CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 432, pp. 7786

2005 Lippincott Williams & Wilkins

Pediatric Hand Trauma

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

fracture associated with soft tissue laceration is the most

frequent hand injury. The second highest incidence peak is
at 12 years of age when the fifth finger proximal phalanx
Type-II epiphysiolysis is generally the most frequent lesion, followed by metacarpal fractures.19 We reviewed the
treatment of children younger than 14 years who had fractures and were treated in the emergency room of our institution between 1993 and 2002 (Table 2).
Our data (Table 2) contrast with those published by
Fetter-Zarzeka and Joseph,15 who found that the thumb
was the most frequently involved digit in their series.
When analyzing the mechanism of injury, our results and
results from the literature are similar; boys younger than 6
years are more likely to be injured at home and children
between 6 and 14 years are more likely to be injured when
playing sports.
Childrens bones have different characteristics from
adult bones and this makes fractures in children different
from fractures in adults. One difference is a thick periosteum in children that allows less movement of bone fragments and induces an intense osteogenesis. This leads to
faster consolidation of fractures and infrequent nonunions.
Another difference is the presence of a physis or growth
plate where fractures are more frequently involved, specifically in the hypertrophy area.
We usually prefer closed immobilization for 3 weeks
and typically obtain excellent results and no bone growth
disturbances. Nevertheless, these injuries should not be
underestimated.19,30,35,51 Fractures that need surgical
treatment comprise from 10 to 20% of pediatric fractures.
In our series, only 2.5% (n 321) of pediatric fractures
needed surgical treatment. Indications for surgery in children do not differ from those indications for surgery in
adults. After reduction, the hand should be functionally
positioned. Since children do not follow splint recommendations very carefully, strict immobilization should be obtained for the necessary time period because stiffness does
not represent a serious problem in children.
One can accept greater angulation of metaphysis fractures than in adults because they are in the motion plane.
Rotations should be corrected carefully. This can be assessed clinically through observation of rotational posi-

Hand injuries in infants are an exciting challenge for those

who treat pediatric trauma patients. We will review different
hand injuries and provide basic rules for their treatment and
followup. We will compare our experience with published
results. When compared with adults, two main differences
arise in treatment of pediatric hand injuries: children have
an exceptional regenerative ability that allows procedures to
be used that would not be useful in older patients (eg, replantation after avulsion injuries) and children have a high
degree of cooperation with physicians. The main goal of
treatment should be to have children return quickly to their
daily leisure and academic activities.

A review42 relevant to the psychiatry of injuries in children noted that hand injuries are common and loss of a
dominant hand or opposition is most important [sic]. Self
esteem and skill are associated with hand sensation, appearance, and functions. Hand and upper limb injuries
represent a high percentage of total injuries during childhood (Table 1).15,19,30,36 The aim of the current study is to
review recent data from the literature in order to establish
main features about infant hand trauma and to compare
them with our experience in an urban university hospital.
Fractures
Lifestyle changes between the 1950s and 1970s increased
a childs risk for having a hand injury. From the 1970s to
the present, this increase has stabilized because of preventative measures. Fractures occur more often in boys than in
girls, and this difference increases with increasing age.
Age distribution follows a bimodal path with an incidencepeak between 1 and 2 years of age when distal phalanx

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

77

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Clinical Orthopaedics
and Related Research

Valencia et al

TABLE 1.

Infant Hand Trauma Related to Age25

Hand and upper

limb

<5 years
old

612 years
old

Total

24.36%

36.3%

31.51%

p < 0.001

tions of adjacent fingernails and radiographically through

the joint images and double-condyle sign.
Carpal Fractures
Scaphoid fracture, although infrequent, is the most common carpal fracture in children and most often occurs
through the distal pole.27 As in adults, radiographic diagnosis is not very accurate. Because of this, immobilization
for 10 days is recommended when these injuries are suspected and until new radiographs are taken.9 Treatment
usually consists of immobilization that includes the forearm and palm and specifically the thumb for a 4-week to
8-week period. Functional prognosis is good and complication incidence is low. Fractures of the scaphoid bone in
children are similar to those in adults. Established pseudarthrosis in children should be treated as it is treated in
adults.
Fractures of the Metacarpals and Phalanges
Different fractures of these bones follow a different pattern
in children than in adults. The most notable lesions are
distal phalanx fracture, neck fractures of the phalanges,
condylar fractures, and epiphysiolysis.
Crushed fingertips are the most frequent lesion in
younger children. In 50% of these cases, a distal phalanx
fracture is found30 with nail bed laceration and partial or

