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JUXTA-EPIPHYSEAL FRACTURES OF THE BASE OF THE PROXIMAL PHALANX OF THE FINGERS IN CHILDREN AND ADOLESCENTS
JUXTA-EPIPHYSEAL FRACTURES OF THE BASE OF THE PROXIMAL PHALANX OF THE FINGERS IN CHILDREN AND ADOLESCENTS M. M. AL-QATTAN From the Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia
A series of 34 juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers of children and adolescents are presented. The pattern of injury appeared identical in all these fractures, with a lateral angulation force separating a small triangular metaphyseal fragment from the base of the phalanx on the side of angulation and the fracture line then continuing through the metaphysis, 1–2 mm distal to the growth plate. Fractures were classified into two types according to the degree of displacement. Type 1 fractures (n = 18) were mildly displaced and were all successfully treated with closed reduction and splinting. Type 2 fractures (n = 16) were severely displaced and problems with obtaining an adequate reduction and long-term residual deformities were encountered. One patient with a severely displaced fracture required open reduction and Kirschner-wire fixation because of flexor tendon entrapment at the fracture site. Another five cases required Kirschner-wire fixation after closed manipulation in order to maintain the reduction. The remaining 10 patients with Type 2 fractures were treated by closed reduction and splinting, and two patients healed with malunion causing a ‘‘pseudo-claw’’ deformity. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 24–30 the metacarpal head, but not through its centre. In type 2 (severely displaced) fractures, the line completely missed the metacarpal head (Fig 1). The ‘‘pencil technique’’ (Wood, 1976) was used for closed reduction of these fractures (Fig 2). After reduction, the finger was splinted to the adjacent uninjured finger and an ulnar gutter splint was worn for 3 weeks. Kirschner-wire fixation was only performed after failure to maintain the closed reduction. A single Kirschner wire was introduced through the proximal interphalangeal joint and passed across the fracture and the flexed metacarpophalangeal joint. The wire was then pulled out of the metacarpal head proximally to free the proximal interphalangeal joint. This technique of Kirschner-wire introduction was used because oblique Kirschner wires introduced into the base of the fractured proximal phalanx tended to displace the fracture. The Kirschner wire was removed at 3 weeks. Follow-up ranged between 5 and 24 months (mean = 14 months). At final follow-up, any decreased range of motion or deformity was documented. In patients with residual angulation, malunion was also confirmed with ‘‘Campbell’s lines’’. If the line missed the centre of the metacarpal head, residual malunion was recorded.
INTRODUCTION The majority of fractures of the proximal phalanx in children and adolescents are thought to be Salter type 2 fractures of the base of the phalanx (Campbell, 1990; Fischer and McElfresh, 1994; Hernden, 1985; Leclercq and Korn, 2000; Stern 1999; Worlock and Stower, 1986). However, close examination of the radiographs suggests that the fracture line is entirely through the metaphysis, 1–2 mm distal to the growth plate. This juxta-epiphyseal fracture pattern was noted by Barton (1979; 1984) and Beatty et al. (1990). This paper reports on a series of children and adolescents with juxtaepiphyseal fractures of the base of the proximal phalanx of the fingers.
PATIENTS AND METHODS All children with juxta-epiphyseal fractures of the base of the proximal phalanx of a finger who were seen by the author during the last 7 years were included in this retrospective study. Age, sex, mechanism of injury, finger involved, degree of fracture displacement, management and complications were documented. Fracture displacement was graded by drawing ‘‘Campbell’s lines’’ (Campbell, 1990) on the radiograph. If a line is drawn through the centres of the phalangeal neck and the phalangeal metaphysis, it should pass through the centre of the metacarpal head in a normal finger, regardless of the joint flexion. Campbell showed that use of these lines is valid for postero-anterior, lateral and oblique radiographs. These lines were used to classify juxta-epiphyseal fractures into two types depending on the degree of fracture displacement. In type 1 (mildly displaced) fractures, the line passed through
RESULTS A total of 34 juxta-epiphyseal fractures of the proximal phalanx were identified in 20 boys and 14 girls, aged between 5 and 14 years (mean = 10 years). The mechanism of injury was sudden ulnar or radial angulation of the finger in a fall or a fight, or during athletic activities such as wrestling. The little finger was 24
PHALANGEAL BASE FRACTURES
25
Fig 1 Campbell’s lines used to grade the degree of fracture displacement. (a) In mildly displaced fractures, the line passes off the centre of the metacarpal head. (b) In severely displaced fractures, the line completely misses the metacarpal head.
