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Wood L, Malin L, Robb J, Ward C, Bohn D. Long-Term Clinical Outcomes Following Nonsurgical Management of Salter-Harris Type II Fractures of the Proximal Phalanx of the Small Finger: A Prospective Cohort Study. J Hand Surg Am 2024:S0363-5023(24)00170-9. [PMID: 38934990 DOI: 10.1016/j.jhsa.2024.04.002] [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: 08/31/2023] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Juxta-physeal fractures at the base of the proximal phalanx (FBPP) of the small finger are one of the most common hand fractures in children. Although many of these fractures are treated nonsurgically, it is unclear which fractures benefit from surgery or the degree of acceptable angulation appropriate for nonsurgical management. Our study aimed to assess long-term, patient-reported outcomes regarding function, appearance, and pain after nonsurgical management of FBPP of the small finger in a pediatric population. METHODS Our hospital Picture Archiving and Communication Systems database was queried to identify radiographs of the small finger of children between the ages of 8 and 16 years old taken from 2011 to 2021. Displacement on initial injury radiographs was calculated using the diaphyseal-metacarpal head angle. Patient-reported function, appearance, and pain were measured using standardized assessment tools sent to patients and parents electronically. Optional clinical photographs were uploaded by parents and assessed for residual clinical deformity. RESULTS One hundred eighty-one eligible subjects were identified. Eighty (44%) agreed to participate, and 40 (22%) parent and 38 patient surveys were completed. The mean age at the time of injury was 11 years old (8-14 years), and the mean age at the time of survey completion was 17 years old (11-23 years). Patient T-scores were higher than the average reference T-score on the Patient-Reported Outcomes Measurement Information System Short Form v2.0-Upper Extremity. Overall, greater than 78% of patients and parents reported appearance as 8/10 or above on a VAS. Ninety-five percent (108/114) of patients reported no pain (0/10) for pain during activities and at rest. CONCLUSIONS Children with up to 26° of initial coronal plane angulation reported better function than a reference population, good appearance, and no pain, at a mean of 6 years after injury. Our findings support nonsurgical management of most FBPP of the small finger in children. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Lily Wood
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Lynsey Malin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | | | - Christina Ward
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN; TRIA Orthopedic Center, Bloomington, MN
| | - Deborah Bohn
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN; TRIA Orthopedic Center, Bloomington, MN.
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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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Arneitz C, Bartik C, Weitzer CU, Schmidt B, Gasparella P, Tschauner S, Castellani C, Till H, Singer G. Distribution and pattern of hand fractures in children and adolescents. Eur J Pediatr 2023:10.1007/s00431-023-04915-3. [PMID: 37016042 PMCID: PMC10257615 DOI: 10.1007/s00431-023-04915-3] [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: 11/15/2022] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 04/06/2023]
Abstract
Hand fractures represent commonly encountered injuries in pediatric patients. However, due to modern means of mobility and product safety, the occurrence and distribution of these fractures have changed during the last decades. Therefore, it was the aim of this study to present an update of the epidemiology, pattern, and treatment of hand fractures in a large pediatric cohort. All patients aged between 0 and 17 years treated in our Department in 2019 with fractures of the phalanges, metacarpus, or carpus were included. The medical records were reviewed for age, gender, injury mechanism, fracture localization, season, and treatment. Patients were divided into three different age groups (0-5, 6-12, and 13-17 years). A total of 731 patients with 761 hand fractures were treated during the 1-year study period. The mean age was 11.1 ± 3.5 years, and the majority was male (65%). Male patients were significantly older compared to female patients (p = 0.008). Also, 78.7% of the fractures affected the phalanges, 17.6% the metacarpals, and 3.7% the carpal bones. The proximal phalanges were the most commonly fractured bones (41.5%). Patients with fractures of the carpus were significantly older compared to children sustaining fractures of the metacarpus or phalangeal bones (p < 0.001). Sixteen percent of our patients were treated surgically; these patients were significantly older compared to conservatively treated patients (p = 0.011). Conclusion: The epidemiology, mechanisms of injury, distribution, and treatment of hand fractures significantly varies among different age groups. This knowledge is of importance for educational purposes of younger colleagues entrusted with care of children and adolescents as well as development of effective prevention strategies. What is Known: • Pediatric hand fractures represent the second most common fractures in children. • The epidemiology of pediatric hand fractures has changed during the last decades and therefore there is a need for an update regarding distribution and epidemiology of pediatric hand fractures. What is New: • In this retrospective cohort study, 761 pediatric hand fractures of 731 patients were analyzed in detail. • The main mechanisms of younger patients were entrapment injuries, older children most commonly sustained their fractures due to ball sport injuries. There was an increasing rate of metacarpal and carpal fractures with increasing age, and these fractures had to be treated operatively more often than phalangeal fractures.