total avulsions, such as near amputations. These injuries

usually happen at home.15,52 Treatment varies depending
on the severity of the injury. We agree with those authors52
who recommend meticulous repair of the damaged tissues
including the nail in order to prevent pain, to allow the
new nail to grow correctly, and to avoid having the eponychium to adhere to the nail bed. Other authors41 do not
agree with this method of treatment. Shaft fractures should
be splinted for 14 days.
Neck fractures of the phalanges usually present a dorsal
dislocation of the distal fragment. A correct radiographic
diagnosis with a pure lateral projection should be done. If
treatment is not adequate, this lesion could become stiff.
These fractures must be reduced properly and percutaneously fixed with K-wires or through an open reduction
fixed with screws.
Unicondylar or bicondylar fractures of the phalanges
are complex lesions. Radiographic diagnosis should be
done through a lateral radiograph that shows two articular
surfaces or a double density shadow in an oblique projection. These fractures can evolve to nonunion, pseudarthrosis, and osteonecrosis. Treatment requires open reduction
and internal fixation, avoiding damage to the collateral
ligaments (Fig 1). Stable fixation and early mobilization
are the key to a correct therapeutic approach to treating
these fractures.
Diaphysis fractures of the phalanges tend to cause a
rotation that can be misdiagnosed in the acute phase if
passive motion of the fingers is not explored and alignment is not tested. Treatment should consist of closed
reduction and percutaneous spinning. The injured finger
can be immobilized together with adjacent ones. Occasionally, external or internal fixation could be required. In

TABLE 2. Fractures Treated at the La Paz

University Hospital Emergency Room
Concept

Value

Number of fractures
Number of patients
Frequency of involved bones
Middle Phalanx
Distal Phalanx
Proximal Phalanx
Metacarpals
Most frequent fractures
Middle phalanx Type-III epiphysiolysis
(avulsion of volar plate)
Most frequently involved finger (our data)
Third
Fifth

7352
7210
39.98% (n = 2940)
27.91% (n = 2052)
21.85% (n = 1607)
10.16% (n = 747)
28.86% (n = 2122)

29.18%
26.04%

Fig 1AB. Preoperative and postoperative radiographic view

of a unicondylar fracture of the proximal phalanx of the thumb
is shown. (A) The preoperative radiographic view is shown. (B)
The postoperative radiograph shows reduction and external
spinning.

Number 432
March 2005

our environment, metacarpal fractures have been occurring more often because of the increasingly aggressive
behavior patterns in children. The most frequently diagnosed fracture is that of the neck of the fifth metacarpal.19
In our series, this lesion represented 80% of metacarpal
injuries in children. Adequate treatment includes closed
reduction and external fixation with a short cast that immobilizes hand and forearm. Accepted angulation of the
neck fractures of the metacarpals varies from 35 in the
fifth finger to 10 to 15 in the second finger. Nevertheless,
it is advisable to obtain the best alignment possible. The
final aim of treatment is to obtain a healthy and painless
function with a good aesthetic result. We do not advise late
open reduction because of possible damage to the growth
plate. These fractures in children are similar to those in
adults, aside from the influence of the periosteum in children. Another feature of these fractures to consider is rotation of the fifth metacarpal. When this happens, closed
reduction and spinning with K-wires is the best therapeutic
option.
Epiphysiolysis exclusively occurs in children when
they are growing. In the hand, this physis belongs to the
pressure type and helps lineal growth of bones. In phalanges, they are located at the base; in metacarpals, they are
at the head. The exception to this rule is the first metacarpal, which has the physis at the base. These growth plates
present four defined areas: provisional calcification, hypertrophic cartilage, proliferation, and germination, which
is in contact with the metaphysis. The best known classification of epiphysiolysis is that of Salter and Harris who
recognized five types of injuries depending on the clinical,
radiographic, and prognostic characteristics. In early childhood, the most frequent injury is Type I (only the growth
plate is involved). When children are getting older, Type II
becomes more common (involves metaphysis and growth
plate; Fig 2). Type IV (transverse fracture of plate, epiphysis and metaphysic) and Type V (plate crush fracture)
injuries are common at any age during childhood. Prognosis of these lesions in order to achieve an adequate bone
growth is good in Types I and II and worse in the other
three types. Type V fractures, which occur infrequently,
have a poor prognosis even when treatment is adequate.
A normal-appearing radiograph does not mean there is
not a Type I injury present. It is necessary then to evaluate
the presence of crepitation or malrotation through active
flexion and passive wrist tenodesis. Type II injury usually
shows the Thurston-Holland triangle radiographic sign,
Type III shows an intra-articular fracture from the articular
aspect to the epiphyseal plate, and Type IV is a more
severe Type III lesion with a vertical fracture line that
runs from the articular surface through epiphysis, physis,
and metaphysis. A Type V lesion usually has a normalappearing radiograph.

