Pediatric Hand Trauma

Jesús Valencia, MD; Francisco Leyva, MD; and Gregorio J. Gomez-Bajo, MD

Hand injuries in infants are an exciting challenge for thosewho treat pediatric trauma patients. We will review differenthand injuries and provide basic rules for their treatment andfollowup. We will compare our experience with publishedresults. When compared with adults, two main differencesarise in treatment of pediatric hand injuries: children havean exceptional regenerative ability that allows procedures tobe used that would not be useful in older patients (eg, re-plantation after avulsion injuries) and children have a highdegree of cooperation with physicians. The main goal oftreatment should be to have children return quickly to theirdaily leisure and academic activities.

A review42 relevant to the psychiatry of injuries in chil-dren noted that “hand injuries are common and loss of adominant hand or opposition is most important [sic]. Selfesteem and skill are associated with hand sensation, ap-pearance, and functions.” Hand and upper limb injuriesrepresent a high percentage of total injuries during child-hood (Table 1).15,19,30,36 The aim of the current study is toreview recent data from the literature in order to establishmain features about infant hand trauma and to comparethem with our experience in an urban university hospital.

FracturesLifestyle changes between the 1950s and 1970s increaseda child’s risk for having a hand injury. From the 1970s tothe present, this increase has stabilized because of preven-tative measures. Fractures occur more often in boys than ingirls, and this difference increases with increasing age.Age distribution follows a bimodal path with an incidence-peak between 1 and 2 years of age when distal phalanx

fracture associated with soft tissue laceration is the mostfrequent hand injury. The second highest incidence peak isat 12 years of age when the fifth finger proximal phalanxType-II epiphysiolysis is generally the most frequent le-sion, followed by metacarpal fractures.19 We reviewed thetreatment of children younger than 14 years who had frac-tures and were treated in the emergency room of our in-stitution between 1993 and 2002 (Table 2).

Our data (Table 2) contrast with those published byFetter-Zarzeka and Joseph,15 who found that the thumbwas the most frequently involved digit in their series.When analyzing the mechanism of injury, our results andresults from the literature are similar; boys younger than 6years are more likely to be injured at home and childrenbetween 6 and 14 years are more likely to be injured whenplaying sports.

Children’s bones have different characteristics fromadult bones and this makes fractures in children differentfrom fractures in adults. One difference is a thick perios-teum in children that allows less movement of bone frag-ments and induces an intense osteogenesis. This leads tofaster consolidation of fractures and infrequent nonunions.Another difference is the presence of a physis or growthplate where fractures are more frequently involved, spe-cifically in the hypertrophy area.

We usually prefer closed immobilization for 3 weeksand typically obtain excellent results and no bone growthdisturbances. Nevertheless, these injuries should not beunderestimated.19,30,35,51 Fractures that need surgicaltreatment comprise from 10 to 20% of pediatric fractures.In our series, only 2.5% (n � 321) of pediatric fracturesneeded surgical treatment. Indications for surgery in chil-dren do not differ from those indications for surgery inadults. After reduction, the hand should be functionallypositioned. Since children do not follow splint recommen-dations very carefully, strict immobilization should be ob-tained for the necessary time period because stiffness doesnot represent a serious problem in children.

One can accept greater angulation of metaphysis frac-tures than in adults because they are in the motion plane.Rotations should be corrected carefully. This can be as-sessed clinically through observation of rotational posi-

From the Plastic Surgery Department and Hand Surgery Unit, La Paz Uni-versity Hospital, Madrid, Spain.Each author certifies that he or she has no commercial associations (eg,consultancies, stock ownership, equity interest, patent/licensing arrange-ments, etc) that might pose a conflict of interest in connection with thesubmitted article.Correspondence to: Gregorio J. Gomez-Bajo MD, Calle Albarracin 4, 28224Pozuelo de Alarcon, Madrid, Spain. Phone: 34913524319; Fax:34913524319; E-mail: ggomezb@terra.es.DOI: 10.1097/01.blo.0000155376.88317.b7

CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 432, pp. 77–86© 2005 Lippincott Williams & Wilkins

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tions of adjacent fingernails and radiographically throughthe joint images and double-condyle sign.

