LETTERS TO THE EDITOR
2345
Letter Regarding “A Stepwise Algorithm for Surgical Treatment of Type II Displaced Pediatric Phalangeal Neck Fractures” To the Editor: We read with great interest the article by Matzon and Cornwall.1 The authors used an algorithm to treat 61 consecutive children with type II displaced phalangeal neck fractures. Although 49 patients in the authors’ series were successfully treated with closed reduction, 12 patients required percutaneous reduction using an intrafocal technique with or without percutaneous osteoclasis. Fixation was then completed using 1 or 2 wires placed retrograde in a crossed pattern (transverse fractures), or in a parallel or divergent configuration (oblique fractures). We have found an additional reduction technique to be helpful in type II phalangeal neck fractures. The steps of this technique are demonstrated by a case (Fig. 1). First, a 0.7-mm (0.028-in) or 0.9-mm (0.035in) Kirschner wire is advanced from the fingertip,
through the distal phalanx intramedullary canal, across the extended distal interphalangeal (DIP) joint and the physis of the middle phalanx (Fig. 1A). The proximal interphalangeal (PIP) joint is then hyperextended sufficiently to bring the articular surfaces of the PIP joint into complete extension (Fig. 1B). The pin is advanced across the joint into the condylar segment. Next, the segment stabilized by the pin is brought into anatomic alignment with the shaft of the proximal phalanx using the pin as a joystick (Fig. 1C). Once reduction has been confirmed fluoroscopically, the pin is advanced into the shaft of the phalanx (Fig. 1D). A supplementary intramedullary pin can be added for rotational stability. Wires are removed in the office after 3 or 4 weeks. When the fracture involves the neck of the middle phalanx, an analogous procedure is used; the
FIGURE 1: Intraoperative fluoroscopic images demonstrating our preferred technique to reduce and pin an unstable proximal phalanx neck fracture. A A Kirschner wire is passed from distal to proximal to the physis of the middle phalanx. B The joint is hyperextended to align the articular segments. C The pin is advanced across the PIP joint into the fractured condylar fragment. This stabilized segment is reduced with the shaft of the proximal phalanx using the pin as a joystick. D After the reduction is confirmed, the pin is advanced into the shaft of the proximal phalanx. A second wire is placed for additional stability.
J Hand Surg Am.
r
Vol. 39, November 2014
2346
LETTERS TO THE EDITOR
pin is advanced across the distal phalanx and DIP joint, the fracture is reduced utilizing DIP hyperextension, and the pin is advanced into the middle phalanx. Potential risks of this technique include degenerative arthrosis due to violation of the uninjured joint and growth arrest due to fixation across the physis. These complications have not been reported in other series that use similar intramedullary techniques.2,3 Matthew E. Hiro, MD Terry R. Light, MD Department of Orthopaedic Surgery and Rehabilitation Loyola University Chicago Maywood, IL http://dx.doi.org/10.1016/j.jhsa.2014.07.057 REFERENCES 1. Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II displaced pediatric phalangeal neck fractures. J Hand Surg Am. 2014;39(3):467e473. 2. Leonard MH, Dubravcik P. Management of fractured fingers in the child. Clin Orthop Relat Res. 1970;73:160e168. 3. Karl JW, White NJ, Strauch RJ. Percutaneous reduction and fixation of displaced phalangeal neck fractures in children. J Pediatr Orthop. 2012;32(2):156e161.
