Dr. Haley Dusek is an Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: • Tufts fracture • Mallet fracture • Seymour fracture • Volar Plate Injury • Base fracture • Phalangeal neck • Condyle fracture • Phalanx dislocations

1. Pediatric Orthopedic Imaging Case Studies
Haley Dusek, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Departments of Emergency Medicine1 & Orthopedic Surgery2
Carolinas Medical Center & Levine Children’s Hospital
Presentation #6
CMC Imaging Mastery Project
Michael Gibbs, MD – Lead Editor

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center.
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. It’s All About The Anatomy!

5. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that the X-
ray beam is attempting to penetrate.
• For reference, X-ray beams travelling through air will be black.
• Versus X-ray beams travelling through bone, which is high density, will
subsequently appear bright white.

6. 1. Confirm patient identity (name, date of birth)
2. Confirm the date of imaging
3. Confirm laterality (right vs. left)
4. Trace the bony cortex and look for irregularities
5. Review images in 2 planes at right angles to each other (AP + lateral)
to characterize fracture patterns, displacement, and angulation
6. Identify which bone and what part of the bone is injured
7. Review X-rays of both the joint above and the joint below the injury
The System: Bony Imaging

7. Example
4-year-old girl with finger
pain after slamming her
hand in a door.
With her fingers overlying
each other on this single
image, it is challenging to
accurately assess for a
fracture.
1. Dedicated finger views
are needed
2. Always be sure to check
two views at right angles
to each other.

8. CMC/LCH Pediatric Phalanx
Fractures & Dislocations

9. Review: Bony Anatomy

10. Review: Cutaneous Innervation

11. Review: Tendon Insertions

12. Phalanx Fractures
• The phalanx is the most commonly injured bone
• Distal > proximal
• Bimodal age distribution
• Toddler – household crush / lacerations
• Adolescent– contact sports
• 2/3 of fractures occur in boys
• Bone growth through the physis
• Located at proximal aspect of the phalanx
• Remain open until approx. 16.5 in males, 14.5 in females
• Associated tendon injuries common
November 2016; 24:11.

13. Condyle
Metaphysis
Physis
Epiphysis
Neck
Shaft
Base
X-Ray Anatomy

14. General Approach
• Visual inspection
• Nail bed / matrix laceration
• Evaluate digital cascade
• Specifically rotational deformity
• Active and passive range of motion
• Flex fingers with passive wrist extension or by squeezing the forearm
• Sensation
• Wrinkle test: place hands in warm water x 10 min, wrinkles on
fingertip indicate intact autonomic sensory function
• X-Ray orders
• AP, lateral and oblique view of individual finger
• Hand X-rays if > 3 fingers involved

15. General Approach
Avoid tight woven gauze wraps
after the evaluation as these
may cause compression injury
of the digit(s)!
Image At Follow-Up After A
Compressive Gauze Was Applied

16. Case #1:
10-year-old girl with
finger pain and
bleeding after her
little brother closed a
cabinet door on her
hand.
What do you see?

17. Case #1:
10-year-old girl with
finger pain and
bleeding after her
little brother closed a
cabinet door on her
hand.
Distal tuft fracture
with associated soft
tissue swelling and a
suspected laceration.

18. Tuft Fracture
• Usually crush injury, toddlers
• Does not involve the physis
• X-rays of individual the fingers
Management:
• Open - treat soft tissue / nail bed injury,
distal amputation if avulsion injury
• Closed – clam shell / mitten cast
• Neutral hand splint 2-3 weeks, active
range of motion of the DIP joint
• Oral antibiotics for open fractures
Ancef -> Keflex x5 days
• Hand Surgery follow up if desired,
around 2-3 weeks

19. What they studied:
Functional and clinical outcomes of fixation of open and
unstable tuft fractures in toddlers using hypodermic needle.
How:
Retrospective chart review study. Exclusion criteria: fractures that
were reduced closed, fractures stable after reduction, closed
fractures, additional upper extremity fractures, distal phalanx
fractures other than tuft fractures.
1. Pediatric anesthesia managed sedation with oral midazolam,
followed by digital block.
2. Hypodermic needle inserted antegrade, passing fracture line
and touching surface of distal phalangeal joint, AP and lateral
images obtained with C arm
3. Nail bed laceration repair and trepanation was performed
with 4 holes using 23-g hypodermic needle to prevent
subungual hematoma
4. Placed in aluminum splint.
5. Discharge with 40 mg/kg/day of amox –clav, BID x 3 days.
What they found:
5/72 patients with superficial tissue infection within 1 week of
discharge. Pin loosening without fracture displacement in 2/72.
No significant difference in age, and time to union between
cosmetic and functional results. Cosmetic outcomes were better
in girls than boys (P = 0.042).
What conclusions can we make?
Fixation of open and unstable tuft fractures in children < 6 yo is
feasible in the ED, which may lead to faster time to union and less
resources than OR treatment, with functionally and cosmetically
satisfactory results.

