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F. M. Senes et al.
tude without surgery because of a spontaneous
recovery thatmight happen within a few months,
whereas open lesions are in need of immediate
treatment as in adults.
Even though the outcome is generally good, a
small percentage of failure has to be taken into
consideration, particularlythose related to open
or closed ulnar nerve injuries.
References
1. Missios S, Bekelis K, Spinner RJ.Traumatic peripheral nerve injuries in children: epidemiology and
socioeconomics. J Neurosurg Pediatr. 2014;10:1–7.
2. Birch R, Achan P.Peripheral nerve repairs and their
results in children. Hand Clin. 2000;16(4):579–95.
3. Waters PM, Bae DS. Distal humerus fracture. In:
Pediatric hand and upper limb surgery. A practical
guide. Philadelphia: Lippincott Williams and Wilkins;
2012. p.287–315.
4. McGraw JJ, Akbarnia BA, Hanel DP. Neurological
complications resulting from supracondylar fractures of the humerus in children. J Pediatr Orthop.
1986;6:647–50.
5. Iqbal M, Habib R. Nerve injuries associated with
supracondylar fracture of the humerus in children. J
Pak Med Assoc. 1994;44:148–9.
6. Babal JC, Mehlman CT, Klein G.Nerve injuries associated with pediatric supracondylar humeral fractures:
a meta-analysis. J Pediatr Orthop. 2010;30(3):253–63.
7. Vincelet Y, Journeau P, Popkov D, Haumont T,
Lascombes P. The anatomical basis for anterior
interosseous nerve palsy secondary to supracondylar fractures in children. Orthop Traumatol Surg Res.
2013;99:543–7.
8. Holstein A, Lewis GM.Fractures of the humerus with
radial nerve palsy. J Bone Joint Surg. 1963;45:1382–8.
9. Rocchi M, Tarallo L, Mugnai R, Adani R.Humeral
shaft fractures complicated by radial nerve palsy: is
surgical exploration necessary? Musculoskelet Surg.
2016;100(Suppl 1):S53–60.
10. Waters PM, Bae DS. Traumatic peripheral nerve
injuries. In: Pediatric hand and upper limb surgery. A
practical guide. Philadelphia: Lippincott Williams and
Wilkins; 2012. p.462–77.
11. Lyons JP, Ashley E, Hoffer MM.Ulnar nerve palsies
after percutaneous cross pinning of supracondylar
fractures in children’s elbow. J Pediatr Orthop.
1998;18:43–5.
12. Tindall A, Dawood R, Povlsen B.Case of the month:
the skin wrinkle test a simple nerve injury test for
pediatric and uncooperative patients. Emerg Med J.
2006;23(11):883–6.
13. Barisic N, Perovic D, Mitrovic Z, Jurenic D, Zagar
M.Assessment of war and accidental nerve injuries in
children. Pediatr Neurol. 1999;21(1):450–5.
14. Carter GT, Robinson LR, Chang VH, Kraft
GH.Electrodiagnostic evaluation of traumatic nerve
injuries. Hand Clin. 2000;16:1–12.
15. Lee J, Bidwell T, Metcalfe R.Ultrasound in pediatric
peripheral nerve injuries: can this affect our surgical decision making? A preliminary report. J Pediatr
Orthop. 2013;33(2):152–8.
16. Yang M, Rawson JL, Zhang EW, Arnold PB,
Lineaweaver W, Zhang F. Comparison of outcomes
from repair of median and ulnar nerve defect with
nerve graft and tubulization: a meta-analysis. J
Reconstr Microsurg. 2011;27:451–60.
17. Senes FM, Catena N, Senes J. Use of tubulization
(nerve conduits) in repairing nerve defects in children.
Indian J Orthop. 2015;49(5):554–60.
18. Senes FM, Campus R, Becchetti F, Catena
N. Upper limb nerve injuries in developmental age.
Microsurgery. 2009;29(7):529–35.
