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27 Pediatric Hand Fractures
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Fig. 27.4 Spiral diaphyseal displaced fractures of III and IV metacarpals treated with closed reduction and Kirshner
wire pinning
319
volar side because of the strong action of
flexor tendons. Often, ulnar angulation is also
observed.
Greenstick metaphyseal or SH type II epiphyseal fractures are most commonly observed at the
level of the V and IV rays. These fractures are
typically due to direct trauma (punch injury) and
are displaced into exion. Acceptable angular
deformities and indications for reduction have
been discussed elsewhere [17–19].
In adolescents, when growth plates are about
to close, the loss of physiological prominence of
metacarpals and the decreased growth potential
of metacarpals require an almost anatomical
reduction. Closedreduction of the angular deviation and cast immobilization are usually performed. Unstable and irriducible fractures are
treated through percutaneous Kirshner wires
pinning. Odgen advises against the use of endomedullary Kirshner wires in metacarpals to avoid
growth retardation and prevent from growth
platedamage. In our opinion, growth plateinjury
is due to repeated attempts at cannulating the
metacarpal rather than physis transxion by a
single wire.
The incomplete correction or reduction determine ametacarpalshortening. This can be due
toepiphysealhealing in a exed position, or to
posttraumatic epiphysiodesis as a result of growth
plateinjury.The lattermechanism is more common in SH type III and IV fractures than in type
II injuries [20, 21].
Fractures of the rst metacarpal are tipically located at the base/proximal third of the
bone as aSH type II injury.Open growth plate
differsthese fractures from Bennet and Rolando’s
fractures observed in adult patients [22, 23]. The
displacement pattern is determined by thestrong
intercapsular volar oblique ligament, which spans
from the trapezium to the base of the I metacarpal
(Fig.27.5).
There is huge variability in terms of clinical
presentation, radiographic ndings, and amount
of displacement of the metaphyseal fragment
[24–26].Generally,metacarpal diaphysisis dorsally and proximally displaced. Furthermore,
diaphyseal shaft is also twisted in supination by
the abductor pollicis longusmuscle, and radially
displaced by the adductor pollicis muscle. The
abundant and thick periosteum limitsa marked
fracture fragments displacement while it provides stabilityto closed reduction.
Although minimaldisplacement can be treated
with cast immobilization, an anatomical reduction
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Fig. 27.5 First metacarpal base displaced fracture treated with closed reduction and Kirshner wire pinning
F. M. Senes et al.
is always advisable. In any case, displacement
>30° must be always corrected and reduced.
Reduction is achieved with longitudinal traction on the extremity of the thumb, along with
abduction, extension, and pronation of the metacarpal. Hyperextension of the metacarpal should
be avoided. The maneuver is completed by pushing at the base of the rst nger while applying
an opposing force on the head of the rst
metacarpal.
Less commonly, a fracture with complete dislocation of the metaphysis through a buttonhole
of the periosteum can be observed. This can prevent closed reduction and makes open reduction
necessary. In these cases, ulnar deviation of the
base of the metacarpal is most often noted.
Non-displaced diaphyseal metacarpal fractures areconservatively treated, while displaced
fractures are reduced following the metacarpallongitudinal axis. As with other metacarpals,
immobilization is maintained for 4 weeks and
can be extended for an extra 2–4 weeks if bone
healing is insufcient.
27.1.4 Phalangeal Fractures
andDislocations
Phalangeal fractures are the most common hand
fractures in children. Although all three phalanxes can be interested from bone damage, the
distal phalanx is the most frequently injured.
Fractures of phalanxes can be classied as fractures of proximal part of the bone (physeal injuries), fractures of the diaphysis (extraphyseal
injuries), and fractures of distal part of the bone
(extraphyseal injuries) (Fig.27.6).
Most commonly, only a small cortical defect
is identied on the X-rays. These injuries can be
treated with a short period of immobilization, achieving a complete resolution of the
symptoms.