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Affiliation(s)
- Christoph Arneitz
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Claudia Bartik
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Claus-Uwe Weitzer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Barbara Schmidt
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Paolo Gasparella
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Sebastian Tschauner
- Division of Paediatric Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Christoph Castellani
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria.
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Abstract
BACKGROUND Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns. METHODS The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed. RESULTS There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001). CONCLUSIONS Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.
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Affiliation(s)
- Landis R. Walsh
- Boston Children’s Hospital and Harvard Medical School, MA, USA
| | - Laura C. Nuzzi
- Boston Children’s Hospital and Harvard Medical School, MA, USA
| | | | - Brian I. Labow
- Boston Children’s Hospital and Harvard Medical School, MA, USA
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Karim K, Beatty E, Waters P, Bae DS. Early Surgical Results of Pediatric Unicondylar Phalangeal Fractures. J Hand Surg Am 2023:S0363-5023(22)00685-2. [PMID: 36599793 DOI: 10.1016/j.jhsa.2022.11.002] [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: 05/10/2022] [Revised: 11/07/2022] [Accepted: 11/16/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Conventional teaching dictates that timely diagnosis and expeditious treatment of unicondylar phalangeal fractures are essential to restore articular congruity, which allows for optimal range of motion and function. The objective of this study was to compare the radiographic and clinical results of surgical treatment of acute and chronic unicondylar phalanx fractures in pediatric patients. METHODS Thirty-four patients with unicondylar phalangeal fractures underwent surgical intervention at a pediatric tertiary care center from 2004 to 2016. A fracture was defined as acute if an interval of 4 weeks or less had elapsed between the date of injury and date of surgery and chronic if an interval of more than 4 weeks had elapsed between the date of injury and date of surgery. Preoperative and postoperative radiographs were assessed. The joint alignment was determined by measuring the angle between the longitudinal axis of the phalanx and a line tangential to the articular condyles on anteroposterior radiographs. RESULTS There were 24 patients (71%) with acute and 10 (29%) with chronic fractures. An oblique volar fracture pattern was most common in both the groups. The average joint alignment obtained from the anteroposterior radiographs at presentation was 6° in the acute group and 12° in the chronic group. The surgical procedures performed included closed reduction and percutaneous pinning, open reduction and internal fixation, osteoclasis or osteotomy and fixation, and corrective advancement osteotomy. The posttreatment alignment was within 3° of neutral in 21 patients (88%) with acute injury and 8 (80%) with chronic injury. The average interphalangeal joint range of motion at the final clinic visit was 1°-92° in the acute group and 4°-85° in the chronic group. One patient with chronic injury developed avascular necrosis after treatment with corrective osteotomy. CONCLUSIONS The patterns and characteristics of unicondylar phalanx fractures are similar between pediatric patients and adults. The radiographic alignment and digital motion are improved with surgical reduction and fixation, regardless of chronicity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Kristin Karim
- Boston Children's Hospital, Orthopedic Center, Boston, MA; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Evan Beatty
- Boston Children's Hospital, Orthopedic Center, Boston, MA; Drexel University College of Medicine, Philadelphia, PA
| | - Peter Waters
- Boston Children's Hospital, Orthopedic Center, Boston, MA; OrthoCarolina - Hand Center & Pediatric Orthopedic Center, Charlotte, NC
| | - Donald S Bae
- Boston Children's Hospital, Orthopedic Center, Boston, MA.
