Management of Child Finger Fracture Through the Metaphysis Ending at the Epiphyseal Plate
The management of a child with a finger fracture through the metaphysis ending at the epiphyseal plate requires closed reduction and splinting for mildly displaced fractures, while severely displaced fractures may need Kirschner wire fixation to prevent growth disturbances and functional impairment.
Classification and Assessment
Finger fractures in children that involve the metaphysis and extend to the epiphyseal plate are typically classified using the Salter-Harris classification system:
- Type I: Fracture through the growth plate only
- Type II: Fracture through the growth plate and metaphysis (most common in this scenario)
- Type III: Fracture through the growth plate and epiphysis
- Type IV: Fracture through the growth plate, epiphysis, and metaphysis
- Type V: Crush or compression injury of the growth plate
These fractures are often juxta-epiphyseal fractures, which show a characteristic pattern with a small triangular metaphyseal fragment at the base of the phalanx 1.
Treatment Algorithm Based on Displacement
Type 1 (Mildly Displaced Fractures)
- Closed reduction and splinting
- Immobilization for 3-4 weeks
- Regular radiographic follow-up at 10-14 days to evaluate position 2
Type 2 (Severely Displaced Fractures)
- Attempt closed reduction first
- If reduction is unstable or inadequate:
- Proceed with Kirschner wire fixation
- Consider open reduction if closed manipulation fails
- Particularly important if there is flexor tendon entrapment 1
Immobilization Technique
- Position of immobilization: Wrist flexion and forearm supination to counteract volar displacement of the distal fragment 2
- Duration: Typically 3-4 weeks for uncomplicated fractures
- Splint type: Custom-molded finger splint that immobilizes the affected digit while allowing adjacent finger motion
Rehabilitation Protocol
- Begin progressive range of motion exercises after the immobilization period (3-4 weeks)
- Full recovery expected within 6-8 weeks 2
- Directed home exercise program including active finger motion exercises to prevent stiffness
Monitoring and Follow-up
- Initial follow-up radiographs at 10-14 days to ensure maintained reduction
- Regular monitoring for signs of growth disturbance
- Long-term follow-up until skeletal maturity if the fracture involves the growth plate significantly
Potential Complications
- Growth disturbance leading to angular deformity or length discrepancy
- Joint stiffness (most common complication)
- Malunion causing "pseudo-claw" deformity 1
- Post-traumatic arthritis
Special Considerations
Age-Related Factors
- Children younger than 11 months with fractures require careful evaluation for potential child abuse, though finger fractures alone are considered to have low specificity for abuse 3
- Growth potential varies with age - younger children have greater remodeling potential but also longer time for growth disturbance to manifest
Anatomical Considerations
- Care must be taken to avoid damage to the epiphyseal growth plate during treatment
- The epiphyseal plate is particularly vulnerable in children and adolescents, and injury can lead to premature closure 4, 5
Pitfalls to Avoid
- Inadequate assessment of stability can lead to failure to recognize unstable patterns requiring surgical intervention 2
- Prolonged rigid immobilization can lead to joint stiffness
- Delayed mobilization can result in poor functional outcomes 2
- Overlooking associated soft tissue injuries
By following this structured approach to management, most children with finger fractures through the metaphysis ending at the epiphyseal plate will achieve good functional outcomes with minimal risk of growth disturbance or long-term deformity.