Keywords Phalanx fracture - rotational sequelae - pediatric hand - metacarpal osteotomy - endomedullar
screw
Introduction
Although most hand fractures in pediatric patients are candidates for closed reduction
and orthopedic treatment, some cases require surgery for anatomical reduction, stabilization,
and normal function. Open physes allow the hand surgeon to accept some displacement
of the fracture lines and still achieve excellent long-term function. However, it
is also true that growth potential can give a false idea of security and comfort when
treating these injuries in children. Bones have good remodeling potential when the
displacement is in the same plane of movement in fractures close to the physis and
younger subjects, who have more time to remodel.[1 ] There is little information on protocols for acceptable and unacceptable deformities.[2 ] Rotational deformities are usually an indication for surgical treatment.[2 ]
[3 ] Phalangeal and metacarpal fractures in pediatric patients require a differential
approach compared to adults due to the growth cartilage, the small size of their structures,
a thick periosteum, and the remodeling potential.
Fortunately, phalangeal rotational sequelae in pediatric patients are rare, and their
treatment may involve a corrective osteotomy of the affected bone. The ideal treatment
must correct the rotational defect, spare the growth cartilage and its growth potential,
avoid extensive scars, and provide a more comfortable postoperative period with no
nail removal.
Hand surgeons increasingly use endomedullary screws. The benefits of these screws
include low morbidity, minimal incisions, small dissection, lower tendon manipulation,
and deperiostization. Their uses in hands from pediatric patients include wrist injuries[4 ]
[5 ]
[6 ] and metacarpal fractures[2 ] in subjects with closed physes but not in metacarpals with open physes or rotational
sequelae of phalangeal fractures.
We present the case of an 11-year-old patient with rotational sequelae from a subcondylar
fracture of the proximal phalanx of the fifth finger of the dominant hand. We performed
a derotation osteotomy of the fifth metacarpal and stabilization with a headless endomedullary
screw for defect correction.
Case Report
Right-handed 11-year-old female patient. She had a closed subcondylar fracture of
the first phalanx of the fifth finger of the right hand. The medical history reported
no angulation or rotational deformity. The patient opted for orthopedic treatment
for four weeks. The patient returned to the clinic two months after the initial consultation
and orthopedic treatment removal with external 25°-rotational sequelae of the fifth
finger of the dominant hand ([Fig. 1 ]). She reported functional alteration but no pain.
Fig. 1 Rotational alteration of the 5th finger and front and profile radiographs.
Under general anesthesia and using a pneumatic cuff, we performed a small (1.5 cm)
incision on the dorsoulnar sector of the fifth metacarpal. We dissected the area between
the common extensor tendon of the fifth finger and the extensor digitorum muscle until
we reached the periosteum. After minimal deperiostization, we performed a transverse
osteotomy with an electric saw ([Fig. 2 ]). We clinically confirmed the rotational deformity correction per nail parallelism
and digital cascade.
Fig. 2 Illustration shows topography of osteotomy in reference to physis. Intraoperative
image with osteotomy and approach on the back of the hand.
From the focus, in a retrograde manner, we passed the guide proximally until it emerged
at the base of the metacarpal bone ([Fig. 3 ]). Next, we passed the guide nail anterogradely through the distal fragment without
reaching the physis ([Fig. 4 ]). We used a 32-mm long, 3.0 self-drilling endomedullary screw (Synthes) with a short
thread in an anterograde manner without reaching the physis ([Fig. 5 ]). We verified the correct digital alignment again, observing adequate digital cascade
in static position ([Fig. 6 ]) and tenodesic maneuvers. We infiltrated 0.25% bupivacaine in the ulnar nerve and
performed wound closure with a monofilament absorbable suture. Before placing the
antebrachial digit splint, we proceeded to fourth and fifth finger syndactylization.
Fig. 3 Illustration shows retrograde placement of the nail through the osteotomy site. The
maneuver is visualized in the intraoperative image.
Fig. 4 Maneuver to reduce rotational alteration by counteracting sequelae. Subsequently,
the nail is passed anterogradely without reaching the physis.
Fig. 5 Illustration of final result and position of the intramedullary screw together with
intraoperative fluoroscopy. Note that the screw does not reach the physis.
Fig. 6 Immediate postoperative period after reduction and stabilization with intramedullary
screw.
The patient remained with the splint for a week and continued with the fourth and
fifth fingers in syndactyly for a month. Her subsequent evolution was good, with rotational
defect correction and no stiffness or pain. She reported the resolution of the previous
functional limitation and had no infections or other complications. ([Fig. 7 a, b, c ], and [d ])
Fig. 7 Final functional result and radiography. Correction of the rotational defect is evident.
