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Original Article Article original FRACTURE OF THE PROXIMAL PHALANX OF THE LITTLE FINGER IN CHILDREN: A CLASSIFICATION AND A METHOD TO MEASURE THE DEFORMITY Ibrahim Shuaib, MD, MMedSc, PhD From the Department of Medicine, University College Cork, Cork, Ireland, and the Melville Hospital, Goose Bay, Labrador, Nfld. Accepted for publication Feb. 17, 1997 Correspondence to: Dr. Ibrahim Shuaib, Melville Hospital, Goose Bay, Labrador, NF A0P 1S0 © 1997 Canadian Medical Association (text and abstract/résumé) OBJECTIVE: To develop an improved method for measuring the deformity caused by fracture of the proxi- mal end of the proximal phalanx of the little finger in children. DESIGN: A prospective case study. SETTING: Regional hospitals with an orthopedic service. PATIENTS: Forty-two children with a proximal phalangeal fracture of the little finger and 42 children with- out a phalangeal fracture, who acted as a control. The type of deformity resulting from the fracture was noted, and the angle of deformity was measured. Rotational deformities were measured clinically in all patients and angulation deformities were measured from radiographs. The deformities were graded and classified. MAIN OUTCOME MEASURES: Measurements of the fracture deformity before and after manipulation. RESULTS: There were 38 ulnar angulation deformities, 26 dorsal angulation deformities, 10 ulnar rotation deformities, 3 palmar angulation deformities, 2 radial angulation deformities and 1 radial rotation defor- mity. The deformities could be graded into 6 different types. CONCLUSION: The measurements of deformity made it possible to describe and classify isolated deformities and combinations of various deformities. OBJECTIF : Mettre au point une meilleure façon de mesurer la déformation causée par une fracture de l’ex- trémité proximale de la phalange proximale de l’auriculaire chez les enfants. CONCEPTION : Étude de cas prospective. CONTEXTE : Hôpitaux régionaux dotés d’un service d’orthopédie. PATIENTS : Quarante-deux enfants qui ont subi une fracture de la phalange proximale de l’auriculaire et 42 enfants qui n’ont pas subi de fracture de la phalange et qui ont servi de témoins. On a noté le type de dé- formation causée par la fracture et mesuré l’angle de la déviation. Les décalages en rotation ont été mesurés en clinique chez tous les patients et les déviations ont été mesurées à partir de radiographies. Les déforma- tions ont été cotées et classées. PRINCIPALES MESURES DES RÉSULTATS : Mesures de la déformation causée par la fracture avant et après la manipulation. RÉSULTATS : On a constaté 38 déviations cubitales, 26 déviations dorsales, 10 décalages en rotation cu- bitale, 3 déviations palmaires, 2 déviations radiales et un décalage en rotation radiale. On a pu classer les déformations en 6 types différents. CONCLUSION : Les mesures de la déformation ont permis de décrire et de classer les déformations isolées et des combinaisons de déformations diverses. CJS, Vol. 40, No. 5, October 1997 363

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Page 1: Original Article Article originalcanjsurg.ca/wp-content/uploads/2014/03/40-5-363.pdf · Original Article Article original FRACTURE OF THE PROXIMAL PHALANX OF THE LITTLE FINGER IN

Original ArticleArticle original

FRACTURE OF THE PROXIMAL PHALANX OF THE LITTLEFINGER IN CHILDREN: A CLASSIFICATION AND A METHODTO MEASURE THE DEFORMITY

Ibrahim Shuaib, MD, MMedSc, PhD

From the Department of Medicine, University College Cork, Cork, Ireland, and the Melville Hospital, Goose Bay, Labrador, Nfld.