Fractures of the proximal phalanx of the
thumb are commonly physeal injuries and are
clinically equivalent to adult ligamentous injuries
interesting the metacarpophalangeal joint. All
types of physeal injuries can be seen at this level;
however, while SH type III and IV fractures usu-
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ab c
Fig. 27.6 Phalangeal fractures can be classied as proximal physeal fractures (a), diaphyseal fractures (b), and distal
extraphyseal fractures (c)
ally require open reduction and internal xation,
SH types I and II can be treated conservatively by
spinting the thumb into adduction to prevent
later displacement. Similarly, neck (subcapital)
fractures of proximal phalanx of the thumbmust
be adequately immobilized because they can easily displace and undergo malunion.
Tubercle fractures of the distal phalanx usually result from a crush injury and are typical in
younger children. On the other hand, epiphyseal
fractures of the distal phalanx are less common
and are seen in older children after a crush injury.
These fractures are at risk of infection, growth
plate damage, and secondary epiphysiodesis.
Furthermore, volar insertion of the FDP tendon
leads to secondary exion displacement of the
distal fragment, while dorsal insertion of the
extensor tendon leads to extension displacement
of the proximal (physeal) fragment. Counteraction
of these forces can be obtained with Kirshner
wire xation, especially in SH type III and IV
injuries.
Basalproximal phalanx fracturesof the long
ngers are usually SH type II injuries with large
metaphyseal fragment (Thurstan-Holland fragment). In older children, these are less commonly
SH type III and IV injuries. SH type V fractures
are exceedingly rare and treatment depends on
the amount of displacement. These fractures are
at risk of growth arrest. In proximal phalanxes,
compression fractures of the proximal third of
the bone are volarly angulated because ofexion
and extension deforming forces of eitherintrinsic
hand muscles orextensor tendons. On the X-rays,
the fracture looks like a greenstick fracture, usually by theulnar side of the cortex. Closed reduction and spinting are generally successful in
obtaining realignment of the fracture.Sometimes,
afull control of the proximal fragment can be difcult to attain. In these cases, a nger spacer
(e.g., a pencil) can be used to displace radially the
distal fragment (Fig. 27.7). Alternatively, MCP
joints can be exed to >90° and fracture
reducedby re-tensioning collateral ligaments and
pushing volarly the distal fragment.
In greenstick fractures, a complete breakage
of contralateral cortex is sometimes needed to
allow reduction of the fracture. However, preserving some continuity of the bone and periosteum allows preservation of some stability and
prevents hypercorrection.
Treatment of non-displaced epiphyseal fractures requires 15–20 days of immobilization with
a tongue blade and elastic bandage. When
the alignment is not acceptable, closed reduction is needed. After reduction, the nger is
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Fig. 27.7 Finger spacer technique for closed reduction
splinted along with the adjacent nger (i.e.,
buddy taping) for 3 weeks. The involved ngers
are immobilized with MCP joints exed at 60°
and PIP joints exed at 15°, making sure that ngers are kept parallel. While in adolescents and
older children, elastic bandages are preferable,
cast immobilization is advisable in younger children. The inclusion of the V metacarpal for ulnar
side ngers, or thenar eminence for radial side
ngers and thumb, allows for a safe and effective
restriction from the activity and better stability. Open reduction and Kirshner wire xation
are preferred methods when closed reduction
isfailed, residual rotatory deformity, or a small
epiphyseal fragment is impeding the reduction
[27]. Usually, close reductionand kirshner wire
percutaneous pinning are successful. In case of
severe palmar displacement of distal fracture
fragment,open reduction is needed [26].
At the level of proximal phalanxes, up to 10°
of coronal displacement can be tolerated because
of the compensatory action of the adjacent MCP
joint. However, middle and distal phalanxes show
a minimal adaptation to coronal displacement.
