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Abadeer AI, Wu CM, Brooks DM, Higgins JP, Giladi AM, Shubinets V. Arterial Perfusion of the Proximal Phalanx Revisited: New Insights Based on Micro-Computed Tomography. J Hand Surg Am 2024; 49:713.e1-713.e7. [PMID: 36333245 DOI: 10.1016/j.jhsa.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To characterize the periosteal and endosteal arterial perfusion of the proximal phalanx using micro-computed tomography angiography (micro-CTA). METHODS Cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Phalanges were imaged using micro-CTA and analyzed with a focus on osseous arterial anatomy. Periosteal and endosteal perfusion was characterized by number of vessels, length, anatomic course, and caliber. RESULTS The base of the proximal phalanx had a significantly greater number (8.0 ± 3.5) of periosteal vessels than those of the shaft (4.1 ± 1.6) and head (1.3 ± 1.1). One-third (34.4%) of the specimens demonstrated a complete absence of periosteal vessels in the head. A nutrient endosteal vessel was noted in 100% of the specimens. Entering at the junction of the middle and distal third of the bone (25.8 ± 3.9 mm from base), the nutrient vessel entered the proximal phalanx of the index finger along its ulnar aspect (8 of 8 specimens), the middle finger along its radial aspect (6 of 8), the ring finger along its ulnar aspect (5 of 8), and the little finger along its radial aspect (7 of 8). The nutrient vessel branched into proximal and distal extensions toward the shaft and head, respectively, with an average endosteal length of 10.7 ± 5.2 mm and average diameter of 0.36 ± 0.11 mm. CONCLUSIONS Periosteal contributions to the perfusion of the proximal phalanx appear to diminish distally. The endosteal arterial anatomy remains consistent, with a single nutrient vessel entering the intramedullary canal with reliable laterality on each digit. This is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise. CLINICAL RELEVANCE An understanding of the patterns of perfusion of the proximal phalanx provides some insight into clinically observed pathology, as well as guidance for operative management.
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Affiliation(s)
- Andrew I Abadeer
- The Curtis National Hand Center, Medstar Union Memorial Hospital, Baltimore, MD; Georgetown University School of Medicine, Washington, DC
| | - Caroline M Wu
- The Curtis National Hand Center, Medstar Union Memorial Hospital, Baltimore, MD; Georgetown University School of Medicine, Washington, DC
| | - Daina M Brooks
- Musculoskeletal Research Center, Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- The Curtis National Hand Center, Medstar Union Memorial Hospital, Baltimore, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, Medstar Union Memorial Hospital, Baltimore, MD
| | - Valeriy Shubinets
- The Curtis National Hand Center, Medstar Union Memorial Hospital, Baltimore, MD.
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Zhi XW, Luo KT, Tan YY, Wu HM, Zhou Y, Xu ZF, Wang JQ, Li YQ, Xu HW, Canavese F, Zeng C. Cast versus Kirschner wire fixation in type II paediatric phalangeal neck fractures. INTERNATIONAL ORTHOPAEDICS 2024; 48:1489-1499. [PMID: 38443716 DOI: 10.1007/s00264-024-06133-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/25/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE To compare the outcomes of type II pediatric phalangeal neck fractures (PPNFs) treated with closed reduction and cast immobilization (CRCI) versus closed reduction percutaneous pinning (CRPP), and evaluated the clinical efficacy of conservative versus surgical treatment of type II PPNFs via meta-analysis. METHODS Patients aged ≤ 14 years with type II PPNFs were divided into conservative (CRCI) and operative (CRPP) groups. Radiographs measured angulation and translation; hand function was assessed with total active range of motion (TAM) and Quick-DASH. Complication rates were also compared between the groups. A meta-analysis of conservative versus operative treatment confirmed the clinical results. Statistical analysis was performed using SPSS 26.0 and R studio 3.0 with two-tailed, chi-squared, and Mann-Whitney U or t-tests, P < 0.05. Meta-analysis used fixed or random effects models, calculating mean differences and odds ratios for outcomes, and assessing heterogeneity with I2 and Q tests. RESULTS Final angulation (3.4° ± 3.7° and 4.9° ± 5.4° vs. 3.6° ± 3.7° and 4.2° ± 4.3°) and displacement (6.3% ± 5.8% and 5.7% ± 4.7% vs. 5.8% ± 5.5% and 3.2% ± 4.2%) in the coronal and sagittal planes were not different statistically between the conservative and surgical groups (P > 0.05), but improved significantly compared to preoperative values (P < 0.05). Although Quick-DASH scores were comparable in both groups (P = 0.105), conservatively treated patients had a significantly better TAM at the last follow-up visit (P = 0.005). The complication rates were 24.2% and 41.7% in the surgical and conservatively treated groups respectively (P = 0.162). However, the latter primarily experienced imaging-related complications, whereas the former experienced functional complications (P = 0.046). Our meta-analysis (n = 181 patients) also showed comparable functional (P = 0.49) and radiographic (P = 0.59) outcomes and complication rates (P = 0.21) between the surgical (94 patients) and conservative (87 patients) groups. CONCLUSIONS Conservative and surgical treatments are both reliable and safe approaches for managing type II PPNF in children. However, conservatively treated patients generally experience similar radiographic outcomes, lower complication rates, and better functional outcomes than surgically treated ones.