19. Shore BJ, Gillespie BT, Miller PE, Bae DS, Waters PM.
Recovery of motor nerve injuries associated with displaced, extension-type pediatric supracondylar humerus
fractures. J Pediatr Orthop. 2017;39(9):e652–6.
Flexor Tendon Lesions inChildren:
https://t.me/medicina_free
Diagnosis, Treatment, andEarly
Active Motion Rehabilitation
ChiaraParolo, GretaCulicchia, RossellaPagliaro,
andGiorgioPajardi
26
Abstract
Flexor tendon injuries in children represent a
diagnostic and therapeutic challenge for surgeons. These injuries can go unnoticed and
rehabilitation is difcult, but good results are
achieved after treatment. In the recent years,
with the evolution of repair techniques of
exor tendons, in adult patients, an early
active motion regime was introduced. In pediatric age, there is not still common consensus
for surgical technique and for postoperative
rehabilitation. In children aged between 3 and
7 years, we prefer the pullout technique while
in children aged between 8 and 12 years the
four-strand suture associated with the peripheral epitendinous suture. Partial early active
motion protocol is started no later than 7 days
after the repair. Between April and December
2018, four children were treated. There were
no complications such as rupture, inammation, infection, or contractures of the proximal
interphalangeal joint at the nal follow-up. No
patient needs tenolysis. Good and excellent
C. Parolo (*) · G. Culicchia · R. Pagliaro
Milan, Italy
e-mail: chiara.parolo@multimedica.it;
grata.culicchia@multimedica.it;
rossella.pagliaro@multimedica.it
G. Pajardi
Department of Hand Surgery and Rehabilitation,
S.Giuseppe Hospital IRCCS MultiMedica, Milan
University, Milan, Italy
e-mail: gpajardi@centrostudimano.it
results were registered in all four digits,
respectively, with the TAM score and the
Strickland method. We do believe that early
active motion by promoting tendon gliding
immediately avoids the exclusion of the hand
and the loss of the motor pattern and favors the
return to play activities.
Keywords
Flexor tendons · Rehabilitation · Mobilization
Injuries
Flexor tendon injuries in children represent a
diagnostic and therapeutic challenge for surgeons. These injuries can go unnoticed and rehabilitation is difcult, but good results are achieved
after treatment.
The incidence of these lesions in children has
been estimated at 3.6/100,000 children per year
[1]. Flexor zones II and V are the most commonly
affected, and it is very strange to see these lesions
in children younger than 2 years old, although
they have been described in newborns occurring
during emergency cesarean deliveries [2]. “Buds”
or higher incidence peaks have also been
observed in holiday times, in which children tend
to manipulate sharp instruments [2].
The most common trauma mechanism is
caused by cutting glass, followed by sharp object
injuries (knives). Associated neurological injuries
are commonly found in exor zones III and V, and
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they are not frequently associated with nger fractures or extensor tendon injuries [1]. These injuries
are more common in men than in women and most
commonly affect the right hand [1, 3].
In the recent years, with the evolution of repair
techniques of exor tendons, in adult patients, an
early active motion regime was introduced. There
are several articles that support this concept seeing
as it improves the gliding of tendons and the
strength of tensile and reduces the adhesion formation and complications. In pediatric age, there
is not still common consensus for surgical technique and for postoperative rehabilitation. In fact,
rehabilitation program after exor tendon repair is
highly controversial. Some authors prefer immobilization while others support different rehabilitation protocols. Postoperative rehabilitation
programs are strictly inuenced by the patient’s
age. In literature, preschoolers (less than 5 years
old) are immobilized while for children between 5
and 10 years old recommend an early motion program under the supervision of the hand therapist.
In this study, we reported the cases of children
between 3 and 12 years old with exor tendon
injury in zones I, II, and III repaired with fourstrand suture associated with epitendinous suture
and with pullout technique. After surgery, they
performed the early active motion protocol.