20. Mallet Deformity /
Fracture
• ANATOMY: Extensor tendon inserts on epiphysis
• Can also have soft tissue injury with mallet
deformity, not associated with fracture (image)
• MECHANISM: Injury usually from forced flexion
• Avulsion fracture at attachment site -> damage
to extensor mechanism -> mallet deformity
• EXAM: distal phalanx flexed without active
extension of DIP, tenderness to palpation over
DIP joint
• EVAL: AP and lateral of isolated finger
• MANAGEMENT:
• Ortho consult: cortical bony misalignment that
persists after reduction attempt, persistent volar
subluxation of distal phalanx, involving more than
1/3 of articular surface
• Bony mallet fractures: immobilize x4 wks min
• Tendinous mallet fracture: immobilize x6 wks min

21. Wehbe & Schneider Management
Type I • No DIP joint subluxation
• Less than 1/3 of articular
surface involvement
• Splint / cast immobilization of
DIP in full extension for 6—8
weeks
• Hand surgery follow up
Type II • DIP joint subluxation
• 1/3 – 2/3 of articular surface
involvement
• Ortho consult
• Surgical management
Type III • Injury to epiphysis and physis
• > 2/3 of articular surface
involvement
• Ortho consult
• Surgical management
Mallet Fracture

22. Case #2:
10-year-old boy
stepped on while
playing with friends
on the school
playground.
What do you see?

23. Case #2:
10-year-old boy
stepped on while
playing with friends
on the school
playground.
Widened physis and
flexion deformity of
distal third phalanx.
Bone almost at the
soft tissue surface
suggesting an
associated nailbed
injury. Findings more
pronounced on the
lateral view.

24. Seymour Fracture
• Juxta-epiphyseal to distal phalanx + concomitant
nail bed laceration.
• Typically from volar force and angulation of
diaphysis compared to epiphysis
• Include physis (as opposed to tuft fractures)
• Usually secondary to hyperextension injury
• EVAL – AP and lateral of isolated finger
• Nail plate must be removed to eval for nail
matrix laceration if suspected
• ATTN: middle finger injury, can arrest growth
and alter normal arcade of finger length
MANAGEMENT:
• Closed – closed reduction, splint, Hand
Surgery follow up 1 week for repeat XR
• Open – repair nail bed laceration, (6-0 or
7-0 absorbable suture), splint, parenteral -
> PO abx x5-7 d, Hand Surgery follow up
• If not repaired, need Hand follow up in 24-
48 hours

25. Mallet v. Seymour Fracture
Tendon injuries are uncommon with Seymour
fractures because the physis is
biomechanically weaker than other
structures and displacement is at the
physis/fracture, and not at the DIP joint.

26. Case #3:
16-year-old boy, with
right 4th finger pain
after baseball
tryouts. The finger is
hyperextended on
exam
What do you see?

27. Case #3:
16-year-old boy, with
right 4th finger pain
after baseball
tryouts. The finger is
hyperextended on
exam
Avulsion fracture of
the base of the 4th
proximal phalanx
with hyperextension
concerning for a
volar plate injury.

28. Middle / Proximal
Phalanx Fracture
Fracture Patterns Management
Volar Plate • Hyperextension injury with localized
bruising over volar aspect of PIP
• Eval XR for avulsion fragment
• Dorsal splint to prevent hyperextension

29. Case #4:
14-year-old girl stuck
out her hand to
brace herself during
a car crash.
What do you see?

30. Case #4:
14-year-old girl stuck
out her hand to
brace herself during
a car crash.
There is an articular
surface fracture of
base and shaft of
middle phalanx, with
avulsion of the volar
surface.

31. Case #4:
14-year-old girl stuck
out her hand to
brace herself during
a car crash.
This is an unstable
injury pattern!
Image on the right
following surgical
fixation (→).

32. Case #5:
6-year-old girl fell
running on the
playground.
What do you see?

33. Case #5:
6-year-old girl fell
running on the
playground.
There is a basal
metaphysis fracture
of the proximal
phalanx, which can
be seen >25 degrees
of valgus angulation
of the distal
fragment measured.
Indications for operative fixation: extra-articular fractures with >10° of angulation or
>2 mm shortening, rotational deformities, and any displaced intra-articular fractures.

34. Middle / proximal
phalanx fracture
Fracture Patterns Management
Shaft / Base • Minimally displaced • Buddy taping / splint for 3-4 weeks
• Routine Orthopedic follow-up
• Vertical oblique and spiral fractures • Plaster / fiberglass rigid splint
• Hand Surgery follow-up 3-4 weeks
• Salter Harris II at the base • ED reduction, neutral hand splint
• Follow-up with Hand Surgery
• Salter Harris III / IV • Neutral hand splint, operative
intervention in > 30% joint involvement
• Hand Surgery follow up

35. Case #6:
13-year-old boy
following a gunshot
wound to the hand.
What do you see?

36. Case #6:
13-year-old boy
following a gunshot
wound to the hand.
4th finger proximal
phalanx diaphysis
fracture with
extensive
comminution.
This is an unstable
injury pattern!

