Operative Fractures of the Phalangeal Head and Neck in Children—Does Open Reduction Affect Outcomes?

Abstract

Background: 

Closed reduction percutaneous pinning of displaced pediatric phalangeal head and neck fractures is preferred to prevent malunion and loss of motion and function. However, open reduction is required for irreducible fractures and open injuries. We hypothesize that osteonecrosis is more common in open injuries than closed injuries that require either open reduction or closed reduction percutaneous pinning.

Methods: 

Retrospective chart review of 165 phalangeal head and neck fractures treated surgically with pin fixation at a single tertiary pediatric trauma center from 2007 to 2017. Fractures were stratified as open injuries (OI), closed injuries undergoing open reduction (COR), or closed injuries treated with closed reduction (CCR). The groups were compared using Pearson χ² tests and ANOVA. Two group comparisons were made with Student t test.

Results: 

There were 17 OI fractures, 14 COR fractures, and 136 CCR fractures. Crush injury was the predominant mechanism in OI versus COR and CCR groups. The average time from injury to surgery was 1.6 days for OI, 20.4 days for COR, and 10.4 days for CCR. The average follow-up was 86.5 days (range, 0 to 1204). The osteonecrosis rate differed between the OI versus COR and OI versus CCR groups (71% for OI, 7.1% for COR, and 1.5% for CCR). Rates of coronal malangulation >15 degrees differed between the OI and COR or CCR groups, but the 2 closed groups did not differ. Outcomes were defined using Al-Qattan’s system; CCR had the most excellent and fewest poor outcomes. One OI patient underwent partial finger amputation. One CCR patient had rotational malunion but declined derotational osteotomy.

Conclusions: 

Open phalangeal head and neck fractures have more concomitant digital injuries and postoperative complications compared with injuries closed on presentation, regardless of whether the fracture underwent open or closed reduction. Although osteonecrosis occurred in all 3 cohorts, it was most frequent in open injuries. This study allows surgeons to discuss rates of osteonecrosis and resultant complications with families whose child presents with phalangeal head and neck fractures that are indicated for surgical treatment.

Level of Evidence: 

Therapeutic, Level III.

Hand fractures are common in the pediatric population, comprising an estimated 15% of fractures seen in the emergency department, and of these fractures, most occur in the phalanges.^1–5 10 percent to 15% of pediatric phalangeal fractures are phalangeal head or neck sub-types.^2,5–9

Pediatric phalangeal neck fractures are described as inherently unstable with poor remodeling potential because they occur at the distal end of the phalanges, away from the physis.^10,11 Al-Qattan originally described and developed a classification and treatment algorithm for phalangeal neck fractures, with Type I being nondisplaced, Type II displaced with bony contact, and Type III displaced without any bony contact (Fig. 1). He recommended pin fixation for unstable, displaced Type II and all Type III fractures, with a strong preference for open reduction.¹⁰ Most displaced phalangeal head and neck fractures in children are treated with closed reduction and percutaneous pinning (CRPP), but if healing and early callus render closed reduction impossible, these fractures require anatomic reduction with either open or percutaneous osteoclasis and percutaneous pinning.^12,13 Additional indications for open reduction include failure of conservative treatment, unsuccessful closed reduction, and delayed presentation with impending malunion.^2,8

FIGURE 1: Illustration of Al-Qattan’s classification of types of phalangeal neck fractures. Reprinted from Injury, Vol 46, Al-Qattan, and Al-Qattan, “A review of phalangeal neck fractures in children, 935-944, Copyright (2015), with permission from Elsevier. Copyright [Al-Qattan and Al-Qattan]. All permission requests for this image should be made to the copyright holder.

Phalangeal head and neck fractures occur in a vascular watershed area of the bone, and disruptions of the blood supply are a concern for both closed versus open pinning procedures. Fortunately, avascular necrosis (AVN) is a rare complication following a phalangeal neck fracture.^9,14 Risk factors for AVN include open fractures, Al-Qattan type III fractures, open reduction of closed fractures, and multiple unskilled attempts at closed reduction.^9,10,14,15 The rate of AVN following either open or closed treatment of these pediatric fractures is currently unknown. We hypothesize that subjects with open injuries would display higher rates of osteonecrosis and poorer postsurgical outcomes than subjects with closed injuries requiring open reduction or those treated with CRPP.