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Affiliation(s)
- Xin-Wang Zhi
- The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Joint Surgery, Center for Orthopedic Surgery, Orthopedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kang-Ting Luo
- Guangzhou Medical University, Guangzhou, 511436, China
| | - Ye-Ya Tan
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hui-Mei Wu
- Guangzhou Medical University, Guangzhou, 511436, China
| | - Yang Zhou
- Guangzhou Medical University, Guangzhou, 511436, China
| | - Zi-Feng Xu
- Guangzhou Medical University, Guangzhou, 511436, China
| | - Jian-Qun Wang
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yi-Qiang Li
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hong-Wen Xu
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Federico Canavese
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
- Department of Pediatric Orthopedic Surgery, Lille University Center and Faculty of Medicine, Jeanne de Flandre Hospital, Avenue Eugène-Avinée, 59000, Lille, France.
| | - Chun Zeng
- The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China.
- Department of Orthopedics, Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China.
- Department of Joint Surgery, Center for Orthopedic Surgery, Orthopedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China.
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3
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Kilty R, Baxter S, McKay MJ, Hiller CE. Advances in Hand Therapy: Best Practice in Conservative Management of Proximal Phalangeal Fractures in Children. J Pediatr Orthop 2024; 44:e446-e451. [PMID: 38532718 DOI: 10.1097/bpo.0000000000002665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Proximal phalangeal fractures are one of the most commonly treated hand injuries in children. Conservative management of these fractures is often to splint for 5 weeks post injury, despite children presenting as clinically healed at 3 weeks post injury. Therefore, we investigated the effect of splinting for only 3 weeks in children who present with clinically healed proximal phalangeal fractures at 3 weeks compared with usual care. METHODS Participants (n=80, aged 10.3 ±2.5 years) presenting to the Hand Clinic of a tertiary Children's Hospital in Sydney, Australia, were randomly allocated into a Current Protocol and a New Protocol group. Following were the inclusion criteria: aged between 5 and 16 years; present with an non-displaced or minimally displaced and stable fracture; no surgical intervention; assessed as clinically healed at 3-week visit. The primary outcome measure was total active motion (TAM) of the injured digit compared with the contralateral digit (deg), at 5 weeks post injury. Secondary outcome measures were grip strength, and a parent-reported questionnaire. Statistical analysis used χ 2 test and the absolute difference described by a 90% CI. The New Protocol was considered noninferior if the 90% CI overlap was > 20% of the Current Protocol. Analysis was by intention to treat. RESULTS There was a 10% loss to follow up at 5 weeks (Current Protocol =4, New Protocol =4). All CIs between groups overlapped by >10%. TAM 90% CI for Current Protocol was 17.7 to 5.4 degrees and for the New Protocol was 4.7 to 1.6 degrees. CONCLUSIONS A change in practice is warranted to cease immobilization for children with conservatively managed proximal phalangeal fractures who present as clinically healed at 3 weeks. Therapist assessment of fracture healing is an appropriate indicator for intervention and can be utilized in a therapist-led model of care. LEVEL OF EVIDENCE Level 1-noninferiority randomized control trial with 2 parallel arms.
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Affiliation(s)
| | | | - Marnee J McKay
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Claire E Hiller
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Szapary HJ, Meulendijks MZ, Moura SP, Veeramani A, Gomez-Eslava B, Hoftiezer YAJ, Chen NC, Eberlin KR. Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation. Hand (N Y) 2024; 19:247-255. [PMID: 35852405 PMCID: PMC10953521 DOI: 10.1177/15589447221109635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures. METHODS A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information. RESULTS The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers' fractures were found to be independently associated with unplanned reoperation. CONCLUSIONS Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.
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Affiliation(s)
- Hannah J. Szapary
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Steven P. Moura
- Massachusetts General Hospital, Boston, USA
- Boston University, MA, USA
| | - Anamika Veeramani
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Barbara Gomez-Eslava
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Neal C. Chen
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Kyle R. Eberlin
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
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Wang H, Wang D, Huang S, Li W, Tan L, Wu H, Pei X. Comparison of splinting immobilization and K-wire fixation in children with type II phalange neck fracture. J Pediatr Orthop B 2024; 33:184-191. [PMID: 37401488 PMCID: PMC10829904 DOI: 10.1097/bpb.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/18/2023] [Indexed: 07/05/2023]
Abstract
To compare outcomes of type II phalangeal neck fractures in children who received closed reduction followed by splinting immobilization or by K-wire fixation. Furthermore, we analyzed the remodeling potential of residual deformities and the relationship between age and outcomes. Patients in Children's Hospital of Fudan University, Xiamen Hospital were included in the study from October 2015 to October 2018. We compared outcomes between the conservation group and operation group. Remodeling of residual deformities was calculated on a series of anteroposterior and lateral radiography. The correlation between age and outcomes was analyzed using Spearman's rank correlation coefficient. Forty patients (25 males) were enrolled. Nineteen patients had subtype IIa, 19 subtype IIb, and two subtype IIc fractures. Left hands were affected more than right hands, and small finger and proximal phalanx were more frequently involved. There were no significant differences between conservation group and operation group among excellent, good, and fair outcomes. And the outcomes were not significantly different between the IIa and IIb subtypes. An average sagittal remodeling rate was 88.5%, and coronal remodeling rate was 56.71%, respectively, in 13 patients with residual deformities. There was a significant correlation between age and final outcomes. Closed reduction and stable splint fixation may be an effective and economical initial treatment option. Fracture subtype does not seem to be a key factor for choosing treatment options. The fractured phalangeal neck had remodeling potential whether on sagittal or coronal plane. Younger age might be a predictor of better outcomes in children with type II phalanx neck fractures.
