Phalanges of the Hand
Phalanges of the hand are the most common site of physeal fracture.
Anatomy and Growth
Phylogenetically, there are physes and epiphyses at both the proximal and distal ends of all tubular hand bones [1]. In humans the distal epiphyses of hand phalanges typically fail to develop secondary centers of ossification. As a corollary, most growth occurs from the proximal physis [13]. Occasionally there is an attempt to develop an ossification center at the dis- tal end of phalanges in very young children. This is
Contents
Anatomy and Growth .. . . ..201
Classification ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...203
Epidemiology .. . . ..203
Literature.Review.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .203
Olmsted.County.Study. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .205
Type.1... . . ..205
Type.2... . . .206
Type.3... . . ..207
Types.4,.5,.and.6... . . ..207
Evaluation . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .208
Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...215
Complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .222
Irreducible.Fractures. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .222
Malrotation.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...224
Premature.Physeal.Arrest.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .224
Degenerative.Arthrosis.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .224
Infection.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .225
Ischemic.Necrosis.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .225
Refracture... . . .225
Author’s Perspective. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .225
References . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .225
called a pseudoepiphysis and is rare [36]. Usually there is only one ossification center in each proximal epiphysis. However, multiple centers can occur, par- ticularly in the proximal phalanx of the thumb [45].
Ossification of the proximal phalangeal epiphyses in the four fingers begins between 10 and 24 months of life, and in the middle and distal phalanges be- tween 16 and 36 months (Fig. 9.1) [19, 41, 42]. Ossifi- cation of the epiphyses of both thumb phalanges oc- curs between 16 and 36 months of life. In the proximal phalanges, ossification begins first in the third finger, followed in order by the second, fourth, and fifth fin- ger, followed by the thumb [42]. There are variations of this order in the middle and distal phalanges. Os- sification begins in girls 3–6 months earlier than boys. There is wide variation from early to late onset ossification of hand epiphyses in both genders. This variation may be due to heredity [41].
The extensor digitorum communis and the exten- sor pollicis longus both insert into the distal phalan- geal epiphyses of their respective rays (Fig. 9.2). The central slip of the extensor digitorum communis ter- minates by inserting into the dorsal aspect of the epiphysis of the middle phalanx. The flexor tendons, the flexor digitorum profundus and the flexor pollicis longus, insert into the metaphysis of their respective distal phalanges.
At both interphalangeal levels the collateral liga- ments originate from the recesses of the phalangeal head both medially and laterally, and insert onto both the epiphysis and the metaphysis of the next distal phalanx, thus spanning the physis (Fig. 9.3) [9, 23]. By extending beyond the physis onto the metaphysis, they protect the growth plate in the coronal (abduc- tion/adduction) plane [13]. This helps account for the rarity of type 4 fractures of the interphalangeal (IP) joints.
At the metacarpophalangeal (MP) joint, the collat-
eral ligaments originate from the metacarpal epiphy-
sis and insert onto the epiphysis of the proximal pha-
lanx (Fig. 9.3) [9]. An exception is the variable amount
of attachment of the proximal fan portion of the ulnar
Fig. 9.1
Onset.of.ossification.of.epiphy- ses.of.phalanges.of.the.hand
Fig. 9.2
Extensor.and.flexor.tendon.insertions.into.the.distal.
phalanx
Fig. 9.3 Ñ
Collateral.ligament.origins.and.insertions.at.interpha- langeal.and.metacarpophalangeal.joints
collateral ligament to the metacarpal metaphysis [9].
Also at the MP joint, the volar plate extends exclu- sively from epiphysis of the metacarpal to epiphysis of the proximal phalanx, whereas at the DIP and PIP joints the volar plate extends from the epiphysis of the more distal phalanx to the metaphysis of the more proximal phalanx. The volar plate is well suited to re- sist hyperextension forces. These anatomical arrange- ments account for the frequency of lateral type 2, 3, and 4 fractures at the MP level. The ligamentous anat- omy about the thumb MP most closely resembles that of interphalangeal joints because of its growth center arrangements.
The epiphyses of all phalanges unite with the di- aphyses between age 14 and 16 years. Although girls’
physes close earlier, the disparity in age of fusion be- tween boys and girls is less than at other anatomic sites [5]. The hand is a good index of the extent of os- sification in the entire skeleton. An early union of epiphyses to metaphyses of the hand indicates a cor- responding early union of all epiphyses [40].
Classification
The classification proposed in Chapter 3 (Fig. 3.6) fits all the needs of finger physeal fractures. Mallet-equiv- alent fractures of the distal phalanx may be type 2, 3, or 4 (Fig. 9.4). Many of the so-called “juxta” physeal fractures may be type 1 fractures (Figs. 3A.1f, 9.5, 9.6) [2, 28, 48].
Epidemiology Literature Review
Fractures of the hand are more common in children than in adults [5]. The hand is the most frequently in- jured part of the body in a child [26, 53]. Physeal frac- tures account for 34-45% of all hand fractures in chil- dren [17, 18, 26, 33], a higher percentage of physeal fractures than reported elsewhere in the immature skeleton (Table 4.1) [26]. Many articles give statistics of hand injuries in children, including physeal frac- tures, but combine both phalangeal and metacarpal fractures in ways that do not allow analysis of phalan- geal and metacarpal fractures separately [18, 26, 32, 33, 43, 46, 54].
When considering phalanges separately, the preva- lence of physeal fracture (48%) (Table 9.1) as com- pared with nonphyseal fracture, is higher than for any other bone. Crush injuries, uncommon at other phy- ses, accounted for 21% of hand fractures in one report [26]. Crush injuries commonly involve one or more physes, but are rarely reported as involving or not in- volving the physis. Crush injuries are more common at the terminal aspect of the digit, but can also affect the middle and proximal phalanges. In young chil- dren prior to ossification of the epiphysis, crush inju- ries that involve the physis are common and more dif- ficult to diagnose and manage. Thus, complications such as infection and premature physeal closure are also more common in crush fractures.
The age at which children sustain physeal fractures of the phalanges is slightly younger than that of phy- seal fractures in general (Fig. 4.2). In Barton’s series [5], the age of maximal incidence was 10 years, males predominated 58% to 42% females, and fractures oc- curred more often on the right hand (75) than the left hand (55).
