A 13-year-old girl presents with left thumb pain after a tumbling injury during gymnastics. On examination, she has moderate swelling about the thumb without any noticeable deformity. Anteroposterior (AP) and lateral radiographs (Figures 1 and 2) demonstrate a Salter-Harris II fracture of the proximal phalanx of the left thumb with displacement. What is the best treatment option for this patient?
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The patient presents with a shortened unstable displaced proximal phalanx fracture of the left thumb. She was taken to the operating room for closed reduction and percutaneous pinning with crossing pins, one pin directed medial to lateral and the other lateral to medial. The thumb was immobilized postoperatively, and the pins were kept in for 4 weeks. Once bridging callus was seen at 4 weeks, the pins were removed.
Hand injuries are the most common orthopedic injuries in the pediatric population. Pediatric phalanx fractures are the second most common reason for emergency room visits for fractures in the United States. Salter II fractures are the most common type of fracture in the proximal phalanx. The phalangeal physes fuse in girls between 13 and 15 years of age and in boys between 14 and 16 years of age. The weakest point of the phalanx is the growth plate, which tends to become injured before the strong surrounding soft tissue and diaphyseal bone. True AP and lateral radiographs are essential in identifying any shortening or rotational deformity of phalanx fractures. Indications for surgery include > 10 degrees of angulation, > 2 mm of shortening, and any rotational deformity. Oblique fractures of the phalanx represent the most unstable fracture pattern. Closed reduction and percutaneous pinning is the preferred method of fracture fixation for displaced phalanx fractures.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Abzug JM, Dua K, Bauer AS, Cornwall R, Wyrick TO. Pediatric phalanx fractures. J Am Acad Orthop Surg. 2016;24:e174-e183.
- Blomberg J. Phalanx fractures. Available at: www.orthobullets.com (Accessed on April 24, 2018).