MATERIALS AND METHODS

We performed a retrospective study of subjects who underwent open or closed surgical treatment of phalangeal head and neck fractures at a single pediatric tertiary referral center from 2007 to 2017. After institutional review board approval, we performed a manual chart review of all phalangeal fractures treated surgically. Cases were identified by ICD-9 and ICD-10 codes for phalangeal fractures. Inclusion criteria were subject age less than eighteen years, fracture pattern involving the phalangeal head or neck of the proximal or middle phalanx of the fingers or the proximal phalanx of the thumb. Patients were not excluded if there were other fractures or injuries. Subjects’ demographic data, mechanism of injury, operative reports, radiographs, associated injuries, and clinical course were recorded in a de-identified electronic database. Subjects presenting with open injuries (OI) were compared with patients who presented with closed injuries that required open reduction (COR) and closed injuries with closed reduction (CCR).

For the purposes of this study, AVN was defined as radiographic sclerosis and fragmentation of the phalangeal head. In addition, the fracture outcomes were measured with the Al-Qattan outcome scores, stiffness, range of motion (ROM), and coronal malangulation. Stiffness was defined as loss of motion, extensor lag, or contracture of at least 10 degrees. The ROM was categorized as excellent, good, fair, or poor according to the Al-Qattan classification. Coronal malangulation was defined as radiographic angulation of ≥10 degrees. The 3 groups were compared using Pearson χ² tests for categorical variables and ANOVA for continuous data. Two group comparisons were made with the Student t test with significance set to P<0.05. Additional analysis of the surgical outcomes was performed, grouping fractures by intra-articular versus extra-articular fractures using Pearson χ² tests.

RESULTS

One hundred sixty-five patients were identified. There were 17 OI in 16 patients, 14 COR fractures, and 136 CCR fractures. The mean age for the OI was 5.9 years; this was significantly younger than CCR (9.8 y) and COR groups (P<0.005, Table 1). The patients were predominantly male, with no statistically significant difference between groups (P>0.5).

TABLE 1 - Demographic, Presurgical and Follow-up Data

	CCR (n=136)	COR (n=14)	OI (Fractures, n=17. Patients, n=16)	OI vs. CCR	OI vs. COR	COR vs. CCR
Age, years (Range, SD)	9.8 (1-17, 4.21)	11.4 (4-16, 4.08)	5.9 (1-16, 4.40)	P<0.005	P<0.005	P=0.08
Male Sex, (%)	66.9	64.3	62.5	P=0.723	P=0.919	P=0.842
Mechanism, n (%)
Crush	25(19.2)	2 (15.4)	9 (56.3)	P<0.0005	P<0.005	P=0.704
Sport	103 (79.2)	11 (84.6)	1 (6.25)	P<0.0005	P<0.0005	P=0.813
Machines	2 (1.54)	0 (0)	3 (18.8)	P<0.0005	P=0.0720	P=0.648
Sharp	0 (0)	0 (0)	3 (18.8)	P<0.0005	P=0.0810	P>0.999
Unknown	6 (4.41)	1 (7.14)	0 (0)	P=0.387	P=0.256	P=0.644
Type of fracture, n (%)
Extra-articular (Subcondylar)	123 (90.4)	9 (64.3)	11 (64.7)	P<0.005	P=0.980	P<0.005
Intra-articular	12 (8.8)	5 (35.7)	6 (35.3)
Bi-condylar	4 (2.9)	4 (28.5)	3 (17.6)	P<0.05	P=0.469	P<0.0005
Unicondylar	8 (5.9)	1 (7.1)	3 (17.6)	P=0.078	P=0.385	P=0.856
Unknown	1 (0.7)	0 (0)	0 (0)	P<0.05		P<0.05
Laterality right, % Right	77 (56.6)	8 (57.1)	8 (47.1)	P=0.455	P=0.576	P=0.970
Finger distribution, n (%)
Thumb	6 (4.4)	0 (0)	2 (11.8)	P=0.200	P=0.185	P=0.423
Index	13 (9.6)	2 (14.2)	1 (5.9)	P=0.620	P=0.431	P=0.575
Middle	23 (16.9)	2 (14.2)	0 (0)	P=0.066	P=0.156	P=0.802
Ring	29 (21.3)	1 (7.1)	4 (23.5)	P=0.835	P=0.217	P=0.207
Small	65 (47.8)	9 (64.3)	10 (58.8)	P=0.391	P=0.756	P=0.240
Phalanx distribution, n (%)
P1	90 (66.2)	10 (71.4)	6 (35.3)	P<0.05	P=.0108	P=0.887
P2	46 (33.8)	4 (28.6)	11 (64.7)
Associated Injuries	1	3	15	P<0.0005	P<0.0005	P<0.05
Injury to surgery time, days (Range, SD)	10.41 (1-30, 5.78)	22.42 (3-76, 18.9)	1.625 (0-11, 2.66)	P<0.05	P<0.05	P<0.05
Follow-up length, days (Range, SD)	61.9 (23-229, 35.0)	147.6 (42-515, 122.2)	250.1 (49-1203, 318.7)	P<0.0001	P=0.133	P<0.0001