Fig 2 A pen or a pencil is placed at the base of the fractured phalanx and acts as a fulcrum during closed reduction of the fracture.
the most commonly involved digit (22 cases), followed by the ring (eight cases) and middle (four cases) fingers. The injured finger was ulnarly deviated in 30 cases and radially deviated in the remaining four. Examina-
tion of the radiographs showed that the fracture line was always entirely through the metaphysis, 1–2 mm distal to the growth plate. On the side of the deviation, the proximal metaphyseal fragment was triangular in
26
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Table 1—Management and complications in 34 cases of juxta-epiphyseal fractures of the proximal phalanx Fracture Type 1 (mildly displaced) Type 2 (severely displaced)
Cases (n)
Management
Complications
18
Closed reduction and splinting in all 18 cases
Nil
16
Closed reduction and splinting (n = 10)
Residual deformity in two patients Nil
Closed reduction and K-wire fixation (n = 5) Open reduction and K-wire fixation (n = 1)
Fig 3 A juxta-epiphyseal fracture of the proximal phalanx with ulnar deviation. The proximal metaphyseal fragment is triangular in shape with an intact periosteal sleeve on the side of deviation.
shape. Occasionally a faint white line was seen running from this triangular fragment to the distal fragment indicating an intact periosteal sleeve (Fig 3). Fracture displacement was mild in 18 cases and severe in the remaining 16 cases. The management and complications of the fractures are summarized in Table 1. All 18 mildly displaced fractures were treated by closed reduction and splinting
Nil
with no complications. However, problems were encountered with obtaining an adequate reduction by closed techniques and long-term complications occurred in the severely displaced (type 2) fractures. Illustrative examples are shown in Figs 4–6. One patient with a severely displaced fracture of the ring finger underwent open reduction and Kirschnerwire fixation because the fracture could not be reduced closed. At surgery, the flexor tendons were found entrapped in the fracture. After retraction of the flexor tendons the fracture readily reduced and the reduction was maintained with a single Kirschner wire for 3 weeks. This patient eventually regained a full range of motion. Another five cases required Kirschner-wire fixation after closed manipulation in order to maintain the reduction. The Kirschner wire was always removed at 3 weeks and all five cases regained full function with no deformity. The remaining ten patients with type 2 fractures were treated with closed reduction and splinting. At final follow-up, full range of motion without deformity occurred in eight out of the ten patients. The other two patients had a persistent ‘‘pseudo-claw’’ deformity: with active extension of the finger, there was 10–150 hyperextension at the metacarpophalangeal joint and 10–150 flexion at the proximal interphalangeal joint. The fingers of the uninjured hand of these two patients did not have lax joints or congenital pseudo-clawing. The deformity on the injured side was thought to be secondary to an inadequate reduction and subsequent inadequate remodelling in the flexion–extension plane. In each case malunion was confirmed by Campbell’s lines.
DISCUSSION This study has several important findings. Firstly, the paediatric fracture which is commonly referred to as a Salter type 2 injury of the base of the proximal phalanx is actually a non-epiphyseal fracture. Secondly, the pattern of injury appears to be identical in these fractures: the lateral angulation force separates a small triangular metaphyseal fragment at the base of the
PHALANGEAL BASE FRACTURES
27
Fig 4 (a) A type 2 fracture which required Kirschner-wire fixation. (b) Full function with no deformity was achieved.
phalanx on the side of angulation and then the fracture line continues through the metaphysis 1–2 mm distal to the growth plate. Thirdly, Campbell’s lines, which were originally devised to assess Salter type 1 fractures of the proximal phalanx, can also be used to assess degree of displacement and malunion following juxta-ephiphyseal fractures of the proximal phalanx. In the current series, juxta-epiphyseal fractures of the proximal phalanx most commonly involved the little finger which usually deviated in an ulnar direction. This common presentation was also noted by other authors (Barton, 1979; Beatty et al., 1990; Fischer and McEl-
fresh, 1994; Wood, 1976) and is often referred to as the ‘‘extra-octave’’ fracture because of the extreme ulnar angulation. During closed reduction of juxta-epiphyseal fractures of the proximal phalanx, it is difficult to gain adequated purchase on the proximal fragment while manipulating the distal fragment. (Beatty et al., 1990), and two techniques of closed reduction have been proposed. In the ‘‘pencil technique’’, which was used in the current study, a pencil is placed in the web space and serves as a fulcrum on which to manipulate the fracture. The other method is to flex the metacarpophalangeal joint to 908, which tightens the collateral
28
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Fig 5 (a) A type 2 fracture which was adequately treated with closed reduction and splinting. (b) Full function with no deformity was achieved.