Carpal FracturesScaphoid fracture, although infrequent, is the most com-mon carpal fracture in children and most often occursthrough the distal pole.27 As in adults, radiographic diag-nosis is not very accurate. Because of this, immobilizationfor 10 days is recommended when these injuries are sus-pected and until new radiographs are taken.9 Treatmentusually consists of immobilization that includes the fore-arm and palm and specifically the thumb for a 4-week to8-week period. Functional prognosis is good and compli-cation incidence is low. Fractures of the scaphoid bone inchildren are similar to those in adults. Established pseud-arthrosis in children should be treated as it is treated inadults.

Fractures of the Metacarpals and PhalangesDifferent fractures of these bones follow a different patternin children than in adults. The most notable lesions aredistal phalanx fracture, neck fractures of the phalanges,condylar fractures, and epiphysiolysis.

Crushed fingertips are the most frequent lesion inyounger children. In 50% of these cases, a distal phalanxfracture is found30 with nail bed laceration and partial or

total avulsions, such as near amputations. These injuriesusually happen at home.15,52 Treatment varies dependingon the severity of the injury. We agree with those authors52

who recommend meticulous repair of the damaged tissuesincluding the nail in order to prevent pain, to allow thenew nail to grow correctly, and to avoid having the ep-onychium to adhere to the nail bed. Other authors41 do notagree with this method of treatment. Shaft fractures shouldbe splinted for 14 days.

Neck fractures of the phalanges usually present a dorsaldislocation of the distal fragment. A correct radiographicdiagnosis with a pure lateral projection should be done. Iftreatment is not adequate, this lesion could become stiff.These fractures must be reduced properly and percutane-ously fixed with K-wires or through an open reductionfixed with screws.

Unicondylar or bicondylar fractures of the phalangesare complex lesions. Radiographic diagnosis should bedone through a lateral radiograph that shows two articularsurfaces or a double density shadow in an oblique projec-tion. These fractures can evolve to nonunion, pseudarthro-sis, and osteonecrosis. Treatment requires open reductionand internal fixation, avoiding damage to the collateralligaments (Fig 1). Stable fixation and early mobilizationare the key to a correct therapeutic approach to treatingthese fractures.

Diaphysis fractures of the phalanges tend to cause arotation that can be misdiagnosed in the acute phase ifpassive motion of the fingers is not explored and align-ment is not tested. Treatment should consist of closedreduction and percutaneous spinning. The injured fingercan be immobilized together with adjacent ones. Occa-sionally, external or internal fixation could be required. In

TABLE 1. Infant Hand Trauma Related to Age2–5

<5 yearsold

6–12 yearsold Total

Hand and upperlimb

24.36% 36.3% 31.51% p < 0.001

TABLE 2. Fractures Treated at the La PazUniversity Hospital Emergency Room

Concept Value

Number of fractures 7352Number of patients 7210Frequency of involved bonesMiddle Phalanx 39.98% (n = 2940)Distal Phalanx 27.91% (n = 2052)Proximal Phalanx 21.85% (n = 1607)Metacarpals 10.16% (n = 747)Most frequent fracturesMiddle phalanx Type-III epiphysiolysis

(avulsion of volar plate)28.86% (n = 2122)

Most frequently involved finger (our data)Third 29.18%Fifth 26.04%

Fig 1A–B. Preoperative and postoperative radiographic viewof a unicondylar fracture of the proximal phalanx of the thumbis shown. (A) The preoperative radiographic view is shown. (B)The postoperative radiograph shows reduction and externalspinning.

