Pediatric emergency medicine trisk 837

CLINICAL PEARLS AND PITFALLS
Special attention is required for injuries to the phalanges looking for
rotational deformity; the tenodesis effect is very useful even in the
noncooperative child.
A finger splint does not provide adequate support for proximal phalanx
fractures; a wrist or forearm splint is necessary.
Small fragments or flecks on radiographs can represent larger injuries
due to immature ossification.

Clinical Considerations
Clinical Recognition
Phalanx injuries are very common in children since the fingers of a child are a
first exploration into their world. Mechanisms of injury most frequently include
crush, hyperextension, and “jamming.” Careful examination with particular
attention to rotational deformity is required. Passively flexing and extending the
wrist allow for observation of the tenodesis effect which is very useful for the
assessment of rotational deformities and for complete tendon injuries ( Figs.
109.1 and 109.5 ). Often, identifying which bone is involved in an interphalangeal
(IP) joint injury can be challenging due to pain and swelling.
Initial Assessment and Management
Distal phalanx injuries are very common and often associated with nail and nail
bed injuries, as discussed in the section on fingertip injuries above. When
associated with nail bed injuries, after the nail is removed (if necessary), the open
fracture should be copiously irrigated and the nail bed repaired, followed by
splinting. These should be referred to a hand specialist for follow-up in case
further intervention, such as pin fixation, is required. Seymour fractures comprise
a special type of injury, with a Salter–Harris I or II fracture of the distal phalanx
associated with exposure of the proximal aspect of the nail and damage to the
germinal matrix ( Fig. 109.6 ). The distal interphalangeal (DIP) joint is often held
at some flexion. Early consultation with a hand specialist is recommended, as
tissue interposed into the physis may prevent the fracture from healing which can

lead to infection and potential nail deformity.


FIGURE 109.5 Image depicting a small palmar laceration at the base of the middle phalanx
leading to abnormal tenodesis in the setting of a flexor tendon injury. (Courtesy of Children’s
Orthopaedic Surgery Foundation.)


Mallet finger injuries are avulsion fractures of the distal phalanx that
commonly result from a finger jam mechanism. In adolescents, the injury is often
seen on a lateral radiograph ( Fig. 109.7 ). A similar tendon avulsion in a younger
child might not have an associated fracture. Mallet finger injuries are managed in
an extension splint. In the emergency room setting, AlumaFoam and stack splints
may be utilized. However, providers should be mindful of appropriate sizing, as
splints designed for adults commonly do not fit. Many of these injuries are treated
with immobilization alone. Even large fragments may not require surgical care,
however all mallet finger injuries should be referred to a hand specialist.

FIGURE 109.6 Seymour fracture. A : Lateral radiograph depicting a displaced distal
phalangeal physeal fracture in the setting of a nail bed injury. B : Intraoperative photograph
after nail plate removal depicting the tear in the germinal matrix of the nail bed and underlying
bony injury. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Jersey finger injuries refer to traumatic avulsion of the flexor digitorum
profundus tendon at the level of the distal phalanx. These commonly occur when
the finger is held in flexion and then sustains forceful extension, for example,
when a football player is attempting to tackle another player with their fingers.
There is often pain on the volar aspect of the finger, with the affected finger held
in slight extension ( Figs. 109.2 and 109.8 ); the patient cannot actively flex the
DIP joint. These injuries commonly occur without an associated fracture but

require urgent referral to a hand specialist for operative repair.


Most middle phalanx injuries are managed by closed management, although
surgical reduction and stabilization may be required in displaced fractures.
Fractures of the head of the phalanx require close management by a hand
specialist because of a high rate of complications. Avulsion fractures of the
middle phalanx at the insertion of the volar plate or extensor central slip are
common. Avulsions on the volar side generally are from hyperextension. Often,
the fragment does not reattach. Prolonged immobilization may result in chronic
stiffness and has potential for permanent loss of range of motion. Splinting is
performed initially, but early range of motion is often started a week later. Small
avulsions on the extensor side are treated similarly, though larger fragments are
treated with longer splinting, and injuries with displaced and larger fracture
fragments with articular involvement may require open reduction ( Fig. 109.9 ).