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Affiliation(s)
- Huaikeng Wang
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
| | - Dahui Wang
- Department of Orthopaedics Surgery, Children’s Hospital of Fudan University, Shanghai, China
| | - Shaomin Huang
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
| | - Wanting Li
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
| | - Lujian Tan
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
| | - Haiyi Wu
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
| | - Xinhong Pei
- Department of Orthopaedics Surgery, Xiamen Hospital, Children’s Hospital of Fudan University, Fujian Province
- Department of Orthopaedics Surgery, Children’s Hospital of Fudan University, Shanghai, China
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6
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Al-Qattan MM. My journey in hand surgery: combining patient care, clinical and basic science research. J Hand Surg Eur Vol 2023; 48:710-724. [PMID: 37125458 DOI: 10.1177/17531934231167061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This review is about my clinical and research journey in hand surgery. The journey has been a worthwhile and meaningful one, especially when I felt there were areas I could influence management, whether this be rare cases, common conditions or where a suggested algorithm may be helpful. I also had the unique privilege of working with geneticists, which has resulted in clinical-pathological publications that could influence patient management, as shared from a clinician's perspective. It is hoped this article will inspire young clinician scientists to pursue a journey of collaboration with other researchers.
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Affiliation(s)
- Mohammad M Al-Qattan
- Division of Plastic and Hand Surgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
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7
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Vaslow AS, Deal JB, Ho CA. Operative Fractures of the Phalangeal Head and Neck in Children-Does Open Reduction Affect Outcomes? J Pediatr Orthop 2023; 43:311-316. [PMID: 36863778 PMCID: PMC10082043 DOI: 10.1097/bpo.0000000000002364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Closed reduction percutaneous pinning of displaced pediatric phalangeal head and neck fractures is preferred to prevent malunion and loss of motion and function. However, open reduction is required for irreducible fractures and open injuries. We hypothesize that osteonecrosis is more common in open injuries than closed injuries that require either open reduction or closed reduction percutaneous pinning. METHODS Retrospective chart review of 165 phalangeal head and neck fractures treated surgically with pin fixation at a single tertiary pediatric trauma center from 2007 to 2017. Fractures were stratified as open injuries (OI), closed injuries undergoing open reduction (COR), or closed injuries treated with closed reduction (CCR). The groups were compared using Pearson χ 2 tests and ANOVA. Two group comparisons were made with Student t test. RESULTS There were 17 OI fractures, 14 COR fractures, and 136 CCR fractures. Crush injury was the predominant mechanism in OI versus COR and CCR groups. The average time from injury to surgery was 1.6 days for OI, 20.4 days for COR, and 10.4 days for CCR. The average follow-up was 86.5 days (range, 0 to 1204). The osteonecrosis rate differed between the OI versus COR and OI versus CCR groups (71% for OI, 7.1% for COR, and 1.5% for CCR). Rates of coronal malangulation >15 degrees differed between the OI and COR or CCR groups, but the 2 closed groups did not differ. Outcomes were defined using Al-Qattan's system; CCR had the most excellent and fewest poor outcomes. One OI patient underwent partial finger amputation. One CCR patient had rotational malunion but declined derotational osteotomy. CONCLUSIONS Open phalangeal head and neck fractures have more concomitant digital injuries and postoperative complications compared with injuries closed on presentation, regardless of whether the fracture underwent open or closed reduction. Although osteonecrosis occurred in all 3 cohorts, it was most frequent in open injuries. This study allows surgeons to discuss rates of osteonecrosis and resultant complications with families whose child presents with phalangeal head and neck fractures that are indicated for surgical treatment. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Aaron S. Vaslow
- T Brian D. Allgood Army Community Hospital, Camp Humpreys, Pyeongtaek, South Korea
| | - James Banks Deal
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Christine A. Ho
- Department of Orthopaedic Surgery, Children’s Health Dallas
- Scottish Rite for Children
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX
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Wu C, Song J, Ning B, Mo Y, Wang D. Clinical outcomes of closed, displaced phalangeal neck fractures in children with different types of kirschner wire fixation: A retrospective observational study. Front Pediatr 2023; 11:1039415. [PMID: 36911019 PMCID: PMC10002975 DOI: 10.3389/fped.2023.1039415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
Objectives Inappropriate treatment of Closed displaced phalangeal neck fractures (CDPNF) in children usually leads to poor outcomes.This study was to evaluate the clinical outcomes of closed/open reduction, age, and different types of fracture and Kirschner wire (K-wire) fixation in the treatment of CDPNF. Materials and methods Participants: Sixty patients (male, 46 and female,14; right-handed, 35 and left-handed, 25; mean age, 7.9-years-old [range, 1.0-14.5 years]) who had CDPNF were included. Preoperative x-rays showed that the fractures were displaced and exhibited obvious deformities. Interventions: First, reduction (four cases of open reduction and 56 cases of closed reduction) was performed followed by percutaneous K-wire fixation (cross fixation, 24 cases; longitudinal and slanting fixation, 17 cases; homolateral fixation, four cases; and single longitudinal fixation, 15 cases,) and immobilized by cast. x-ray examination following removal of the K-wires showed that the fractures were healed; the criteria for fracture healing were callus formation and the absence of fracture lines. Clinical outcome and radiographs between groups were compared. Results According to the visual analogue scale, the pain scores were excellent. According to the Al-Qattan Grade system(AGS),all the patients presented with closed, type II phalangeal neck fractures,the results were excellent in 36 cases (36/60, 60%), good in 15 cases (15/60, 25%), fair in 5 cases (5/60, 8.3%) and poor in 4 cases (4/60, 6.7%). There were significant differences in different fracture type groups (P = 0.013*), operation age groups (P = 0.025*) and open/closed reduction groups (P = 0.042*). There was no significant difference in K-wire fixation type groups (P > 0.05). Conclusions Patients with open reduction, the more serious fracture type, the older at the operation, were more likely to have poor AGS result. Different K-wire fixation types for CDPNF in children had the same satisfactory results.