37. Middle / proximal
phalanx fracture
Fracture Patterns Management
Neck • Type I - nondisplaced • Immobilization 3-4 wks
Considered
extra-articular
transverse
fracture
• Type II – displaced, unstable • Surgical management
• Neutral hand splint under surgical repair
/ eval by Hand within few days of injury
• Buddy taping / short arm splint with PIP
joint in 40-50 degree and DIP in 10 to 20
degree flexion similar outcomes1
• Type III - displaced with rotational
deformity
• Surgical management

38. Middle / proximal
phalanx fracture
Fracture Patterns Management
Condyle • Lateral avulsion • Operative fixation
From direct
axial
compression,
avulsion force,
or subchondral
shearing
• Unicondylar • Operative fixation
• Bicondylar • Operative fixation
• Subcondylar shearing • Operative fixation

39. Case #7:
Similar initial injury
pattern to Case 5
following reduction
and K-wire fixation of
the proximal
phalanx.
There is also a
longitudinal hairline
fracture of the base
and shaft of the
middle phalanx (→).

40. Phalanx dislocation
• Typically result from hyperextension injury
• Proximal phalanx dorsal > volar dislocation
• Simple dislocation: reduced by placing wrist
and proximal interphalangeal joint in flexion,
apply translational force at the base of the
proximal phalanx
Sumarriva G, Cook B, Godoy G, Waldron S. Pediatric Complex Metacarpophalangeal Joint Dislocation of the Index Finger. Ochsner J. 2018;18(4):398-401.
• Complex dislocation: irreducible to closed
maneuvers -> surgical fixation
• Increased odds of complex dislocation with
MCP dislocation, specifically volar plate
interposition into MCP joint, and presence
of sesamoid bones

41. What they studied:
Characterization of pediatric hand fractures that were reduced
in the ED and subsequently required repeat reduction.
How:
Retrospective chart review.
Exclusion criteria: > 18 yo, open injury, delayed presentation > 2
wks after initial injury, no follow up in hand surgery clinic or
ultimately requiring surgical fixation.
Need for repeat reduction was based on judgement of treated
physician / surgeon based on clinical exam and XR.
What they found:
2/36 proximal phalanx base fractures, 1/6 proximal
phalanx neck fractures required repeat reduction.
1/21 PIP dislocation and 2/9 MCP dislocations required
repeat reduction.
No injuries that required repeat reduction involved the
physes.
> 90% first attempt success by ED physicians.
What can we take away?
ED physicians will likely be successful with closed
reductions for pediatric hand injuries. MCP dislocations
and proximal phalanx neck fractures may be more
likely to require repeat reduction regardless.

42. Summary of This
Month’s Diagnosis
• Distal Phalanx
• Tufts fracture
• Mallet fracture
• Seymour fracture
• Middle / Proximal Phalanx
• Volar Plate Injury
• Base fracture
• Phalangeal neck
• Condyle fracture
• Phalanx dislocations

43. Additional References
• Park KB, Lee KJ, Kwak YH. Comparison Between Buddy Taping With a Short-Arm Splint and Operative
Treatment for Phalangeal Neck Fractures in Children. J Pediatr Orthop. 2016;36(7):736-742.
doi:10.1097/BPO.0000000000000521
• Sumarriva G, Cook B, Godoy G, Waldron S. Pediatric Complex Metacarpophalangeal Joint Dislocation
of the Index Finger. Ochsner J. 2018;18(4):398-401. doi:10.31486/toj.18.0032
• Market M, Bhatt M, Agarwal A, Cheung K. Pediatric Hand Injuries Requiring Closed Reduction at a
Tertiary Pediatric Care Center. HAND. 2021;16(2):235-240. doi:10.1177/1558944719850635
• Cornwall R. Pediatric Finger Fractures: Which Ones Turn Ugly? J Pediatr Orthop.
2012;32(Supplement 1):S25-S31. doi:10.1097/BPO.0b013e31824b2582
• Lankachandra M, Wells CR, Cheng CJ, Hutchison RL. Complications of Distal Phalanx Fractures in
Children. J Hand Surg. 2017;42(7):574.e1-574.e6. doi:10.1016/j.jhsa.2017.03.042
• Dinh P, Franklin A, Hutchinson B, Schnall SB, Fassola I. Metacarpophalangeal Joint Dislocation. J Am
Acad Orthop Surg. 2009;17(5):7.
• https://www.rch.org.au/clinicalguide/guideline_index/fractures/Phalangeal_Finger_Fractures/
• https://www.orthobullets.com/hand/6038/phalanx-dislocations