Shaft fractures of the proximal and middle phalanxes follow similar patterns and treatment strategies. More than 75% of phalanx fractures are
treated conservatively with a brief period of
immobilization. Only 15% of fractures require a
closed reduction, while roughly 10% will
F. M. Senes et al.
require open procedures. According to Leonard
and Dubravcik, in 40% of casessurgically treated
fractures are located in the metaphyseal area,
while 26% are diaphyseal [27, 28].
Non-displaced diaphyseal fractures of the
phalanxes are conservatively treated by3 weeks
of immobilization. In cases of displaced or unstable fracture patterns (e.g., oblique or spiral fractures), an open reduction is indicated with
Kirshner wire xation followed by 6 weeks of
immobilization. Surgical approach should
becautious in diaphyseal fractures because of the
poor vascularity of the distal fragment. Delayed
angulation can be prevented by immobilizing
MCP and interphalangeal joints into exion.
Loss of correction and malunion leads to loss of
digital cascade during exion with overlapping
of the ngers.
As long as axial and transverse plane alignment is preserved, pediatric patients can make up
formalalignment of phalanx fractures. Rotatory
defects are the main complication of diaphyseal
nger fractures and must be prevented through a
careful clinical examination. There are three
main causes of rotatory defects: a missed rotatory
displacement at the time of the fracture, incomplete reduction of the fracture, and inappropriate
immobilization. A thorough X-ray examination
of the fracture through lateral and oblique views
allows early recognition of a rotatory defect. In
cases of a delayed diagnosis, a rotational osteotomy is the only viable option of treatment. In
well-aligned fractures involving only one cortex
and presenting withminimal metaphyseal angulation, a 15–20 days of casting or splinting period
is sufcient.
Neck (subcapital) fractures of the phalanxes
are equally common. They usually present with
a dorsal displacement of the distal fragment.
Furthermore, rotatory malalignment is often
present due to the action of the volar plate on the
condylar fragment, which can be incarcerated in
the capsule and the collateral ligament. The
presence of rotatory malalignment must be ruled
out on X-ray lateral views, before and after a
closed reduction. Percutaneous xation with
Kirshner wires is advised, whether an open or
closed reduction is performed. Healing of these
fractures happens as early as 3 weeks, and
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323
malalignment at this level leads to a reduction of
the range of motion of the adjacent joints.
Furthermore, the risk of malunion or nonunion
is increased [29].
A frequent fracture of fth digitproximal phalanx is the “extra-octave” fracture, which
involves the base of the proximal phalanx with
extreme ulnar deviation of the distal fragment. It
is a type II epiphyseal fracture that can be easily
reduced with closed manipulation. Reduction is
achieved by placing a pencil in the web space and
pushing the fth digit radially. The reduced nger
is splinted to the adjacent, uninjured nger.
Immobilization is maintained for 3 weeks. Rarely,
open reduction with pinning is required to maintain reduction until complete fracture healing.
Small epiphyseal fractures of the phalanxes
can be observed at the insertion of the collateral
ligaments. These are almost always pure cartilaginous fractures and do not affect bone growth.
In cases of bigger fractures, articular involvement
should be ruled out as this may lead to loss of
articular congruence.
Fractures of the distal phalanx with mallet nger deformity are similar to adult lesions,
although there are some anatomical differences
between the two age groups. In small children,
SH type I or II fracturesare typical, while in adolescents SH type III and IV lesions are more
common. Extensor tendon detachmentat the distal phalanx is rare in children. Furthermore, ossication of the epiphyseal portion of the phalanx
lately occurs, making diagnosis and treatment
more difcult. Epiphyseal fractures requireDIP
joint casting into hyperextension for 3 weeks,
while 4–6 weeks immobilization is advised in
cases of isolated tendon injuries. If closed anatomical reduction cannot be obtained, surgery is
indicated, and an open reduction is performed
with Kirshner wire xation (Fig.27.8).
