especially being associated with an avascular fingertip ( Fig. 56.3 ). Since the smallest displacement is poorly tolerated, all types apart from type I require open reduction and K-wiring, but have progressively worse prognoses.

Hand therapy intervention for these patients is minimum as younger children rarely become stiff at the DIP joint and instinctively start functional use once the bulky bandage or splint has been removed. Older children may require a volar splint of the affected digit until pain has settled alongside edema control work.

It is worth remembering that there is no gain in changing the dressings in nailbed injuries before 10 days, unless you are worried about infections, which of course is a different matter.

Metacarpal Fractures

Metacarpal fractures can be divided into their anatomical location or configuration, but most commonly occur in the little or ring fingers and the thumb.