Pediatric emergency medicine trisk 840

significantly angulated or displaced fractures can often be predicted based on
examination. Most nondisplaced shaft fractures can be managed with
immobilization, though fractures with significant displacement may require
operative stabilization.

FIGURE 109.13 Anteroposterior radiograph of the hand depicting a displaced fifth metacarpal
neck fracture. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Fractures of the metacarpals are least likely to occur in the base of the bone.
When these occur, they usually involve the small finger. There will be significant
pain and dorsal edema, which can make accurate diagnosis challenging. Plain


radiograph imaging can be difficult to interpret and at times will require CT scan
to fully characterize the injury. Minimally or nondisplaced fractures are generally
managed with a splint or cast. Displaced fractures often require closed reduction,
possible pinning, and subsequent casting. Carpometacarpal dislocations alone or
in conjunction with a base fracture are unstable and often require operative
stabilization ( Fig. 109.14 ). Bennett fractures, or intra-articular fractures of the
base of the thumb metacarpal, mandate special attention, as the thumb
carpometacarpal joint is critical for full use of this digit ( Fig. 109.15 ). Similarly,
Rolando fractures, comminuted fractures of the base of the thumb metacarpal,
also require careful attention. These fractures can be addressed temporarily with a
thumb spica splint and timely referral.

CARPALS
CLINICAL PEARLS AND PITFALLS
The scaphoid is the most commonly fractured carpal bone.
Ligamentous injuries and dislocations can be subtle but have
significant morbidity.

FIGURE 109.14 Radiographs demonstrating carpometacarpal dislocation. (Courtesy of
Children’s Orthopaedic Surgery Foundation.)

Clinical Considerations
Clinical Recognition
The incidence of carpal fractures is relatively low in children, although increasing
awareness has led to improved recognition. In infancy, the carpals are completely
cartilaginous and are nearly immune to injury. They progressively ossify
beginning with the capitate. The scaphoid is by far the most common fractured
carpal bone, with most fractures occurring in late childhood and adolescence.
Falls are the most frequent cause.


FIGURE 109.15 Radiographs of the thumb depicting a Bennett fracture. (Courtesy of
Children’s Orthopaedic Surgery Foundation.)

Initial Assessment and Management
Physical examination requires attention to edema, range of motion, and point
tenderness to localize carpal injuries. Snuffbox tenderness is a useful tool for
detecting scaphoid fractures. Pain with axial thumb compression can also be a
sign of scaphoid injury. Radiographs are obviously limited in infancy and early
childhood because of the lack of ossification. As the patient ages and the carpals
are progressively ossifying, comparison with the contralateral side may be of
benefit. Dedicated scaphoid views or computed tomography may help to identify
some fractures not seen on routine hand or wrist films. Nondisplaced scaphoid
fractures may not be obvious on initial x-rays but will be visible on repeat
imaging performed 2 weeks following the injury. A missed scaphoid injury can
lead to significant morbidity.