In Reply: The authors describe a clever means of reducing and stabilizing type II phalangeal neck fractures in children. I am familiar with this technique and agree that it can be successful in acute, displaced fractures, although I have concerns that make me hesitant to adopt it. First, as the authors point out, a single intramedullary pin does not provide rotational control, and as many of these fractures are rotationally displaced, a second interfragmentary pin is still required. Second,
the pinning technique violates uninjured bones and joints, as again the authors point out. This concern is especially important for proximal phalanx neck fractures, as it can be difficult to traverse the distal and middle phalanges in a small digit with a single pin on the first attempt. Third, I find it difficult to accurately assess the angulation of the fracture in its displaced position, making it difficult to hyperextend the adjacent joint the correct amount to allow subsequent anatomic reduction of the fracture with return of the adjacent joint to a safe position of flexion/extension. Finally, this technique does not address the problem of a nascent malunion, as it cannot be used to disrupt the callus that prevents reduction in the late presenting fracture. In our article,1 we describe an algorithm for displaced type II phalangeal neck fractures, regardless of the time from injury to presentation. We recognize that many techniques of closed, percutaneous, and open reduction exist. We simply attempted to position each category of reduction technique in a stepwise algorithm to aid in surgical decision making. The presently described technique can certainly be considered when the fracture is amenable to closed reduction, although objectively analyzed results of its use would be welcomed in the peer-reviewed literature. Roger Cornwall, MD Division of Orthopaedic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, OH http://dx.doi.org/10.1016/j.jhsa.2014.07.055 REFERENCE 1. Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II displaced pediatric phalangeal neck fractures. J Hand Surg Am. 2014;39(3):467e473.
Gentle Manual Reduction for Traumatic Bowing/Plastic Deformation of the Ulna With Radial Head Dislocation To the Editor: Traumatic bowing is a child-specific fracture pattern. Pediatric bone absorbs considerably more energy before failure than adult bone1 and a slowly applied longitudinal force bends immature bone into its plastic zone, resulting in traumatic bowing.2,3 Traumatic bowing that causes a cosmetically or functionally unacceptable angular deformity4 must be manipulated by a strong J Hand Surg Am.
r
(20- to 30-kg) gradual force applied over 2 to 3 minutes to attain acceptable alignment.5 Reductive pressure applied over a rolled towel, block, or surgeon’s knee followed by a 3-point molded cast can substantially correct the deformity. Direct pressure over the adjacent epiphyses is avoided to prevent physeal fracture. Because this procedure is painful, general anesthesia or deep sedation is required. As a gentler Vol. 39, November 2014
2345
Letter Regarding “A Stepwise Algorithm for Surgical Treatment of Type II Displaced Pediatric Phalangeal Neck Fractures” To the Editor: We read with great interest the article by Matzon and Cornwall.1 The authors used an algorithm to treat 61 consecutive children with type II displaced phalangeal neck fractures. Although 49 patients in the authors’ series were successfully treated with closed reduction, 12 patients required percutaneous reduction using an intrafocal technique with or without percutaneous osteoclasis. Fixation was then completed using 1 or 2 wires placed retrograde in a crossed pattern (transverse fractures), or in a parallel or divergent configuration (oblique fractures). We have found an additional reduction technique to be helpful in type II phalangeal neck fractures. The steps of this technique are demonstrated by a case (Fig. 1). First, a 0.7-mm (0.028-in) or 0.9-mm (0.035in) Kirschner wire is advanced from the fingertip,
through the distal phalanx intramedullary canal, across the extended distal interphalangeal (DIP) joint and the physis of the middle phalanx (Fig. 1A). The proximal interphalangeal (PIP) joint is then hyperextended sufficiently to bring the articular surfaces of the PIP joint into complete extension (Fig. 1B). The pin is advanced across the joint into the condylar segment. Next, the segment stabilized by the pin is brought into anatomic alignment with the shaft of the proximal phalanx using the pin as a joystick (Fig. 1C). Once reduction has been confirmed fluoroscopically, the pin is advanced into the shaft of the phalanx (Fig. 1D). A supplementary intramedullary pin can be added for rotational stability. Wires are removed in the office after 3 or 4 weeks. When the fracture involves the neck of the middle phalanx, an analogous procedure is used; the
FIGURE 1: Intraoperative fluoroscopic images demonstrating our preferred technique to reduce and pin an unstable proximal phalanx neck fracture. A A Kirschner wire is passed from distal to proximal to the physis of the middle phalanx. B The joint is hyperextended to align the articular segments. C The pin is advanced across the PIP joint into the fractured condylar fragment. This stabilized segment is reduced with the shaft of the proximal phalanx using the pin as a joystick. D After the reduction is confirmed, the pin is advanced into the shaft of the proximal phalanx. A second wire is placed for additional stability.