In children aged between 3 and 7 years, we prefer the pullout technique while in children aged
between 8 and 12 years the four-strand suture associated with the peripheral epitendinous suture. The
pullout technique, described for the rst time by
Bunnel in 1940, is used for the repair of the profundus exor tendon in zone I with the aim of transferring the tendon suture to the button placed on the
digital apex (Fig.26.1). This technique allows the
two tendon stumps to be brought together, eliminating tension during muscle contraction. In recent
decades, a four-strand repair associated with a
peripheral epitendinous suture has been the main
repair technique for exor tendons. This promotes
greater resistance and sealing force and less gapping at the repair site and allows for inherent healing by limiting adhesion formation. The associated
peripheral epitendinous suture has the purpose of
leveling and reducing the repair thickness ensuring
greater sliding. When the tendon is too small, we
use a smaller suture than adults in order to permit a
four-strand technique.
C. Parolo et al.
Fig. 26.1 Pull-out technique
Fig. 26.2 Double 4 strand in exor tendon repair
After surgery, a dorsal thermoplastic splint
was applied at the end of surgery to protect the
tendon suture, and this is usually worn for 6
weeks. The splint keeps the wrist at 0–30° of
extension, the metacarpophalangeal joints at 30°
of exion, and the interphalangeal joints fully
extended. Prior to initiating an active motion
regime, maximal passive digital exion should be
restored (Fig.26.2). This will assist in reducing
the work of exion on the repaired tendon and
preventing joint stiffness. Edema also plays a sig-
26 Flexor Tendon Lesions inChildren: Diagnosis, Treatment, andEarly Active Motion Rehabilitation
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311
nicant role in the limitation of motion, especially in the early phase following surgery. For
this reason, active mobilization regime begins on
the third to fth days in line with current thinking
on the subsidence of postoperative edema. Active
exion exercises were initiated from the distal
interphalangeal (dip) joint, and motion should be
conned to the outer range or rst third of exion. In fact, resistance to digital exion increases
over the rst two-thirds of exion increasing veto tenfold in the nal third. The degrees of digital
active exion will be increased after 1 week until
reaching the complete active exion in the fourth
week. Active IP (interphalangeal) joint extension
exercises are very important and should be performed regularly to prevent the loss of extension
at the IP joints, which is a common complication
in this type of injury. Patients did not move the
wrist until the third week and performed passive
and active digital exercises with the wrist immobilized inside the splint. From the third to the
sixth weeks, the patient removed the splint only
to perform the exercise (Table 26.1). With the
pullout technique, the risk of tendon rupture is
lower. For this reason, the active mobilization
regime of the ngers and wrist begins immediately without any limit in the degrees of movement. The splint was worn only at night and in
dangerous activities. The pullout is removed at 6
weeks after a surgical check (Table26.2).
The study was conducted from 2017 to 2018in
the Hand Surgery and Rehabilitation department
Table 26.1 Rehabilitation regime for exor tendon
repair with a four-strand suture
• Begin the motion at 3–5 days postoperative
• Protective dorsal splint applied to be worn for 6
weeks
• Prioritize restoration of full passive digital exion
• Start early active motion from the DIP joint
• Encourage active digital extension exercise
• Move the wrist at 3 weeks
• Begin the complete active exion of ngers at 4
weeks
• At 6 weeks, remove splint during the day but worn it
for the night
• At 6 weeks, commence stretching and splinting of
residual exion deformity
• Return to normal activity between 10 and 12 weeks
Table 26.2 Rehabilitation regime for exor tendon
repair with pullout technique
• Begin the motion at 3–5 days postoperative
• Protective dorsal splint worn at night and in
dangerous activities for 6 weeks
• Prioritize restoration of full passive digital exion
• Start active movement of the ngers in all degrees of
exion
• Encourage active digital extension exercise
• Stimulate to use the ngers in activity of the day
• At 6 weeks, remove the pullout
• At 6 weeks, commence stretching and splinting of
residual exion deformity
• Return to normal activity between 10 and 12 weeks
at the IRCCS (Scientic Institute of Recovery
and Care) Multimedica group of Lombardy.