Physeal fractures occur more commonly on the proximal phalanx (75%), followed in order by the dis- tal and middle phalanges (Table 9.2). The physes of the border digits are the most commonly fractured;
the little finger followed by the thumb, long, ring, and
Fig. 9.4
Mallet-equivalent.fractures.of.the.distal.phalanx.may.
be.fracture.type.2,.3,.or.4
Table 9.1.. Hand.phalangeal.physeal.fractures.by.location
Locationa Authorb Total Percent
Leonard (1970) [32] Barton (1979) [5] Worlock (1986) [54]
Epiphyseal 108 120 43 271 48 0
Shaft.(diaphysis) . 70 . 45 36 151 26 8
Joint . 47 . . 9 . 1 . 57
Neck.(metaphysis) . 38 . . – . – . 38
Fingertip . . – . 36 . – . 36
Comminuted . . – . 9 . 2 . 11
ToTal 263 219 82 564
a. .The.largest.number.in.each.series.was.“epiphyseal,”.which.for.the.total.reported.in.these.articles.comprised.48% .Since.
each.author.used.different.criteria.in.classifying.the.location.of.nonepiphyseal.fractures,.the.percentages.of.most.non- epiphyseal.fractures.cannot.be.determined .Possible.physeal.involvement.of.fractures.designated.joint,.fingertip,.and.
comminuted.is.not.specified .Some.of.the.shaft.and.neck.fractures.could.also.have.involved.the.physis
b.The.Leonard.and.Worlock.articles.have.more.than.one.author;.see.References
Table 9.2.. Finger.physeal.fractures.by.phalanx
Year Authora Proximal Distal Middle Total
1979 Barton.[5] 103 18 9 130
1993 Bhende.[7] 23 21 0 . 44
1994 Fischer.[18] 253 42 36 331
ToTal 379 81 45 505
Percent 75 16 9 100
a.The.Bhende.and.Fischer.articles.have.more.than.one.author;.see.References
Table 9.3.. Hand.phalangeal.physeal.fractures.by.digit
Year Author Little Thumb Long Ring Index Total
1979 Barton.[5] 42 31 20 18 17 128
Percent 32 8 24 2 15 6 14 1 13 1 100 0
Table 9.4. Hand.phalangeal.physeal.fractures.by.type.(Salter-Harris.classification)
Year Authora Type Unclassified Total
1 2 3 4 5
1979 Barton.[5] . 0 . 76 . . 4 2 0 . 82
1984 Hastings.[26] . 9 . 94 . 15 2 0 120
1987 Mizuta.[35] . 7 . 74 . . 8 2 0 . 91
1988 Crick.[13] . 7 . 21 . 29 0 0 . 57
1994 Fischer.[18] 14 260 . 49 3 0 5 331
2001 Rajesh.[43] . 5 . . 9 . . 1 0 1 . 16
ToTal 42 534 106 9 1 5 697
Percent . 6 0 . 76 6 . 15 2 1 3 0 1 0 7 . 99 9
a.Most.articles.have.more.than.one.author;.see.References
index, respectively (Table 9.3). Thus, fracture of the proximal phalanx of the little finger is the most com- mon hand physeal fracture. When the central digits (long, ring, and index) are involved, the fractures are less displaced and easier to treat. Phalangeal physeal fractures are more common in the sagittal plane than in the coronal plane.
Type 2 fractures account for 77% of phalangeal physeal fractures (Table 9.4). A type 2 fracture of the little finger proximal phalanx (Fig. 9.15) is the most common fracture overall [22]. One triplane fracture (Salter-Harris type 4) of a thumb proximal phalanx has been reported [21]. The only S-H type 5 fracture reported in hand phalanges (a middle phalanx of the long finger) was neither discussed nor illustrated [43].
The majority of phalangeal fractures are nondis- placed. Displacement is considered significant if roent- genographically there is more than 2 mm translation, 5 degrees angulation, or any clinical malrotation.
Displacement is more common in the proximal pha- lanx. In one study [26], displaced fractures had a 50%
chance of a good outcome, while nondisplaced had a 100% chance of a good outcome.
The most common cause of finger phalangeal frac- tures is a fall, followed by crushing injury (e.g., clos-
ing door, stepped on, etc.), finger struck by a moving object (e.g., a ball), and gymnastics. Several authors noted a high proportion of phalangeal fractures occur during participation in sports, particularly those involving a ball [18, 33, 54].
Multiple phalangeal physeal fractures occurring in a patient at the same time are not uncommon (9%
in Barton’s series [5]). These may involve different fingers on the same or opposite hand, or multiple physes on each finger. Compound fractures are not uncommon. In one series [10], 10 of 100 (10%) con- secutive physeal hand fractures were compound and were treated by debridement, repair of soft tissue, and pin fixation. Open fractures often occur in the distal phalanx when the metaphysis displaces though the nailbed dorsally (Fig. 9.5), as described by Sey- mour [48].
Olmsted County Study
When considering physeal fractures at all body sites, phalanges of the hand are by far the most common site, accounting for 37% in the Olmsted County study (Table 4.12) [39]. This vast preponderance of fractures of hand phalangeal physes is not surprising if one considers that each upper extremity has 14 phalangeal physes and only one distal radial (or any other long bone) physis. In addition, the hand is the body part farthest from the axial skeleton, predisposing it to in- jury, is frequently used as a protective device, and is usually unprotected (with for example gloves or mit- tens).
As with physeal fractures at most other sites, boys predominate. Boys sustained 239 phalangeal fractures (67%) and girls 117 (33%) for a boy:girl ratio of 2:1 (Table 9.5). The annual incidence of hand phalangeal physeal fractures in the Olmsted County study was 142.9 fractures per 100,000 for boys, and 68.6 frac- tures per 100,000 for girls. The age of maximal inci- dence of boys is 14 years (496.3 per 100,000 boys age 14 years), and for girls is 11 years (404.9 per 100,000 girls age 11 years. The age of maximal incidence, and of all types combined was 11 years (Table 9.6). Type 2 fracture accounted for 68% of the fractures.
