What are the concerns and treatment options for a 6-year-old with a finger fracture?

Finger Fractures in 6-Year-Olds: Key Concerns and Management

Yes, there are several important concerns when a 6-year-old breaks a finger, including the need to rule out child abuse, assess for growth plate involvement, prevent finger stiffness, and ensure proper alignment to avoid rotational deformity.

Critical Initial Concerns

Child Abuse Screening

• Any fracture in a child under 5-7 years old warrants consideration of non-accidental trauma, particularly if the mechanism of injury is unclear or inconsistent with the child's developmental stage 1
• Document a detailed history including the exact mechanism of injury, witnesses present, timing of injury, and any delay in seeking care 1
• Perform a complete skin examination looking for bruising in unusual locations (ears, neck, trunk) or patterned injuries 1
• If abuse is suspected or the history is inconsistent, a skeletal survey is necessary in children under 24 months and appropriate in select cases up to age 5 years 1

Growth Plate (Physeal) Injuries

• Approximately 40% of pediatric hand fractures involve the growth plate, with Salter-Harris II fractures being most common 2
• Growth plate fractures require careful assessment as they can affect future bone growth if improperly managed 3, 4
• Thumb metacarpal base fractures involving the physis deserve special attention, as Salter-Harris III and IV fractures are unstable and require surgical management 3

Specific Fracture Patterns and Their Concerns

Rotational Deformity

• Check for finger crossover by having the child make a fist - rotational malalignment will not remodel and requires reduction 3
• Metacarpal shaft fractures from rotational forces are particularly prone to this complication 3
• Even small rotational errors can cause significant functional impairment that persists after healing 5

Acceptable Angulation

• Metacarpal neck fractures (the most common finger fracture type) have different acceptable angulation limits depending on which finger is involved 3:
  • Index finger: 10° maximum
  • Middle finger: 20° maximum
  • Ring finger: 30° maximum
  • Little finger: 40° maximum
• Angulation beyond these limits requires reduction 3

Compartment Syndrome Risk

• Metacarpal base fractures, especially in young children, often result from high-energy injuries and carry increased risk of compartment syndrome 3
• Monitor for severe pain, swelling, and decreased perfusion requiring urgent surgical evaluation 3

Prevention of Finger Stiffness

The most critical intervention to prevent long-term disability is immediate active finger motion of uninvolved digits 1:

• Instruct the child and parents at the first encounter to move all uninjured fingers regularly through complete range of motion 1
• Finger stiffness is one of the most functionally disabling complications and is very difficult to treat after fracture healing 1
• This intervention is cost-effective, requires no additional visits, and has no adverse effects on an adequately stabilized fracture 1

Treatment Approach

Conservative Management (Majority of Cases)

• 75% of pediatric hand fractures can be managed with immobilization alone 2
• An additional 23% require only bedside closed reduction followed by immobilization 2
• Immobilization should not exceed one month - prolonged immobilization increases stiffness risk 5
• Begin mobilization as soon as the fracture is stable, which is often immediately for properly immobilized fractures 5

When Surgery Is Needed (Rare)

• Only 2.3% of pediatric hand fractures require operative intervention 2
• Indications include:
  • Open fractures 5, 2
  • Fractures that remain malpositioned despite proper immobilization 5
  • Unstable thumb metacarpal base fractures (Salter-Harris III/IV) 3
  • Intra-articular metacarpal head fractures requiring anatomic reduction 3

Special Considerations for Fingertip Injuries

If the injury involves the fingertip (common in young children from door crush injuries) 4, 6:

• Any nail bed injury requires surgical repair - absence of proper treatment causes permanent deformity 4
• Sub-ungual hematomas covering more than half the nail should be drained with a cold lancet 6
• Detached nails must be removed to examine and suture the nail bed if injured 6
• Nail dystrophy occurs in 25% of cases, more frequently after pulp amputation 6

Follow-Up Monitoring

• Monitor for signs of infection: gingival swelling, increased pain, purulent drainage 7
• Reassess if pain is unremitting during follow-up 1
• Watch for late complications including sensory disorders (8% incidence) and nail dystrophy (25% incidence) 6
• Follow growth plate injuries until skeletal maturity to detect growth disturbances 1

Common Pitfalls to Avoid

• Do not accept inadequate radiographs - poor quality images miss fractures and fail to detect rotational malalignment 5
• Do not immobilize uninjured fingers - this dramatically increases stiffness risk 1
• Do not dismiss seemingly minor fingertip injuries - they require meticulous care to prevent permanent sequelae 4, 6
• Do not overlook pseudoepiphyses on radiographs, which can be confused with fractures but are distinguished by careful physical examination 3