Fig. 27.8 Mallet nger injury treated with Kirshner wire pinning through closed reduction (Ishiguro technique)
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Fig. 27.9 Open fractures with nail avulsion
F. M. Senes et al.
Open reduction and xation are also indicated in doubtful cases with rupture of the
extensor tendon. A similar technique can be
used in rare lesions of the volar portion of the
distal phalanx with displacement due to FDP
insertion [30, 31].
Open fractures with mallet nger deformityin
distal phalanxes can be seen after crush injuries.
These fractures are in high-stakes of infection.Debridement of the nail bed at the fracture
site (Seymour fracture), repair of the nail bed,
and repositioning of the nail with immobilizationare usually performed.
Fractures of the tubercle or meta-epiphyseal
region of the distal phalanx are associated with
nail laminal or germinal matrix injuries. As
open fractures, bacterial contamination and
infectionare typical complications [32]. Severe
diastasis of the fracture fragments is uncommon
because of the presence of brous septa.
Treatment consists of nailrepositioning intoits
bedand suture xation to allow regrowth of the
nail. Stitches should be placed atraumatically
(with 5–6/0 sutures) to allow a rapid reconstruction and minimize residual deformities
(Fig. 27.9) [33]. A wound soft bandage acts
like fracture xation until complete healing is
obtained.
Minor ngertip injuries are very common in
children and young adolescents. Simple wound
care is sufcient in achieving complete healing of
the wound and preserving the length and neuro-
logical function of the nger. In cases of larger
skin loss with tubercle exposure, a simple
advancement ap can be used for coverage. Less
commonly, regional aps (e.g., cross-nger ap,
thenar eminence ap) or a skin graft from the
wrist or forearm can be used. The choice of the
graft/coverage strategy depends on the amount of
skin loss, age of the patient, surgeon’s experience, and parents’ expectations. If apical skin
loss is minimal, a local V-Y skin ap can be used
with very good results (Fig.27.10).
In cases of subamputation with a thin skin
pedicle, a simple wound margin apposition with
stitching can be attempted. Most of the time, satisfactory healing can be obtained. Nevertheless,
it is of utmost importance to carefully and regularly check the repair process until complete
healing is obtained.
27.1.5 Metacarpal-Phalangeal
Dislocations
Dislocations of the MCP joints are a quite common in children, although not frequently
reported. The I and II rays aretypically involved
[34]. A forceful hyperextension of the II nger
due to a fall on the oor with open hand is
the usual injury mechanism. The volar plate is
broken at the level of the metacarpal head.
Dorsal displacement of the phalanx leads to the
intra-articular dislocation of the volar plate
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ab
Fig. 27.10 Local aps in skin loss: V-Y (a) and bilateral Kutler (b)
325
(complex dislocation). The resulting ulnarization of the exor tendons and radialization of the
lumbricals locks triggerthe volar dislocation of
the metacarpal head, which loses its natural
brocartilaginous stabilizers. The metacarpal
head also penetrates through the metacarpal
transverse ligament and supercial palmar fascia, further obstructingthe reduction.
Closed reduction can be difcult and sometimes impossible because of the intra-articular
dislocation of the volar plate (Fig.27.11).
It is preferable to avoid repeated attempts at
closed reduction and proceed with an open procedure. The surgical approach consists of a volar
exposure of the ray through a Brunner-type
incision with a complete A1 pulleyopening. A
small longitudinal incision of the volar plate is
performed to reduce the tension of the collateral
ligament and allow atraumatic reduction of the
metacarpal head. In cases of delayed diagnosis
and treatment (usually after 3–4 weeks), an additional dorsal surgical approach is needed to cut
and release ulnar collateral ligament [34]. After
surgery, cast immobilization is applied to avoid
hyperextension of the joint and keep MCP joints
in exion.
MCP joint dislocation at the thumb determines a volar dislocation of the metacarpal head
through the thenar muscles (i.e., exor pollicis
brevis) and the articular capsule. The buttonhole
through the joint capsule locks the metacarpal
head impeding reduction. Closed reduction
is attained by exing the proximal phalanx
toreleaseintrinsic musculature and applying longitudinal traction. When closed reduction is
unsuccessful, an open reduction is indicated.