Type 1
The 36 type 1 physeal fractures of hand phalanges ac- counted for 10% of all phalangeal physeal fractures (Table 9.6). They accounted for 24.5% of all type 1 fractures at all sites (Table 3A.2) and for 4% of all phy- seal fractures at all sites (Table 4.12). They were noted to occur between ages 4 years and 15 years with the
Fig. 9.5
a. Nail. anatomy. association. with. the. distal. phalanx . . b.Juxtaphyseal.fracture.(Seymour.[48])
age of maximal incidence at 14 years (51.8 fractures per 100,000 children) (Table 9.6). The hand surgeons of Mayo Clinic did an excellent job of documenting the type of physeal fracture in each patient during the study period 1979-1988. But since type 1 fractures were unknown and had not yet been classified, they were only discovered during the review of roentgeno- graphs at the conclusion of the study (Figs. 9.6, 9.10, 9.11). Most likely, many type 1 fractures were record- ed as fractures of the metaphysis, and went undetect- ed. Thus, had the type 1 fracture been known at the onset of the study, and had metaphyseal fractures also been reviewed, it is likely that the actual incidence and relative frequency of type 1 fractures would have been higher.
Type 2
The most common hand phalangeal physeal fractures were type 2, accounting for 68% (243 of 356, Ta- ble 9.6). These 243 type 2 hand phalangeal physeal
Table 9.5.. Hand. phalangeal. physeal. fracture. by. age. and.
gender.in.Olmsted.County,.Minnesota,.1979–1988.[39]
Age (year) Boys Girls
. 0 . . 0 0
. 1 . . 1 1
. 2 . . 1 0
. 3 . . 0 1
. 4 . . 5 0
. 5 . . 1 3
. 6 . . 2 1
. 7 . . 6 5
. 8 . . 3 9
. 9 . 13 14
10 . 19 15
11 . 28 30
12 . 34 21
13 . 35 10
14 . 40 5
15 . 29 0
16 . 16 1
17 . . 2 0
18 . . 4 0
19 . . 0 0
20 . . 0 1
ToTal 239 117
Percent . 67 1 32 9
Table 9.6..Hand.phalangeal.physeal.fractures.by.age.(years).and.type.in.Olmsted.County,.Minnesota,.1979–1988.[39] Age0123456789101112131415161718192021TotalPercent Type.1––––1––336531482––––––.36.10 1 Type.2––1134279182849423125127–3–1–243.68 3 Type.3–2–––––––21353–4–1––––.21..5 9 Type.4–––––––1–––37699511–––.42.11 8 Type.5–––––––––1–––1325–––––.12..3 4 Type.6––––1–1–––––––––––––––..2..0 6 ToTal02115431112273458554545291724010356100 1
fractures accounted for 48% of all type 2 fractures at all sites (Table 3B.2) and for 26% of all physeal fractures at all sites (Table 4.12). They occurred from age 2 through age 20 years, with the maximal inci- dence at age 11 years (316.1 fractures per 100,000 chil- dren) (Table 9.6). An 18 year 5 month old boy is illus- trated in Fig. 9.16 .
Type 3
Type 3 physeal fractures of the hand accounted for 6%
of all phalangeal physeal fractures (Table 9.6), 17% of all type 3 fractures (Table 3C.2), and 2% of all physeal fractures at all sites (Table 4.12). They all occurred be- tween ages 9 and 17 years (with the exception of two cases at age 1 year), with the maximal incidence at age 12 years (35.9 fractures per 100,000 twelve-year-old children).
Types 4, 5, and 6
Types 4, 5, and 6 fractures are uncommon in phalan- ges of the hand, accounting for 12, 3, and 1%, respec- tively, (Table 9.6), and 4, 1, and 0.2%, respectively, of all physeal fractures (Table 4.12). However, of type 4 fractures at all sites, hand phalanges comprised 40% (Table 3D.2, Figs. 3D.4, 3D.5). Of all type 5 frac- tures, the hand phalanges comprise 19% (Table 3E.2, Fig. 3E.3). The majority of type 4 fractures occurred between ages 11 and 16 years with the maximal inci- dence at ages 14 and 15 years (58.3 fractures per 100,000 fourteen-year-old children). All but one of the type 5 fractures occurred between ages 13 and 16 years with the maximal incidence at age 16 years (27.5 fractures per 100,000 sixteen-year-old children).
The two type 6 finger phalangeal fractures in the Olmsted County study occurred in 4- and 6-year-old
Fig. 9.6
Juxtaphyseal.fracture.–.actually.a.type.1.fracture .This.
12.year. 9.month. old. boy. fell. off. a. bicycle. injuring. his.
left.little.finger.proximal.phalanx .a.The.AP.film.shows.
a.classic.juxtaphyseal.fracture.(arrows).with.no.physeal.
involvement .b.The.oblique.view.shows.definite.exten- sion. of. the. fracture. to. the. physis. (arrow). confirming.
type.1.fracture.(compare.with.Fig .3A 1f) .The.fracture.
was.reduced.and.splinted .c.Three.weeks.later.there.is.
new. subperiosteal. bone . Fracture. involvement. of. the.
physis.is.now.present.on.this.AP.view
children, one from a lawn mower injury and one from a knife injury. However, type 6 fractures were under- reported because they were not included in the clas- sification system at the time of data collection.
Evaluation
The hands of young children have proportionally more fat than adults. The amount of edema that col- lects in the fat may be significant. An angulated frac- ture may easily “hide” in a toddler’s swollen finger, making roentgenographs essential [6]. Dynamic insta- bility is difficult to diagnose, again requiring reliance on roentgenographic studies [6]. The rotation of the fingertips in a slightly flexed position must be com- pared to the other hand. Traumatic avulsion of a fin- gernail in skeletally immature patients should arouse suspicion of an associated bone injury (Fig. 9.5) [16].
Roentgenographs in at least two planes are re- quired. The physis can be properly evaluated only when the plane of the x-ray is parallel to and in line with the physis. This is rarely accomplished for all phalanges on a single hand roentgenograph since the
phalanges are rarely in the same plane (Fig. 9.7). This gives the false impression that a physis may be closed.
There may also be vagaries on different projections which suggest physeal injury (Fig. 9.8). These require close correlation with the physical examination. The true lateral film is the most difficult to read. The short digits and metacarpals will be superimposed in all but the largest children. If the fingers cannot be sepa- rated adequately for a good lateral film, a lateral to- mogram may be helpful [6]. Since epiphyses appear and physes close at different ages in each digit, it is sometimes appropriate to take roentgenographs of the opposite, uninjured joint for comparison [27].