Small patients aged 3–12 years with lesions of
the exor tendons in areas 1, 2, and 3 operated
from 2017 to 2018 were included. The inclusion
criteria were lesion of the exor digitorum profundus tendon, of the exor digitorum supercialis, a combination of the FDP (exor digitorum
profundus) and FDS (exor digitorum supercialis) tendon, and of the exor pollicis longus;
injury zones I, II, and III; concomitant neurovascular injury; surgical repair with a four-strand
suture associated with epitendinous suture or
with pullout technique; and start of the partial
early active motion protocol no later than 7 days
after repair. The exclusion criteria were associated injuries such as fractures, volar plate, and
pulley injury. In children aged 8–12 years, the
exor tendons were repaired with a four-strand
associated with epitendinous suture using the
Prolene 3.0 for the central suture and Prolene 5.0
for the peripheral suture. The pullout technique
was used for children aged 3–7 years. After the
surgical repair, a dorsal thermoplastic splint
(photo) was applied and the patients were started
the rehabilitation regimen based on the partial
early active motion protocol. The exercises were
performed several times a day at home under
parental supervision and with the hand therapist
three times a week. The evaluation scales used
were AROM (active range of motion), TAM
(total active motion), % TAM, Strickland, BuckGramcko, and Scala Vas.
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C. Parolo et al.
Active exion and extension at the proximal
and distal interphalangeal joints of the injured
ngers were measured by a hand therapist using
a goniometer. Postoperative outcome for joint
function was assessed using the total active of
motion (TAM) scoring system suggested by the
American Society for Surgery of the Hand. The
results were also established using BuckGramcko score and the Strickland and Glogovac
Grading System with excellent (85–100%), good
(70–84%), fair (50–69%), and poor (<50%) postoperative function.
Between April and December 2018, four children were treated. Of them, two were males and
two were females. The mean age was 6 years
(range 3–9 years). In total, four digits were
affected: thumb n= 1, middle nger n = 2, and
small nger n=1. The exor digitorum profundus
(FDP) tendon was affected in two ngers, the
exor pollicis longus (FLP) tendon in one nger
and the combination of the exor digitorum profundus (FDP) and the exor digitorum supercialis (FDS) tendons in one nger. The number of
tendon laceration in zone I was two and in zone II
was two. Concomitant neurovascular transection
was diagnosed in two patients. The patients were
subdivided by age into two groups: 3–7 years (two
digits) whose tendons were repaired with pullout
technique and 8–12 years (two digits) whose tendons were repaired with a four-strand suture associated with the epitendinous suture. There were no
complications such as rupture, inammation,
infection, and contractures of the proximal interphalangeal joint at the nal follow- up. No patient
needs tenolysis. Good and excellent results were
registered in all four digits, respectively, with the
TAM score and the Strickland Method. According
to the Buck- Gramcko evaluation system, all digits
showed excellent functional results. Mean Vas
score was 1 only given to the 8–12 years’ group
and the nal mean was 1. All parents were happy
with the nal results.
In adults, early active motion is the principle
of exor tendon rehabilitation. The need for a
stronger central suture to resist the early active
movement regimen has been underlined for several years in adults. Several studies have shown
excellent results with the four-strand technique
associated with the epitendinous suture. The
suture technique is a critical factor in children
compared to adults. Although it is possible to
place more than one core suture in an adult-size
tendon, this might not always be possible in the
smaller pediatric-size tendon. In this study, we
have not wanted to compare different suturing
techniques, but the suture technique and the postoperative rehabilitation program are greatly
inuenced by the age group and by the cooperation of child. In literature, many different forms
of early mobilization programs have been used.
