Salter-Harris type III dorsal fracture-dislocation of the second and third proximal interphalangeal joints: a case report

Abstract

Background

Paediatric fracture-dislocation of the second (2nd) or third (3rd) proximal interphalangeal (PIP) joint is a rare injury and often associated with growth plate injury. There are few case reports regarding this uncommon injury, and no study has reported on Salter-Harris (SH) -type III injuries.

Case presentation

We present the case of a 6-year-old softball player who suffered from irreducible SH-type III fracture-dislocations of the 2nd and 3rd PIP joints at different time points, which were treated by open reduction without internal fixation. The injury mechanism for the fracture-dislocations of the 2nd and 3rd PIP joints was the same when he caught a ball with his right hand in a left-hand softball globe. The palmar epiphysis of the middle phalanx was displaced dorsally in an upside-down position and was interposed within the PIP joint during both surgeries. After reducing the bony fragment gently using an elevator, the fragment remained congruent and stable in the extension of the PIP joint without instability of the collateral ligaments under fluoroscopy. Therefore, internal fixation of the fragment was not performed at both surgeries. At the latest follow-up examinations (7 years after surgery for the 2nd PIP joint and 5 years after surgery for the 3rd PIP joint), the patient showed no pain or restrictions in finger range of motion. However, the plain radiography showed early closure of the growth plate of the 2nd middle phalanx.

Conclusions

We herein firstly presented the case of a patient with Salter-Harris type III irreducible fracture-dislocation of the 2nd and 3rd PIP joints that required open reduction without internal fixation. The injury mechanism and the location of the displaced palmar epiphysis of the middle phalanx were specific. At the midterm follow-up examinations, the patient showed no pain or restriction of the finger range of motion, although early closure of the growth plate in the 2nd middle phalanx was found on plain radiography.

Introduction

Hand fractures, especially phalangeal fractures, are one of the most common injuries, and are often concomitant with growth plate injuries in pediatric patients [1–3]. It is well known that these pediatric phalangeal fractures and growth plate injuries most frequently occur in the little finger [1, 3]. According to a recent study by Zhu et al. [3], second (2nd) and third (3rd) phalangeal fractures are rare, and growth plate injuries of the 2nd and 3rd middle phalanxes are quite uncommon, with an incidence of 0.41% (1/246 growth plate injuries of the hands).

Fracture-dislocation of the 2nd or 3rd proximal interphalangeal (PIP) joint is also rare, and there are few case reports on the short-term surgical outcomes [4–8]. When fracture-dislocation of the PIP joint is irreducible, open reduction with or without internal fixation is generally considered. Furthermore, to the best of our knowledge, no previous studies have reported on surgically-treated Salter-Harris type III fracture-dislocation of the 2nd or 3rd PIP joint. In this article, we report a case of Salter-Harris type III irreducible fracture-dislocation of the 2nd and 3rd PIP joints at different time points that required open reduction without internal fixation.

Case presentation

A 6-year-old boy was referred to our department for the treatment of an irreducible fracture- dislocation of the 2nd PIP joint of the right hand. He was a softball player but a beginner with only two months of experience. The index finger was injured when catching a ball with his right hand in a left-hand softball globe. The 2nd PIP joint was flexed when the softball hit the dorsal aspect of the middle phalanx. The dislocated PIP joint was manually irreducible although closed reductions were attempted two times under local anesthesia using fluoroscopy in a private orthopaedic clinic. Therefore, he was referred to our hospital. At his first presentation, there were no signs or symptoms suggestive of associated neurological or vascular complications. Plain radiography and computed tomography (CT) showed a dorsally dislocated PIP joint of the index finger with a small bony fragment (Fig. 1).

Fig. 1.

Radiographic findings at the presentation of fracture-dislocation of the second proximal interphalangeal joint. A Anteroposterior view. B Lateral view. C Computed tomography image. Red arrow indicates a small bony fragment

Surgery was performed under general anesthesia eleven days after the index injury. Firstly, a zigzag incision was made over the palmar side of the PIP joint to evaluate volar plate injury. No obvious injury to the volar plate was observed macroscopically. Then, a second curved incision was made over the dorsal aspect of the PIP joint, and the extensor tendons were retracted laterally. When the joint capsule was incised and opened, an osteochondral fragment in an upside-down position was interposed within the PIP joint (Fig. 2-A). We confirmed that the palmar epiphysis of the middle phalanx was the origin of this small fragment (Salter-Harris type III injury of the middle phalanx of the index finger). After gently reducing the bony fragment using an elevator (Fig. 2-B), the fragment remained congruent and stable in the full extension of the PIP joint and through the arc of motion (> 30°flexion was not also required to maintain the reduction of the PIP joint). In addition, no instability of the collateral ligaments was confirmed by manual stress under fluoroscopy. Therefore, internal fixation of the fragment was not performed. Postoperatively, the PIP joint was immobilized with a finger splint for two weeks. From two weeks after surgery, range of motion (ROM) exercises were initiated as tolerated with applying buddy taping. Buddy taping was applied until six weeks after surgery. The bone union was confirmed by plain radiography at four weeks postoperatively. He was able to return to softball three months after surgery.