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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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Crum RP, Cervantes L, Berger AJ. Pediatric hand ultrasound: common indications, injury, inflammation and masses. Pediatr Radiol 2022; 52:1671-1686. [PMID: 35368212 DOI: 10.1007/s00247-022-05286-x] [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: 08/02/2021] [Revised: 12/01/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Ultrasound is a uniquely valuable tool for evaluating musculoskeletal problems in the pediatric hand. Acute and chronic injuries involving tendons and ligaments of the hand can be quickly assessed and can guide surgical decision-making. Using ultrasound, palpable lesions and masses can be evaluated for cystic and solid components aiding in differential diagnosis. Additionally, ultrasound provides evaluation of acute versus chronic changes of inflammatory arthritis, assessing disease severity and subclinical synovitis and serving as an adjunct to medical management. This review will cover common indications and ultrasound findings of the pediatric hand, focusing on common injuries, inflammatory arthritis and masses. Important anatomical features of the hand will be discussed as well as imaging technique and evaluation in the pediatric patient.
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Affiliation(s)
- Rachel Pevsner Crum
- Department of Pediatric Radiology, Nicklaus Children's Hospital, 3100 SW 62 Ave., Miami, FL, 33155, USA.
| | - Luisa Cervantes
- Department of Pediatric Radiology, Nicklaus Children's Hospital, 3100 SW 62 Ave., Miami, FL, 33155, USA
| | - Aaron J Berger
- Division of Pediatric Plastic Surgery, Nicklaus Children's Hospital, Miami, FL, USA
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Tan C, Depiazzi J, Bear N, Blennerhassett L, Page R, Gibson N. Exercise handout and one-on-one hand therapy for management of stiffness after plaster cast immobilization of simple phalangeal and metacarpal fractures in children: A randomized, noninferiority trial. J Hand Ther 2021; 34:423-432.e7. [PMID: 32571602 DOI: 10.1016/j.jht.2020.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a noninferior, single-blind, randomized controlled trial. INTRODUCTION Joint stiffness is common after plaster cast immobilization for simple phalanx and metacarpal fractures in children. The limited literature suggests this joint stiffness in children resolves without one-on-one therapy; however, without robust studies confirming that there is no detrimental effect from withdrawing treatment, many children are still referred. PURPOSE OF THE STUDY The purpose of this study was to determine if an educational handout for self-management of stiffness is noninferior to one-on-one hand therapy for achieving full range of motion (ROM). METHODS Participants were randomly assigned to group one who received the handout or group two who received hand therapy in addition to the handout. The ROM was measured by composite flexion and total active motion (TAM). The noninferiority margin was 10% difference between the two groups in the proportion of participants who achieved full ROM at two weeks after cast removal. RESULTS Sixty participants in each group completed the study. Group difference for composite flexion was 1.7% (95% CI: -3.9% to 7.2%), demonstrating noninferiority. Group difference for TAM was inconclusive at 8.3% (95% CI: -2.1% to 18.7%). Sensitivity analysis adjusting for participants with full composite flexion at the baseline resulted in the group difference for composite flexion of 3.1% (95% CI: -3.6% to 9.8%), maintaining noninferiority, but group difference for TAM at 10.4% (95% CI: 0.0% to 20.9%), was inconclusive with the handout group significantly worse. CONCLUSION An educational handout is noninferior to hand therapy for achieving full ROM in composite flexion but not TAM. This needs to be taken into consideration for changing clinical practise.