27.1.6 Collateral Ligament
oftheThumb
Isolated lesions of the ulnar collateral ligament of
the thumb (i.e., Stener lesion) are rare in children.
These injuriesare usually due to an SH type III
fracture of proximal phalanx epiphysis, while
they areinconstly associated with a metacarpal
basal fracture [35]. Surgery is often required to
reconstruct the articular surface and avoid instability at the base of the thumb.
27.1.7 Interphalangeal Dislocations
Interphalangeal dislocations are rare pediatric
injuries that typically occur in adolescents.
They are due to direct trauma and common it
found in the PIP joint. Diagnosis is easy and
clear from clinical presentation. Sometimes,
an associated epiphyseal fracture can be
observed. This is due to the strong insertion of
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F. M. Senes et al.
Fig. 27.11 Suspected intra-articular dislocation of the volar plate in the metacarpophalangeal joint
the collateral ligaments around the joint [36].
Malalignment of an untreated epiphyseal
fracture can be permanent; therefore, this
must be always ruled out before and after
reduction. Reduction of interphalangeal joint
dislocations is obtained by hyperextending
the joint and then distally and volarlypushing
the distal fragment. In cases of unsuccessfulclosed reduction interposition of the volar
plate or epiphyseal fracture fragmentshould
be take into consideration. After reduction,
the stability of collateral ligaments and joint
range of motion should be checked by comparison to the contralateral side. Post-
reduction splinting(15 days) will befollowed
by active mobilization. In older children,
buddy taping can be used instead of rigid
immobilization.
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Replantation
https://t.me/medicina_free
MonaI.Winge andMagneRøkkum
28
Abstract
Most replantations are indicated in children
due to their advantageous nerve regeneration,
greater healing potential and functional outcome. A replanted limb has better functional
results than a prosthesis. The proper care of
the amputated extremity is essential during an
expedient transfer to a replantation centre. The
ischaemia time of an amputated part with
musculature should not exceed 6 h, and a vascular shunt must be considered if possible.
Vasospasms are more often encountered in
children and must be recognised promptly and
treated as early as possible considering the
small vessel size. The outcomes depend on the
type of injury, level of injury, the child`s
weight, the ischaemia time and microsurgical
competence of the surgical team. Increased
survival rates are present when two veins are
repaired. The follow-up is multidisciplinary
and long term.
M. I. Winge (*)
Division of Orthopaedic Surgery, Oslo University
Hospital, Oslo, Norway
e-mail: mwinge@ous-hf.no
M. Røkkum
Oslo, Norway
e-mail: mrokkum@ous-hf.no
Keywords
Amputation · Children · Digit · Hand injuries
Lower limb · Microsurgery · Paediatric
Replantation · Revascularisation · Upper
extremity
28.1 Background
The operating microscope was rst used in 1921
for a middle ear operation with an introduction to
ophthalmology in 1946 [1]. The rst reported
microvascular anastomosis using an operating
microscope was performed by Jacobsen and
Suarez in 1960 [2]. In 1962, Malt and McKhann
successfully replanted a completely amputated
upper extremity in a 12-year-old boy [3]. Kleinert
and Kasdan performed the rst successful anastomosis of a digital artery and revascularised a
subtotally amputated thumb in 1962 [4]. Komatsu
and Tamai replanted a completely amputated
thumb in 1965 [5]. The renement of suture
materials and delicate microsurgical instruments
made possible the development of microvascular
surgical techniques [1]. In addition to replantations, microsurgical advances led to the introduction of free vascularised autotransplantations of
the skin, bone, joints and toes [6, 7]. The rst free
vascularised composite allotransplantation of the
upper extremity using modern immunosuppression was performed in an adult in 1998 and in an
eight-year-old child in 2017 [8–10].
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_28
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