ligaments and thus stabilizes the proximal fragment. Reduction is then accomplished by pushing the distal fragment across into the correct alignment (Beatty et al., 1990; Hastings and Simmons, 1984). In the latter technique, the metacarpophalangeal joints are locked in 908 of flexion during manipulation which helps correct any extension deformity. However, following manipulation in the abduction–adduction plane by the ‘‘pencil technique’’, residual extension of the fracture should be looked for and reduced. Whichever technique of closed reduction is used, over-correction is generally recommended. The periosteal sleeve is usually intact on the side of the angulation and generally prevents overreduction and provides stability in the reduced position. Once the fracture is reduced, the finger should be splinted to the adjacent uninjured finger before an ulnar gutter splint is applied. These precautions are essential, especially in ‘‘extra-octave’’ fractures of the little finger in which the pull of the abductor digiti minimi muscle tends to redisplace the fracture. In the current study, juxta-ephiphyseal fractures were classified into two types according to the degree of displacement. All type 1 or mildly displaced fractures
were successfully treated with closed reduction and splinting. However, Kirschner-wire fixation was necessary to maintain the reduction in five of the 16 severely displaced (type 2) fractures. Fracture instability in these cases might be related to disruption of the periosteal sleeve on the side of the angulation. One of the type 2 fractures was irreducible by closed methods because of entrapment of the flexor tendons. There are three previous reports of irreducible juxta-epiphyseal fractures of the proximal phalanx: flexor tendons were entrapped at the fracture site in two cases (Harryman and Jordan, 1990; Von Raffler, 1964) and there was fibrous tissue interposition in the third (Leonard and Dubravcik, 1970). Remodelling following juxta-epiphyseal fractures of the base of the proximal phalanx depends on several factors, including the age of the patient and the degree and type of deformity. Fischer and McElfresh (1994) stressed that remodelling is less likely to occur in adolescents than young children and it is also generally accepted that angulation in the same plane as the joint movement (plane of flexion–extension) will usually correct with growth. If the angulation is in the opposite
PHALANGEAL BASE FRACTURES
29
Fig 6 A type 2 fracture which was inadequately treated with closed reduction and splinting. (a) X-ray at the time of presentation. (b) Oblique view immediately after closed reduction. Note the residual extension deformity. (c) Postero-anterior X-ray at 1-year follow-up. Clinically there was no lateral angulation of the finger but Campbell’s line did not pass through the centre of the metacarpal head, indicating mild malunion. (d) Oblique view at 1-year follow-up. Clinically there was 108 of hyperextension at the metacarpophalangeal joint and 158 of flexion at the proximal interphalangeal joint. Malunion was confirmed with Campbell’s line on this radiograph.