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Affiliation(s)
- Cheng Tan
- Physiotherapy Department, Perth Children's Hospital, Perth, Western Australia, Australia.
| | - Julie Depiazzi
- Physiotherapy Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Natasha Bear
- Department of Clinical Research and Education, Child Adolescent Health Service, Perth, Western Australia, Australia
| | - Lewis Blennerhassett
- Department of Plastics and Reconstructive Surgery, Child and Adolescent Health Service, Perth, Western Australia, Australia
| | - Rohan Page
- Department of Plastics and Reconstructive Surgery, Child and Adolescent Health Service, Perth, Western Australia, Australia
| | - Noula Gibson
- Physiotherapy Department, Perth Children's Hospital, Perth, Western Australia, Australia
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns. SUMMARY Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.
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Pediatric Upper Extremity Trauma. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bernardes M, Ventura M, Grazina R, Miragaia L, Duarte G, Canela P. Deep Flexor Tendon Entrapment in a Diaphyseal Fracture of the Proximal Phalanx - A Case Report. J Orthop Case Rep 2020; 9:86-89. [PMID: 32548037 PMCID: PMC7276608 DOI: 10.13107/jocr.2019.v09.i06.1602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The proximal phalanx fracture is a common fracture of the hand in pediatric ages. Most of these fractures can be treated conservatively with immobilization. There are only few cases reporting tendon entrapment in literature and most of them refer to epiphyseal fractures with only one case reporting tendon entrapment after diaphyseal fracture. Case Report A 15-year-old boy went to the emergency department after suffering trauma in his right hand caused by a fall. He complained of pain in his second finger of the right hand which was swollen. An imaging study was performed and a fracture of the proximal phalanx diaphysis of the second finger of the right hand was diagnosed. Due to deviation, reduction, syndactyly, and immobilization with Zimmer splint were performed. The control X-ray showed acceptable reduction and the patient was referred for follow-up at an outpatient consultation. During follow-up, the reduction was maintained and the conservative treatment was kept for 25 days, with apparent fracture healing. The patient presented active flexion limitation of the finger that was interpreted as a sequel of the immobilization and he was referred for physical therapy rehabilitation. Six weeks after the initial trauma, the patient was observed at the emergency department for new right-hand trauma. On examination, no active flexion of the third phalanx of the second finger of the right hand was noticed. The patient underwent an ultrasound that revealed deep flexor tendon entrapment at the fracture focus. A surgery was performed consisting in tenolysis and reconstruction of the pulleys using a portion of the long palmar tendon. The patient has good clinical evolution with almost complete recovery of mobility. Conclusion This case illustrates an entrapment of deep flexor tendon after a diaphyseal fracture of the proximal phalanx, with only few cases reported in literature. The authors highlight the importance of having a high index of suspicion to detect this situation once it restrains the success of the conservative treatmentand makes the surgery mandatory to avoid definite sequels and disabilities.
