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FIGURE 109.9 This lateral radiograph demonstrates a small volar avulsion fracture of the
proximal middle phalanx (A ), then a larger pilon fracture of the proximal middle phalanx (B ).
(Courtesy of Children’s Orthopaedic Surgery Foundation.)

Proximal phalanx injuries to the thumb are unique. In adolescents and adults, a
skier’s or gamekeeper’s thumb occurs with rupture of the ulnar collateral
ligament (UCL) during an abduction stress of the thumb. In children, a fracture of
the base of the proximal phalanx is more likely than a UCL injury, with Salter–
Harris I and II fractures predominating in younger children and Salter–Harris III
fractures in older children. Thumb spica splinting is appropriate for this
constellation of injuries in the emergency department. Extra-articular injuries may