Routine views should always precede stress views (Fig. 9.9) since the stress maneuver may produce dis- placement, converting a fracture that could have been treated nonoperatively to one that requires ORIF.
Although the flexor tendon may protect the distal phalanx from hyperextension, in the presence of a fracture it may act as a deforming force producing flexion (Fig. 9.4) [13]. The central slip of the extensor tendon, attaching to the epiphysis, predisposes to type 2 and 3 fractures in young children, and may produce type 4 fractures in older children (Table 9.6)
Fig. 9.7
Normal.hand.roentgenographs.of.a.10.year.5.month.old.girl .Note.the.phalangeal,.metacarpal,.and.distal.radius.and.
ulnar.physes.appear.open.on.some.projections.and.indistinct.or.closed.on.another .This.is.a.consequence.of.the.x-ray.
projection.being.parallel.with.some.physis.and.oblique.to.others .All.projections.were.taken.on.the.same.day
Fig. 9.8
Normal. thumb. roentgeno- graphs. suggestive. of. a. type.3.
fracture. of. the. proximal. pha- lanx . This. 11.year. 1.month. old.
girl. fell. on. her. outstretched.
hand . Roentgenographs. were.
taken.to.assess.suspected.inju- ry. of. the. distal. radius. (none).
and.included.the.thumb .a.The.
AP,. lateral,. and. oblique. views.
show.a.possible.type.3.fracture.
of. the. proximal. phalanx. (ar- row) .Examination.of.the.thumb.
was.normal .No.treatment.was.
given .b. Fifteen. months. later.
the. patient. was. re-examined.
for. follow-up. (left to right. AP,.
oblique,.and.lateral) .The.same.
findings.exists.(arrow) .
[13, 22, 23, 27, 50, 53]. As with most type 4 fractures, this could be related to beginning physeal closure.
These are sometimes called “mallet-equivalent” or
“pseudo-mallet” fractures. The proximal epiphysis may be rotated as much as 180° and the nail may be partially avulsed [2, 53].
A closely related injury is the “juxta-epiphyseal fracture of the terminal phalanx” (Figs. 9.5, 9.6) which, as described by Seymour [48], is a “fracture line usually entirely through the metaphysis, 1–2 mm
distal to the growth plate” of the distal phalanx. This fracture is identical to the Foucher type 2 (Fig. 1.1), Bergenfeldt type 6 (Fig. 3.1), and Ogden type 9. In examples shown in the literature, sometimes the fracture lines appear to involve the physis. With more precise imaging many of these might actually be type 1 fractures. The fact that premature physeal clo- sure is common with Seymour fractures [2] supports the suspicion some are type 1 fractures.
Fig. 9.9
Thumb.proximal.phalanx.type.2.fracture.diagnosed.by.
stress.test .This.13.year.7.month.old.boy.fell.while.skiing.
one.day.prior.to.seeking.advice.for.swelling.and.tender- ness. at. the. left. thumb. MP. joint .a. The. AP. shows. mild.
metaphyseal-epiphyseal. offset. of. the. thumb. proximal.
phalangeal. epiphysis. (arrow) .b. The. lateral. view. was.
read. as. normal .c. The. oblique. view. shows. soft. tissue.
swelling.at.the.MP.joint.level .All.three.roentgenographs.
were. read. normal . Since. a. diagnosis. was. not. evident.
stress. views. were. ordered .d. Stress. view. (arrow). con- firms.physeal.disruption.and.instability.with.a.small.me- taphyseal.fragment.attached.to.the.epiphysis.(Holland.
sign).confirming.a.type.2.fracture .The.fracture.was.re- duced.and.immobilized.in.a.thumb.spica.splint .e.Three.
weeks. later. (age. 13.years. 8.months). the. splint. was. re- moved .There.is.new.subperiosteal.bone.formation.and.
no.transmetaphyseal.sclerosis.
Another, more uncommon, related deformity in childhood is the so-called Kirner’s deformity. This has the appearance of an ununited physeal fracture of the distal phalanx. There is usually no history of injury and the etiology is unknown [27, 44].
Type 1 fractures [37] of phalanges are very com- mon, but will frequently be misdiagnosed as juxtam- etaphyseal (Fig. 9.6), metaphyseal (Fig. 9.10), or type 2 fractures (Fig. 9.11). They occur in all phalanges.
Type 2 fractures are usually easy to diagnose
Fig. 9.10
Little. finger. middle. phalanx.
type.1. fracture. initially. misdi- agnosed. as. a. metaphyseal.
fracture . This. 15.year. 0.month.
old. boy. jammed. his. left. fifth.
finger.playing.football .a.An.AP.
view. shows. an. irregular. frac- ture.through.the.proximal.me- taphysis.of.the.middle.phalanx . b.The.oblique.view.shows.cor- tical.disruption.of.the.metaph- ysis .c. The. lateral. view. reveals.
fracture. of. both. metaphyseal.
cortices.with.fracture.lines.ex- tending.to.the.physis.centrally,.
confirming. a. type.1. fracture . Reduction.using.MP.block.an- esthesia. improved. alignment . An.ulnar.gutter. cast.including.
the. ring. and. long. fingers. was.
applied.with.fingers.in.moder- ate.flexion .Discomfort.prompt- ed.removal.of.cast.on.the.11th.
day.the.fingers.were.taped.to- gether.and.an.orthoplast.splint.
applied .d. Three. months. fol- lowing.injury.the.fracture.was.
healing. in. mild. hyperexten- sion .There.was.a.30°.extensor.
lag. of. the. distal. phalanx . The.
fracture.eventually.remodeled.
and. function. returned. to. nor- mal
(Fig. 9.12), occasionally being confused with type 1 fractures (compare Fig. 9.12 with Fig. 9.11). Type 3 fractures may have returned to an anatomic position by the time the initial roentgenograph is taken. The diagnosis is then dependent on stress views (Fig. 9.13).
Differentiation between type 4 and 5 fractures is de- pendent on visualizing the tiny metaphyseal fragment (Fig. 9.14). In older children this is mostly academic, since there it little growth remaining and reduction of the articular surface is the primary concern.
Fig. 9.11
Thumb. proximal. phalanx.
type.1.fracture.confused.with.a.
type.2. fracture . This. 13.year.