Discussion
This work is the first report on correcting rotational sequelae of a phalanx fracture
through a metacarpal derotation osteotomy and stabilization with an endomedullary
self-drilling screw.
The remodeling potential of neck fractures of the proximal and middle phalanges is
higher than previously believed. Notwithstanding, rotational or coronal alterations
>15° or patients with less than a year of bone growth potential require surgery.[2 ]
Kebrle and Schmoranzova describe good outcomes in 13 pediatric patients undergoing
phalangeal and metacarpal osteotomies who, after the initial orthopedic treatment,
presented malunion. These authors reported that they did not perform posterior osteosynthesis
in three patients and four osteotomies; however, they did not describe the type of
osteosynthesis performed in the remaining patients[7 ] or sequelae.
Phalangeal corrective osteotomies are technically very demanding. These procedures
require tenotomy of the extensor apparatus and extensive detachment with the consequent
risk of producing scars and stiffness. Furthermore, it may be difficult to recognize
the fracture line, especially in pediatric patients, due to its consolidation characteristics.
In subcondylar fractures, corrective osteotomies have a high risk of condylar osteonecrosis
resulting from poor vascularization.[8 ] Wecksser was the first to publish a metacarpal osteotomy to correct a phalangeal
rotational deformity.[9 ] This technique has demonstrated good outcomes in rotational sequelae of the middle
and proximal phalanges in adult and pediatric patients.[10 ]
[11 ] he advantage of using the metacarpal bones for deformity correction lies in its
technical lower complexity resulting from less tendon dissection and manipulation,
fewer adhesions, and a lower tendency to delayed consolidation. In addition, metacarpophalangeal
joint rotation does not hinder a good functional outcome.[12 ]
Berthold et al. described a technique for measuring the rotation degrees of the long
fingers using computed tomography. Although these authors concluded that this was
a reproducible and accurate study, it employed adult cadavers. Moreover, it involved
radiation and required strict positioning, often difficult to achieve in children
without general anesthesia or sedation. Yet, the authors mentioned not only interindividual
variability but also interindividual variability between both hands. We did not find
similar studies in pediatric patients, and we infer that its implementation is more
complex due to the age-related variability of the bone skeleton, the importance of
reducing irradiation at early ages, and considering the significance of the clinical
picture of the patient with the dynamic intraoperatively examination.[13 ]
Two authors reported good outcomes post-osteotomy: Kebrle et al., with orthopedic
treatment,[7 ] nd Bindra et al., after fixation with plates and screws.[8 ] Each fixation method has its advantages and disadvantages, and its selection relies
on the analysis of each clinical case. Endomedullary screws avoid the greater deperiostization
required for plate and screw placement and result in minimal scars and early mobilization.
In addition, they do not require nail removal, which is a traumatic event for children
is still a traumatic event.
Although articular cartilage damage was a concern soon after endomedullary screw introduction,
several papers minimize this injury.[14 ] To date, there are no long-term studies published attributing this technique to
metacarpophalangeal osteoarthritis.[15 ] The anterograde use of the screw avoided physeal injury rather than the eventual
articular cartilage damage. When treating acute fractures and their sequelae, it is
paramount to avoid injury and address the physis. This is not feasible in all cases.
On these occasions, instruments of the smallest possible caliber and with no thread
are preferred to reduce the potential for injury.[16 ] In our clinical case, the screw had commercial measurements, and we would have selected
one with a smaller diameter. We cannot ensure this technique does not compromise metacarpal
growth until bone maturity. Even so, we believe there will be no bone growth delay
because of the antegrade screw placement and physeal sparing. The patient will undergo
clinical and radiological follow-up semiannually in the first year and, if possible,
annually until bone maturity.
Proximal phalangeal malrotation correction through metacarpal rotation positions the
metacarpophalangeal joint relatively rotated compared to its peers. Clinically, this
procedure did not result in a functional deficit in our patient.
As disadvantages, this technique is difficult to implement in the central metacarpal
bones due to the anterograde placement of the screw since retrograde placement would
imply its passage through the physis. In addition, the nail guide and the screw could
have been placed exclusively in a retrograde and anterograde manner, respectively.
However, the entry through the central metacarpal bones is more complex compared with
the radial and ulnar edges. Proximal phalangeal and fifth finger fractures are among
the most frequent in the pediatric population.[17 ]
[18 ]
[19 ] Therefore, we believe this technique must be within the therapeutic arsenal of a
pediatric hand surgeon.
This work received no funding.
