Pediatric emergency medicine trisk 839

FIGURE 109.10 Radiographs of a displaced small finger proximal phalangeal neck fracture.
Note the relatively subtle and benign radiographic appearance on the anteroposterior view (A ).
Fracture displacement is best seen on a dedicated lateral view (B ) as well as on oblique
projections of the small finger (C ). (Courtesy of Children’s Orthopaedic Surgery Foundation.)


FIGURE 109.11 Anteroposterior radiograph depicting an intra-articular fracture of the head of
the small finger proximal phalanx involving the radial condyle. (Courtesy of Children’s
Orthopaedic Surgery Foundation.)


FIGURE 109.12 Radiograph depicting complex dislocation of the thumb metacarpophalangeal
joint. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Rapidity of relocation is particularly important when there is any concern
regarding the neurovascular status. Following relocation, these injuries should be
splinted to maintain stability until reevaluation.

METACARPALS
CLINICAL PEARLS AND PITFALLS


Metacarpal fractures can occur at the base, shaft, or neck of the bone,
with the neck of the 5th metacarpal being the most common.
The amount of fracture angulation allowed in metacarpal neck fractures
increases across the metacarpals, from 10 to 20 degrees for the index
finger up to 40 degrees for the small finger.

Clinical Considerations
Clinical Recognition
Injuries to the metacarpals include fractures and dislocations of the MCP joint.

Carpometacarpal joint dislocation is rare in children, although such a dislocation
may coexist with another injury. The metacarpals may be fractured at the base,
shaft, or neck. These injuries often occur from crushing trauma in younger
patients as well as from impact along the axis of the bones, such as in punching or
falling in older children and adolescents. Compartment syndrome in the hand can
occur, particularly with multiple fractures and crush injury, thus careful physical
examination and appropriate suspicion are required.
Initial Assessment and Management
The most common metacarpal fracture occurs at the neck of the bone, with the
majority involving the small finger (the boxer’s fracture) ( Fig. 109.13 ).
Inspection for rotational displacement of the fracture is again important, as is
close attention to evidence of skin trauma that might indicate contamination from
an opponent’s mouth during a fight. Any open wound with exposure to human
oral secretions requires antibiotic prophylaxis as well as consideration of formal
irrigation and debridement, as these wounds are associated with high rates of
infection. A considerable amount of angulation of the fracture can be tolerated
without limiting ultimate hand function. The amount of angulation allowed
increases across the metacarpals, from 10 to 20 degrees for the index finger up to
40 degrees for the small finger. Closed reduction is often all that is needed in
fractures that exceed the tolerable amount of angulation, except in unstable
fractures.
Metacarpal shaft fractures are uncommon in the pediatric population. When
they occur, they tend to involve the middle, ring, and small fingers. They are most
often spiral in nature, indicating a rotational component to the injuring force.
Careful attention to the alignment of the fingers when making a fist may
demonstrate subtle rotational deformity (see Fig. 109.1 for clinical presentation of
rotational deformity). These injuries also result in significant edema, but