Pediatric Fractures

Fractures in pediatric population occur due to crush, twisting and bending forces such as hyperextension or hyperflexion. One should be aware of rotational malalignment. Loss of any of the following two suggests malrotation: 1) when flexed all fingers should point towards the scaphoid tuberosity; 2) when the fingers are adducted, semiflexed and viewed end-on, the nails lie in the same plane.

Fractures in phalanges can be located in the head, neck, shaft or the base. Head and base fractures are usually intra-articular. Neck and shaft fractures can be transverse, oblique, spiral and comminuted. Bending forces cause transverse or oblique fractures, torsional forces cause spiral fractures, and crushing forces cause comminuted fractures. If the fracture is undisplaced or if it is stable after reduction, it can be treated by a splint that immobilizes the involved joint as well as the immediately proximal and distal ones. Sometimes, buddy strapping the finger to the adjacent uninjured one suffices. If the fracture is displaced or angulated more than 100, it usually requires open reduction and internal fixation with crossed K wires or plates and screws.

Distal phalanx fractures are usually associated with nailbed injuries. The fibrous septae of the pulp stabilize fragments. This on one hand reduces displacement but may work adversely to keep fragments apart leading to nonunion. These fractures can be treated conservatively with a gutter splint or thimble splint. If comminuted and associated with an open wound, unattached fragments can be excised. Loss of the distal half of the shaft may lead to a hooked nail deformity.

Mallet finger can be seen with an avulsion fracture of the terminal slip of the extensor mechanism. The distal phalanx adopts a dropped position and cannot be actively extended. These may be associated with an injury to the proximal epiphysis. Anatomic reduction is essential and is achieved either by closed or open methods. Suitably molded splints that keep the DIP joint in extension may maintain reduction. Occasionally, internal fixation with a K wire may be needed.

Jersey Finger is an avulsion fracture of the insertion of the flexor profundus tendon into the distal phalanx. The avulsed fragment may lie as far proximally as in the palm. This almost always requires open reduction and internal fixation with a mini screw or K wires.


Metacarpal Fractures

Metacarpal fractures can occur at the head, neck, shaft and base. Neck fracture of the 5thmetacarpal is called “Boxer’s fracture”. Head fractures are usually due to axial compression forces. This involves the epiphysis in all metacarpals except the thumb. In the thumb metacarpal, the epiphysis is distal while it is proximal in all other metacarpals.

Often isolated shaft and neck fractures of the middle and ring finger metacarpals do not require splinting as they are immobilized quite adequately by the other intact metacarpals. In other metacarpals a splint can treat undisplaced fractures with the hand in the universal position of immobilization. Displaced and unstable fractures can be fixed with K wires or plates & screws.

Base fractures are usually caused by axial forces with or without an associated bending component.
A special fracture in this category is a fracture of the base of the thumb metacarpal, which is called Bennet’s injury. This involves the epiphysis and generally requires internal fixation with smooth K wires. If undisplaced, can be treated by a splint with the hand in the universal position of immobilization. Often isolated fractures of the middle and ring finger metacarpals do not require splinting as they are immobilized quite adequately by the other intact metacarpals. Displaced and unstable fractures can be fixed with K wires or plates & screws.


Carpal Fractures

The scaphoid is the most common carpal bone to be involved. The cartilaginous nature of the carpus provides a certain amount of resilience that protects most other carpal bones from injury. Obtaining radiograms of the opposite side and looking for asymmetry is especially important in carpal injuries. Considerable force is required to fracture the relatively resilient carpal bones in children. Hence, associated metacarpal or ligamentous injuries are quite often seen. Almost all carpal fractures can be treated conservatively by splinting the wrist in 200 to 300 of dorsiflexion. If indicated, internal fixation is achieved with smooth K wires.

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