Pediatric Hand Trauma

79

Fig 2AB. (A) Salter-Harris Type II and (B) Type III fractures
are shown.

Treatment for these fractures depends on the fragment

displacement and distance. It is important to obtain the
best possible reduction, especially in Types III and IV. If
fragment displacement is longer than 2 mm, open reduction should be done. Treatment preferably should be done
in the 10 days after trauma. Late or inadequate manipulations can be dangerous.
The most frequent articular injury in children is the
volar plate avulsion, a Salter-Harris Type III lesion. This
fracture is stable and it only requires immobilization and
buddy taping of the fingers after the initial few days of
immobilization. At first, buddy taping will be necessary all
the time, gradually progressing to buddy taping only during sports or other exerting activities with affected hand.
The second most frequent articular injury is a Type II
fracture of the proximal phalanx of the fifth finger. It is
caused by forced abduction. Treatment usually consists of
closed reduction and immobilization of the metacarpophalangeal (MP) joint in 90 flexion in order to keep collateral
ligaments extended, for 3 weeks.26
Thumb fractures
The most frequent fractures involving the thumb are those
of the diaphysis, generally called greenstick fractures.
They are similar in children and in adults but a childs
ability to remodel is stronger. This is the reason why they
support wider angulations. Another typical fracture in children is Type III Salter and Harris epiphysiolysis of the first
metacarpal base and that of the proximal phalanx. The first
of these two injuries can evolve to a Bennetts fracture
(treated with the same surgical indications as those occurring in adults), requiring preferably intermetacarpal spinning following Tubiana or Iselin.27,39,47 The second injury
behaves as an ulnar collateral ligament avulsion in adults,
probably requiring open reduction and internal fixation.13

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Traumatic Articular Injuries

Isolated ligament injuries of the joints cannot usually be
diagnosed on radiographs. Partial sprains are common in
children. The symptoms include pain and tenderness. The
joint usually is stable and articular effusion usually is
present. The most frequently involved joint is the proximal
interphalangeal (PIP) with a volar plate sprain and fourth
finger. Radial collateral ligament sprains of the MP joint
of the fifth finger and of the ulnar collateral ligament of the
MP joint of the second finger are frequent too. We agree
with the vast majority of authors that best therapy is nonoperative, immobilizing the joint in a functional position
for 5 to 7 days and beginning with early mobilization plus
buddy taping for 2 more weeks.
Total ligament rupture can occur alone or together with
a dislocation that was reduced previously. The most important feature is articular instability. Treatment is nonoperative except when the ulnar collateral ligament of the
MP joint is involved.
Dislocations can be incomplete, complete, and complex. They occur less frequently in children than in adults
because ligaments are stronger than the physis hypertrophic plate; what takes place is a volar plate avulsion instead of a dislocation. Total dislocations usually are dorsal
and only need nonoperative treatment through immobilization for 2 weeks. In dislocations considered complex
because of interposition of soft tissues between bones, a
dorsal approach, in order to avoid volar collateral nerve
damage, is advised. Anyway, our experience shows that
open reduction is needed less frequently in children than in
adults.
Distal interphalangeal (DIP) joint dislocations are infrequent and usually they only need closed reduction except when osteochondral fracture is present.10 Another
problem related to these dislocations is extensor tendon
injury. Early mobilization with extension protection is recommended when treating these injuries.
For all these lesions, palliative measures, especially arthrodesis, must be considered. These therapies, although
infrequent, are well tolerated in the DIP joint and thumb
interphalangeal (IP) joint.39 Our experience reveals that no
other measure generally is needed.
Tendon Injuries
These lesions are infrequent in children. Only a mallet
finger after crush represents a considerable proportion of
tendon injuries in children. Examination of these patients
is difficult because of inability to cooperate with assessment of motor function. Nevertheless, treatment options
used in children are similar to those treatment options used
in adults and the only difference is that the repair technique should be more meticulous in children. Strict immobilization for 3 to 4 weeks is mandatory, except when