30
plane (ulnar or radial deviation), or is rotational, it will not correct. Barton (1979) also stressed that a distinction should be made between fractures near the metacarpophalangeal joints and fractures near the interphalangeal joints. Juxta-epiphyseal fractures occur at the base of the proximal phalanx close to the metacarpophalangeal joint, which is not only a hinge but also allows lateral movement: hence such fractures may remodel in both planes. In this study the type 2 juxta-ephiphyseal fractures were usually not only angulated radially or ulnarly but also lay in extension. Thus it is imperative that the finger is reduced in both planes, since residual deformity may persist even in the plane of flexion–extension and cause a ‘‘pseudo-claw’’ deformity. The mechanism by which the pseudo-claw deformity occurs is as follows: residual extension of the fracture leads to relative shortening of the extensor surface of the proximal phalanx causing relative lengthening of the central slip and ineffective extension of the proximal interphalangeal joint. Following closed reduction, this residual extension deformity can easily be missed because it is difficult to get good lateral views of the fracture, especially if there is a plaster-cast. A residual extension deformity is also more likely to occur when ulnar slabs are applied with the metacarpophalangeal joints in extension. Therefore, immobilization should be in the Edinburgh position, with the metacarpophalangeal joints flexed to 908, which should help correct any extension of the fracture.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
References Barton NJ (1979). Fractures of the phalanges of the hand in children. The Hand, 11: 134–143. Barton NJ (1984). Fractures of the hand. Journal of Bone and Joint Surgery, 66B: 159, 167. Beatty E, Light TR, Belsole RJ, Ogden JA (1990). Wrist and hand skeletal injuries in children. Hand Clinics, 6: 723–738. Campbell RM (1990). Operative treatment of fractures and dislocations of the hand and wrist region in children. Orthopedic Clinics of North America, 21: 217–243. Fischer MD, McElfresh EC (1994). Physeal and periphyseal injuries of the hand: patterns of injury and results of treatment. Hand Clinics, 10: 287–301. Harryman DT, Jordan TF (1990). Physeal phalangeal fracture with flexor tendon entrapment. Clinical Orthopaedics and Related Research, 250: 194–196. Hastings H, Simmons BP (1984). Hand fractures in children: a statistical analysis. Clinical Orthopaedics and Related Research, 188: 120–130. Herndon JH (1985). Hand injuries – special considerations in children. Emergency Medicine Clinics of North America, 3: 405–413. Leclercq C, Korn W (2000). Articular fractures of the fingers in children. Hand Clinics, 16: 523–534. Leonard MH, Dubravcik P (1970). Management of fractured fingers in the child. Clinical Orthopaedics and Related Research, 73: 160–168. Stern PJ. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Peterson WC (eds). Green’s Operative Hand Surgery, Vol 1, 4th Edn., New York, Churchill Livingstone, 1999: 711–771. Von Raffler W (1964). Irreducible juxta-epiphyseal fracture of a finger. Journal of Bone and Joint Surgery, 46B: 229. Wood VE (1976). Fractures of the hand in children. Orthopedic Clinics of North America, 7: 527–542. Worlock PH, Stower MJ (1986). The incidence and pattern of hand fractures in children. Journal of Hand Surgery, 11B: 198–200.
Received: 12 March 2001 Accepted after revision: 15 June 2001 Mr M. M. Al-Qattan, Division of Plastic Surgery, PO Box 18097, Riyadh 11415, Saudi Arabia. # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0661, available online at http://www.idealibrary.com on
A series of 34 juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers of children and adolescents are presented. The pattern of injury appeared identical in all these fractures, with a lateral angulation force separating a small triangular metaphyseal fragment from the base of the phalanx on the side of angulation and the fracture line then continuing through the metaphysis, 1–2 mm distal to the growth plate. Fractures were classified into two types according to the degree of displacement. Type 1 fractures (n = 18) were mildly displaced and were all successfully treated with closed reduction and splinting. Type 2 fractures (n = 16) were severely displaced and problems with obtaining an adequate reduction and long-term residual deformities were encountered. One patient with a severely displaced fracture required open reduction and Kirschner-wire fixation because of flexor tendon entrapment at the fracture site. Another five cases required Kirschner-wire fixation after closed manipulation in order to maintain the reduction. The remaining 10 patients with Type 2 fractures were treated by closed reduction and splinting, and two patients healed with malunion causing a ‘‘pseudo-claw’’ deformity. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 24–30 the metacarpal head, but not through its centre. In type 2 (severely displaced) fractures, the line completely missed the metacarpal head (Fig 1). The ‘‘pencil technique’’ (Wood, 1976) was used for closed reduction of these fractures (Fig 2). After reduction, the finger was splinted to the adjacent uninjured finger and an ulnar gutter splint was worn for 3 weeks. Kirschner-wire fixation was only performed after failure to maintain the closed reduction. A single Kirschner wire was introduced through the proximal interphalangeal joint and passed across the fracture and the flexed metacarpophalangeal joint. The wire was then pulled out of the metacarpal head proximally to free the proximal interphalangeal joint. This technique of Kirschner-wire introduction was used because oblique Kirschner wires introduced into the base of the fractured proximal phalanx tended to displace the fracture. The Kirschner wire was removed at 3 weeks. Follow-up ranged between 5 and 24 months (mean = 14 months). At final follow-up, any decreased range of motion or deformity was documented. In patients with residual angulation, malunion was also confirmed with ‘‘Campbell’s lines’’. If the line missed the centre of the metacarpal head, residual malunion was recorded.