AVN indicates Avascular Necrosis; CCR, closed injury treated with closed reduction; COR, closed injury undergoing open reduction; OI, open injury.

Mechanisms of injury were classified as crushing, sports (low-energy blunt injuries including falls), machines, and sharp. Open injuries were more likely to be caused by a crush injury, while in the CCR and COR groups, sports injuries predominated. Intra-articular injuries, particularly bi-condylar fractures, were seen more frequently in the COR and OI groups (P<0.05) (Table 1).

OI subjects were operated on earlier than those in the COR or CCR group, even with 1 outlier in the OI group; this patient’s procedure was delayed until 11 days post-injury, following irrigation and primary closure at an outlying facility. In the COR group, 3 patients required open reduction of fractures that were irreducible by closed means (injury-surgery interval 3-5 d), while the remainder were able to be reduced by percutaneous osteoclasis (interval 12-76 d). Each group showed a statistically significant difference in the time to operation, with the OI group undergoing the soonest operation and the COR undergoing the latest (Table 1). Follow-up for all fractures averaged 86.5 days (range, 0 to 1203), with the OI group having the longest follow-up (250.1 d) and the CCR group the shortest (61.9 d).

Concomitant injuries were present in 15 of 16 OI subjects, consisting of 12 extensor tendon ruptures, 6 ipsidigital fractures, 3 digital nerve transections, 2 flexor tendon ruptures, and 1 vascular disruption requiring microsurgical repair. The COR group had 3 patients with concomitant injuries, 1 with a 90% partial rupture of the terminal extensor tendon and 2 patients with 2 P2 shaft fractures on other digits. The OI group was significantly more likely to have associated injuries than the COR or CCR group (P<0.0005).

Postoperatively, AVN was noted in 70.6% in the OI group, 7.1% in COR, and 1.5% in CCR (Table 2). The 1 fracture in the COR group with AVN was hit by a baseball. The 2 AVN patients in the CCR group sustained a crush injury and the other a fall, with the latter patient having complete radiographic remodeling of the digit over a period of 6 years. AVN was diagnosed at a mean time of 132 days from injury with a median time of 71 days (range, 28 to 608 d). However, there were 4 patients who did not return to the clinic after the pin pull and subsequently re-presented from 4 to 20 months after the initial injury due to deformity and stiffness. Without the 4 outliers, the mean time to radiographic AVN diagnosis was 60.5 days from injury with a median time of 61 days (range, 28 to 101).

TABLE 2 - Postoperative Outcomes

	CCR	COR	OI	OI vs CCR	OI vs COR	COR vs CCR
AVN, n (%)	2 (1.5)	1 (7.1)	12 (70.6)	P<0.0005	P<0.0005	P>0.05
Coronal malangulation, n (%)	3 (2.2)	0 (0)	5 (29.4)	P<0.0005	P=0.396	P<0.005
Stiffness, n (%)	24 (17.6)	8 (57.1)	11 (64.7)	P<0.0005	P<0.0005	P=0.400
Range of motion, n (%)	(120)	(12)	(15)	—	—	—
Excellent	111 (92.5)	3 (25.0)	4 (23.5)	P<0.0005	P=0.921	P<0.0005
Good	4 (3.3)	2 (16.7)	2 (11.7)	P=0.076	P=0.809	P<0.05
Fair	5 (4.2)	6 (50.0)	6 (35.3)	P<0.0005	P=0.414	P<0.0005
Poor	0 (0)	1 (8.3)	3 (17.6)	P<0.0005	P<0.05	P<0.0005
Mean total active motion (deg)	279	261	258	P<0.05	P=0.394	P<0.05
Al-Qattan Outcome, n (%)
Excellent	111 (81.6)	3 (21.4)	1 (5.88)	P<0.0005	P=0.141	P<0.0005
Good	15 (11.0)	3 (21.4)	1 (5.88)	P=0.513	P=0.198	P=0.254
Fair	7 (5.1)	4 (28.6)	2 (11.8)	P<0.005	P=0.842	P<0.005
Poor	3 (2.20)	4 (28.6)	13 (76.4)	P<0.0005	P<0.05	P<0.0005

AVN indicates Avascular Necrosis; CCR, closed injuries undergoing closed reduction; COR, closed injuries undergoing open reduction; OI, open injuries.