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Affiliation(s)
- Chunxing Wu
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, & National Children's Medical Center, Shanghai, China
| | - Jun Song
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, & National Children's Medical Center, Shanghai, China
| | - Bo Ning
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, & National Children's Medical Center, Shanghai, China
| | - Yueqiang Mo
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, & National Children's Medical Center, Shanghai, China
| | - Dahui Wang
- Department of Pediatric Orthopaedics, Children's Hospital of Fudan University, & National Children's Medical Center, Shanghai, China
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Chaudhry S. Unique Considerations for Paediatric Proximal Phalanx Fractures. J Hand Surg Asian Pac Vol 2022; 27:761-771. [PMID: 36285762 DOI: 10.1142/s2424835522300055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Paediatric hand fracture care presents unique considerations and challenges. The proximal phalanx is the most injured location. This review details pearls for the examination of the injured paediatric hand, immobilisation considerations and treatment strategies. Over-treatment can lead to unnecessary stiffness, missed activities, increased healthcare costs or unnecessary surgical morbidity. Undertreatment can promote malunion and dysfunction. Fracture patterns discussed include those of the phalangeal head, neck, shaft and base. The concepts covered will help optimise the evaluation and treatment of children with injured proximal phalanges. Level of Evidence: Level V (Therapeutic).
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Affiliation(s)
- Sonia Chaudhry
- Connecticut Children's Medical Center, University of Connecticut, Hartford, CT, USA
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10
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Chen KJ, Huang YP, Lo IN, Huang YC. Corrective osteotomy for distal condylar malunion of the proximal phalanx in adolescents: comparison of K-wire and locking plate fixation. J Hand Surg Eur Vol 2022; 47:935-943. [PMID: 35579202 DOI: 10.1177/17531934221098006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This retrospective study reviewed 28 patients, aged 10 to 17 years, who underwent corrective osteotomy for malunion of the proximal phalangeal distal condyles at a mean of 9 weeks (range 2-52) from injury. There were 19 patients treated with K-wire and nine patients with locking plates. The two groups were comparable for trauma mechanism, fracture type, time delay from injury and the type of initial treatment. The K-wire group had a shorter duration of operation and shorter time to union than the plating group. For both groups, postoperative radiographs showed significant correction, which remained unchanged until the final follow-up (minimum 12 months), although greater residual coronal angulation was found in the K-wire group. The outcomes in 17 of the 28 patients were graded as excellent or good according to the Al-Qattan classification, with no difference between the groups. The complication rate was also similar between the groups, while the locking plate group had a higher rate of secondary surgery.Level of evidence: III.
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Affiliation(s)
- Kuan-Jung Chen
- Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,China Medical University Hsinchu Hospital, Hsinchu,Taiwan
| | - Yu-Po Huang
- Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - I-Ning Lo
- Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,China Medical University Hsinchu Hospital, Hsinchu,Taiwan.,Taipei General Veterans Hospital Taitung Branch, Taitung, Taiwan
| | - Yi-Chao Huang
- Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
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11
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GERMANO S, CAVALIERI E, PATANÈ L, CLEMENTE A, MERLINO G, BORSETTI M. Outcomes of a Mini External Fixator System for the Treatment of Unstable Periphyseal Hand Fractures. J Hand Surg Asian Pac Vol 2022; 27:672-677. [DOI: 10.1142/s2424835522500679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Most unstable hand fractures in children are treated by closed methods. If osteosynthesis is required, Kirschner (K)-wires are commonly used, though they carry a risk of injury to the physis. We have been using a mini external fixator system (MEFS) for the treatment of unstable periphyseal fractures of the hand. The aim of this study is to describe the application and report the outcomes of MEFS for the treatment of periphyseal fractures of the hand. Methods: We retrospectively reviewed all the patients with periphyseal fracture of the hand treated with MEFS from March 2010 to December 2019. Data with regard to age, sex, hand dominance, digit and bone injured, mechanism of injury, medical records and related radiographs were collected. Salter–Harris classification was used to classify epiphyseal fractures and the Al-Qattan classification for categorising neck fractures. Range of motion and residual deformity of the affected fingers were evaluated during follow-up and at 3 months postoperatively. Results: Fourteen periphyseal unstable fractures were treated using closed reduction and MEFS. Only one patient with a fracture of the neck of the proximal phalanx of the little finger required revision surgery. No patient had pin site infection or pin loosening and the device was well tolerated by all patients. All fractures united and all the patients recovered a full range of motion at final follow-up. Conclusions: The MEFS is a reasonable alternative for unstable periphyseal fractures with good outcomes and avoids the risk of iatrogenic physeal injury from K-wire fixation. Level of Evidence: Level IV (Therapeutic)
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Affiliation(s)
- Silvia GERMANO
- Division of Plastic Surgery, Hand Surgery and Microsurgery, Surgical Department of ASL Città di Torino, Maria Vittoria Hospital, Turin, Italy