INTRODUCTION The majority of fractures of the proximal phalanx in children and adolescents are thought to be Salter type 2 fractures of the base of the phalanx (Campbell, 1990; Fischer and McElfresh, 1994; Hernden, 1985; Leclercq and Korn, 2000; Stern 1999; Worlock and Stower, 1986). However, close examination of the radiographs suggests that the fracture line is entirely through the metaphysis, 1–2 mm distal to the growth plate. This juxta-epiphyseal fracture pattern was noted by Barton (1979; 1984) and Beatty et al. (1990). This paper reports on a series of children and adolescents with juxtaepiphyseal fractures of the base of the proximal phalanx of the fingers.
PATIENTS AND METHODS All children with juxta-epiphyseal fractures of the base of the proximal phalanx of a finger who were seen by the author during the last 7 years were included in this retrospective study. Age, sex, mechanism of injury, finger involved, degree of fracture displacement, management and complications were documented. Fracture displacement was graded by drawing ‘‘Campbell’s lines’’ (Campbell, 1990) on the radiograph. If a line is drawn through the centres of the phalangeal neck and the phalangeal metaphysis, it should pass through the centre of the metacarpal head in a normal finger, regardless of the joint flexion. Campbell showed that use of these lines is valid for postero-anterior, lateral and oblique radiographs. These lines were used to classify juxta-epiphyseal fractures into two types depending on the degree of fracture displacement. In type 1 (mildly displaced) fractures, the line passed through
RESULTS A total of 34 juxta-epiphyseal fractures of the proximal phalanx were identified in 20 boys and 14 girls, aged between 5 and 14 years (mean = 10 years). The mechanism of injury was sudden ulnar or radial angulation of the finger in a fall or a fight, or during athletic activities such as wrestling. The little finger was 24
PHALANGEAL BASE FRACTURES
25
Fig 1 Campbell’s lines used to grade the degree of fracture displacement. (a) In mildly displaced fractures, the line passes off the centre of the metacarpal head. (b) In severely displaced fractures, the line completely misses the metacarpal head.
Fig 2 A pen or a pencil is placed at the base of the fractured phalanx and acts as a fulcrum during closed reduction of the fracture.
the most commonly involved digit (22 cases), followed by the ring (eight cases) and middle (four cases) fingers. The injured finger was ulnarly deviated in 30 cases and radially deviated in the remaining four. Examina-
tion of the radiographs showed that the fracture line was always entirely through the metaphysis, 1–2 mm distal to the growth plate. On the side of the deviation, the proximal metaphyseal fragment was triangular in
26
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Table 1—Management and complications in 34 cases of juxta-epiphyseal fractures of the proximal phalanx Fracture Type 1 (mildly displaced) Type 2 (severely displaced)
Cases (n)
Management
Complications
18
Closed reduction and splinting in all 18 cases
Nil
16
Closed reduction and splinting (n = 10)
Residual deformity in two patients Nil
Closed reduction and K-wire fixation (n = 5) Open reduction and K-wire fixation (n = 1)
Fig 3 A juxta-epiphyseal fracture of the proximal phalanx with ulnar deviation. The proximal metaphyseal fragment is triangular in shape with an intact periosteal sleeve on the side of deviation.
shape. Occasionally a faint white line was seen running from this triangular fragment to the distal fragment indicating an intact periosteal sleeve (Fig 3). Fracture displacement was mild in 18 cases and severe in the remaining 16 cases. The management and complications of the fractures are summarized in Table 1. All 18 mildly displaced fractures were treated by closed reduction and splinting
Nil
with no complications. However, problems were encountered with obtaining an adequate reduction by closed techniques and long-term complications occurred in the severely displaced (type 2) fractures. Illustrative examples are shown in Figs 4–6. One patient with a severely displaced fracture of the ring finger underwent open reduction and Kirschnerwire fixation because the fracture could not be reduced closed. At surgery, the flexor tendons were found entrapped in the fracture. After retraction of the flexor tendons the fracture readily reduced and the reduction was maintained with a single Kirschner wire for 3 weeks. This patient eventually regained a full range of motion. Another five cases required Kirschner-wire fixation after closed manipulation in order to maintain the reduction. The Kirschner wire was always removed at 3 weeks and all five cases regained full function with no deformity. The remaining ten patients with type 2 fractures were treated with closed reduction and splinting. At final follow-up, full range of motion without deformity occurred in eight out of the ten patients. The other two patients had a persistent ‘‘pseudo-claw’’ deformity: with active extension of the finger, there was 10–150 hyperextension at the metacarpophalangeal joint and 10–150 flexion at the proximal interphalangeal joint. The fingers of the uninjured hand of these two patients did not have lax joints or congenital pseudo-clawing. The deformity on the injured side was thought to be secondary to an inadequate reduction and subsequent inadequate remodelling in the flexion–extension plane. In each case malunion was confirmed by Campbell’s lines.