4.month.old.boy.fell.from.a.bi- cycle.injuring.the.right.thumb . a. The. AP. view. (left). shows.
breaks.in.both.the.medial.and.
lateral. metaphyseal. cortices.
suggestive. of. a. metaphyseal.
fracture. (arrows) . The. lateral.
view. (middle). shows. a. dorsal.
triangular. metaphyseal. frag- ment. suggestive. of. a. type.2.
fracture . The. metaphysis. is.
more. wide. than. it. should. be.
relative. to. the. adjacent. dia- physis,.yet.the.epiphysis.is.not.
displaced. on. the. metaphysis . The.oblique.view.(right).shows.
breaks. in. both. the. volar. (ar- row).and.dorsal.surfaces,.which.
along.with.fracture.line.exten- sion. to. the. physis. confirms.
type.1. fracture . A. short. arm.
thumb. fiberglass. spica. cast.
was.applied.and.worn.3.weeks . b.At.the.time.of.cast.removal,.
AP,. lateral,. and. oblique. views.
all.show.transmetaphyseal.scle- rosis.(arrows),.no.subperiosteal.
new.bone,.and.normal.physis,.
consistent.with.type.1.fracture ..
A. hand-based. thumb. spica. . orthoplast. splint. was. worn.
3.weeks .(Continuation see next page)
Fig. 9.11 (continued)
c. Three. years. 5.months. post.
fracture.(age.16.years.9.months).
the. thumb. is. clinically. and.
roentgenographically. normal . Note:.This.case.was.erroneous- ly. designated,. and. eventually.
coded,. as. a. type.2. fracture. by.
both. a. radiologist. and. an. or- thopedist
Fig. 9.12
Thumb. proximal. phalanx.
type.2. fracture . This. 12.year.
2.month. old. boy. injured. his.
left. thumb. playing. basketball . a.The.AP.view.shows.an.undis- placed. fracture. of. the. meta- physeal. cortex. on. the. radial.
side. of. the. proximal. phalanx . . b. The. lateral. view. shows. an.
oblique. fracture. of. the. dorsal.
metaphysis. and. widening. of.
the. volar. physis,. typical. of.
type.2 .A.thumb.spica.cast.was.
applied. for. 2.weeks. followed.
by. an. orthoplast. splint. for.
2.weeks .c. Four. weeks. post.
fracture. oblique. view. shows.
sclerosis. only. along. the. frac- ture. line. (arrows). differentiat- ing.it.from.the.type.1.fracture
Fig. 9.13
Management
Phalangeal physeal fractures deserve the same care as other physeal fractures. Many will be undisplaced and require only immobilization for comfort and protection against redisplacement. The location and type of fracture normally dictate the type of treat- ment and the type of immobilization used.
There is a tendency toward “conservatism” among clinicians in the treatment of children’s hand frac- tures. Greater degrees of displacement and deformity are tolerated on the assumption that the patient’s potential growth will remodel the deformity. Physeal separations at the base of the proximal phalanx re-
model in both the coronal and sagittal planes. At the middle phalanx remodeling occurs primarily in the sagittal (flexion-extension) plane [27]. Thanks to the rapid healing of children’s physeal fractures, the du- ration of treatment is short and complications are few, if reduction is adequate. Nevertheless, as in other lo- cations, there is limited capacity to remodel coronal plane angular deformity, and no capacity to remodel rotational deformity [18].
Undisplaced type 1, 2, and 3 fractures can usually be treated by splinting (Fig. 9.15). A single digit with a fracture may be immobilized with adjacent finger or fingers [27].
Displaced type 1, 2, and 3 fractures require reduc- tion and splinting [15, 22, 27]. Reduction of the com- mon type 2 and 3 fractures of the proximal phalanx is achieved by repositioning the displaced, angulated, often rotated diaphysis onto the epiphysis, which re- mains in its normal anatomic position. One technique is to place a padded, firm, thin object (e.g., a pen or pencil) into the web space between the inured digit and the adjacent normal digit. This object serves as a fulcrum to lever the diaphysis onto the physis [47].
The epiphysis is stabilized by flexion of the metacar- pophalangeal (MP) joint, which tightens the lateral ligaments. Supplemental stabilization by percutane- ous pin fixation is available for residual instability (Fig. 9.16).
Adequate anesthesia should be obtained before any attempted manipulation. Hematoma anesthesia alone is usually insufficient anesthesia for reduction. In- stead, nerve blocks (digital nerve, or median, radial, or ulnar nerve), or general anesthesia should be con- sidered [47, 50]. The specific choice will depend on the fracture, the child, and the expertise of anesthesia services available.
Some displaced type 3, 4, and 5 fractures require reduction and internal fixation. This can often be done by closed reduction and percutaneous fixation, but occasionally require ORIF (Fig. 9.13). Intra-artic- ular type 4 fractures should be treated by open re- duction if there is more than 1 mm displacement
É Fig. 9.13
Thumb.proximal.phalanx.type.3.fracture .This.11.year.7.month.old.girl.fell.while.skiing.injuring.the.right.thumb.meta- carpophalangeal.(MP).joint .There.was.swelling.and.ecchymosis.from.thumb.tip.to.wrist .a.AP,.lateral,.and.oblique.
roentgenographs.show.soft.tissue.swelling.and.no.fracture .b.Radial.stress.test.revealed.type.3.fracture.of.the.proximal.
phalanx .Rupture.of.the.ulnar.collateral.ligament.was.also.suspected.and.found.to.be.complete.at.time.of.ORIF .c.The.
fracture.was.reduced.and.stabilized.with.a. 028.Kirschner.wire.and.the.collateral.ligament.repaired .A.short.arm.thumb.
spica.cast.was.worn.4 5.weeks;.the.wire.was.removed.at.3 5.weeks.post.surgery .d.The.thumb.MP.joint.was.stable.and.
physeal.growth.normal.at.16.months.post.injury.(age.12.years.11.months) .Note:.This.case.demonstrates.that.physeal.
fracture.can.co-exist.with.ligamentous.rupture,.most.frequently.noted.in.the.knee
Fig. 9.14
Little.finger.distal.phalanx.type.5.fracture .This.15.year.
11.month.old.boy.jammed.his.right.little.finger.playing.
football .AP.roentgenograph.shows.the.major.compo- nent.of.the.fracture.is.epiphyseal .The.tiny.metaphy- seal. component. (arrow). makes. this. a. type.5. fracture.