Clinical Orthopaedicsand Related Research78 Valencia et al

our environment, metacarpal fractures have been occur-ring more often because of the increasingly aggressivebehavior patterns in children. The most frequently diag-nosed fracture is that of the neck of the fifth metacarpal.19

In our series, this lesion represented 80% of metacarpalinjuries in children. Adequate treatment includes closedreduction and external fixation with a short cast that im-mobilizes hand and forearm. Accepted angulation of theneck fractures of the metacarpals varies from 35° in thefifth finger to 10 to 15° in the second finger. Nevertheless,it is advisable to obtain the best alignment possible. Thefinal aim of treatment is to obtain a healthy and painlessfunction with a good aesthetic result. We do not advise lateopen reduction because of possible damage to the growthplate. These fractures in children are similar to those inadults, aside from the influence of the periosteum in chil-dren. Another feature of these fractures to consider is ro-tation of the fifth metacarpal. When this happens, closedreduction and spinning with K-wires is the best therapeuticoption.

Epiphysiolysis exclusively occurs in children whenthey are growing. In the hand, this physis belongs to thepressure type and helps lineal growth of bones. In phalan-ges, they are located at the base; in metacarpals, they areat the head. The exception to this rule is the first metacar-pal, which has the physis at the base. These growth platespresent four defined areas: provisional calcification, hy-pertrophic cartilage, proliferation, and germination, whichis in contact with the metaphysis. The best known classi-fication of epiphysiolysis is that of Salter and Harris whorecognized five types of injuries depending on the clinical,radiographic, and prognostic characteristics. In early child-hood, the most frequent injury is Type I (only the growthplate is involved). When children are getting older, Type IIbecomes more common (involves metaphysis and growthplate; Fig 2). Type IV (transverse fracture of plate, epiph-ysis and metaphysic) and Type V (plate crush fracture)injuries are common at any age during childhood. Prog-nosis of these lesions in order to achieve an adequate bonegrowth is good in Types I and II and worse in the otherthree types. Type V fractures, which occur infrequently,have a poor prognosis even when treatment is adequate.

A normal-appearing radiograph does not mean there isnot a Type I injury present. It is necessary then to evaluatethe presence of crepitation or malrotation through activeflexion and passive wrist tenodesis. Type II injury usuallyshows the Thurston-Holland triangle radiographic sign,Type III shows an intra-articular fracture from the articularaspect to the epiphyseal plate, and Type IV is a moresevere Type III lesion with a vertical fracture line thatruns from the articular surface through epiphysis, physis,and metaphysis. A Type V lesion usually has a normal-appearing radiograph.

Treatment for these fractures depends on the fragmentdisplacement and distance. It is important to obtain thebest possible reduction, especially in Types III and IV. Iffragment displacement is longer than 2 mm, open reduc-tion should be done. Treatment preferably should be donein the 10 days after trauma. Late or inadequate manipula-tions can be dangerous.

The most frequent articular injury in children is thevolar plate avulsion, a Salter-Harris Type III lesion. Thisfracture is stable and it only requires immobilization andbuddy taping of the fingers after the initial few days ofimmobilization. At first, buddy taping will be necessary allthe time, gradually progressing to buddy taping only dur-ing sports or other exerting activities with affected hand.The second most frequent articular injury is a Type IIfracture of the proximal phalanx of the fifth finger. It iscaused by forced abduction. Treatment usually consists ofclosed reduction and immobilization of the metacarpopha-langeal (MP) joint in 90° flexion in order to keep collateralligaments extended, for 3 weeks.26

Thumb fracturesThe most frequent fractures involving the thumb are thoseof the diaphysis, generally called greenstick fractures.They are similar in children and in adults but a child’sability to remodel is stronger. This is the reason why theysupport wider angulations. Another typical fracture in chil-dren is Type III Salter and Harris epiphysiolysis of the firstmetacarpal base and that of the proximal phalanx. The firstof these two injuries can evolve to a Bennett’s fracture(treated with the same surgical indications as those occur-ring in adults), requiring preferably intermetacarpal spin-ning following Tubiana or Iselin.27,39,47 The second injurybehaves as an ulnar collateral ligament avulsion in adults,probably requiring open reduction and internal fixation.13

Fig 2A–B. (A) Salter-Harris Type II and (B) Type III fracturesare shown.