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Affiliation(s)
- Marco Bernardes
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
| | - Moisés Ventura
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
| | - Rita Grazina
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
| | - Luís Miragaia
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
| | - Guido Duarte
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
| | - Pedro Canela
- Department of Orthopaedic, Ortophaedics and Traumatology Service of Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
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Nonarticular Base and Shaft Fractures of Children's Fingers: Are Follow-up X-rays Needed? Retrospective Study of Conservatively Treated Proximal and Middle Phalangeal Fractures. J Pediatr Orthop 2019; 39:e657-e660. [PMID: 30628978 DOI: 10.1097/bpo.0000000000001335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Phalangeal fractures of the hand are common in children, and most extra-articular fractures can be treated with nonoperative management. Minimally or nondisplaced fractures may simply be immobilized, whereas displaced fractures need closed reduction before immobilization. Although few of these fractures displace secondarily, most schemes currently recommend follow-up x-rays after initial diagnosis. Our primary objective was to identify subgroups of finger fractures that are stable, thus requiring no radiographic monitoring. METHODS This study was designed as a retrospective, single-center analysis of conservatively treated pediatric finger fractures of the proximal and middle phalanges. We included patients up to 16 years with base or shaft fractures of the index to little fingers who underwent nonoperative treatment and standardized follow-up controls in our pediatric hand surgery outpatients' clinic between 2010 and 2016. Fracture angular deformity in x-rays taken at diagnosis and after 1 and 3 weeks were reassessed blinded, and a statistical analysis was conducted to identify fracture types that are prone to secondary angular deformity. RESULTS A total of 478 patients were eligible; 113 were lost due to missing final radiographic controls. Overall, 365 patients were analyzed; they had a mean age of 9.7 years (range, 1 to 16), and 33.4% required a primary closed reduction. A secondary angular deformity occurred in 2.2% (8/365) of all finger fractures. No secondary angulation occurred in primary minimally and nondisplaced fractures, but 6.6% (8/122) of the reduced fractures showed a subsequent loss of reduction. CONCLUSIONS Minimally angulated (<10 degrees) and nondisplaced metaphyseal and diaphyseal fractures of proximal and middle phalanges of the index to little fingers are stable and therefore do not need radiographic follow-ups. However, initially angulated fractures requiring closed reduction bear a risk of subsequent loss of reduction. LEVEL OF EVIDENCE Level III-retrospective study.
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Kattan AE, AlShomer F, Alhujayri AK, Alfowzan M, Murrad KA, Alsajjan H. A case series of pediatric seymour fractures related to hoverboards: Increasing trend with changing lifestyle. Int J Surg Case Rep 2017; 38:57-60. [PMID: 28735119 PMCID: PMC5522954 DOI: 10.1016/j.ijscr.2017.06.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
We would like to thank the journal and potential reviewers for assessing this manuscript. The article showed a causal relation with the use of Hoverboards and Seymour Fractures in pediatric population. Parental supervision and faulty design checkup are recommended prior to operate such machinery.
Background Several recreational activities such as roller skating, skateboarding, and scooter riding create the risk for hand injuries, which are the fourth most commonly injured body part in relation to their use. Seymour first identified a specific pattern of digit injury as an open fracture affecting the distal phalangeal physis associated with nail avulsion from the eponychial fold. In this article, we report a series of Seymour fractures associated with misuse of the newly emerging recreational/transportation vehicle, the hoverboard. Method The study includes a retrospective chart review of patients who presented to a tertiary hospital between December 2015 and October 2016 with a Seymour fracture caused while operating a hoverboard. Results A total of 13 patients were treated for Seymour fractures. The majority were male patients, and the group had a mean age of 10.3 years (±2.21). The affected digits were primarily the middle and ring fingers of the non-dominant hand. The injury mechanism reported by patients or families indicated that the child was operating the hoverboard in a sitting position with the hands grasping the wheel rim parts. Conclusion We report a case series of a fracture pattern resulting from the improper/unsafe use of a hoverboard. This type of fracture occurs with a tremendous load of energy. Although improper use was a factor, design fault also plays a role in causing the injury. Parent awareness and supervision are important to prevent such injuries.
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Affiliation(s)
- A E Kattan
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
| | - F AlShomer
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
| | - A K Alhujayri
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
| | - M Alfowzan
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
| | - K A Murrad
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
| | - H Alsajjan
- Plastic and Reconstructive Surgery, Surgery Department, King Khalid University Hospital, King Saud University, College of Medicine, Saudi Arabia.