| | - Enrico CAVALIERI
- Division of Plastic Surgery, Hand Surgery and Microsurgery, Surgical Department of ASL Città di Torino, Maria Vittoria Hospital, Turin, Italy
- Department of Surgery ‘Pietro Valdoni’ Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Luca PATANÈ
- Department of Surgery ‘Pietro Valdoni’ Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Alessandra CLEMENTE
- Division of Plastic Surgery, Hand Surgery and Microsurgery, Surgical Department of ASL Città di Torino, Maria Vittoria Hospital, Turin, Italy
| | - Giorgio MERLINO
- Division of Plastic Surgery, Hand Surgery and Microsurgery, Surgical Department of ASL Città di Torino, Maria Vittoria Hospital, Turin, Italy
| | - Marco BORSETTI
- Division of Plastic Surgery, Hand Surgery and Microsurgery, Surgical Department of ASL Città di Torino, Maria Vittoria Hospital, Turin, Italy
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12
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Krueger A, Qudsi R, Eckstein K, Cornwall R. Is a Right Angle the Right Angle? Normal Coronal Radiographic Alignment in the Pediatric Finger Phalanges. J Pediatr Orthop 2021; 41:e617-e623. [PMID: 34224505 DOI: 10.1097/bpo.0000000000001889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Quantifying pediatric phalanx fracture displacement requires understanding the normal radiographic alignment of pediatric phalanges, which has never been assessed in the coronal plane, although prior studies have assumed the articular surfaces and physes to be perpendicular to the diaphyses. This study tests the hypothesis that these relationships are not uniformly perpendicular and instead vary by digit and age. METHODS Normal hand bone age radiographs were retrospectively reviewed from 40 males and 40 females 2 to 18 years old. For each finger proximal phalanx (P1) and middle phalanx (P2), 2 raters each measured twice the angle between the diaphysis and distal articular surface (D-DA), diaphysis and physis (D-P, when physis present), and diaphysis and proximal articular surface (D-PA). Intra-rater and inter-rater reliability were calculated with intraclass correlation coefficients. 95% confidence intervals were calculated for each angle for each digit, phalanx, age group, and sex to determine which angles ~90 degrees. Variability among ages and sex was assessed with analysis of variance. RESULTS Intra-rater and inter-rater intraclass correlation coefficients were >0.90, except in P2 ∠D-DA in children under 8 years old with unossified P2 condyles. Overall, only 173 (47.8%) of 362 confidence intervals included 90 degrees. Three angles of the small finger (P1 ∠D-DA, P2 ∠D-P, P2 ∠D-PA) never ~90 degrees at any age or sex, with an average 10 degrees ulnar tilt of the small finger proximal interphalangeal joint. Of the 24 angles across digits and phalanges, 10 varied significantly with age, especially in the index and middle finger P1 where initially wedge-shaped epiphyses progressively became more symmetric with age. CONCLUSIONS The coronal radiographic angles between the phalangeal diaphyses and articular surfaces or physes differ from 90 degrees more than half the time in pediatric fingers, and nearly half the angles vary by age. These findings demonstrate that the articular surfaces and physes of the pediatric finger phalanges are not uniformly perpendicular to the diaphyses, underscoring the need to consider the variability among digits, phalanges, ages and subjects. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | | | | | - Roger Cornwall
- Division of Pediatric Orthopaedics
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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13
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Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3543. [PMID: 33889473 PMCID: PMC8057756 DOI: 10.1097/gox.0000000000003543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/14/2021] [Indexed: 12/23/2022]
Abstract
Background: Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon. Methods: A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index. Results: Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity. Conclusions: A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.
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Al-Qattan MM. "Bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers. Injury 2021; 52:537-540. [PMID: 33032801 DOI: 10.1016/j.injury.2020.09.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/13/2020] [Accepted: 09/21/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of unstable fractures of the proximal phalanx is a challenge. OBJECTIVE The purpose of this study is to introduce to the literature the use of "bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers. PATIENTS AND METHODS This is a retrospective study of 30 patients with such fractures treated by the author over the last 10 years. Demographic data were collected and surgical complications were documented. The outcome was considered excellent, good, fair and poor if the total active motion of the finger was >260o, 250o-259o, 210o - 249o, and <210o; respectively. RESULTS The worst outcome was seen in an elderly patient who sustained multiple fractures and concurrent flexor tendon injury. The remaining 29 patients were relatively young (mean age of 29 years, range = 19 - 42 years) and sustained an isolated single fracture from a fall or a fight. Out of these 29 patients, the outcome was excellent in 27 patients and good in the remaining 2 patients. CONCLUSIONS The "bi-cortical" periarticular k-wire fixation is best suited for transverse extra-articular fractures of the base of the proximal phalanx. The wire avoids all joints and hence, early post-operative mobilization is feasible. The technique is simple and obtains a favorable outcome in most patients. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Mohammad M Al-Qattan
- Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery, Riyadh Care (National) Hospital, P.O. Box 18097, Riyadh 11415, Saudi Arabia.