No significant coronal malangulation on the final follow-up x-rays for each patient was found in the COR group, but 3 (2.2%) patients in the CCR group and 5 (29.4%) patients in the OI group (P<0.05) had significant coronal malangulation.

Postoperative stiffness was noted in 64.7% and 57.1% of patients in OI and COR groups, respectively, versus only 17.1% in the CCR group (P<0.05, Table 2). Detailed ROM data was available for 15 fractures in OI group, 12 in COR group, and 120 fractures in the CCR group. Two patients in the OI group were excluded. One patient went on to amputation, and the other was noted to have limited ROM, but no measurements were available. Two fractures in the COR group were excluded due to a lack of measurements, but both were noted to have limited ROM. The exclusions in the CCR group included 9 patients who were referred to OT or started on a home exercise program due to concern for stiffness, but no measurements of ROM were made, 6 patients due to lack of data, but no complications were noted, 1 excluded due to reinjury, and another was referred for surgery for cascade-altering deformity. The total active motion was 279 degrees in the CCR group, 261 degrees in COR, and 257 degrees in OI. The CCR group had higher total active motion than the OI and COR groups, and there was no difference between the COR and OI group. Using the Al-Qattan ROM classification, the CCR group had more excellent and fewer good, fair, and poor ROM outcomes than both the OI and COR groups (Table 2).

Based on Al-Qattan’s classification, the CCR group had significantly more excellent results than both COR and OI groups (P<0.00050), with OI having significantly more poor results compared with COR and CCR (P<0.05) (Table 2). Among 13 patients with poor results in the OI group, 12 had AVN, 8 had significant stiffness, and 3 had residual deformity great enough to compromise function. Several patients had multiple issues that caused poor function. One patient with a proximal phalanx neck fracture and associated digital nerve, artery, and extensor mechanism injuries went on to undergo a partial finger amputation at the P1 level of the fracture after the failure of arterial repair 11 days postoperatively. No AVN of the bone was noted at the time of amputation. Another patient developed a nonunion that was asymptomatic. For the 2 poor results in the COR group, 1 was stiff at the PIP joint, and 1 had AVN. Of the CCR group’s poor results (3 patients) 2 had AVN, and the other had cascade-altering rotational deformity but ultimately declined corrective surgery. Three infections were reported; 2 in the OI group and 1 in CCR which all resolved with a 14-day course of Clindamycin.

There were a total of 142 extra-articular fractures, 23 intra-articular fractures, and 1 unknown without available injury radiographs. Intra-articular fractures showed a significantly higher rate of AVN (30.4% vs. 5.6%, P<0.0005) (Table 3). Stiffness was present in 19.7% of extra-articular versus 39.1% of intra-articular fractures (P<0.05). ROM data was available for 128 extra-articular and 19 intra-articular fractures. ROM was excellent in 85.2% of extra-articular and 47.4% of intra-articular fractures and fair in 7.0% of extra-articular and 42.1% of intra-articular fractures (P<0.05). No difference was seen between a good and poor range of motion outcomes for the 2 groups. Based on Al-Qattan’s classification of results, the extra-articular fractures had significantly more excellent results, and the intra-articular group had a greater proportion of poor results than the extra-articular group (P<0.005).

TABLE 3 - POSTOPERATIVE OUTCOMES Intra-articular Versus Extra-articular fractures

	Extra-articular (n=142)	Intra-articular (n=23)
AVN, n (%)	8 (5.6)	7 (30.4)	P<0.0005
Stiffness, n (%)	28 (19.7)	9 (39.1)	P<0.05
Range of motion, n (%)	128	19	—
Excellent	109 (85.2)	9 (47.4)	P<0.0005
Good	7 (5.5)	1 (5.3)	P=0.971
Fair	9 (7.0)	8 (42.1)	P<0.0005
Poor	3 (2.3)	1 (5.3)	P=0.465
Coronal malangulation, n (%)	5 (3.5)	3 (13.0)	P=0.054
Al-Qattan outcome, n (%)
Excellent	106 (81.6)	9 (21.4)	P<0.005
Good	16 (11.0)	3 (21.4)	P=0.786
Fair	10 (5.1)	3 (28.6)	P=0.311
Poor	12 (2.20)	8 (28.6)	P<0.0005

AVN indicates Avascular Necrosis.