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Traumatic Articular InjuriesIsolated ligament injuries of the joints cannot usually bediagnosed on radiographs. Partial sprains are common inchildren. The symptoms include pain and tenderness. Thejoint usually is stable and articular effusion usually ispresent. The most frequently involved joint is the proximalinterphalangeal (PIP) with a volar plate sprain and fourthfinger. Radial collateral ligament sprains of the MP jointof the fifth finger and of the ulnar collateral ligament of theMP joint of the second finger are frequent too. We agreewith the vast majority of authors that best therapy is non-operative, immobilizing the joint in a functional positionfor 5 to 7 days and beginning with early mobilization plusbuddy taping for 2 more weeks.

Total ligament rupture can occur alone or together witha dislocation that was reduced previously. The most im-portant feature is articular instability. Treatment is nonop-erative except when the ulnar collateral ligament of theMP joint is involved.

Dislocations can be incomplete, complete, and com-plex. They occur less frequently in children than in adultsbecause ligaments are stronger than the physis hypertro-phic plate; what takes place is a volar plate avulsion in-stead of a dislocation. Total dislocations usually are dorsaland only need nonoperative treatment through immobili-zation for 2 weeks. In dislocations considered complexbecause of interposition of soft tissues between bones, adorsal approach, in order to avoid volar collateral nervedamage, is advised. Anyway, our experience shows thatopen reduction is needed less frequently in children than inadults.

Distal interphalangeal (DIP) joint dislocations are in-frequent and usually they only need closed reduction ex-cept when osteochondral fracture is present.10 Anotherproblem related to these dislocations is extensor tendoninjury. Early mobilization with extension protection is rec-ommended when treating these injuries.

For all these lesions, palliative measures, especially ar-throdesis, must be considered. These therapies, althoughinfrequent, are well tolerated in the DIP joint and thumbinterphalangeal (IP) joint.39 Our experience reveals that noother measure generally is needed.

Tendon InjuriesThese lesions are infrequent in children. Only a malletfinger after crush represents a considerable proportion oftendon injuries in children. Examination of these patientsis difficult because of inability to cooperate with assess-ment of motor function. Nevertheless, treatment optionsused in children are similar to those treatment options usedin adults and the only difference is that the repair tech-nique should be more meticulous in children. Strict im-mobilization for 3 to 4 weeks is mandatory, except when

treating very cooperative adolescents. The analysis of ourexperience has shown better results in children than inadults.

Extensor TendonsMallet finger in children is similar to mallet finger inadults, but there is a special characteristic in mallet fingerin children: a Type IV epiphyseal fracture. These injuriescan be treated using closed reduction and immobilizationfor 3 to 4 weeks.18–20 The main problem is instability andpossible interposition of matrix, then requiring open re-duction and internal fixation using K-wires or metallicsutures (Mantero technique),48 keeping the joint extended.

Flexor TendonsFrom 1993 to 2002, we treated 244 pediatric patients whohad 317 flexor tendon injuries of the hand and wrist at theemergency room. Thirty percent of patients had more thanone tendon involved, associated with neurovascular le-sions. Isolated flexor tendon injuries are not very commonduring childhood and they often are associated with glasstrauma. Incidence in adolescents is similar to the incidencein adults, and domestic accidents are the most frequentcause. In young children, surgical exploration usually isdone using general anesthesia and cuff-obtained ischemia.We also advise the use of magnifying glasses and avoid-ance of any traumatic maneuvers. We try to obtain directsuture of every involved structure whenever it is possible,except when a small laceration is observed; then we preferto cut the damaged zone to avoid triggering. We recom-mend a modified Lange suture with 4/0 monofilamentthread and continuous epitendinous suture with a 6/0monofilament suture. Whenever possible, we try to repairpulleys and sheaths. We also agree with different au-thors18,46 about the adequacy of suturing superficial anddeep flexor tendons in zone II. Immobilization should bemaintained for 4 weeks and regular activity is recom-mended after 7 to 8 weeks, depending on the patient andthe severity of the injury. Generally, results are better inchildren than in adults.46 This improvement is quantifiedthrough the Strickland and Glogovac scale,44 comparingresults obtained in a patient population younger than 14years and comparing results obtained in adults between 30and 50 years old. We have not found poor results in un-complicated lesions. Extension deficits are considerablycorrected through discontinuous dynamic splinting in chil-dren older than 8 years.

