TRAUMA SUPPLEMENT
Pediatric Finger Fractures: Which Ones Turn Ugly?
Roger Cornwall, MD
Abstract: The majority of pediatric finger fractures can be
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treated by closed means with expected excellent outcomes.
However, a subset of fractures can turn “ugly,” with compli-
cations such as growth arrest, malunion, and joint dysfunction if
not recognized and treated appropriately. The present paper
discusses several fractures in a child’s fingers that can cause
substantial problems if not recognized promptly, highlighting
important themes in the evaluation and treatment of a child’s
injured finger.
Key Words: pediatric, finger, fracture, phalanx, complications
(J Pediatr Orthop 2012;32:S25–S31)
BACKGROUND
The hand is the most frequently injured part of a
child’s body.1 The majority of hand fractures in children
occur in the phalanges, especially the proximal and the
distal phalanges.2,3 The incidence of hand fractures in
children follows a bimodal age distribution, with young
children sustaining household injuries and older children
sustaining predominantly sports-related injuries. The in-
cidence of hand injuries in children appears to be in-
creasing,4 although the causes of this increase are
unknown. Although the majority of pediatric hand and
finger fractures can be treated conservatively with ex-
cellent results, a subset of these fractures requires more
specific treatment.5 Therefore, it behooves the pediatric
orthopaedic surgeon to be aware of the pitfalls in the
treatment of these common injuries.
CLASSIFICATION
No single pediatric phalangeal fracture classification
is in widespread use today. However, not all fractures
behave in a similar manner, and fractures should be
individually considered on the basis of the patient’s age,
fracture location, involvement of the physis, and local
soft tissue anatomy. Similar fractures in patients of dif-
ferent ages may vary by energy of injury, fracture pattern,
stability imparted by the periosteal sleeve, and the
potential for remodeling. In general, younger children
From the Cincinnati Children’s Hospital, Cincinnati, OH.
The author declares no conflict of interest.
Reprint: Roger Cornwall, MD, Cincinnati Children’s Hospital, 3333 Burnet
Ave., Cincinnati, OH 45229. E-mail: roger.cornwall@cchmc.org.
Copyright r 2012 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
fare better than older children, although no discrete age
cutoffs exist for certain fracture treatment options. The
location of fracture is important, including which phalanx
is injured, and where in the phalanx the fracture is. For
instance, a Salter-Harris type 2 fracture of the distal
phalanx often involves a laceration of the nail matrix,
making it an open fracture prone to infection, but a
Salter-Harris type 2 fracture of the proximal phalanx
rarely involves meaningful soft-tissue injury. Similarly, a
tuft fracture of the distal phalanx carries with it few of the
risks associated with an epiphyseal fracture of the same
bone. Physeal involvement should be identified, as it
carries with it the risk of growth disturbance, especially if
the fracture is open. Finally, knowledge of the local soft
tissue anatomy is critical, especially in the setting of
avulsion fractures. For example, an avulsion fracture of
the volar lip of the base of the middle phalanx implies an
injury to the volar plate, whereas an identical fracture on
the dorsal lip of the same bone implies an injury to the
central slip of the extensor mechanism. The former re-
quires early mobilization to prevent stiffness, expecting a
radiographic nonunion, whereas the latter requires im-
mobilization to achieve radiographic union and to pre-
vent a boutonniere deformity.
INDICATIONS AND TECHNIQUES FOR
NONOPERATIVE TREATMENT
The majority of pediatric finger fractures can be
treated with closed means. Buckle fractures of the pha-
langes are inherently stable and amenable to many forms
of closed immobilization, ranging from buddy taping to
splints or casts. Many displaced fractures can be treated
with closed immobilization without reduction, given the
remodeling potential in young children. For instance, a
metacarpal neck fracture angulated at 30 degrees of
flexion in a 10-year-old boy will remodel completely
without reduction. Many fractures that are displaced
enough to require reduction are stable after reduction
because of the thick periosteal sleeve. For example, a
Salter-Harris type 2 fracture of the small finger proximal
phalanx in a 6-year-old will heal reliably in a cast after a
successful closed reduction.