DISCUSSION

Pediatric phalangeal neck fractures can be challenging to treat. Displaced fractures are often unstable, and the potential exists for nonunion and poor remodeling. Many authors recommend percutaneous pin fixation of these fractures with either open or closed reduction to reduce those risks.^10,12,13 Delayed presentation of these fractures provides additional challenges as a closed reduction may not be sufficient to achieve adequate alignment, and open reduction increases the risk for postoperative stiffness and other complications.

Two previous authors have described AVN complications as a result of open reduction.^10,14 To mitigate this risk, some surgeons avoid open treatment until no other alternative is viable. Waters et al¹⁶ described their treatment of 8 patients with percutaneous osteoclasis through the dorsal callus for malunions. They described good results with no cases of AVN. Nearly all reports discuss AVN in the setting of closed injuries with open treatment, and few reports exist regarding the rate after open injuries. Our results show that opening the fracture either surgically or at the time of injury increases the postoperative risk of AVN compared with closed treatment. The OI and COR study groups had higher proportions of high energy mechanisms, including crush injuries and concomitant injuries, than the CCR group. This supports that the differences in outcomes are related to the higher amount of initial trauma that each finger sustains. Soft tissue injury from the initial mechanism as well as the surgical procedure, increases the risk for stiffness and less than optimal range of motion postprocedure. In addition, open treatment was more likely to be required for fractures that were intra-articular, as they are often more difficult to treat and involve smaller bone fragments which may be more vulnerable to vascular compromise. Our data supports this, as intra-articular fractures demonstrated a higher rate of AVN than extra-articular fractures. Fractures of the joint surface may also comprise the motion of the joint. Parents of patients with open injuries, intra-articular fractures, and fractures that may require open reduction should be counselled appropriately to the increased risk of AVN of their child’s fracture and increased likelihood of a less than the excellent outcome.

Limitations of this study include its retrospective nature, short follow-up period (as is typical for postoperative uncomplicated CRPP of finger fractures), lack of detailed OT notes, and small group sizes of the OI and COR cohorts. With longer follow-up and/or OT, many patients with stiffness may have achieved a full ROM. In addition, disruption to the blood supply to the phalangeal head may occur after aggressive open reduction or open trauma, but we were not able to prove conclusively, which was the culprit for open fractures that had an open reduction. Given the short duration of follow-up for the CCR group compared with the COR and OI groups, leading to follow-up bias, we may have been able to detect more AVN in the CCR group with a longer duration of follow-up, while the increased duration of follow-up and increased injury severity may have led to the increased rate of detection in the OI group. Time to the identification of AVN was also subject to follow-up bias due to the 4 patients who failed to return for routine follow-up until months to years after injury, but for those who returned to the clinic as scheduled, both mean and median time for radiographic identification of AVN were 61 days from injury, leading the authors to believe that AVN may be identified much earlier than we had previously assumed.

It remains unclear how much remodeling potential phalangeal neck fractures in patients with residual malangulation or AVN possess. We had 1 patient with AVN who demonstrated excellent remodeling after 6 years. In addition, Cornwall et al¹⁷ presented a case report of a 5-year-old child with near complete remodeling of a proximal phalangeal neck fracture malunion with an excellent final ROM and function as did Hennrikus and Cohen¹⁸ in 3 late presenting phalangeal neck fractures in 2 children. Puckett and colleagues retrospectively reviewed 8 patients with displaced and angulated pediatric phalangeal neck fracture malunions treated without surgery. All patients went on to union with significant remodeling and no functional loss of motion.¹⁹ Although these reports have small numbers, they support the potential for continued remodeling in skeletally immature, displaced pediatric phalangeal neck fractures with advanced healing rather than risk AVN and stiffness after open reduction.

CONCLUSION

Pediatric phalangeal head and neck fractures presenting as open injuries or requiring open reduction have increased postoperative risks of stiffness, AVN, and overall less favorable outcomes compared with fractures with closed reduction and pin fixation. Parents should be counselled appropriately for these risks.