J Hand Surg Am.
r
Vol. 39, November 2014
2346
LETTERS TO THE EDITOR
pin is advanced across the distal phalanx and DIP joint, the fracture is reduced utilizing DIP hyperextension, and the pin is advanced into the middle phalanx. Potential risks of this technique include degenerative arthrosis due to violation of the uninjured joint and growth arrest due to fixation across the physis. These complications have not been reported in other series that use similar intramedullary techniques.2,3 Matthew E. Hiro, MD Terry R. Light, MD Department of Orthopaedic Surgery and Rehabilitation Loyola University Chicago Maywood, IL http://dx.doi.org/10.1016/j.jhsa.2014.07.057 REFERENCES 1. Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II displaced pediatric phalangeal neck fractures. J Hand Surg Am. 2014;39(3):467e473. 2. Leonard MH, Dubravcik P. Management of fractured fingers in the child. Clin Orthop Relat Res. 1970;73:160e168. 3. Karl JW, White NJ, Strauch RJ. Percutaneous reduction and fixation of displaced phalangeal neck fractures in children. J Pediatr Orthop. 2012;32(2):156e161.
In Reply: The authors describe a clever means of reducing and stabilizing type II phalangeal neck fractures in children. I am familiar with this technique and agree that it can be successful in acute, displaced fractures, although I have concerns that make me hesitant to adopt it. First, as the authors point out, a single intramedullary pin does not provide rotational control, and as many of these fractures are rotationally displaced, a second interfragmentary pin is still required. Second,
the pinning technique violates uninjured bones and joints, as again the authors point out. This concern is especially important for proximal phalanx neck fractures, as it can be difficult to traverse the distal and middle phalanges in a small digit with a single pin on the first attempt. Third, I find it difficult to accurately assess the angulation of the fracture in its displaced position, making it difficult to hyperextend the adjacent joint the correct amount to allow subsequent anatomic reduction of the fracture with return of the adjacent joint to a safe position of flexion/extension. Finally, this technique does not address the problem of a nascent malunion, as it cannot be used to disrupt the callus that prevents reduction in the late presenting fracture. In our article,1 we describe an algorithm for displaced type II phalangeal neck fractures, regardless of the time from injury to presentation. We recognize that many techniques of closed, percutaneous, and open reduction exist. We simply attempted to position each category of reduction technique in a stepwise algorithm to aid in surgical decision making. The presently described technique can certainly be considered when the fracture is amenable to closed reduction, although objectively analyzed results of its use would be welcomed in the peer-reviewed literature. Roger Cornwall, MD Division of Orthopaedic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, OH http://dx.doi.org/10.1016/j.jhsa.2014.07.055 REFERENCE 1. Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II displaced pediatric phalangeal neck fractures. J Hand Surg Am. 2014;39(3):467e473.
Gentle Manual Reduction for Traumatic Bowing/Plastic Deformation of the Ulna With Radial Head Dislocation To the Editor: Traumatic bowing is a child-specific fracture pattern. Pediatric bone absorbs considerably more energy before failure than adult bone1 and a slowly applied longitudinal force bends immature bone into its plastic zone, resulting in traumatic bowing.2,3 Traumatic bowing that causes a cosmetically or functionally unacceptable angular deformity4 must be manipulated by a strong J Hand Surg Am.
r
(20- to 30-kg) gradual force applied over 2 to 3 minutes to attain acceptable alignment.5 Reductive pressure applied over a rolled towel, block, or surgeon’s knee followed by a 3-point molded cast can substantially correct the deformity. Direct pressure over the adjacent epiphyses is avoided to prevent physeal fracture. Because this procedure is painful, general anesthesia or deep sedation is required. As a gentler Vol. 39, November 2014