DISCUSSION This study has several important findings. Firstly, the paediatric fracture which is commonly referred to as a Salter type 2 injury of the base of the proximal phalanx is actually a non-epiphyseal fracture. Secondly, the pattern of injury appears to be identical in these fractures: the lateral angulation force separates a small triangular metaphyseal fragment at the base of the
PHALANGEAL BASE FRACTURES
27
Fig 4 (a) A type 2 fracture which required Kirschner-wire fixation. (b) Full function with no deformity was achieved.
phalanx on the side of angulation and then the fracture line continues through the metaphysis 1–2 mm distal to the growth plate. Thirdly, Campbell’s lines, which were originally devised to assess Salter type 1 fractures of the proximal phalanx, can also be used to assess degree of displacement and malunion following juxta-ephiphyseal fractures of the proximal phalanx. In the current series, juxta-epiphyseal fractures of the proximal phalanx most commonly involved the little finger which usually deviated in an ulnar direction. This common presentation was also noted by other authors (Barton, 1979; Beatty et al., 1990; Fischer and McEl-
fresh, 1994; Wood, 1976) and is often referred to as the ‘‘extra-octave’’ fracture because of the extreme ulnar angulation. During closed reduction of juxta-epiphyseal fractures of the proximal phalanx, it is difficult to gain adequated purchase on the proximal fragment while manipulating the distal fragment. (Beatty et al., 1990), and two techniques of closed reduction have been proposed. In the ‘‘pencil technique’’, which was used in the current study, a pencil is placed in the web space and serves as a fulcrum on which to manipulate the fracture. The other method is to flex the metacarpophalangeal joint to 908, which tightens the collateral
28
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Fig 5 (a) A type 2 fracture which was adequately treated with closed reduction and splinting. (b) Full function with no deformity was achieved.
ligaments and thus stabilizes the proximal fragment. Reduction is then accomplished by pushing the distal fragment across into the correct alignment (Beatty et al., 1990; Hastings and Simmons, 1984). In the latter technique, the metacarpophalangeal joints are locked in 908 of flexion during manipulation which helps correct any extension deformity. However, following manipulation in the abduction–adduction plane by the ‘‘pencil technique’’, residual extension of the fracture should be looked for and reduced. Whichever technique of closed reduction is used, over-correction is generally recommended. The periosteal sleeve is usually intact on the side of the angulation and generally prevents overreduction and provides stability in the reduced position. Once the fracture is reduced, the finger should be splinted to the adjacent uninjured finger before an ulnar gutter splint is applied. These precautions are essential, especially in ‘‘extra-octave’’ fractures of the little finger in which the pull of the abductor digiti minimi muscle tends to redisplace the fracture. In the current study, juxta-ephiphyseal fractures were classified into two types according to the degree of displacement. All type 1 or mildly displaced fractures
were successfully treated with closed reduction and splinting. However, Kirschner-wire fixation was necessary to maintain the reduction in five of the 16 severely displaced (type 2) fractures. Fracture instability in these cases might be related to disruption of the periosteal sleeve on the side of the angulation. One of the type 2 fractures was irreducible by closed methods because of entrapment of the flexor tendons. There are three previous reports of irreducible juxta-epiphyseal fractures of the proximal phalanx: flexor tendons were entrapped at the fracture site in two cases (Harryman and Jordan, 1990; Von Raffler, 1964) and there was fibrous tissue interposition in the third (Leonard and Dubravcik, 1970). Remodelling following juxta-epiphyseal fractures of the base of the proximal phalanx depends on several factors, including the age of the patient and the degree and type of deformity. Fischer and McElfresh (1994) stressed that remodelling is less likely to occur in adolescents than young children and it is also generally accepted that angulation in the same plane as the joint movement (plane of flexion–extension) will usually correct with growth. If the angulation is in the opposite
PHALANGEAL BASE FRACTURES
29
Fig 6 A type 2 fracture which was inadequately treated with closed reduction and splinting. (a) X-ray at the time of presentation. (b) Oblique view immediately after closed reduction. Note the residual extension deformity. (c) Postero-anterior X-ray at 1-year follow-up. Clinically there was no lateral angulation of the finger but Campbell’s line did not pass through the centre of the metacarpal head, indicating mild malunion. (d) Oblique view at 1-year follow-up. Clinically there was 108 of hyperextension at the metacarpophalangeal joint and 158 of flexion at the proximal interphalangeal joint. Malunion was confirmed with Campbell’s line on this radiograph.