Preschoolers are frequently immobilized in a cast
for 3–4 weeks, while for children between 5 and
10 years of age, most of the recent articles recommends a modied early mobilization program
under the supervision of a hand therapist but the
ngers are immobilized between physiotherapy
sessions [4]. In our experience, the children aged
0–2 years are frequently immobilized with splint
for 3–4 weeks [5] in children between 3 and 7
years of age with exor tendon injury in zone I,
we use the pullout repair technique and the active
motion regime start immediately without any
limitation of the movements at the level of the
ngers and wrist. This is because the pullout
technique is safer and the possibility of tendon
rupture is lower. So it is used in younger children
where the use of splint is difcult to manage and
rehabilitation does not require complex exercises. For patients between 8 and 12 years, we
use an early active motion regimen after the tendon reparation with a four- strand suture associated with the epitendinous suture, as for adult
injuries. In this case, our postoperative rehabilitation protocol involves an early but partial active
movement of the ngers for the rst 3 postoperative weeks because resistance to digital exion
increases over the rst two-thirds of exion
increasing ve- to tenfold in the nal third week.
The wrist is immobilized inside the splint until 3
weeks, and only after this period it is possible to
move it. There was not any difference in the postoperative outcomes between groups of age in this
study. In fact, using the Strickland criteria and
Buck-Gramcko evaluation, all children qualied
for an excellent outcome in all four ngers.
Comparing our data with the Nietosvaara and
26 Flexor Tendon Lesions inChildren: Diagnosis, Treatment, andEarly Active Motion Rehabilitation
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313
Al-Qattan’s studies who promote immediate
active mobilization, we obtained 50% of the
excellent results before a year according to the
Strickland criteria. Moreover, in our study, there
were not cases of tendon rupture and of contractures of the proximal interphalangeal joint and
tenolysis. The VAS scale was administered only
to the 8–12 years’ group by reason of poor compliance and understanding of children under 7
years old, and we had a very low score at the end
of the treatment.
We did not evaluate the grip strength and the
DASH (Disabilities of the Arm, Shoulder, and
Hand) questionnaire because it was developed
and validated for adults. However, the results
obtained with early active motion after exor tendon repair are encouraging considering the tendency to reduce complication rates and early
recovery of nger movement and functionality.
In addition, we believe that early active motion
by promoting tendon gliding immediately avoids
the exclusion of the hand and the loss of the
motor pattern and favors the return to play activities. We have shown that it can easily be applied
to children and is well tolerated by them and their
families.
References
1. Nietosvaara Y, Lindfors NC, Palmu S, Rautakorpi
S, Ristaniemi N. Flexor tendon injuries in pediatric
patients. J Hand Surg Am. 2007;32(10):1549–57.
2. Al-Qattan MM.Flexor tendon injuries in the child. J
Hand Surg Eur. 2013;39(1):46–53.
3. Sikora S, Lai M, Arneja JS.Flexor tendon injuries
pediatric: a 10-year outcome analysis. Can J Plast
Surg. 2013;21(3):181–5.
4. Moehrlen U, Mazzone L, Bieli C, Weber DM. Early
mobilization after exor tendon repair in children.
Eur J Pediatr Surg. 2009;19(2):83–6.
5. Kato H, Minami A, Suenaga N, Iwasaki N, Kimura
T.Long term results after primary repairs of zone 2
exor tendon lacerations in children younger than age
6 years. J Pediatr Orthop. 2002;22(6):732–5.
Pediatric Hand Fractures
https://t.me/medicina_free
FilippoM.Senes, LuigiA.Nasto,
NunzioCatena, andChiaraArrigoni
27
Abstract
Pediatric hand fractures can be anatomically
classied as fractures or dislocations of the
wrist, carpus, metacarpals, and phalanxes.
