Hand Trauma

Key Points:

  • Young children frequently present with crush injuries to the digits, while hand injuries in older children tend to be sports-related.
  • While the majority of hand injuries in children can be treated with a short course of simple immobilization, certain fractures do require operative management to optimize outcomes. 
  • Seymour fractures are open fractures. Treatment should include removal of the nail with irrigation and debridement of the fracture, along with appropriate nailbed repair and fracture treatment.
  • Bony mallet fractures are more common in children than adults. A true lateral x-ray should be obtained on all children presenting with a mallet injury.
  • Phalangeal neck fractures have limited remodeling potential and are therefore generally treated with percutaneous pinning. Open reduction should be avoided when possible due to the risk of avascular necrosis.

Description:

Epidemiology

Hand fractures are among the top five most common fractures occurring in childhood. The highest incidence of phalangeal fractures occurs in the 0-4 year age group, at a rate of approximately 0.2% of children in that age group. Metacarpal fracture and carpal fractures occur slightly more rarely, at a rate of approximately 0.1% of children overall (Chung 2001). 

Anatomy

The major difference between adult and pediatric hand anatomy is the ongoing ossification of the hand and fingers in children. Ossification in the hand begins in the capitate between 1-3 months of age and progresses to the hamate. The scaphoid begins to ossify at the age of 5 years and the trapezoid and trapezium at 6 years.  The secondary ossification centers of the phalanges and metacarpals become apparent between 1-3 years, earlier in girls than boys. The physes of the phalanges begin to fuse for girls between 13-15 years old and 14-16 years for boys (Stuart 1962). 

Epidemiology:

Clinical Findings:

It is important to know when and how the injury occurred. Many children present late with hand injuries, as the initial injury can be underappreciated by the patient, family, and healthcare providers. The child’s hand should be examined for edema, bruising, and any open wounds. Sharp open wounds on the volar surface of the hand or forearm should be presumed to include a nerve and/or tendon injury unless a good exam or operative exploration proves otherwise. For finger injuries, the resting position of the affected digit in flexion and extension should be evaluated and compared with the contralateral side if necessary. Rotation of the digit can be assessed by examining the position of the nail plate. To assess for digital nerve injury, 2-point discrimination can be used in older, cooperative children. Semmes-Weinstein monofilament assessment can generally be performed in children after 4 or 5 years of age to test sensation. In younger children, the affected hand or finger can be immersed in water to assess for wrinkling of the skin. If the digital nerve is injured, the skin in the affected distribution will not wrinkle in water.

Imaging Studies:

Initial evaluation should include proper radiographs in nearly all cases to identify or rule out fractures. In-office fluoroscopy can be helpful in cases where a true lateral image is difficult to obtain through conventional radiography. Occasionally, CT scan is needed to fully evaluate intra-articular fractures in the hand and fingers. Ultrasound can be used to identify tendon injuries in young children who cannot comply with physical examination.

Etiology:

Treatment:

POSNA Academy Videos

Finger Fractures

Complications:

Specific Injuries:

Flexor Tendon Injuries

Acute flexor tendon injuries in children are managed operatively similarly to adults. A four strand core suture repair with an epitendinous suture is used whenever possible. Occasionally in young children, only a 2 strand repair will be possible (O’Connell 1994). Generally patients are casted for 4 weeks after tendon repair and follow a delayed active motion protocol after that. Adult protocols such as early active motion are generally not appropriate for children. Late-presenting tendon injuries are common in children. In these cases, options include tendon repair if possible, versus one or two-stage tendon reconstruction (Amadio 1988). Understanding the patient and family’s goals and ability to comply with postoperative therapy is important before undertaking tendon reconstructions. Procedures such as tenolysis that require cooperation with therapy immediately after surgery are generally not performed in children younger than 6 or 7 years of age.