Clinical Orthopaedics
and Related Research

treating very cooperative adolescents. The analysis of our

experience has shown better results in children than in
adults.
Extensor Tendons
Mallet finger in children is similar to mallet finger in
adults, but there is a special characteristic in mallet finger
in children: a Type IV epiphyseal fracture. These injuries
can be treated using closed reduction and immobilization
for 3 to 4 weeks.1820 The main problem is instability and
possible interposition of matrix, then requiring open reduction and internal fixation using K-wires or metallic
sutures (Mantero technique),48 keeping the joint extended.
Flexor Tendons
From 1993 to 2002, we treated 244 pediatric patients who
had 317 flexor tendon injuries of the hand and wrist at the
emergency room. Thirty percent of patients had more than
one tendon involved, associated with neurovascular lesions. Isolated flexor tendon injuries are not very common
during childhood and they often are associated with glass
trauma. Incidence in adolescents is similar to the incidence
in adults, and domestic accidents are the most frequent
cause. In young children, surgical exploration usually is
done using general anesthesia and cuff-obtained ischemia.
We also advise the use of magnifying glasses and avoidance of any traumatic maneuvers. We try to obtain direct
suture of every involved structure whenever it is possible,
except when a small laceration is observed; then we prefer
to cut the damaged zone to avoid triggering. We recommend a modified Lange suture with 4/0 monofilament
thread and continuous epitendinous suture with a 6/0
monofilament suture. Whenever possible, we try to repair
pulleys and sheaths. We also agree with different authors18,46 about the adequacy of suturing superficial and
deep flexor tendons in zone II. Immobilization should be
maintained for 4 weeks and regular activity is recommended after 7 to 8 weeks, depending on the patient and
the severity of the injury. Generally, results are better in
children than in adults.46 This improvement is quantified
through the Strickland and Glogovac scale,44 comparing
results obtained in a patient population younger than 14
years and comparing results obtained in adults between 30
and 50 years old. We have not found poor results in uncomplicated lesions. Extension deficits are considerably
corrected through discontinuous dynamic splinting in children older than 8 years.
Nerve Injuries
From 1993 to 2002, we reviewed 458 nerve injuries in 353
patients younger than 14 years. In this review, we included
nerve injuries produced by lacerations involving the hand

Number 432
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and the upper extremity (including two humerus fractures). Although these lesions are uncommon, we show
that age is a basic factor in order to establish possible
nerve regeneration.3,6
The most frequent nerve injuries are those caused by
broken glass. Those nerve injuries associated with fractures (eg, humerus supracondylar) are infrequent and the
initial treatment approach should be nonoperative, as different authors have concluded.7,29,31
Careful exploration of the injury, including clinical history and cause of injury, is mandatory. An exact diagnosis
usually is achieved, especially in younger infants, by surgical exploration using general anesthesia. Primary repair
is the goal of therapy whenever possible. Loss of neural
substance or complex lesions associated with traffic injuries usually require secondary repair. The most commonly
used technique is epiperineural suture. Immobilization of
surrounding joints lasts from 3 to 4 weeks. When the ulnar
nerve is involved, the fourth and fifth finger should be
immobilized to prevent claw deformities.
A motor defect of the radial nerve requires immobilization to let the nerve heal and to prevent the wrist extension deficit. Median nerve injuries do not require any special immobilization.
In complex injuries, we advocate the repair of every
involved structure. We usually obtain information about
the injuries in children younger than 6 years from their
parents and teachers. We also try to prevent trauma, especially in burns, in those areas that present hypoesthesia.
Followup lasts at least 2 years, and usually examining
these patients when they are 10 years old. We try to assess
objectively trophic disturbances and algesic sensory repair. We consider following Moberg33 as good resulta
two-point discrimination less than 1 to 2 mm. Motion
evaluation in younger children can only be observed by
watching their movements in their regular activities and
appreciating their apparent defects.
Complex Injuries
Complex injuries are those that involved two or more
structures of the hand: skin, bones, tendons, vascular structures or nerves threatening viability or function of the
hand.16 The most frequent hand complex injuries in infants are amputations and avulsion injuries.
Amputations
The primary consideration in any situation in which a
patient has been treated with a partial or complete hand
amputation is focusing on the functional rehabilitation of
the patient. The goals of amputation surgery in the hand
should be: a) preservation of functional length; b) preservation of utility; c) prevention of symptomatic neuromas;