Nerve InjuriesFrom 1993 to 2002, we reviewed 458 nerve injuries in 353patients younger than 14 years. In this review, we includednerve injuries produced by lacerations involving the hand

Clinical Orthopaedicsand Related Research80 Valencia et al

and the upper extremity (including two humerus frac-tures). Although these lesions are uncommon, we showthat age is a basic factor in order to establish possiblenerve regeneration.3,6

The most frequent nerve injuries are those caused bybroken glass. Those nerve injuries associated with frac-tures (eg, humerus supracondylar) are infrequent and theinitial treatment approach should be nonoperative, as dif-ferent authors have concluded.7,29,31

Careful exploration of the injury, including clinical his-tory and cause of injury, is mandatory. An exact diagnosisusually is achieved, especially in younger infants, by sur-gical exploration using general anesthesia. Primary repairis the goal of therapy whenever possible. Loss of neuralsubstance or complex lesions associated with traffic inju-ries usually require secondary repair. The most commonlyused technique is epiperineural suture. Immobilization ofsurrounding joints lasts from 3 to 4 weeks. When the ulnarnerve is involved, the fourth and fifth finger should beimmobilized to prevent claw deformities.

A motor defect of the radial nerve requires immobili-zation to let the nerve heal and to prevent the wrist exten-sion deficit. Median nerve injuries do not require any spe-cial immobilization.

In complex injuries, we advocate the repair of everyinvolved structure. We usually obtain information aboutthe injuries in children younger than 6 years from theirparents and teachers. We also try to prevent trauma, espe-cially in burns, in those areas that present hypoesthesia.Followup lasts at least 2 years, and usually examiningthese patients when they are 10 years old. We try to assessobjectively trophic disturbances and algesic sensory re-pair. We consider following Moberg33 as good result—atwo-point discrimination less than 1 to 2 mm. Motionevaluation in younger children can only be observed bywatching their movements in their regular activities andappreciating their apparent defects.

Complex InjuriesComplex injuries are those that “involved two or morestructures of the hand: skin, bones, tendons, vascular struc-tures or nerves threatening viability or function of thehand.”16 The most frequent hand complex injuries in in-fants are amputations and avulsion injuries.

AmputationsThe primary consideration in any situation in which apatient has been treated with a partial or complete handamputation is focusing on the functional rehabilitation ofthe patient. The goals of amputation surgery in the handshould be: a) preservation of functional length; b) preser-vation of utility; c) prevention of symptomatic neuromas;

d) prevention of adjacent joint contractures; e) early mor-bidity; f) early prosthetic fitting when applicable; and g)early return of the patient to play and/or academic activi-ties.28 Amputations in children should be treated with anextremely nonoperative approach. It is always advisable todo a second-look procedure than to treat a child initiallywith an aggressive resection.

Digital Tip Amputations

These injuries represent the most common type of ampu-tation seen in the upper extremity. There are two mainforms: digital tip amputations with skin or pulp loss onlyand digital tip amputations with exposed bone.

Digital Tip Amputations with Skin or Pulp Loss Only

When the digital tip is amputated, the geometry of thedefect dictates the various treatment possibilities. The lossmay be transverse or oblique, with more volar skin lossthan dorsal skin loss, or the reverse may be true. There arethree basic therapeutic procedures.