Before nonoperative treatment is recommended for
any pediatric hand fracture, however, care must be taken
to perform a thorough physical examination and radio-
graphic evaluation. As the physical examination of a
child’s injured hand may be difficult, passive tests and
clinical signs can be particularly useful. Rotational
alignment of the digits can be assessed using passive wrist
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Cornwall J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012

FIGURE 1. A to D, These (A) anteroposterior and (B) lateral radiographs show a typical Seymour fracture. Note the widening of
the physis on the anteroposterior view (arrow) and the flexion deformity and dorsal physeal widening on the lateral view. C, The
clinical appearance of the same fracture shows exposure of the proximal end of the nail plate from underneath the eponychial
fold. Note the lack of skin laceration, which can lull the physician into believing that the injury is closed. D, After removal of the
nail plate, the open physis is seen easily through the nail bed laceration. Adapted with permission from Cornwall and Ricchetti.5

extension to obtain tenodesis flexion of the fingers when
the patient will not actively flex the injured finger. Com-
pression of the flexor muscle mass in the forearm can
accentuate this effect. Similarly, examining the resting
cascade of the digits can give clues to the loss of flexor
tendon competence. For radiographic evaluation of an
injured digit, specific radiographs of that digit are essen-
tial. A leading cause of poor outcome after finger frac-
tures in children is the failure to appreciate the
displacement on initial radiographs.1 This failure most
often occurs in the attempt to evaluate the sagittal
alignment of a finger fracture on radiographs of the hand,
with the fingers overlapping on the lateral view. There-
fore, it is essential that each injured digit be evaluated
with dedicated lateral views of each finger in addition to
standard posteroanterior views.
A discussion of the indications and various techni-
ques for nonoperative treatment of pediatric finger frac-
tures is beyond the scope of this paper, and is not the
focus. Instead, the paper will discuss the various fractures
for which specific treatment is required to avoid an “ugly”
outcome.
INDICATIONS AND TECHNIQUES FOR
OPERATIVE TREATMENT
The following section will discuss several specific
fractures that deserve increased scrutiny and specific

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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
FIGURE 2. A and B, These (A) anteroposterior and (B) lateral
radiographs show a proximal phalangeal neck fracture with
the typical displacement pattern of extension and ulnar devi-
ation angulation. On the lateral radiograph, note the volar
spike (arrow) on the proximal fragment obliterating the sub-
condylar fossa. Adapted with permission from Cornwall and
Ricchetti.5
treatment. This list is not meant to be all-inclusive, as
many other fracture types in a child’s fingers can produce
challenges and complications. However, discussion of
these specific fractures will highlight several important
principles in the care of a child’s injured finger.
Seymour Fracture
The so-called “Seymour fracture”6 is a physeal or
juxtaphyseal fracture of the distal phalanx with an asso-
ciated laceration of the nail matrix and avulsion of the
proximal end of the nail plate (Figs. 1A–D). In most
cases, the nail is completely avulsed from the eponychial
fold but is still adherent to the sterile matrix distally. The
eponychium itself is not lacerated, but the nail matrix
laceration beneath it exposes the fracture to the envi-
ronment as the nail plate is avulsed. Conversely, the
avulsion of the nail plate may not be complete, and the
nail may still remain beneath the eponychial fold at pre-
sentation. However, in such cases, the cuticle seal is dis-
rupted, as indicated by bleeding emanating from beneath
the eponychial fold and atop the nail plate. This dis-
ruption of the cuticle seal exposes the fracture site to
contamination and possible infection. In either case,
radiographs reveal a typical physeal or juxtaphyseal frac-
ture of the distal phalanx with the fracture flexed through
the fracture site. In some cases, the radiographic abnor-
mality only appears as a dorsal widening of the physis.
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Pediatric Finger Fractures: Which Ones Turn Ugly?
FIGURE 3. A and B, These (A) anteroposterior and (B) lateral
radiographs show a typical percutaneous pin fixation for a
proximal phalangeal neck fracture, now healed and ready for
pin removal. Adapted with permission from Cornwall and
Ricchetti.5
If a Seymour fracture is suspected, the nail plate
must be removed to allow inspection of the nail matrix. If
identification of a nail matrix laceration confirms the
presence of an open fracture, thorough but gentle irriga-
tion and debridement of the fracture site is required. Once
the fracture is irrigated, the flap of torn nail matrix that
typically falls into the fracture site is removed and the
fracture is reduced. In many cases, the fracture is stable
after reduction, especially in older children in whom the
metaphyseal and epiphyseal surfaces of the physis inter-
lock. However, in younger children, the fracture often
remains unstable, and percutaneous pinning is required to
prevent recurrent flexion through the fracture from the
volar pull of the flexor tendon insertion onto the dia-
physis and the dorsal pull of the terminal extensor tendon
onto the epiphysis. Once fracture reduction and stability
are obtained, the nail matrix can be repaired with ab-
sorbable sutures, although often the matrix laceration is
too proximal and too complex to repair easily. In such
cases, nail matrix healing is adequate without direct re-
pair. Whether or not the matrix is sutured, the nail plate
should be replaced beneath the eponychial fold and
sutured to the lateral nail folds to prevent synechia for-
mation in the germinal matrix. The use of prophylactic
antibiotics, chosen according to local flora, is prudent to
help prevent infection after irrigation and debridement.
