Early Functional Treatment of Proximal Phalanx Fractures in Children: A Case Series Study

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

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.

Advances in Hand Therapy: Best Practice in Conservative Management of Proximal Phalangeal Fractures in Children

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.