Accepted for publication Feb. 17, 1997

Correspondence to: Dr. Ibrahim Shuaib, Melville Hospital, Goose Bay, Labrador, NF A0P 1S0

© 1997 Canadian Medical Association (text and abstract/résumé)

OBJECTIVE: To develop an improved method for measuring the deformity caused by fracture of the proxi-mal end of the proximal phalanx of the little finger in children.DESIGN: A prospective case study.SETTING: Regional hospitals with an orthopedic service.PATIENTS: Forty-two children with a proximal phalangeal fracture of the little finger and 42 children with-out a phalangeal fracture, who acted as a control. The type of deformity resulting from the fracture wasnoted, and the angle of deformity was measured. Rotational deformities were measured clinically in all patients and angulation deformities were measured from radiographs. The deformities were graded andclassified.MAIN OUTCOME MEASURES: Measurements of the fracture deformity before and after manipulation.RESULTS: There were 38 ulnar angulation deformities, 26 dorsal angulation deformities, 10 ulnar rotationdeformities, 3 palmar angulation deformities, 2 radial angulation deformities and 1 radial rotation defor-mity. The deformities could be graded into 6 different types.CONCLUSION: The measurements of deformity made it possible to describe and classify isolated deformitiesand combinations of various deformities.

OBJECTIF : Mettre au point une meilleure façon de mesurer la déformation causée par une fracture de l’ex-trémité proximale de la phalange proximale de l’auriculaire chez les enfants.CONCEPTION : Étude de cas prospective.CONTEXTE : Hôpitaux régionaux dotés d’un service d’orthopédie.PATIENTS : Quarante-deux enfants qui ont subi une fracture de la phalange proximale de l’auriculaire et 42enfants qui n’ont pas subi de fracture de la phalange et qui ont servi de témoins. On a noté le type de dé-formation causée par la fracture et mesuré l’angle de la déviation. Les décalages en rotation ont été mesurésen clinique chez tous les patients et les déviations ont été mesurées à partir de radiographies. Les déforma-tions ont été cotées et classées.PRINCIPALES MESURES DES RÉSULTATS : Mesures de la déformation causée par la fracture avant et après lamanipulation.RÉSULTATS : On a constaté 38 déviations cubitales, 26 déviations dorsales, 10 décalages en rotation cu-bitale, 3 déviations palmaires, 2 déviations radiales et un décalage en rotation radiale. On a pu classer lesdéformations en 6 types différents.CONCLUSION : Les mesures de la déformation ont permis de décrire et de classer les déformations isolées etdes combinaisons de déformations diverses.

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CJS, Vol. 40, No. 5, October 1997 363

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Fractures of the base of the prox-imal phalanx are common inchildhood and result in angula-

tion and rotational deformities. Wor-lock and Stower1 described the causesof hand fractures in children as thosefrom falls, sports or fighting. Of thephalangeal fractures, the proximal pha-lanx was the one most commonly in-jured. The force causing fracture of theproximal phalangeal epiphysis was re-garded as torsional in nature. Leonardand Dubravcik2 reported failed closedreduction of a proximal epiphyseal frac-ture due to the interposition of soft tis-sue. The fracture was subsequently re-duced by open reduction and internalfixation with Kirschner wires. They didnot report any adverse effects such asinfection or premature closure. Hast-ings and Simmons3 immobilized thephalangeal fractures using an ulnar gut-ter or aluminum splint. Barton4 warnedreaders to be careful when assessingproximal phalangeal fractures since theangulation can easily be overlookedclinically because the fracture is nearthe metacarpophalangeal joint. Thereare no detailed reports in the literature

on the type of deformities caused byproximal phalangeal fractures.The purpose of this study was to

devise a method to measure and doc-ument deformities caused by a frac-ture of the proximal phalanx and touse the same method in the follow-upof the patients.

PATIENTS AND METHODS

Forty-two children (13 girls, 29boys) who presented to the emer-gency department of several regionalhospitals between 1992 and 1995 andhad fractures of the base of the proxi-mal phalanx and an unfused growthplate were studied. All children hadsustained a Salter–Harris type II injuryto the growth plate (Fig. 1). Themean age of the children was 9.1 years(range from 2 to 14 years). Another42 children with a mean age of 9.3years (range from 2 to 14 years) andno phalangeal fracture on anteropos-terior and lateral x-ray films were as-signed to the control group. Angula-tion and rotation were measured inthese children.

