Pediatric emergency medicine trisk 3345 3345
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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.