Fracture healing generally occurs in approximately 3 to 4
weeks, at which point the pin can be pulled and im-
mobilization discontinued.
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Cornwall
FIGURE 4. A and B, These (A) anteroposterior and (B) lateral radiographs demonstrate a middle phalangeal radial condyle
fracture. Note the double density (arrows) on the lateral view with extension displacement of the condyle, despite the apparent
nondisplaced appearance on the AP view. Adapted with permission from Cornwall and Ricchetti.5
Seymour fractures turn ugly when they are not ini-
tially recognized and a thorough irrigation is not per-
formed. Attempts at closed reduction (without removing
the nail plate and irrigating the fracture site) are fre-
quently met with infection, osteomyelitis, and growth
arrest. Delayed presentation or treatment usually results
in similar complications. The immediate infection can be
treated with irrigation and debridement, and osteomye-
litis is not impossible to treat given the good vascularity
of the distal phalanx. However, a growth arrest cannot be
reliably corrected. As the mechanism of injury in a Sey-
mour fracture typically involves axial loading, the middle
finger is often injured. A growth arrest of the distal
phalanx in the middle finger has the potential to alter the
normal arcade of finger lengths and result in cosmetic
deformity.
Phalangeal Neck and Condyle Fractures
Periarticular fractures of the distal end of the
proximal and middle phalanges present particular prob-
lems, similar to those occurring at the distal end of the
humerus. The phalangeal neck fracture is an extra-artic-
ular transverse or oblique fracture equivalent to a
supracondylar humerus fracture, whereas a phalangeal
condyle fracture is an intra-articular fracture equivalent
to a lateral condyle or T-condylar fracture of a distal
humerus. Placing these phalangeal fractures into the
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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
context of the more commonly encountered distal
humerus fractures underscores for the pediatric ortho-
paedic surgeon the potential threats these fractures pose
to adjacent joint function.
Phalangeal neck fractures almost exclusively occur
in children, and are usually displaced.7 The fracture typ-
ically displaces into hyperextension, as does a supra-
condylar humerus fracture, and the volar spike of the
proximal fragment creates a block to adjacent joint flex-
ion (Figs. 2A, B), as does the anterior spike of the distal
humerus in an extension-type supracondylar fracture.
Coronal angulation and rotation are also common.
However, 2 important differences exist between pha-
langeal neck fractures and supracondylar humerus frac-
tures. First, the remodeling potential of phalangeal neck
fractures is very limited. In the phalanges, only a prox-
imal physis is present, making remodeling (which only
occurs in the sagittal plane) of distal fractures very slow.8
Second, rotational malunions of the phalanges cause
overlapping of the digits during flexion and are poorly
tolerated in contrast to a rotational malunion of the
humerus that can be overcome with compensatory
shoulder rotation.
Displaced phalangeal neck fractures are notoriously
unstable and require pin fixation to maintain stability
after reduction.7 Reduction can be obtained by closed
means before percutaneous pinning if the reduction is
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FIGURE 5. A lateral radiograph shows a typical volar plate
avulsion fracture (arrow). Adapted with permission from
Cornwall and Ricchetti.5
performed within the first 1 to 2 weeks after injury. Be-
yond 3 weeks after injury, however, closed reduction is
usually not possible. It is at this point, however, that open
reduction begins to lead to an increased risk of avascular
necrosis of the condyles.9 For this reason, techniques have
been developed to achieve reduction of incipient mal-
unions of phalangeal neck fractures with percutaneous
osteoclasis.10 Once reduction is achieved, pins are inserted
in a crossed or divergent configuration depending on the
obliquity of the fracture (Figs. 3A, B). The pins are
protected in a cast for 3 to 4 weeks and then pulled once
radiographs demonstrate adequate healing.
Phalangeal condyle fractures are intra-articular
fractures that may appear innocuous on initial radio-
graphs but progress to intra-articular malunion relatively
quickly. The initial displacement of a phalangeal condyle
fracture may be best viewed on the lateral radiograph of
the digit, on which a double ring sign of the translated
condyles is seen (Figs. 4A, B). Intra-articular remodeling
of a phalangeal condyle fracture is not possible, as in a
malunited lateral humeral condyle fracture, and therefore
anatomic reduction is required. Such a reduction may be
achieved percutaneously or through open reduction,
although attention must be paid to the soft tissue at-
tachments on the fragment to preserve its vascularity
during open reduction. Pin or screw fixation is required
until fracture healing, which may be slower than for
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Pediatric Finger Fractures: Which Ones Turn Ugly?