Fractures were treated by closed re-duction within 24 hours of injury. Af-ter fracture reduction, the childrenwere treated by strapping the little fin-ger to the ring finger. Fractures con-sidered unstable radiologically andclinically were also immobilized in avolar slab. One closed reduction failedafter two attempts: an open reductionand cross Kirschner-wire fixation wasdone; it was found that the fragmentof the metaphysis attached to thegrowth plate was long and pointedand was blocking the reduction. Thefingers were immobilized in radio-transparent splints with the metacar-pophalangeal joint in 70° to 80° offlexion5 for a mean period of 3 weeksbut not more than 5 weeks. All chil-dren were seen in the outpatient de-partment after 1 week. Follow-up an-teroposterior and lateral radiographswere obtained, and the children wereseen again at 2 weeks. In 37 children,the hand was then mobilized, afterfurther follow-up radiography and as-sessment. Four other children had thefinger immobilized in plaster of parisfor a further 2 weeks, by which timethe fracture had united successfully sothat the finger could be mobilized.The child whose fracture was fixedwith a Kirschner wire was broughtinto the hospital as a day case after 4weeks. The plaster and Kirschner wirewere removed and the little finger wasmobilized.

Measurement of deformity

Fracture angle

The fracture angle was measured onstandard anteroposterior and lateralfilms, with the x-ray tube approxi-mately 1 m from the hand. Abduction(ulnar angulation) and adduction (ra-dial angulation) were measured on astandard anteroposterior film. The de-formity was recorded by measuring the

SHUAIB

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364 JCC, Vol. 40, No 5, octobre 1997

FIG. 1. Salter–Harris type II fracture at the base of the proximal phalanx of the little finger with anabduction and dorsal angulation deformity.

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angulation from neutral in terms ofmovement of the line through the cen-tre of the shaft of the proximal pha-lanx, taking the line through the baseof the epiphysis as a reference (Fig. 2)to minimize the risk of an inaccuratereading due to small positional errorson the radiographs. In a patient withno angulation, this line usually runsthrough the centre of the shaft of thephalanx. Dorsal and palmar angula-tions were measured from a standardlateral radiograph by drawing a parallelline at the base of the proximal epiph-

ysis. A line was erected from the baseof the proximal epiphysis, usually pass-ing through the centre of the epiphysisand the shaft of the proximal phalanxin patients with no deformity.

Fracture rotation

Rotational deformity was measuredby sticking a tape to the base of thenail horizontally and putting the tip ofthe little finger opposite the 90° lineon a protractor (Fig. 3). A plastic clipwith a flat surface was attached to the

fingertip at the base of the nail snuglyand to the medial and lateral sides ofthe finger. A 3-cm rigid plastic tapewas attached horizontally to the up-per flat surface of the clip. This wasdone to minimize false-positive resultsbecause the surface of the nail is notflat. The angle of rotation was mea-sured in terms of movement of therigid tape in accordance with the typeof rotational deformity. To validatethe accuracy of the method used whenmeasuring the rotation deformity, alevel measuring device was used on 10patients in the control group who hadno fracture or deformity and no rota-tion of the nail on clinical examina-tion. The clip was mounted over thebase of the fingernail and attached tothe sides of the finger securely, thusobtaining a three-point contact withthe finger (surface of the base of thenail, medial and lateral borders of thefinger). The finger with the clip in situwas put on a flat table surface, and thelevel was put on the flat upper surfaceof the clip. The level confirmed thatthe flat surface of the clip was exactlyhorizontal (no rotation).

Fracture classification

The deformities were measured in

CHILDHOOD PHALANGEAL FRACTURE

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CJS, Vol. 40, No. 5, October 1997 365

FIG. 2. Diagram to show how angulation deformities were measured from standard anteroposteriorand lateral radiographs.

