Pediatric emergency medicine trisk 839

FIGURE 109.10 Radiographs of a displaced small finger proximal phalangeal neck fracture Note the relatively subtle and benign radiographic appearance on the anteroposterior view (A ) Fracture displacement is best seen on a dedicated lateral view (B ) as well as on oblique projections of the small finger (C ) (Courtesy of Children’s Orthopaedic Surgery Foundation.) FIGURE 109.11 Anteroposterior radiograph depicting an intra-articular fracture of the head of the small finger proximal phalanx involving the radial condyle (Courtesy of Children’s Orthopaedic Surgery Foundation.) FIGURE 109.12 Radiograph depicting complex dislocation of the thumb metacarpophalangeal joint (Courtesy of Children’s Orthopaedic Surgery Foundation.) Rapidity of relocation is particularly important when there is any concern regarding the neurovascular status Following relocation, these injuries should be splinted to maintain stability until reevaluation METACARPALS CLINICAL PEARLS AND PITFALLS Metacarpal fractures can occur at the base, shaft, or neck of the bone, with the neck of the 5th metacarpal being the most common The amount of fracture angulation allowed in metacarpal neck fractures increases across the metacarpals, from 10 to 20 degrees for the index finger up to 40 degrees for the small finger Clinical Considerations Clinical Recognition Injuries to the metacarpals include fractures and dislocations of the MCP joint Carpometacarpal joint dislocation is rare in children, although such a dislocation may coexist with another injury The metacarpals may be fractured at the base, shaft, or neck These injuries often occur from crushing trauma in younger patients as well as from impact along the axis of the bones, such as in punching or falling in older children and adolescents Compartment syndrome in the hand can occur, particularly with multiple fractures and crush injury, thus careful physical examination and appropriate suspicion are required Initial Assessment and Management The most common metacarpal fracture occurs at the neck of the bone, with the majority involving the small finger (the boxer’s fracture) ( Fig 109.13 ) Inspection for rotational displacement of the fracture is again important, as is close attention to evidence of skin trauma that might indicate contamination from an opponent’s mouth during a fight Any open wound with exposure to human oral secretions requires antibiotic prophylaxis as well as consideration of formal irrigation and debridement, as these wounds are associated with high rates of infection A considerable amount of angulation of the fracture can be tolerated without limiting ultimate hand function The amount of angulation allowed increases across the metacarpals, from 10 to 20 degrees for the index finger up to 40 degrees for the small finger Closed reduction is often all that is needed in fractures that exceed the tolerable amount of angulation, except in unstable fractures Metacarpal shaft fractures are uncommon in the pediatric population When they occur, they tend to involve the middle, ring, and small fingers They are most often spiral in nature, indicating a rotational component to the injuring force Careful attention to the alignment of the fingers when making a fist may demonstrate subtle rotational deformity (see Fig 109.1 for clinical presentation of rotational deformity) These injuries also result in significant edema, but ... amount of angulation, except in unstable fractures Metacarpal shaft fractures are uncommon in the pediatric population When they occur, they tend to involve the middle, ring, and small fingers They