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Mims L, Khodaee M. Extra-Octave Fracture in a 14-Year-Old Basketball Player. J Pediatr 2017; 186:206-206.e1. [PMID: 28408129 DOI: 10.1016/j.jpeds.2017.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/07/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Logan Mims
- Department of Family Medicine University of Colorado School of Medicine Denver, Colorado
| | - Morteza Khodaee
- Department of Family Medicine University of Colorado School of Medicine Denver, Colorado
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16
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Comparison Between Buddy Taping With a Short-Arm Splint and Operative Treatment for Phalangeal Neck Fractures in Children. J Pediatr Orthop 2017; 36:736-42. [PMID: 25955173 DOI: 10.1097/bpo.0000000000000521] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Phalangeal neck fractures in children are difficult to treat conservatively because of the difficulty in maintaining reduction, obtaining satisfactory follow-up x-rays, and the limited remodeling potential. The purpose of this study was to present the results after using buddy taping with a short-arm splint for phalangeal neck fracture in children and to compare with operative treatment. METHODS Thirty-seven patients below 12 years old who had phalangeal neck fractures were included. Nineteen patients were underwent conservative treatment and 18 patients were underwent operative fixation with Kirschner wires. Clinical outcome and radiographs between groups were compared. RESULTS There were no significant differences between conservative group and operative group in the sagittal angulation, coronal angulation, and translation at immediately after reduction, at the 6-week, and final follow-up examination. CONCLUSION Buddy taping with a short-arm splint for treating phalangeal neck fractures had acceptable outcomes compared to that with surgical correction.
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Al-Qattan MM. Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis: Outcome 10 years following open reduction and K-wire fixation. Int J Surg Case Rep 2017; 31:14-16. [PMID: 28076751 PMCID: PMC5222955 DOI: 10.1016/j.ijscr.2016.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/25/2016] [Indexed: 11/29/2022] Open
Abstract
We report on a case of Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis. Open reduction and K-wire fixation was done. Ten years later, the injured thumb was smaller in width and the diaphysis of the injured proximal phalanx had a constricted appearance.
Introduction Salter-Harris type IV fracture of the proximal phalanx with 90° rotation of the epiphysis is very rare. We report on a case of Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis and document the outcome 10 years after surgery. Presentation of case A 5-year old boy presented with Salter-Harris type IV fracture of the thumb with 90° rotation of the epiphysis. Open reduction and K-wire fixation was done. Ten years later, the injured thumb was smaller in width when compared to the contralateral thumb, although there was no length discrepancy. Clinically, there was full range of motion. Radiologically, the physis was still open but there were minor irregularities at the adjacent metaphyseal base and epiphysis. The diaphysis of the injured proximal phalanx had a constricted appearance when compared to the contralateral normal side. Discussion After an extensive literature review, we found one reported case which was similar to our case and had long term assessment. At skeletal maturity, there was complete remodeling and full range of motion of the digit with no shortening. The X-ray showed a constricted diaphysis of the proximal phalanx with an identical appearance to our case. Conclusion We present a rare case of Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis. Long term outcome was satisfactory but there was diaphyseal constriction leading to a narrower thumb.
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Affiliation(s)
- Mohammad M Al-Qattan
- From the Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia.
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18
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Abstract
Phalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits for fractures in the United States. The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, which coincides with the time that most children begin playing contact sports. Younger children are more likely to sustain a phalangeal fracture in the home setting as a result of crush and laceration injuries. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. A thorough physical examination is necessary to assess the digital cascade for signs of rotational deformity and/or coronal malalignment. Plain radiographs of the hand and digits are sufficient to confirm a diagnosis of a phalangeal fracture. The management of phalangeal fractures is based on the initial severity of the injury and depends on the success of closed reduction techniques. Nondisplaced phalanx fractures are managed with splint immobilization. Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. Unstable, displaced phalanx fractures require surgical management, preferably via closed reduction and percutaneous pinning.