(compare.with.Fig .9 19a)
Fig. 9.15
Little. finger. proximal. phalanx. type.2. fracture . This.
12.year. 8.month. old. boy. fell. while. riding. a. bicycle . . a.The.AP.view.shows.fracture.of.the.proximal.phalanx.
metaphysis .b.An.oblique.view.confirms.a.type.2.frac- ture . The. finger. was. placed. in. an. ulnar. gutter. splint. . for. 3.weeks .c. Eighteen. months. later. (age. 14.years.
2.months).the.finger.is.clinically.and.roentgenographi- cally. normal .d. Six. years. 5.months. post. fracture. (age.
19.years.1.month).the.finger.is.clinically.and.roentgen- ographically.normal .The.films.in.c.and.d.were.taken.for.
evaluation.of.subsequent.hand.injuries
Fig. 9.16
Thumb. proximal. phalanx. type.2. fracture. with. ORIF . This.18.year.5.month.old.boy.sustained.a.laceration.on.
the.palmar.surface.of.the.base.of.the.left.thumb.during.
a. crush. injury . Following. suturing. of. the. laceration,.
roentgenographs. revealed. a. fracture .a. An. AP. view.
(left). shows. what. appears. to. be. a. transmetaphyseal.
fracture. (arrows) . Note. open. physis. of. distal. phalanx.
and.apparent.closure.of.the.proximal.phalanx.(due.to.
the.plane.of.the.roentgenograph.being.tangential.to.
the.physis) .Lateral.view.(right).shows.fracture.at.level.of.
physis.dorsally.and.metaphyseal.fragment.attached.to.
epiphysis.volarly.(Holland.sign) .Two.days.after.the.in- jury. the. fracture. was. reduced. closed. under. axillary.
nerve. block. and. percutaneously. pinned. with. two.
crossed. 045.Kirschner.wires .Exploration.of.the.lacera- tion.revealed.intact.digital.arteries.and.nerves .A.radial.
splint.was.applied .b.Three.weeks.post.fracture.roent- genographs. more. adequately. display. the. type.2. frac- ture . The. K-wires. were. removed . There. was. no. infec- tion . A. thumb. spica. cast. was. applied .c. Four. months.
post. fracture. (age. 18.years. 9.months). the. fracture. is.
healed.and.all.physes.are.closed .Motion.of.the.inter- phalangeal.joint.is.0–30°.(right.0–80°),.and.at.the.MP.
joint.is.0–45°.(right.0–50°) .His.only.complaint.was.cold.
intolerance. while. at. work. which. includes. cold. expo- sure . Will. motion. improve. in. the. future?. The. patient.
was. followed. at. our. clinic. another. 20.years. for. other.
conditions.with.no.mention.of.thumb.dysfunction
(Fig. 9.17) [20, 50, 53]. Tiny fragment type 4 fractures can be treated nonoperatively, but if more than 10% of the articular surface is involved and displaced, ORIF is advocated [22]. Type 4 fracture of the proximal phalanx of the thumb has been called a child’s game- keeper’s thumb [20, 50]. Tension band wiring is an option in type 3 and 4 fractures of the thumb [31, 49].
Type 5 fractures of the phalanges are uncommon (Table 9.6), are frequently minimally displaced, and if so can be treated nonoperatively (Fig. 9.18). Displaced fractures need reduction.
Type 6 fractures all require initial debridement and skin closure. The subsequent physeal bar may become noticeable only months or years after the in- jury and is invariably unresponsive to bar excision (Fig. 9.19).
In young, often poorly compliant children, immo- bilization of almost all finger phalangeal fractures except those of the distal phalanx, should include the wrist [50].
Fig. 9.17
Little.finger.proximal.phalanx.type.4.fracture .This.16.year.5.month.old.boy.injured.his.right.little.finger.playing.football.
four.days.previously .a.There.is.a.mildly.displaced.fracture.of.the.epiphysis.on.the.radial.side .Compare.with.Fig .9 3.to.
note.how.the.radial.collateral.ligament.might.restrict.motion.of.the.epiphysis.during.ulnar.(abduction).stress.of.the.
finger .b.Closed.reduction.using.metacarpal.nerve.block.anesthesia.and.finger.trap.traction.was.satisfactory,.but.could.
not.be.maintained.without.traction .Two.days.later.under.general.anesthesia.the.fragment.could.not.be.satisfactorily.
reduced.and.maintained.by.percutaneous.pinning .ORIF.was.accomplished.by.stabilizing.the.fragment.with.a.towel.
clip.while.two. 035.Kirschner.wires.were.inserted.from.the.ulnar.to.the.radial.side .Articular.surface.alignment.was.
confirmed.visually .An.ulnar.gutter.splint.was.applied .c.Seventeen.days.post.surgery .The.K-wires.were.removed.and.
active.motion.begun.protected.by.intermittent.use.of.an.ulnar.gutter.splint .d.Age.17.years.4.months.(11.months.post.
fracture).the.finger.was.asymptomatic.and.had.full.motion .The.fracture.has.healed.with.a.slight.metaphyseal.promi- nence.and.excellent.articular.contours .He.was.allowed.to.resume.football.(new.season)
Immediate surgery, including closed reduction and percutaneous pinning, or ORIF, is performed at ap- proximately the same rate as at other sites (7.3%, Ta- ble 6.1) [32], except for one study [10] which reported 20 of 100 (20%) were treated surgically. In the Olmst-
ed County study [39], of 356 phalangeal physeal frac- tures 21 (6%) were treated initially with surgery and 11 (3%) with late reconstructive surgery. This lower percentage of initial surgery may reflect the absence of referral patients in the Olmsted County study.
Fig. 9.18
Thumb. proximal. phalanx.
type.5. fracture . This. 16.year.
3.month.old.boy.was.kicked.on.
the. right. thumb .a. AP,. lateral,.
and.oblique.views.shown.mini- mal. displaced. type.5. fracture . A. thumb. spica. cast. was. ap- plied . b. Two. weeks. later. a.
molded.forearm-based.thumb.
shell.splint.was.applied ..(Con- tinuation see next page)
Fig. 9.18 (continued)
c.Six.weeks.later.the.splint.was.
discontinued
Fig. 9.19
Thumb.distal.phalanx.type.6.fracture .This.boy.received.multiple.lacerations.from.a.lawn.mower.injury.at.age.3.years.