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15
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Bohr S, Mammadli T. Early Functional Treatment of Proximal Phalanx Fractures in Children: A Case Series Study. Pediatr Emerg Care 2021; 37:e105-e109. [PMID: 29794955 DOI: 10.1097/pec.0000000000001523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to assess proper indications a nonsurgical treatment regime for pediatric fractures of the proximal phalanx based on principles of early functional treatment. METHODS A case series (evidence level 4) of 30 pediatric patients with fractures of the proximal phalanx were treated nonsurgically using protective dynamic splinting techniques and fiberglass casting material. Assessments were performed clinically and by x-ray within 4 to 8 weeks of commencement of treatment. Outcome measures included Disabilities of the Arm, Shoulder, and Hand score questionnaire as well as fingertip palm distance (cm) and dynamic pain interval assessments. RESULTS All fractures healed without any clinically apparent bony deformities. Disabilities of the Arm, Shoulder, and Hand scores were of 25.17 ± 5.29 (mean ± SD), which indicated good functional results usually within 2 weeks of removal of dynamic splints. Fingertip palm distance measurements at endpoints were of 0.17 ± 0.27 cm (mean ± SD), which indicated an almost free range of finger motion. Absence of pain perception under active finger motion (dynamic pain interval) was noted at 14.10 ± 6.79 days (mean ± SD). CONCLUSIONS Well-established criteria for surgical treatment of phalangeal fractures exist. However, in our experience, a majority of pediatric fractures of the proximal phalanx can be safely treated nonsurgically with dynamic splinting along with shorter intervals of immobilization of the affected fingers and faster restoration of overall hand function compared to surgical treatment.
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Affiliation(s)
| | - Toghrul Mammadli
- From the Department of Plastic and Hand Surgery, Burn Center, University Clinics RWTH Aachen
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16
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A Comparison of Casting Versus Splinting for Nonoperative Treatment of Pediatric Phalangeal Neck Fractures. J Pediatr Orthop 2021; 41:e30-e35. [PMID: 32991491 DOI: 10.1097/bpo.0000000000001687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Phalangeal neck fractures account for 13% of pediatric finger fractures. Al Qattan type I (undisplaced) fractures are treated nonoperatively. There is increasing evidence that Type 2 (displaced) fractures achieve remarkable fracture remodeling with nonoperative treatment and patients frequently make a full functional recovery. The options available for nonoperative management of these fractures are either a plaster cast or a removable splint. We hypothesized that there would be no significant difference in radiologic outcome in pediatric phalangeal neck fractures (Types I and II) treated with splint or cast immobilization. METHODS This is a retrospective study of patients aged 18 and below with phalangeal neck fractures treated nonoperatively from 2008 to 2017. Radiographs were compared at <1 week and >3 weeks after injury. Translation and angulation in coronal and sagittal planes were measured and compared using Student t tests. Baseline variables were compared using χ or Fisher exact tests. RESULTS There were 47 patients with phalangeal neck fractures treated nonoperatively during the study period. There were 9 type I and 38 type II fractures. The mean age was 10 years with 40 males and 7 females. Fractures occurred in 33 dominant and 14 nondominant hands and involved 29 proximal and 18 middle phalanges. Nineteen children were treated in casts and 28 with removable splints. The mean duration of follow-up was similar between the 2 groups. The most affected phalanx was the proximal phalanx of the small finger and the most common fracture pattern was type IIA. There was no significant difference in clinical and radiologic outcomes between children who were treated in casts and those treated in removable splints. CONCLUSION There was no difference in the clinical and radiologic outcomes in pediatric phalangeal neck fractures treated with cast or splint immobilization. Splinting has the added benefits of increased comfort and hygiene and we routinely offer splinting as a viable alternative in the nonoperative treatment of Al Qattan type I and type II phalangeal fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Level III-therapeutic studies.
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17
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Pientka WF, Cheng J. Percutaneous Fixation of Pediatric Fractures of the Proximal Phalanx Neck: A Novel Technique. Tech Hand Up Extrem Surg 2020; 25:175-182. [PMID: 33239500 DOI: 10.1097/bth.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Proximal phalanx neck fractures occur almost exclusively in children. Fractures of the proximal phalanx neck can be difficult to treat nonoperatively given the anatomic location and associated extrinsic forces. A divergent or crossed pin configuration is often utilized for the stabilization of these fractures. PURPOSE We present a surgical technique with a single Kirschner (K-wire) placed axially along the affected finger, with a hyperextension reduction maneuver, to reduce and fixate proximal phalanx neck fractures in children and adolescents. METHODS We performed a retrospective review of all pediatric proximal phalanx neck fractures treated by a single surgeon. Demographic data, as well as clinical and radiographic outcomes were recorded. We then directly compared axial pinning [14 patients; average age 6.63 y (9 mo to 17 y)] with nonoperative treatment [28 patients; average age 8.03 y (9 mo to 16 y)], and open treatment [8 patients; average age 8.13 y (1 to 14 y)]. RESULTS Patients who underwent closed reduction and axial pinning had significantly improved final coronal alignment compared with nonoperative treatment. Compared with fractures which required open reduction, closed reduction with axial pinning resulted in significantly shorter surgical duration and time to radiographic healing. The final range of motion showed no difference between intervention types, as all patients regained full range of motion. CONCLUSIONS We find this axial pinning technique to be simpler and faster than divergent pin fixation, with no significant differences in time to radiographic healing, time to full activity, final proximal interphalangeal active flexion or extension, loss of reduction, or radiographic parameters. LEVEL OF EVIDENCE Level III-Therapeutic.