Wrist fractures (i.e., distal metaphyseal radius
and/or ulna fractures) represent 20% of all fractures in growing children. These injuries can be
classed as simple fractures with no displacement, greenstick fractures, and complete fractures with dislocation and overlapping of the
fracture fragments. However, in almost 90% of
cases they require conservative treatment.
Pediatric carpal fractures are rare, commonly observed in adolescents rather than in
children because of the cartilaginous matrix of
carpal bones. Metacarpal and phalanxes show
F. M. Senes (*)
Department of Hand Surgery and Rehabilitation,
S. Giuseppe MultiMedica Hospital, Milan University,
Milano, Italy
e-mail: lipposenes@fastwebnet.it
L. A. Nasto
UOC Ortopedia e Traumatologia, IRCCS Istituto
Giannina Gaslini, Genova, Italy
N. Catena
UOSD Microchirurgia Ricostruttiva e Chirurgia della
Mano, IRCCS Giannina Gaslini, Genova, Italy
C. Arrigoni
Scuola di Specializzazione in Ortopedia e
Traumatologia, Università degli Studi di Torino,
Torino, Italy
typical fracture patterns: metacarpal fractures
are most commonly metaphyseal compression
fractures or Salter-Harris (SH) type II physeal
fractures and are frequently observed in the I
and V rays; phalangeal fractures are the most
common hand fractures in children and the distal phalanx is the most injured. Dislocation of
metacarpophalangeal (MP) and interphalangeal (IP) joints is not frequently reported in
children. Minor ngertip injuries are very common instead. Sometimes simple wound care
will be enough in achieving complete healing,
but in cases of larger skin loss with exposed
fractures, advancement ap or, more rarely,
regional aps or skin grafts could be required.
Keywords
Pediatric · Children · Hand · Fractures ·
Dislocations · Wound
27.1 Introduction
Pediatric hand fractures can be classied anatomically as fractures and dislocations of the wrist
region, carpus, metacarpals, and phalanxes [1].
27.1.1 Wrist Region Fractures
Wrist fractures (i.e., distal metaphyseal radius
and/or ulna fractures) represent 20% of all frac-
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G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_27
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F. M. Senes et al.
tures in growing children. These injuries can be
classied as simple fractures with no displacement, greenstick fractures (i.e., monocortical
fractures), and complete fractures with dislocation and overlapping of the fracture fragments
[2]. Finally, epiphyseal fractures of the distal
radius are also very common and can be associated with a fracture of the distal ulna.
Pain, tenderness, and local swelling are the
three most common ndings in wrist fractures. In
displaced fractures, there is an obvious clinical
deformity of the wrist, typicallya bayonet deformity with dorsal displacement of the distal fragment. X-ray imaging helps in establishing a
correct diagnosis, although it can be negative in
cases of SH type I of the distal radius.
Not displaced fractures, greenstick fractures,
and complete fractures can be treated with cast
immobilization. If some signicant displacement
or angulation is present, this can be usually
reduced in the casting roomafter a brief procedural analgesia. This allows conservative treatment for almost 90% of fractures in the distal
radius and ulna region. However, displaced fractures with signicant overlapping of the fracture
fragments will require reduction under anesthesia. If the reduction is unstable, temporary pinning of the fracture is advised. The upper limb is
immobilized in a well-molded cast after the procedure, with exion of the wrist if needed. X-ray
imaging is obtained 1 week after reduction to
exclude any loss of correction, and the cast is
removed at 5 weeks.
Displaced SH type I or II distal radius fractures are very easy to diagnose, and an X-ray
shows the direction of the displacement. The
complete reduction can be achieved at this level
by closed means and short procedural anesthesia.
The wrist is immobilized in a closed well-molded
cast for 4 weeks. X-ray imaging is always
obtained 1 week after reduction torule out any
loss of correction.
Fractures and epiphyseal injuries of the wrist
show very good healing with almost complete
restoration of the anatomy even in cases of moderate displacement. This is due to the great
growth and repair potential of this anatomical
region in growing children and pediatric patients.