Nonoperative treatment requires three different stagesthat lead to stump closure and remodeling: 1) the inflam-matory phase, in which homeostasis and careful cleaningof the wound should be done; 2) the proliferative phase, inwhich granulation tissue appears; and 3) the differentiationphase, in which scarring and epithelialization occur. Thisapproach has a special indication in children because theyhave an intense regenerative ability and spontaneous re-modeling of the stump. Main advantages of this techniqueare good aesthetic result and sensory results. The disad-vantage is the prolonged period of time until definitiveclosure (16 ± 3 days) and painful dressing changes.

Skin graft coverage is the most recommended surgicaloption. Nevertheless, we consider that results obtained us-ing this technique are no better than those obtainedthrough spontaneous closure. This conclusion also wasobtained in different studies that found that patients’ sat-isfaction after secondary healing was close to 90%, andafter skin grafting it was 56%, causing hyperesthesia in26% of those treated nonoperatively and in 67% of thosewho were treated with skin grafts.28 Sensory retention ofthe stump was not good.

Primary closure is recommended by some authors,36

but we do not recommend it, based on our experience.Neither the stump’s quality nor the postoperative com-plaints from patients justify this treatment. There are twomain problems: the need for shortening the stump in orderto obtain a good aesthetic result and a higher incidence ofhyperesthesia.

Digital Tip Amputation with Exposed Bone

When bone is exposed, reparation usually is achievedthrough different local flaps. Composite grafts have not

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offered good results, showing a survival rate in the bestseries of 58% in those amputations distal to eponychiumand 43% in those situated between the eponychium andDIP joint.20 Geometry of the injury dictates which repairtechnique is indicated.

The Atasoy volar V-Y advancement flap1 is a trianglepattern made to cover the dimensions of the defect. Thebase of the triangle will be the distal cut edge, with theapex being at the DIP flexion crease. The full thickness ofthe skin is cut. The digital nerves and blood vessels of theflap are preserved. Separation between the flexor sheathand the subcutaneous tissue facilitates advance of the flapdistally. The base of the triangle is sutured to the nail bedor remaining nail, and the resulting V incision on the pal-mar aspect of the digit is closed, converting it to a Y. Someslight defatting may be necessary to facilitate a tension-free skin closure.

Kutler lateral flaps24 use two triangular flaps developedand reflected from lateral positions to cover the tip of thedigit (Fig 3). Preparation is similar to that explained in theAtasoy flap. It is the choice flap when volar skin lossmakes the Atasoy flap not suitable. Main complications ofthis flap are suture edge necrosis (usually partial and notvery important) and stump dysesthesias. This last featureoccurred in 54% of the 22 patients in our series.

The literature shows a large collection of describedflaps28 that can be used in digital tip amputation, includ-ing the cross-finger flap, thenar H-flap, and others.They are more applicable theoretically than they are inpractice.

Proximal Amputations of the FingersProximal amputations of the fingers occur at levels proxi-mal to the digital skin pad involving bone.

Amputations through DIP Joint

When doing an amputation through the DIP joint, occa-sionally it could be appropriate to shorten the phalanx inorder to avoid primary closure. It is not agreed on whetherit is advisable to maintain articular cartilage of the phalanxor not. Those who advocate its maintenance indicated thatthis measure presents less inflammatory response. Thosewho recommend its resection together with lateral con-dyles remodeling indicate that uniformity of the stump ismore important. Using this technique also prevents un-necessary pain for the patient. Additionally, volar and lat-eral plates and flexor tendon fragments should be re-moved. The collateral nerves should be translocated awayfrom the cutaneous scar to an area where the inevitableneuromas will not become symptomatic because of con-tact. The use of low-voltage electrocoagulation also hasbeen described.

Amputations through Middle Phalanx

Flap reconstruction is not indicated when amputation isproximal to the DIP joint. Bone must be shortened andprimary closure should be obtained, using preferably volarskin because of its better sensory capacity.