FIG. 3. Measuring the finger rotation with a rigidtape and a protractor.

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degrees with the hand in pronation.From these measurements it was pos-sible to devise a classification to de-scribe the deformities alone or in com-bination as follows: type I —abduction (ulnar angulation); type II— adduction (radial angulation); typeIII — dorsal angulation; type IV —palmar angulation; type V — ulnar ro-tation; type VI — radial rotation.

RESULTS

The mean, range and standard de-viation for each of the 6 types of de-formities, alone and in combination,are shown in Table I for the 42 chil-dren who had various phalangeal de-formities. The total number of defor-mities was greater than the number ofchildren because most of the deformi-ties occurred in combination.Two fractures slipped after 1 week.

Remanipulation was successful. Ulnarangulation was the most common de-formity followed by dorsal angulation,indicating that the forces producingthese fractures are directed in abduc-tion and dorsally. The position of thefinger at the time of injury is also im-portant. The fingers are abducted

when one is balancing or using thehand for support when falling down.This is a significant factor in produc-ing abduction and dorsal angulationdeformities in the little finger, whichhas no protection on the outside.The fracture that was fixed with a

Kirschner wire had a residual abduc-tion angulation of 12°, which was notnoticeable clinically. The child re-gained full movement. Children re-gain joint movement quickly, andjoint stiffness is not a common com-plication. All the patients regained fullmovement within 2 to 4 weeks aftermobilization.In 39 patients of the control group,

the angle of rotation was 0°. In 3 pa-tients, a mean ulnar rotation of 10.6°was noted, which was comparable bi-laterally. In 41 of the 42 patients inthe control group, the anatomic angleof the proximal phalanx was 90° (con-sidered as 0° of deformity). In 1 pa-tient, the adduction angle on the an-teroposterior film was 20°. There wasno history of injury to the finger.

DISCUSSION

Fracture of the little finger is com-

mon in children. Landin6 reportedthat fractures were the commonesthand injury in children and Worlockand Stower1 reported that they werethe second most common hand in-jury. The little finger is more vulnera-ble because it is a peripheral fingerwith no outside protection.According to Hastings and Sim-

mons,3 the incidence of the Salter–Harris type I epiphyseal injury is 7.4%.The Salter–Harris classification de-scribes various types of growth-plateinjuries effectively,7 but since many ofthe Salter–Harris type I injuries maynot have a wide separation of thegrowth plate and may go unnoticed,the percentage of these injuries re-ported by Hastings and Simmons maybe an underestimation. They reportedthe incidence of Salter–Harris type IIinjuries as 78.7% of all epiphyseal handinjuries.Epiphyseal fractures of the pha-

langes and fractures through themetaphysis are usually easy to reduce,and closed reduction with manipula-tion is recommended.8 According toBarton, if one attempt is not success-ful, further measures are not justifiedbecause remodelling corrects any de-formity in almost all the cases. In myexperience, adequate closed reductionof Salter–Harris type II fractures ofthe proximal phalanx is sometimes dif-ficult when a piece of metaphysis at-tached to the growth plate blocks thereduction. Failure of closed reductionhas also been reported by von Raffler9

because of the interposition of flexortendon at the fracture site. Open re-duction and internal fixation withKirschner wires is advisable in such asituation. Fracture fixation with oneor two fine Kirschner wires does notinterfere with the growth plates.However, multiple penetration of thegrowth plate with Kirschner wiresshould be avoided.These fractures should be immobi-

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366 JCC, Vol. 40, No 5, octobre 1997

Table I

3.5

16

11

5.6

16

Standarddeviation

Mean, Range and Standard Deviation of Deformities in 41 Children With Fracture of theProximal Phalanx of the Little Finger