Pediatric Hand Trauma

81

d) prevention of adjacent joint contractures; e) early morbidity; f) early prosthetic fitting when applicable; and g)
early return of the patient to play and/or academic activities.28 Amputations in children should be treated with an
extremely nonoperative approach. It is always advisable to
do a second-look procedure than to treat a child initially
with an aggressive resection.
Digital Tip Amputations
These injuries represent the most common type of amputation seen in the upper extremity. There are two main
forms: digital tip amputations with skin or pulp loss only
and digital tip amputations with exposed bone.
Digital Tip Amputations with Skin or Pulp Loss Only
When the digital tip is amputated, the geometry of the
defect dictates the various treatment possibilities. The loss
may be transverse or oblique, with more volar skin loss
than dorsal skin loss, or the reverse may be true. There are
three basic therapeutic procedures.
Nonoperative treatment requires three different stages
that lead to stump closure and remodeling: 1) the inflammatory phase, in which homeostasis and careful cleaning
of the wound should be done; 2) the proliferative phase, in
which granulation tissue appears; and 3) the differentiation
phase, in which scarring and epithelialization occur. This
approach has a special indication in children because they
have an intense regenerative ability and spontaneous remodeling of the stump. Main advantages of this technique
are good aesthetic result and sensory results. The disadvantage is the prolonged period of time until definitive
closure (16 3 days) and painful dressing changes.
Skin graft coverage is the most recommended surgical
option. Nevertheless, we consider that results obtained using this technique are no better than those obtained
through spontaneous closure. This conclusion also was
obtained in different studies that found that patients satisfaction after secondary healing was close to 90%, and
after skin grafting it was 56%, causing hyperesthesia in
26% of those treated nonoperatively and in 67% of those
who were treated with skin grafts.28 Sensory retention of
the stump was not good.
Primary closure is recommended by some authors,36
but we do not recommend it, based on our experience.
Neither the stumps quality nor the postoperative complaints from patients justify this treatment. There are two
main problems: the need for shortening the stump in order
to obtain a good aesthetic result and a higher incidence of
hyperesthesia.
Digital Tip Amputation with Exposed Bone
When bone is exposed, reparation usually is achieved
through different local flaps. Composite grafts have not

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Clinical Orthopaedics
and Related Research