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Affiliation(s)
- William F Pientka
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
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18
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Kattan AE, Al-Qattan MM. Hand Surgery in Saudi Arabia. J Hand Microsurg 2020; 13:2-3. [PMID: 33707915 DOI: 10.1055/s-0040-1718976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Hand surgery is a unique field that incorporates multiple specialties, aiming to provide the patient with a best possible functional and aesthetic results. Hand surgeons deal with different pathologies that require skills in several aspects of surgery. The field of hand surgery has evolved significantly over the past decades across the globe. This specialty has also been evolving in Saudi Arabia over the past 25 years. Some of the services offered to patients include specialized centers for brachial plexus, peripheral nerve, and pediatric hand surgery as well as centers for work-related hand injuries. There has also been significant contribution to the hand surgery literature from the hand surgeons working in Saudi Arabia, with hundreds of papers published in journals pertaining to hand surgery, orthopedic surgery, and plastic surgery, as well as the publication of several novel mutations causing congenital hand defects in journals concerned with genetics. The recent approval of a hand and microsurgery fellowship program in Saudi Arabia will also help boost this field in the country and the region.
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Affiliation(s)
- Abdullah E Kattan
- Department of Hand and Plastic Surgery, Kind Saud University, Riyadh, Saudi Arabia
| | - Mohammad M Al-Qattan
- Department of Hand and Plastic Surgery, Kind Saud University, Riyadh, Saudi Arabia
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Outcomes of Phalangeal Neck Fractures in a Pediatric Population. J Hand Surg Am 2020; 45:880.e1-880.e6. [PMID: 32327337 DOI: 10.1016/j.jhsa.2020.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/20/2020] [Accepted: 02/28/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Displaced pediatric phalangeal neck fractures are regarded as unstable, and hence, surgical fixation is traditionally recommended. In our experience, some patients with displaced fractures treated nonsurgically healed with a good clinical outcome and no further displacement. We studied the outcome of displaced phalangeal neck fractures treated nonsurgically with attention to the change in fracture displacement over time and hypothesized that displaced phalangeal neck fractures can be treated nonsurgically with maintenance of acceptable radiological parameters. METHODS A retrospective review of 35 patients aged 16 and younger was conducted. Included patients had at least 10° of angulation or 25% translation in either the coronal or the sagittal plane, with no malrotation. Angulation and translation of the distal fracture fragment in the coronal and sagittal planes was measured from radiographs taken at 2 intervals-within 7 days of the injury and at least 21 days after the injury. Initial and final measurements were compared to determine the amount of fracture displacement that occurred. RESULTS Thirty-five patients with type II A, B, and C fractures (classification according to Al-Qattan) comprised our study sample. Twelve patients had undergone manipulation and reduction. Average radiological follow-up was 4.3 months (range, 0.7-86 months; median, 1.2 months; SD, 14.7). These fractures treated nonsurgically did not displace as the fracture healed, suggesting that type II fractures, although traditionally regarded as unstable, may maintain their radiological parameters without surgical fixation. CONCLUSIONS Our findings suggest that displaced phalangeal neck fractures do not necessarily displace with nonsurgical treatment. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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20
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Lateral Pinning of the Pediatric Phalangeal Neck Fracture. Tech Hand Up Extrem Surg 2020; 25:116-119. [PMID: 32868695 DOI: 10.1097/bth.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Closed reduction and percutaneous pinning is the treatment of choice for displaced pediatric phalangeal neck fractures. Multiple techniques have been described to address challenges in managing these unstable fractures. We describe our technique of closed reduction and percutaneous pinning, which avoids the physis and increases the wire insertion accuracy, minimizing the number of attempts and wire passes made at percutaneous pinning.
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21
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Al-Qattan MM, Almohrij SA, Alaskar B, Alhassan TS. Type II D Phalangeal Neck Fractures in Children: A Series of 20 Cases Treated According to a Preset Stepwise Algorithm. J Hand Microsurg 2020; 13:221-227. [PMID: 34744382 DOI: 10.1055/s-0040-1703097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Introduction Type II phalangeal neck fractures are defined as displaced fractures with bone-to-bone contact at the fracture site. In the type II D subtype, the distal fracture fragment is thin. A review of the literature did not reveal any study investigating the outcome of management of these fractures. Patients and Methods This is a retrospective study of 20 consecutive children with type II D phalangeal neck fractures treated over the past 4 years. Demographic data were reviewed. All cases were managed according to the preset stepwise algorithm. The outcome of management at final follow-up was documented using Al-Qattan's grading system. Results The mean age was 30 months (range 12-80 months). There were 12 males and 8 females. The mean follow-up was 2 years (range 7 months to 3 years). The largest two categories within the management algorithm were patients with minimally displaced fractures treated conservatively ( n = 8) and those with displaced fractures treated with closed reduction and percutaneous K-wire fixation ( n = 9). Fischer exact test was used to compare the outcome in these two groups and the p value was significant ( p = 0.015), indicating a significantly better outcome in the former group. Conclusion Several conclusions were made from the study. Type II D of phalangeal neck fractures tend to occur in young children and the majority involve the middle phalanx. The thinness of the distal fracture fragment makes standard techniques of closed reduction more difficult. However, flexion of the proximal and distal joints appears to be effective in reducing dorsally displaced type II D fractures by closed means. Finally, a more conservative approach to minimally displaced type II D fractures results in a better outcome compared with closed reduction and percutaneous K-wire fixation.