Fig 3A–B. (A) Tip amputation and (B) Kutler lateral V-Y flapsreconstruction are shown.

Clinical Orthopaedicsand Related Research82 Valencia et al

Amputations Proximal to Middle Phalanx

Amputations through the PIP joint should be done simi-larly to those done through the DIP joint. If amputation hasoccurred proximal to the PIP joint, the remaining proximalsegment is under the motor control of the intrinsic musclesand the extensor digitorum communis. This will allowactive flexion of the proximal phalanx of approximately45°. If amputation has occurred near or at the MP level, amore proximal ray amputation, especially in the centraltwo rays, should be considered.

Ray Amputations

Complete ray amputations usually are done because ofposttraumatic complications rather than because of directtrauma. In the majority of these cases, they are electivesurgery before which the impact of this amputation on thefunction of the hand must carefully be considered. Second-ray amputation is associated with a 20% loss of powergrip, key pinch, and supination strength. Pronationstrength was diminished by 50% of predicted value.34

Multiple Digit Injuries

Basic principles that contribute to the treatment of theseinjuries are those that tend to conserve viable tissues inorder to do late reconstruction. This reconstruction in-volves transposition of viable tissues or removing uselessfragments trying to preserve basic functions of the hand:grip and pinches (Fig 4).

In children, most amputations should be replanted un-less severely damaged, because if it is successful, a goodfunction and healthy growth may be expected.40 In onestudy4 on digital replantation done in children, averagebone growth of 93% compared with the contralateral non-injured side was found. With the epiphysis affected, bonegrowth was reduced to 86% of the contralateral side. Themean total active motion of fingers was 151°. Sensibilityrecovery was excellent, with normal two-point discrimi-nation of 88%. Nineteen of 20 preselected activities ofdaily living could be accomplished. Relative grip strengthwas 79% that of the healthy side and the relative pinchstrength was 88%. Cold intolerance was slight or moderatein 40% of patients. The circulatory status of the replantedfingers was excellent in 88% of digits and good in 12%.All patients and their parents were satisfied with the resultsof the digital replantation.12

Amputations through the ThumbIn infants, this represents an absolute indication for replan-tation when injury conditions and quality of the fragmentsallow it.40 If replantation cannot be done in the acutephase, there are different surgical options secondary tothumb amputations. Nevertheless, thumb functional re-

quirements must be considered: adequate sensibility, ap-propriate length, motion able to allow opposition to otherfingers, and painless sensation.43 There is no consensus onwhat length defines a functional sequel secondary tothumb amputation. When the proximal phalanx is present,adequate function usually is achieved and no lengtheningtechniques are required. When amputation has occurred atthe MP level or at the proximal phalanx base, a stump isnot enough to restore basic functions of the hand properly.There are various surgical options that can be used inthumb amputations.

Fig 4A–B. (A) Multiple digit injury is shown. (B) Repair main-taining two useful stumps in order to keep power grip andpinches is shown.

Number 432March 2005 Pediatric Hand Trauma 83

First-ray Lengthening Techniques

First-ray lengthening techniques usually are done throughtransposition of viable fragments of other fingers in casesin which injury involved different digits. Grafts obtainedfrom iliac crest also are suitable. Osseous distractionthrough external spinning also has been described in theliterature, but pediatric patients are not the ideal group forthis technique. We consider adults more appropriate pa-tients for this procedure.

First Web Space Deepening

First web space deepening usually is achieved through theuse of single or multiple Z-plasty flaps. Dorsal rotationalflaps also have been used.