offered good results, showing a survival rate in the best

series of 58% in those amputations distal to eponychium
and 43% in those situated between the eponychium and
DIP joint.20 Geometry of the injury dictates which repair
technique is indicated.
The Atasoy volar V-Y advancement flap1 is a triangle
pattern made to cover the dimensions of the defect. The
base of the triangle will be the distal cut edge, with the
apex being at the DIP flexion crease. The full thickness of
the skin is cut. The digital nerves and blood vessels of the
flap are preserved. Separation between the flexor sheath
and the subcutaneous tissue facilitates advance of the flap
distally. The base of the triangle is sutured to the nail bed
or remaining nail, and the resulting V incision on the palmar aspect of the digit is closed, converting it to a Y. Some
slight defatting may be necessary to facilitate a tensionfree skin closure.
Kutler lateral flaps24 use two triangular flaps developed
and reflected from lateral positions to cover the tip of the
digit (Fig 3). Preparation is similar to that explained in the
Atasoy flap. It is the choice flap when volar skin loss
makes the Atasoy flap not suitable. Main complications of
this flap are suture edge necrosis (usually partial and not
very important) and stump dysesthesias. This last feature
occurred in 54% of the 22 patients in our series.
The literature shows a large collection of described
flaps28 that can be used in digital tip amputation, including the cross-finger flap, thenar H-flap, and others.
They are more applicable theoretically than they are in
practice.
Proximal Amputations of the Fingers
Proximal amputations of the fingers occur at levels proximal to the digital skin pad involving bone.
Amputations through DIP Joint
When doing an amputation through the DIP joint, occasionally it could be appropriate to shorten the phalanx in
order to avoid primary closure. It is not agreed on whether
it is advisable to maintain articular cartilage of the phalanx
or not. Those who advocate its maintenance indicated that
this measure presents less inflammatory response. Those
who recommend its resection together with lateral condyles remodeling indicate that uniformity of the stump is
more important. Using this technique also prevents unnecessary pain for the patient. Additionally, volar and lateral plates and flexor tendon fragments should be removed. The collateral nerves should be translocated away
from the cutaneous scar to an area where the inevitable
neuromas will not become symptomatic because of contact. The use of low-voltage electrocoagulation also has
been described.

Fig 3AB. (A) Tip amputation and (B) Kutler lateral V-Y flaps
reconstruction are shown.

Amputations through Middle Phalanx

Flap reconstruction is not indicated when amputation is
proximal to the DIP joint. Bone must be shortened and
primary closure should be obtained, using preferably volar
skin because of its better sensory capacity.

Number 432
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Pediatric Hand Trauma

83

Amputations Proximal to Middle Phalanx

Amputations through the PIP joint should be done similarly to those done through the DIP joint. If amputation has
occurred proximal to the PIP joint, the remaining proximal
segment is under the motor control of the intrinsic muscles
and the extensor digitorum communis. This will allow
active flexion of the proximal phalanx of approximately
45. If amputation has occurred near or at the MP level, a
more proximal ray amputation, especially in the central
two rays, should be considered.
Ray Amputations
Complete ray amputations usually are done because of
posttraumatic complications rather than because of direct
trauma. In the majority of these cases, they are elective
surgery before which the impact of this amputation on the
function of the hand must carefully be considered. Secondray amputation is associated with a 20% loss of power
grip, key pinch, and supination strength. Pronation
strength was diminished by 50% of predicted value.34
Multiple Digit Injuries
Basic principles that contribute to the treatment of these
injuries are those that tend to conserve viable tissues in
order to do late reconstruction. This reconstruction involves transposition of viable tissues or removing useless
fragments trying to preserve basic functions of the hand:
grip and pinches (Fig 4).
In children, most amputations should be replanted unless severely damaged, because if it is successful, a good
function and healthy growth may be expected.40 In one
study4 on digital replantation done in children, average
bone growth of 93% compared with the contralateral noninjured side was found. With the epiphysis affected, bone
growth was reduced to 86% of the contralateral side. The
mean total active motion of fingers was 151. Sensibility
recovery was excellent, with normal two-point discrimination of 88%. Nineteen of 20 preselected activities of
daily living could be accomplished. Relative grip strength
was 79% that of the healthy side and the relative pinch
strength was 88%. Cold intolerance was slight or moderate
in 40% of patients. The circulatory status of the replanted
fingers was excellent in 88% of digits and good in 12%.
All patients and their parents were satisfied with the results
of the digital replantation.12
Amputations through the Thumb
In infants, this represents an absolute indication for replantation when injury conditions and quality of the fragments
allow it.40 If replantation cannot be done in the acute
phase, there are different surgical options secondary to
thumb amputations. Nevertheless, thumb functional re-

Fig 4AB. (A) Multiple digit injury is shown. (B) Repair maintaining two useful stumps in order to keep power grip and
pinches is shown.

quirements must be considered: adequate sensibility, appropriate length, motion able to allow opposition to other
fingers, and painless sensation.43 There is no consensus on
what length defines a functional sequel secondary to
thumb amputation. When the proximal phalanx is present,
adequate function usually is achieved and no lengthening
techniques are required. When amputation has occurred at
the MP level or at the proximal phalanx base, a stump is
not enough to restore basic functions of the hand properly.
There are various surgical options that can be used in
thumb amputations.