FIGURE 6. A lateral radiograph demonstrates a Salter-Harris
type 4 volar shear fracture of the middle phalanx that differs
from the typical volar plate avulsion fracture in children. Note
the loss of congruous articular surfaces at the proximal inter-
phalangeal joint.
phalangeal neck fractures. Premature removal of pins
may allow late redisplacement. Osteotomy of a malunited
phalangeal condyle fracture is technically possible but
carries a risk of avascular necrosis of the condyle.
Phalangeal neck and condyle fractures turn ugly
when the initial displacement is underappreciated or when
the displaced fracture is treated with closed reduction
without pinning, leading to a malunion. Such fractures
can also be complicated by avascular necrosis and non-
union, either from late open reduction or crushing injury
mechanisms. Malunions create cosmetic deformities and
adjacent interphalangeal joint dysfunction and are par-
ticularly difficult to treat safely.
Volar Plate Fractures
A hyperextension injury to the proximal inter-
phalangeal joint of a finger typically causes an avulsion
fracture at the insertion of the volar plate on the base of
the middle phalanx. Such fractures are typically seen as a
small fleck of bone avulsed from the epiphysis of the
middle phalanx on the lateral or oblique radiographic
view (Fig. 5). A history of dorsal dislocation may also be
present. Such fractures are easily treated with early mo-
bilization, with 1 week of splinting or buddy taping and
another 2 weeks of active range-of-motion exercises.
Among athletes, return to play is advised upon restora-
tion of the normal range of motion, usually 2 to 3 weeks
after injury. Longer immobilization may be required if the
joint is unstable, with either coronal instability or dorsal
subluxation of the joint in extension. A radiographic
nonunion is the expected outcome, although full finger
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Cornwall
FIGURE 7. Radiographs and clinical photographs for case report 1. Please see text for description.
function is expected to return despite the persistent
radiographic abnormality.
Volar plate fractures turn ugly when prolonged
immobilization is used in an attempt to achieve radio-
graphic union of the avulsed fleck of bone. Permanent
stiffness may result from immobilization beyond 1 to 2
weeks, even in children. Such fractures also turn ugly
when the fracture fragment involves a substantial portion
of the articular surface, instead representing the more
typical adult fracture pattern of shearing rather than
avulsion. These fractures are rare in the skeletally im-
mature, but may appear as a Salter-Harris type 4 fracture
(Fig. 6). In such fractures, joint congruity must be es-
tablished and maintained until fracture healing, which
may require transarticular pinning, open reduction and
internal fixation of the fracture, or both.
CASE PRESENTATIONS
Case 1
A 4-year-old boy sustained a crush injury to his
index finger, leading to a comminuted proximal phalanx
fracture (Fig. 7A). Initial closed reduction and pin fix-
ation were limited because of severe proximal comminu-
tion and resulted in a nonunion of the phalangeal neck
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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
component (Fig. 7B). Revision fixation and bone grafting
achieved bony union, but with redisplacement after fix-
ation leading to a rotational malunion (Fig. 7C). A
proximal rotational osteotomy restored bony alignment
(Fig. 7D), but led to extensor tendon adhesions and an
extensor lag that was only partially corrected by a sub-
sequent tenolysis.
Case 2
An 11-year-old boy sustained an injury to his mid-
dle finger in a fight. Initial radiographs revealed a Salter-
Harris type 4 fracture of the base of the middle phalanx
with < 1 mm of displacement at the articular surface
(Fig. 8A). The loss of joint congruity was not appreciated,
however, and the fracture was treated in a splint, leading
to late joint dislocation (Fig. 8B). A late open reduction
and internal fixation of the fracture with temporary
transarticular pinning restored anatomic joint alignment
(Fig. 8C). Excellent range of motion was maintained at
last follow-up 14 months postoperatively (Fig. 8D).
SUMMARY OF 3 MOST IMPORTANT POINTS
1. A thorough physical examination and dedicated
radiographic evaluation of each injured digit is
required to avoid poor outcomes.
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J Pediatr Orthop  Volume 32, Number 1 Supplement, June 2012
FIGURE 8. Radiographs and clinical photographs for case report 2. Please see text for description.
2. Phalangeal neck and condyle fractures of the fingers
require anatomic reduction and stable fixation to
avoid problematic malunion.
3. Knowledge of soft tissue anatomy is essential to avoid
complications from Seymour fractures and periarticu-
lar avulsion fractures of the digits.
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their site and type in childhood. Clin Radiol. 2001;56:667–669.
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Pediatric Finger Fractures: Which Ones Turn Ugly?
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