Pollicization of Index Finger

This technique, initially described by Buck-Gramcko8,9 astreatment for hypoplastic and aplastic thumbs, representsone of the most interesting therapeutic options for trau-matic thumb amputation. Even when the second finger isthe most easily used for pollicization because it is adjacentto the thumb, translocation of third, fourth, or fifth fingersalso has been described in the literature.11

Toe to Thumb Transplantation

This technique first was described by Nicoladoni at thebeginning of the 20th century. Because microsurgery hasbecome a standard procedure, this kind of surgery has hada growing importance.43 The main disadvantage is thedifferent size between the first toe and thumb, provoking asometimes unacceptable aesthetic result. Some authorshave tried solving this problem by using just half of the toeor the second finger.21 In this kind of transplantation, 92%of the transplanted toes survived; in 38% of the cases,complications occurred and a second procedure was nec-essary. Two-point-sensibility was present in 62% of thetransplantations; the largest range of motion of 50° wasobtained in the MP joint.

Amputation of the HandApart from accepting the amputation, the only possibletherapy is acute replantation. When this fails or when it isnot indicated, amputation and fitting a patient with a pros-thesis is the only treatment option.

Avulsion Injuries

These kinds of traumas usually are secondary to mechani-cal forces applied in different and opposite directions. Thedifference between avulsion injuries and amputations isthat avulsion injuries are more complex lesions and aremore difficult repair. There are two types of avulsion in-juries: partial avulsion injuries and complete avulsion in-juries.

Partial Avulsion InjuriesIn these injuries, the skin is rolled over without involvingdeep osteotendinous structures. It is commonly called de-gloving. In adults, these injuries are associated with ringsand in children they usually are associated with imitativebehavior using circle objects usually sharper than rings.Prognosis of these injuries is determined by the degree ofvessels in the lesion and especially the degree of the ve-nous return. When these structures are preserved, func-tional prognosis is good, although rolled skin can sufferpartial or total necrosis (Fig 5).

Complete AvulsionsThis kind of injury represents the typical nonreplantationindication. The important tissue involvement and associ-ated vascular damage does not allow microsurgical repair.

Fig 5A–B. (A) Partial avulsion injury with (B) minimum necro-sis of the wound edges is shown.

Clinical Orthopaedicsand Related Research84 Valencia et al

There are only two exceptions to this rule: thumb avulsioninjury and avulsion in pediatric patients.

Thumb Avulsion Injury

The overall survival rate in thumb replantation after avul-sion injury is 48%. In one study avulsions at or proximalto the MP joint had a survival rate of 83% compared witha 38% survival rate distal to the MP joint.2 This differencewas related to the difference size of the vessels.

Avulsion in Pediatric Patients

The excellent regenerative ability of pediatric patients hasmade replantation after complete avulsion injuries a sur-gical option in this group of patients. General survival ratein this situation has been 70.4%. Occasionally, applicationof a primary interpositional vein graft has been necessary.

Prosthesis in InfantsChildren who have had amputations present a permanentchallenge. Even with improvements in surgical techniques,prosthesis fixation, and rehabilitation programs, there stillare challenges to overcome when treating these patients.Professionals assisting these patients must be familiar withavailable technological devices available to treat to thesechildren and to advise their families on how to cope withthe situation. Although a prosthesis is never going to sub-stitute for an amputated finger or hand, its meticulousprescription and its use and training coordinated with thegrowth of the child can optimize results.

Hand injuries in pediatric patients represent a challengefor physicians and other medical professionals involved inthis care and treatment of these patients. Results obtainedin this group of patients usually are better than those ob-tained in adults because of the regenerative potential ofchildren’s bodies and their high degree of cooperation withphysicians. Meticulous repair of damaged structures is al-ways indicated when treating hand injuries in children.Long-term followup and advice for the children and theirfamilies also are necessary.

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struction of the amputated finger with a triangular volar flap: A newsurgical procedure. J Bone Joint Surg 52A:921–926, 1970.

2. Aziz W, Arakaki A, Kutz JE: Avulsion injuries of the thumb: Sur-vival factors and functional results of replantation. Orthopedics21:1113–1117, 1998.

3. Barrios C, De Pablos J: Surgical management of nerve injuries ofthe upper extremity in children: A 15-year survey. J Pediatr Orthop11:641–645, 1998.

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