8.months .One.laceration.caused.removal.of.a.superficial.portion.of.physis.on.the.radial.side.of.the.left.thumb,.distal.
phalanx .a.At.age.8.years.6.months.there.is.a.well.formed.bar.on.the.radial.side.of.the.distal.phalanx.and.20.degree.ra- dial.angulation .b.By.age.9.years.9.months.the.radial.angulation.had.increased.to.26.degrees .c.The.bar.was.excised.at.
age.9.years.9.months.and.accompanied.by.corrective.closing.wedge.osteotomy.on.the.ulnar.side .The.bar.defect.was.
filled.with.fat.from.the.forearm.and.the.osteotomy.held.with.a.single.0 28.Kirschner.wire .(Continuation see next page)
Fractures of the distal phalanx require special at- tention because of the fingernail (Fig. 9.5a). Avulsion of a nail at its proximal end in a child is usually asso-
ciated with type 2, 3, or 4 fractures (Fig. 9.4), or a Seymour’s fracture, many of which are type 1 physeal fractures (Fig. 9.5b). The distal portion of the phalanx is invariably angled volarly, which in a child is some- times called a “mallet-equivalent” (Fig. 19.20). The fracture is compound (open) and requires thorough cleaning, reduction, and preservation of the nail [2, 11]. The nail should not be removed as this further exposes the open fracture and increases instability.
Stable reduction is accomplished by appropriate irri- gation and debridement, meticulous repair of the nail
É Fig. 9.19 (continued)
d. Within. 2.months. the. bar. had. reformed .e. At. age.
11.years. 10.months. (2.years. 1.month. postoperative).
there. was. slight. radial. reangulation . The. remaining.
physis. gradually. closed. with. no. further. angulation . Note:.The.interval.between.injury.and.discovery.of.the.
bar.was.4.years.10.months .The.mild.angular.deformity.
suggests.that.the.bar.began.to.develop.only.recently,.
probably.years.after.the.injury
Fig. 9.20
Little.finger.distal.phalanx.mallet-equivalent.type.2.fracture .This.15.year.11.month.old.boy.injured.his.right.little.finger.
playing.football .a.There.is.an.open.type.2.fracture.of.the.distal.phalanx .The.base.of.the.nail.was.elevated.and.the.
distal.fragment.was.visible .The.fracture.was.cleaned.and.reduced.in.the.emergency.room.using.1%.Xylocaine.meta- carpal.nerve.block.anesthesia .The.proximal.nail.was.replaced.beneath.the.nail.fold .b.A.dorsal.splint.was.applied.and.
held.with.a.finger.dressing .c.Three.days.later.the.position.was.unchanged .Immobilization.was.changed.to.a.molded.
Brand.cast,.attempting.to.hyperextend.the.distal.phalanx .The.cast.was.worn.3.weeks .d.Five.weeks.post.injury.(age.
16.years.0.months) .There.was.mild.tenderness.over.the.DIP.joint .Active.motion.was.full.and.painless .He.was.advised.
to.wear.a.dorsal.monoarticular.Alumafoam.splint.when.active.for.an.additional.3.weeks
matrix with 5-0 or 6-0 chromic suture, perforating the nail to allow for subungual hematoma drainage, replacing the base of the nail beneath the proximal nail fold, and applying a slight hyperextension force to the distal phalanx. A small metal or plastic splint, or cast, can be used to hold the distal interphalangeal joint in extension for 3 weeks (Fig. 9.20). Type 3 frac- tures may be unstable and if so, internal fixation by a Kirschner wire becomes appropriate (Fig. 9.21). In most instances internal fixation is usually unneces- sary and can lead to complications [6, 11, 48, 50, 53].
Antibiotics are appropriate [16, 50, 55].
Complications
Most physeal fractures of the hand have no complica- tions [46]. In the Olmsted County study [39], 21 of the 365 hand physeal fractures (6%, Table 8.6) had 26 complications. There were 11 angular deformities, 10 growth arrests, 3 functional impairments, and 2 length discrepancies (Table 8.1). The 21 patients who developed a complication represented 2.5% of all 850 patients with a physeal fracture.
Irreducible Fractures
The most commonly reported early complication is irreducibility. When a displaced physeal phalangeal fracture cannot be reduced closed, entrapment of in- terposed soft tissue is likely, or the epiphysis is dis- placed, rotated, and restrained by tendon attachment.
Failure of reduction is manifested clinically by lack of full passive motion that persists even with the finger anesthetized. Roentgenographs confirm incomplete reduction.
More irreducible physeal fractures have been re- ported for hand phalanges than for physeal fractures at other sites. This may be a reflection of the numeri- cal preponderance of phalangeal fractures, or possi- bly their small size requiring less force to produce displacement. The tissue impinged is varied. Most irreducible physeal fractures are in the distal or mid- dle phalanges (Table 9.7). All reported cases, except one, are male. Males predominate partly because pha- langeal physeal fractures are also more common in males (Table 9.5).
Fig. 9.21
Long.finger.distal.phalanx.mal- let-equivalent. type.3. fracture . This.12.year.3.month.old.boy’s.
long. finger. was. in. a. crevice. . of. a. chair. when. the. chair. fell. . backward .The.nail.was.avulsed.
proximally . Left. Compound.
type.3. fracture. with. volar. an- gulation. of. distal. phalanx . . Middle. The. fracture. was. de- brided,. reduced,. and. pinned.
under.general.anesthesia .The.
0 28.Kirschner.wire.was.insert- ed. antegrade. into. the. distal.
fragment,.reversed.and.driven.
retrograde. proximally. across.
the. epiphysis,. the. joint,. and.
into. the. middle. phalanx . The.
nailbed. was. repaired. and. the.
skin. closed . The. pin. was. re- moved. 2.weeks. post. fracture.
and.a.Stack.splint.applied .Right.