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Trimaille A, Kerfant N, Monnerie C, Le Nen D, Fenoll B, Henry AS, Hu W. La main traumatique de l’enfant. ANN CHIR PLAST ESTH 2016; 61:528-535. [DOI: 10.1016/j.anplas.2016.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 11/26/2022]
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20
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Lee YK, Park S, Lee M. Flexor Tendon Entrapment at the Malunited Base Fracture of the Proximal Phalanx of the Finger in Child: A Case Report. Medicine (Baltimore) 2015; 94:e1408. [PMID: 26334897 PMCID: PMC4616507 DOI: 10.1097/md.0000000000001408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The proximal phalangeal base is the most commonly fractured hand bone in children. Such fractures are rarely reported as irreducible due to flexor tendon entrapment. Here, we describe a patient who sustained a malunited fracture on the right fifth finger proximal phalanx with flexor tendon entrapment after treatment with closed reduction with K-wires fixation.A 13-year-old patient came to the clinic following a bicycle accident 6 weeks ago. He presented with flexion limitation in his small finger on the right hand. During physical examination, the patient felt no pain, and the neurovascular structures were intact. However range of motion (ROM) in his small finger was not normal. Plain radiographs displayed a Salter-Harris type II fracture of the small finger proximal phalanx base and volar angulation with callus formation. During the operation, it was established that the flexor digitorum superficialis (FDS) around the fracture had a severe adhesion, whereas the flexor digitorum profundus (FDP) was entrapped between the volarly displaced metaphyses and the epiphyses and united with the bone. We removed the volarly displaced metaphyses and freed FDP and repaired the A2 pulley. The bone was anatomically fixed with K-wires. In the treatment after the operation, on the 2nd day, the patient was permitted the DIP joint motion by wearing a dynamic splint.At the 12-months follow-up, the patient had regained full ROM with no discomfort and the proximal phalanx growth plate of the small finger closed naturally with normal alignment.When treating a proximal phalangeal base fracture in children, the possibility of flexor tendon entrapment should be considered and should be carefully dealt with in its treatment.
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Affiliation(s)
- Young-Keun Lee
- From the Department of Orthopedic Surgery, Chonbuk National University Hospital, Jeonju (Y-K L, M L); Graduate Scool of MOT/ Sogang Institute of Advanced Technology, Sogang University, Seoul, Korea
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21
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Dhamangaonkar AC, Patankar HS. TREATMENT OF ATROPHIC NONUNION OF MIDDLE PHALANX IN A NINE-YEAR-OLD BOY WITH EXTERNAL DISTRACTION AND BONE GRAFTING. ACTA ACUST UNITED AC 2014; 19:449-53. [DOI: 10.1142/s0218810414720356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nonunion of phalangeal fractures is uncommon and even rarer in the paediatric age group. There is paucity of literature relating to the treatment of atrophic non-union of phalangeal fractures in the paediatric age group. We present a case of five years old atrophic non-union of the middle phalanx of the index finger of the dominant hand in a nine-year-old male child, managed with a staged treatment protocol of initial fracture site distraction with a threaded external fixator followed by delayed bone grafting. This treatment was successful in attaining length and bony union in case of atrophic non-union of the middle phalanx with a good pinch strength and gaining a good range of motion at the proximal interphalangeal joint with little soft tissue dissection.
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Affiliation(s)
- Anoop C. Dhamangaonkar
- Patankar's Hand and Limb Reconstruction Clinic, 204, Garodia Market, Plot No. 8-A, D.K. Sandu Marg, Chembur, Mumbai-400071, Maharashtra, India
| | - Hemant S. Patankar
- Patankar's Hand and Limb Reconstruction Clinic, 204, Garodia Market, Plot No. 8-A, D.K. Sandu Marg, Chembur, Mumbai-400071, Maharashtra, India
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22
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Abstract
The majority of pediatric finger fractures can be treated by closed means with expected excellent outcomes. However, a subset of fractures can turn "ugly," with complications such as growth arrest, malunion, and joint dysfunction if not recognized and treated appropriately. The present paper discusses several fractures in a child's fingers that can cause substantial problems if not recognized promptly, highlighting important themes in the evaluation and treatment of a child's injured finger.