27.1.2 Carpal Bone Fractures
Pediatric carpal bone fractures are rare and usually observed in adolescents [3]. Carpal bones are
largely cartilaginous in children, thus less prone
to fractures. Higher-energy trauma normally
causes multiple fractures of the carpal bones with
associated metacarpal fractures [4].
The scaphoid is the most commonly injured
carpal bone. The scaphoid fracture can be
observed either in isolation or with a distal radius
fracture. This fracture is exceedingly rare before
the age of seven [4, 5]. In more than 50% of
cases, a distal pole fracture is observed, while
fractures of the body or proximal pole are less
common [6, 7].
Clinically, focal tenderness is observed at the
anatomical snuffbox and along the axis of the
rst ray. A scaphoid fracture can be easily missed
on X-rays, especially if only a small angulation is
present or a limited interruption of the cortex.
However, if focal tenderness can be elicited at the
anatomical snuffbox in presence of negative
X-ray, a short period of immobilization (2 weeks)
with a cast is advised. X-ray is then repeated at
the end of the immobilization period to conrm
the presence of a fracture. In children, treatment
is nonoperative. Cast immobilization is maintained for 4 weeks in incomplete fractures, while
complete fractures are splintedfor 4–8 weeks. In
cases of belated diagnosis or delayed healing,
cast immobilization can be extended up to 8–16
weeks until complete healing is achieved.
Ossication of the scaphoid bone proceeds in
a distal to proximal direction. This is followed by
rapid vascularization, which explains why complications typical of adult patients (i.e., nonunion,
bone necrosis) are usually absent in children. At
the end of the ossication period, vascularization
of the bone decreases and becomes more similar
to the adult pattern. Avascular necrosis is very
rare in children [6–8]. Similarly, nonunion is very
rare in pediatric patients [9–12] (Fig.27.1).
Interestingly, the lack of ossication or complete bone bridging on the X-ray is not necessarily a demonstration of nonunion in pediatric
patients. Often, a brous tissue bridge develops
between the fracture fragments. Nevertheless,
27 Pediatric Hand Fractures
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317
Fig. 27.1 Shaft scaphoid fracture hesitated in nonunion
prolonged immobilization allows complete healing of the fracture. The rare cases of pediatric
scaphoid bone nonunion have been successfully
treated with bone grafting through a volar
approach to the fracture site [13, 14] (Fig.27.2).
Very rare fractures of other carpal bones
(Fig.27.3).
27.1.3 Metacarpal Fractures
andDislocations
Metacarpals and phalanxes show typical fracture
patterns. The presence of a single growth plate
explains the typical fracture patterns seen in these
bones.
Metacarpal fractures are most commonly
observed in I and V rays. These injuriesare generally metaphyseal compression or SH type II
physealfractures. The epiphysis of the I metacar-
pal is located at the base of the bone, while in the
remaining metacarpals, the epiphysis is located
distally, at the head of the bone.
Diaphyseal fractures of metacarpals are
unusual. Oblique or spiral fracture pattern and
modest displacement occur, as adult fractures.
These are most commonly observed in the II
and III metacarpal. Isolated or multiple diaphyseal fractures can be immobilized in a cast with
MCP joints exed and PIP and DIP joints
extended. If bone fragments are severely displaced, closed reduction should be attempted
and followed by 4 weeks cast splinting.
Sometimes, Kirshner wire pinning is needed to
maintain reduction; rarely, plate and screw xationare required (Fig.27.4).
Fractures of the distal third of II, III, and IV
metacarpals are rare in children and adolescents [15, 16]. In distal metaphyseal fractures,
the metacarpal heads are always tilted on the
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Fig. 27.2 Scaphoid
nonunion treated with
allograft from the distal
radius
F. M. Senes et al.
Fig. 27.3 Triquetral fracture
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