30
plane (ulnar or radial deviation), or is rotational, it will not correct. Barton (1979) also stressed that a distinction should be made between fractures near the metacarpophalangeal joints and fractures near the interphalangeal joints. Juxta-epiphyseal fractures occur at the base of the proximal phalanx close to the metacarpophalangeal joint, which is not only a hinge but also allows lateral movement: hence such fractures may remodel in both planes. In this study the type 2 juxta-ephiphyseal fractures were usually not only angulated radially or ulnarly but also lay in extension. Thus it is imperative that the finger is reduced in both planes, since residual deformity may persist even in the plane of flexion–extension and cause a ‘‘pseudo-claw’’ deformity. The mechanism by which the pseudo-claw deformity occurs is as follows: residual extension of the fracture leads to relative shortening of the extensor surface of the proximal phalanx causing relative lengthening of the central slip and ineffective extension of the proximal interphalangeal joint. Following closed reduction, this residual extension deformity can easily be missed because it is difficult to get good lateral views of the fracture, especially if there is a plaster-cast. A residual extension deformity is also more likely to occur when ulnar slabs are applied with the metacarpophalangeal joints in extension. Therefore, immobilization should be in the Edinburgh position, with the metacarpophalangeal joints flexed to 908, which should help correct any extension of the fracture.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
References Barton NJ (1979). Fractures of the phalanges of the hand in children. The Hand, 11: 134–143. Barton NJ (1984). Fractures of the hand. Journal of Bone and Joint Surgery, 66B: 159, 167. Beatty E, Light TR, Belsole RJ, Ogden JA (1990). Wrist and hand skeletal injuries in children. Hand Clinics, 6: 723–738. Campbell RM (1990). Operative treatment of fractures and dislocations of the hand and wrist region in children. Orthopedic Clinics of North America, 21: 217–243. Fischer MD, McElfresh EC (1994). Physeal and periphyseal injuries of the hand: patterns of injury and results of treatment. Hand Clinics, 10: 287–301. Harryman DT, Jordan TF (1990). Physeal phalangeal fracture with flexor tendon entrapment. Clinical Orthopaedics and Related Research, 250: 194–196. Hastings H, Simmons BP (1984). Hand fractures in children: a statistical analysis. Clinical Orthopaedics and Related Research, 188: 120–130. Herndon JH (1985). Hand injuries – special considerations in children. Emergency Medicine Clinics of North America, 3: 405–413. Leclercq C, Korn W (2000). Articular fractures of the fingers in children. Hand Clinics, 16: 523–534. Leonard MH, Dubravcik P (1970). Management of fractured fingers in the child. Clinical Orthopaedics and Related Research, 73: 160–168. Stern PJ. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Peterson WC (eds). Green’s Operative Hand Surgery, Vol 1, 4th Edn., New York, Churchill Livingstone, 1999: 711–771. Von Raffler W (1964). Irreducible juxta-epiphyseal fracture of a finger. Journal of Bone and Joint Surgery, 46B: 229. Wood VE (1976). Fractures of the hand in children. Orthopedic Clinics of North America, 7: 527–542. Worlock PH, Stower MJ (1986). The incidence and pattern of hand fractures in children. Journal of Hand Surgery, 11B: 198–200.
Received: 12 March 2001 Accepted after revision: 15 June 2001 Mr M. M. Al-Qattan, Division of Plastic Surgery, PO Box 18097, Riyadh 11415, Saudi Arabia. # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0661, available online at http://www.idealibrary.com on