Four. weeks. post. fracture. the.
wound. was. healing. with. no.
clinical.sign.of.infection .There.
was. full. flexion. and. extension.
of. the. distal. interphalangeal.
joint .The.splint.was.continued.
an.additional.2.weeks
Table 9.7..Irreducible.hand.phalangeal.physeal.fractures YearAuthoraAgebGenderPhalanxFingerTypecDisplacementdTissue interposedTreatmente 1980Michelinakis.[34]3MDistalMiddle3DorsalFibrous.tissueOR 1983Zielinski.[56]11MDistalLittle2VolarTendonOR 1992Banjeree.[4]14FDistalMiddle3–Nailfold.skinOR 11MDistalRing3–Nailfold.skinOR 1993Waters.[52]1MDistalIndex3DorsalTendonEpiphysis.excised 3MDistalIndex3Dorsal–– 1998Al-Qattan.[3]14MDistalIndex2DorsalNailfold.skinNone 1975Cowen.[12]13MMiddleLittle2–Shaft.button.holed. through.dorsal.hoodORIF 1981Blair.[8]4MMiddleLittle3DorsalTendonORIF 1984Keene.[30]1MMiddleLong3DorsalVolar.plateOR 1985Jones.[29]12MMiddleRing3VolarTendonORIF 1996Hashizume.[25]6MMiddleLittle3DorsalTendonORIF 1964Von.Raffler.[51]7MProximalLittle2–TendonORIF 1990Harryman.[24]12MProximalMiddle2–TendonORIF a.Most.articles.have.more.than.one.author;.see.References b.Age.in.years c.Fracture.type.(Peterson.classification).[38] d.Displacement.means.epiphysis.undisplaced.in.joint,.metaphysis.displaced e.Treatment:.OR.open.reduction,.ORIF.open.reduction.and.internal.fixation
Some irreducible fractures are type 3 fractures with the epiphyses extruded from the joint. The epiphysis is usually dorsally displaced, rotated 90°
and held by the extensor tendon mechanism. Several authors noted that once reduced, stability was suffi- cient to preclude internal fixation. No case of redis- placement is recorded.
After immobilization is discontinued, formal physical or occupational therapy is unnecessary. Res- toration of function will occur as the child uses his hand in normal play and everyday activities. Attempts at passive stretching only prolong and increase dis- ability attributable to joint involvement. Active range of motion is encouraged. Parents should be advised that swelling and stiffness may be present for several months [53].
Irreducibility has been recorded in two young chil- dren whose phalangeal epiphyses had not yet ossified [52]. In each case the epiphysis had dislocated out of the joint dorsally (type 3 fractures). Because the epiphysis was not visible roentgenographically its dis- placement was unrecognized until 9 and 3 years later, respectively. This resulted in a dorsal prominence, limited flexion, and relative shortening of the distal phalanx in both patients. Treatment consisted of exci- sion of the epiphysis in the older boy and was pending in the younger boy.
Malrotation
Malrotation is the most frequent late complication of phalangeal physeal fractures and is due to failure to recognize and correct the deformity. When the fin- gers are semiflexed the planes of the nails are an ad- ditional guide. True AP and lateral roentgenographs of the phalanx may not reveal the malrotation due to incomplete ossification, particularly of the epiphysis which often appears as a round disk on any projec-
tion. Correcting malrotation in a fresh fracture is relatively easy, but if healing occurs with malrotation, correction can be achieved only by osteotomy. Most malrotations occur in the proximal phalanx [6].
Premature Physeal Arrest
Premature complete physeal arrest of phalanges is probably common, particularly if there is associated crushing or infection [16, 26]. The primary conse- quence is a mildly short digit, and no treatment is usually necessary. Thus, the reported incidence is low [26], approximately 1% (Table 9.8).
Premature partial arrest (physeal bar) is even more uncommon (Fig. 9.19), probably because the physis is so small in area that any injury to it causes a complete arrest. Culp and Osgood [14] reported one case with angular deformity. If partial arrest occurs the most expeditious management would be closure of the re- maining physis, resulting in a short phalanx, com- bined with osteotomy, if necessary, to correct any an- gulation or rotation deformity. Physeal bar excision in the hand is rare (Table 33.3). Figure 9.19 is such a case.
Degenerative Arthrosis
Finger joint stiffness is uncommon due to rapid heal- ing and good remodeling potential [13, 26]. Residual irregularity of the articular surface (post-traumatic arthritic change) resulting in deformity, functional impairment, and pain is unusual in a child [47], but may occur in adults from a childhood injury. Treat- ment options include arthrodesis, resection arthro- plasty, resurfacing arthroplasty, replacement arthro- plasty, and vascularized joint transfer [50], all of which are beyond the scope of this text.
Table 9.8.. Percentage.of.hand.phalangeal.physeal.fractures.with.premature.physeal.closurea
Year Authorb Number of cases Number of closures Percent closure
1970 Leonard.[32] . 276 . 0 0
1979 Barton.[5] . 80 . 1 1 3
1984 Hastings.[26] . 120 . 2 1 6
1988 Crick.[13] . 167 . 1 0 6
1994 Fischer.[18] . 378 . 3 0 8
1994 Peterson.[39] . 356 10 2 8
ToTal 1377 17 1 2
a.Most.articles.did.not.record.duration.of.follow-up,.or.distinguish.between.complete.or.partial.closure
b.Most.articles.have.more.than.one.author;.see.References
Infection
Infection is uncommon and follows only open frac- tures, particularly those with severe trauma of the distal phalanx [18] or with an avulsed or surgically removed fingernail [16, 48, 55]. Subsequent osteomy- elitis has resulted in amputation of the finger [48].
Ischemic Necrosis
Ischemic necrosis (IN), also known as avascular or osteonecrosis, was noted in one completely displaced distal phalangeal epiphysis treated by ORIF [46]. This resulted in deformity and stiffness.
Refracture
Refracture of the same physis is rare (Fig. 8M.2).
Author’s Perspective
Hand phalangeal physeal fractures are much more common than previously recognized. Many of these children are treated locally and do not reach institu- tions which might gather such statistics, or are seen in hand clinics not associated with pediatric orthopedic units. Fortunately, most patients do well.
References
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3. Al-Qattan MM: An unusual Salter type 2 fracture of the distal phalanx. J Hand Surg 23B:283-284, 1998
4. Banerjee A: Irreducible distal phalangeal epiphyseal inju- ries. J Hand Surg 17B:337-338, 1992
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11. Campbell RM Jr: Operative treatment of fractures and dis- locations of the hand and wrist in children. Orthop Clin N Am 21:217-243, 1990
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