Seymour Fractures

This is a juxta-physeal fracture of the distal phalanx that is “open” through a nail bed laceration. On examination, there is generally swelling and bruising of the distal phalanx, with a subungal hematoma and/or bleeding beneath the proximal nail fold. In addition, the nail plate can usually be seen displaced dorsal to the proximal nail fold. With this displacement, the germinal matrix can become interposed into the physis. Treatment includes removal of the nail plate, thorough fracture debridement, repair of the nail bed, and fracture reduction. Fracture fixation can be performed with smooth K-wires placed retrograde through the fracture and DIP joint (Krusche-Mandl  2013, Abzug 2013). 

Bony Mallet Fractures

Mallet injuries in children tend to be bony avulsions (Salter-Harris III or IV) of the epiphysis.  Extension splinting is an effective treatment for most bony mallet fractures that are diagnosed acutely, with excellent return of function and bony remodeling. For younger patients, splinting compliance may be an issue, and so other options such as placing a long arm cast over the splint or percutaneous pinning across the DIP joint may be necessary. Operative indications for bony mallet fractures include open fractures, DIP joint subluxation that is not correctable in an extension splint, and fractures that are not amenable to closed reduction due to physeal-epiphyseal injury (Okafor 1997). Many surgeons will also consider avulsion fractures of ≥30% of the articular surface to be a relative indication for surgery, as these larger fragments are more likely to lead to DIP joint subluxation if not reduced anatomically. Extension block pinning can be used in cases of difficult fracture reductions. 

Phalangeal Neck Fractures

Fractures of the phalangeal neck present several potential complications. They are difficult to recognize radiographically, with a high propensity to displace and a low potential for remodeling. These fractures occur 10 times more frequently in children than in adults.  The fractures tend to be transverse and can involve either the proximal or middle phalanx. Phalangeal neck fractures are ideally managed when recognized at the time of injury.  Non-displaced fractures can be treated with cast immobilization. Displaced fractures are generally treated with closed reduction and pinning (Karl 2012). For late-presenting displaced fractures, it is important to note on examination whether the child still has tenderness over the fracture site, as this is a sign that the fragment is still mobile. Treatment of incipient malunions should consist of the stepwise algorithm described by Matzon and Cornwall of closed reduction and pinning, followed by percutaneous reduction and pinning, with open reduction as a last resort (Matzon 2014). Because the blood supply to the phalangeal condyles enters through the collateral ligaments, open reduction has the potential to cause avascular necrosis. For patients who present with healed malunions and limited joint flexion, subcondylar fossa reconstruction, via an open palmar approach, is an alternative to osteotomy for correction (Simmons 1987).

References:

  1. Abzug JM, Kozin SH. Seymour fractures. J Hand Surg Am. 2013;38(11):2267-70; quiz 70
  2. Amadio PC, Wood MB, Cooney WP, Bogard SD. Staged flexor tendon reconstruction in the fingers and hand. J Hand Surg 1988; 13A: 559-62.
  3. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-15.
  4. Karl JW, White NJ, Strauch RJ. Percutaneous reduction and fixation of displaced phalangeal neck fractures in children. J Pediatr Orthop. 2012;32(2):156-61.
  5. Krusche-Mandl I, Kottstorfer J, Thalhammer G, Aldrian S, Erhart J, Platzer P. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am. 2013;38(2):258-64.
  6. 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.
  7. O’Connell SJ, Moore MM, Strickland JW, Frazier GT, Dell PC. Results of zone I and zone II flexor tendon repairs in children. J Hand Surg 1994; 19A: 48-52.
  8. Okafor B, Mbubaegbu C, Munshi I, Williams DJ. Mallet deformity of the finger. Five-year follow-up of conservative treatment. J Bone Joint Surg Br. 1997;79(4):544-7.
  9. Simmons BP, Peters TT. Subcondylar fossa reconstruction for malunion of fractures of the proximal phalanx in children. J Hand Surg Am. 1987;12(6):1079-82.
  10. Stuart HC, Pyle SI, Cornoni J, Reed RB. Onsets, completions and spans of ossification in the 29 bone growth centers of the hand and wrist. Pediatrics. 1962;29:237-49.

Top Contributors:

Andrea Bauer MD