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23
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Suresh SS, Zaki H. Paediatric thumb fracture remodelling as a hook deformity: case report. J Hand Surg Eur Vol 2011; 36:332-3. [PMID: 21406568 DOI: 10.1177/1753193411400679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Zipoli B, Donon L, Ribeyre D. [Surf and Seymour's fractures]. CHIRURGIE DE LA MAIN 2010; 29:263-265. [PMID: 20724203 DOI: 10.1016/j.main.2010.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 06/28/2010] [Accepted: 06/29/2010] [Indexed: 05/29/2023]
Abstract
The authors present four cases of Seymour-like juxtaepiphyseal fractures related to surf accidents. All four patients were novices at the sport, had the same fractures in identical circumstances. In all cases, reduction was achieved using an 'in-and-out' 1.2 K-wire serving as a 'joystick' which was then also used for fixation. The nail was fixed at the end.
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Affiliation(s)
- B Zipoli
- Centre hospitalier de Dax, France.
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26
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Al-Qattan MM, Al-Zahrani K, Al-Boukai AA. The relative incidence of fractures at the base of the proximal phalanx of the thumb in children. J Hand Surg Eur Vol 2009; 34:110-4. [PMID: 18936134 DOI: 10.1177/1753193408092494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is disagreement in the literature about the most common fracture type at the base of the proximal phalanx of the thumb in children below the age of adolescence. In this prospective study, 58 consecutive children aged 10 years or less with isolated fractures of the base of the proximal phalanx of the thumb were included and their radiographs were reviewed. The study included 38 boys and 20 girls with a mean age of 8 (range 1-10) years. After excluding one patient, in whom the type of fracture could not be determined, the most common fracture in the remaining 57 cases was the Salter-Harris type II fracture (72%), followed by the juxta-epiphyseal type II fracture (18%).
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Affiliation(s)
- M M Al-Qattan
- Department of Surgery, College of Medicine, and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
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27
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Al-Qattan MM, Al-Zahrani K, Al-Boukai AA. The relative incidence of fractures at the base of the proximal phalanx of the fingers in children. J Hand Surg Eur Vol 2008; 33:465-8. [PMID: 18687834 DOI: 10.1177/1753193408090146] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is debate regarding the most common fracture type at the base of the proximal phalanx of the fingers in children prior to closure of the epiphysis. In total, 100 consecutive children presenting with 103 fractures were included in a prospective study and their X-rays were reviewed by a consultant musculoskeletal radiologist. The study included 61 boys and 39 girls with a mean age of 10 (range 4-14) years. The most common fracture observed was the juxta-epiphyseal type II fracture (53%), followed by the Salter-Harris type II fracture (26%). Other fractures observed included Salter-Harris type I (4%), Salter-Harris type IV (5%), juxta-epiphyseal type I (8%), transverse metaphyseal (2%) and oblique metaphyseal (2%).
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Affiliation(s)
- M M Al-Qattan
- Department of Surgery, King Saud University, Riyadh, Saudi Arabia.
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28
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Täger G, Podleska LE, Ruchholtz S, Sommerfeldt D, Nast-Kolb D. [Fractures close to the epiphysis in children. Part I: upper extremities]. Unfallchirurg 2007; 110:867-82; quiz 883. [PMID: 17896094 DOI: 10.1007/s00113-007-1336-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fractures in children require special knowledge and skills due to the differences in biological and biomechanical properties of growing skeletons. Children suffer from fractures of the upper extremities much more than fractures of the lower extremities. While fractures of the diaphysis have a high regenerative and proliferation potential, impairment of the growth plate with consecutive disturbance of growth can be found more often in fractures close to the epiphysis. Most epiphysis fractures in children can be identified by a set of 2-plane X-ray images but precise knowledge about the skeletal maturation is required. In order to correctly decide about treatment regimes (conservative versus operative treatment) the limitations and limits of the ability of bone to correct misalignment must be anticipated. Clinical examination following fracture healing is mandatory to recognize differences in length, misalignment and deficits in function, which should receive further treatment.
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Affiliation(s)
- G Täger
- Klinik für Unfallchirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstrasse 55, 45122 , Essen, Germany.
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