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Affiliation(s)
- Mohammad M Al-Qattan
- Department of Hand and Plastic Surgery, King Saud University, Riyadh, Saudi Arabia.,Consultant Hand Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Saad A Almohrij
- Department of Pediatric Orthopedics, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Batool Alaskar
- Department of Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Turki S Alhassan
- Department of Plastic Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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22
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Hartley RL, Lam J, Kinlin C, Hulin K, Temple-Oberle C, Harrop AR, Fraulin FOG. Surgical and Nonsurgical Pediatric Hand Fractures: A Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2703. [PMID: 32537358 PMCID: PMC7253283 DOI: 10.1097/gox.0000000000002703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/21/2020] [Indexed: 11/29/2022]
Abstract
Pediatric hand fractures are common and approximately 10% require surgery. METHODS This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. RESULTS One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). CONCLUSIONS Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.
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Affiliation(s)
- Rebecca L Hartley
- Section of Plastic Surgery, Department of Surgery, University of Calgary
| | - Josh Lam
- University of Calgary, Alberta, Canada
| | - Ceilidh Kinlin
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Karen Hulin
- Department of Rehabilitation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | | | - A Robertson Harrop
- Section of Plastic Surgery, Department of Surgery, University of Calgary
- Section of Pediatric Surgery, Department of Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Frankie O G Fraulin
- Section of Plastic Surgery, Department of Surgery, University of Calgary
- Section of Pediatric Surgery, Department of Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
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Abstract
Evaluation of the pediatric musculoskeletal system may be difficult because of differences between children and adults. As children mature, their physical structure approaches that of an adult. However, in the meantime, varying stages of ossification and developmental timelines may confuse the average clinician. Congenital abnormalities of the upper extremity are extremely numerous, but here we present 10 that often are seen in clinical practice. The article discusses the diagnosis, evaluation, treatment, and outcomes of each condition.
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24
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Chen KJ, Huang HK, Wang JP. Double antegrade intramedullary pinning for proximal phalangeal neck fractures in children. J Hand Surg Eur Vol 2019; 44:323-325. [PMID: 30636510 DOI: 10.1177/1753193418820178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Kuan-Jung Chen
- 1 Department of Surgery, School of Medicine, National Yang-Ming University.,2 Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Kuang Huang
- 1 Department of Surgery, School of Medicine, National Yang-Ming University.,2 Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,3 Department of Orthopaedics, Chiayi Christian Hospital, Chiayi, Taiwan.,4 Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Jung-Pan Wang
- 1 Department of Surgery, School of Medicine, National Yang-Ming University.,2 Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
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25
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Closed reduction and percutaneous "periarticular" single K-wire fixation for displaced unstable transverse fractures of the proximal phalanx in elderly osteoporotic women: A case series of five patients. Int J Surg Case Rep 2017; 39:110-114. [PMID: 28829987 PMCID: PMC5565631 DOI: 10.1016/j.ijscr.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 11/22/2022] Open
Abstract
No literature was found on fractures of the proximal phalanx in osteoporotic women. We present a case series of five patients with 7 fractured fingers. The results were excellent in 5 fingers and good in 2 fingers.
Introduction A literature review did not reveal any study investigating the results of surgical management of fractures of the proximal phalanx in elderly osteoporotic women. We present a case series of five patients. Patients and methods Five consecutive cases with seven fractures of the shaft/base of the proximal phalanx were retrospectively reviewed. The mean age of the study group was 72.4 years (range, 70–76 years). All patients were on treatment for osteoporosis at the time of injury. All patients were treated with closed reduction and percutaneous “periarticular” single K-wire fixation followed by immediate active mobilization of all joints. Results Two minor complications were seen: superficial pin tract infection in one case; and slight fracture displacement after K-wire removal resulting in malunion in the other case. After a mean follow-up of 4 months, the total active motion was considered excellent in 5 fingers and good in 2 fingers. Conclusion We demonstrate a favorable outcome following closed reduction and percutaneous “periarticular” single K-wire fixation for displaced unstable transverse fractures of the proximal phalanx in elderly osteoporotic women.
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26
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Abstract
Seymour fractures are open juxta-physeal fractures of the distal phalanx. A true lateral radiograph should be obtained for diagnosis, and treatment should include removal of the nail, irrigation and debridement of the fracture, and percutaneous Kirschner wire stabilization. Mallet fractures are more common in children than adults, and treatment is generally nonoperative for nondisplaced or minimally displaced fractures without volar subluxation of the distal phalanx; however, splinting compliance should be carefully assessed in younger populations. Phalangeal neck fractures have a limited potential to remodel and a propensity to redisplace. A true lateral radiograph will show displacement best; treatment is generally with percutaneous pinning. Open reduction should be avoided when possible because of the risk of osteonecrosis of the phalangeal condyles. The epidemiology of scaphoid fractures in children is changing, with waist fractures now the most common type. This may be due to an increase in body mass index (BMI) as well as high-level sports participation in today's pediatric population. Although the vast majority of acute scaphoid fractures can be treated successfully with cast immobilization, children who present with established nonunions should be offered open reduction and internal fixation as the primary treatment.
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Affiliation(s)
- Parker B Goodell
- UC Davis School of Medicine, 2101A Education Building, 4610 X Street, Sacramento, CA 95817
| | - Andrea Bauer
- Boston Children's Hospital, HUN 213, 300 Longwood Avenue, Boston, MA 02115
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