Type of deformity

I — ulnar angulation. Incombination with DA, PA, RR, UR

II — radial angulation. Incombination with DA

III — dorsal angulation. Incombination with UA, RA

IV — palmar angulation. Incombination with UA

V — ulnar rotation. Incombination with UA 10

3

26

2

38

No. of deformities

28–38

12–44

15–60

20–28

6–72

Range, o

32

26

33

24

32

Mean, o

VI — radial rotation. Incombination with UA 1 22 22

DA = dorsal angulation, PA = palmar angulation, UA = ulnar angulation, RA = radial angulation, UR = ulnar rotation, RR = radial rotation

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lized in radiotransparent splints andslabs, because the fracture cannot beassessed properly when the finger is ina plaster of paris cast owing to inade-quate imaging. James10 recommendeda position to immobilize these frac-tures: the metacarpophalangeal jointsare flexed and the interphalangealjoints are extended. Each joint is im-mobilized in the opposite position tothat in which a contracture is likely todevelop.Full correction of these fractures is

sometimes difficult. After closed re-duction, the finger of one patient had16° of dorsal angulation and 3° of ul-nar rotation. Another had 14° of ab-duction angulation and 4° of ulnar ro-tation. One patient had a finger withulnar rotation of 10° and another wasleft with a residual abduction angle of7°. The fracture fixed with a Kirschnerwire healed with a residual abductionangle of 12°. All these patients re-gained full movement of their littlefingers without functional or cosmeticimpairment. An angle of angulation ofless than 20° does not result in impair-ment of function or movement and arotational deformity of less than 10°will not result in functional impair-ment or cosmetic deformity.In current practice, the rotation of

the finger resulting from a fracture isassessed clinically with no accuratemeasurement and documentation. It

would be helpful to standardize amethod for accurate scientific mea-surement of the deformities for eval -uating, treatment and follow-up.Therefore, a classification is neededfor phalangeal fractures in relation tovarious types of deformity occurringas a consequence of these fractures.The method described in this paperwas effective during follow-up becauseit detected small fracture displace-ments in four children (3°, 4°, 7° and10°) that were not detected clinically.It should be remembered that be-

cause the little finger is a peripheraldigit, excessive residual angulation willleave the finger with an abduction de-formity that may not be cosmeticallyacceptable and can result in functionalimpairment. Manipulation and correc-tion of a Salter–Harris type II fractureof the proximal phalanx of the littlefinger is usually not difficult. The sur-geon’s aim should be to attainanatomic reduction. Good anteropos-terior and lateral radiographs are essen-tial for proper radiologic assessment ofthese fractures. Inappropriate lateralviews can be misleading. It would beof benefit to design a device thatwould hold the hand in a desired posi-tion so as to avoid positional inaccura-cies during radiography. Clinical as-sessment and documentation of thesefractures is important in diagnosis, fol-low-up and medical communication.

References

1. Worlock PH, Stower MJ. The inci-dence and pattern of hand fracturesin children. J Hand Surg [Br] 1986;11 (2):198-200.

2. Leonard MH, Dubravcik P. Manage-ment of fractured fingers in the child.Clin Orthop 1970;73:160-8.

3. Hastings H 2d, Simmons BP. Handfractures in children. A statistical analy-sis. Clin Orthop 1984;188:120-30.

4. Barton NJ. Fractures of the hand. JBone Joint Surg [Br] 1984;66(2):159-67.

5. Mansoor IA. Fractures of the proxi-mal phalanx of fingers. A method ofreduction. J Bone Joint Surg [Am]1969;51(1):196-8.

6. Landin LA. Fracture patterns in chil-dren. Acta Orthop Scand 1983;54:suppl 202.

7. Salter RB, Harris WR. Injuries in-volving the epiphyseal plate. J BoneJoint Surg [Am] 1963;45:587-622.

8. Barton NJ. Fractures of the phalangesof the hand in children. Hand 1979;11(2):134-43.

9. von Raffler W. Irreducible juxta-epiphysial fracture of a finger. J BoneJoint Surg [Br] 1964;46:229.

10. James JI. The assessment and man-agement of the injured hand. Hand1970; 2(2):97-105.

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