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Valencia et al

First-ray Lengthening Techniques

First-ray lengthening techniques usually are done through
transposition of viable fragments of other fingers in cases
in which injury involved different digits. Grafts obtained
from iliac crest also are suitable. Osseous distraction
through external spinning also has been described in the
literature, but pediatric patients are not the ideal group for
this technique. We consider adults more appropriate patients for this procedure.
First Web Space Deepening
First web space deepening usually is achieved through the
use of single or multiple Z-plasty flaps. Dorsal rotational
flaps also have been used.
Pollicization of Index Finger
This technique, initially described by Buck-Gramcko8,9 as
treatment for hypoplastic and aplastic thumbs, represents
one of the most interesting therapeutic options for traumatic thumb amputation. Even when the second finger is
the most easily used for pollicization because it is adjacent
to the thumb, translocation of third, fourth, or fifth fingers
also has been described in the literature.11

Clinical Orthopaedics
and Related Research

Partial Avulsion Injuries

In these injuries, the skin is rolled over without involving
deep osteotendinous structures. It is commonly called degloving. In adults, these injuries are associated with rings
and in children they usually are associated with imitative
behavior using circle objects usually sharper than rings.
Prognosis of these injuries is determined by the degree of
vessels in the lesion and especially the degree of the venous return. When these structures are preserved, functional prognosis is good, although rolled skin can suffer
partial or total necrosis (Fig 5).
Complete Avulsions
This kind of injury represents the typical nonreplantation
indication. The important tissue involvement and associated vascular damage does not allow microsurgical repair.

Toe to Thumb Transplantation

This technique first was described by Nicoladoni at the
beginning of the 20th century. Because microsurgery has
become a standard procedure, this kind of surgery has had
a growing importance.43 The main disadvantage is the
different size between the first toe and thumb, provoking a
sometimes unacceptable aesthetic result. Some authors
have tried solving this problem by using just half of the toe
or 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 necessary. Two-point-sensibility was present in 62% of the
transplantations; the largest range of motion of 50 was
obtained in the MP joint.
Amputation of the Hand
Apart from accepting the amputation, the only possible
therapy is acute replantation. When this fails or when it is
not indicated, amputation and fitting a patient with a prosthesis is the only treatment option.
Avulsion Injuries
These kinds of traumas usually are secondary to mechanical forces applied in different and opposite directions. The
difference between avulsion injuries and amputations is
that avulsion injuries are more complex lesions and are
more difficult repair. There are two types of avulsion injuries: partial avulsion injuries and complete avulsion injuries.

Fig 5AB. (A) Partial avulsion injury with (B) minimum necrosis of the wound edges is shown.

Number 432
March 2005

There are only two exceptions to this rule: thumb avulsion

injury and avulsion in pediatric patients.
Thumb Avulsion Injury
The overall survival rate in thumb replantation after avulsion injury is 48%. In one study avulsions at or proximal
to the MP joint had a survival rate of 83% compared with
a 38% survival rate distal to the MP joint.2 This difference
was related to the difference size of the vessels.
Avulsion in Pediatric Patients
The excellent regenerative ability of pediatric patients has
made replantation after complete avulsion injuries a surgical option in this group of patients. General survival rate
in this situation has been 70.4%. Occasionally, application
of a primary interpositional vein graft has been necessary.
Prosthesis in Infants
Children who have had amputations present a permanent
challenge. Even with improvements in surgical techniques,
prosthesis fixation, and rehabilitation programs, there still
are challenges to overcome when treating these patients.
Professionals assisting these patients must be familiar with
available technological devices available to treat to these
children and to advise their families on how to cope with
the situation. Although a prosthesis is never going to substitute for an amputated finger or hand, its meticulous
prescription and its use and training coordinated with the
growth of the child can optimize results.
Hand injuries in pediatric patients represent a challenge
for physicians and other medical professionals involved in
this care and treatment of these patients. Results obtained
in this group of patients usually are better than those obtained in adults because of the regenerative potential of
childrens bodies and their high degree of cooperation with
physicians. Meticulous repair of damaged structures is always indicated when treating hand injuries in children.
Long-term followup and advice for the children and their
families also are necessary.
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