Fig. 2.

Intraoperative pictures. A Dorsal approach to the second proximal interphalangeal (PIP) joint. The palmar epiphysis of the middle phalanx (black arrow) was dorsally displaced and interposed within the PIP joint. B Palmar approach to the second PIP joint. The displaced palmar epiphysis of the middle phalanx (black arrow) was reduced. D, distal; P, proximal

Two years after the above injury, this patient experienced a 3rd PIP joint injury during playing softball. This occurred by the same injury mechanism as the fracture-dislocation of the 2nd PIP joint. He was referred to our hospital as an irreducible dorsal fracture-dislocation of the 3rd PIP joint. Plain radiography and CT showed findings similar to those at the time of fracture-dislocation of the 2nd PIP joint (Fig. 3). Closed reduction was not attempted because the clinical presentation was the same as those of the fracture-dislocation of the 2nd PIP joint.

Fig. 3.

Radiographic findings at the presentation of fracture-dislocation of the third proximal interphalangeal joint. A Anteroposterior view. B Lateral view. C Computed tomography image. Red arrow indicates a small bony fragment

Surgery was performed under general anesthesia twelve days after the injury. Considering the similar presentation at the time of fracture-dislocation of the 2nd PIP joint, we approached the 3rd PIP joint dorsally using a curved incision. An epiphysis of the 3rd middle phalanx in an upside-down position was again interposed between the PIP joint (Fig. 4). The epiphysis was gently reduced using an elevator without fixation using a Kirschner-wire. The postoperative protocol was the same as that used after surgery of the 2nd PIP joint. The bone union was confirmed by plain radiography at four weeks after surgery. He was able to return to softball three months after surgery.

Fig. 4.

Intraoperative picture. (A) Dorsal approach to the third proximal interphalangeal joint (PIP). The palmar epiphysis of the middle phalanx (black arrow) was dorsally displaced and interposed within the PIP joint. D, distal; P, proximal

At the latest follow-up examinations (7 years after surgery for the 2nd PIP joint and 5 years after surgery for the 3rd PIP joint), there was no pain or restriction to finger ROMs. Plain radiography showed early closure of the growth plate in the 2nd middle phalanx, whereas there was no closure of the growth plate in the 3rd middle phalanx (Fig. 5). He was able to play softball at the same preinjury performance level without any complaints.

Fig. 5.

Plain radiographic findings at the latest follow-up examinations (7 years after surgery for the second PIP joint and 5 years after surgery for the third PIP joint). A Anteroposterior view. B Lateral view

Discussion

We herein firstly presented the case of a patient with Salter-Harris type III irreducible fracture-dislocation of the 2nd and 3rd PIP joints that required open reduction without internal fixation. At the midterm follow-up examinations, the patient showed no pain or restriction of the finger ROM, although early closure of the growth plate in the 2nd middle phalanx was found on plain radiography.

Hand fractures are common injuries among pediatric patients, with an annual incidence of 448/100000 by Lempesis et al. [9]. Pediatric phalangeal fractures most frequently occur in the fifth finger while playing ball sports [1]. However, there are few papers that reported on irreducible fracture-dislocation of the 2nd or 3rd PIP joint in pediatric patients [4–8]. Jones et al. [4], Keene et al. [5] and Hashizume et al. reported on Salter-Harris type Ⅰ fracture-dislocation of the PIP joints while Ghanghurde et al. [7] and Urness et al. [8] have reported Salter-Harris type II injuries. In the present case, a 6-year-old boy experienced Salter-Harris type III fracture-dislocations of the 2nd and 3rd PIP joints at different time points, which has not been reported in the literature.

The injury mechanisms of fracture-dislocation of the PIP joint include extension, axial load with extension, flexion, and axial load with flexion [10]. In the present case, the patient was a beginner softball player and injured his right PIP joints when catching a ball with his right hand within a left-hand softball globe. The PIP joint was flexed when the softball hit the dorsal aspect of the middle phalanx. In addition, intraoperatively, there was no volar plate injury and the palmar epiphysis of the middle phalanx dorsally displaced in an upside-down position. Therefore, it was speculated that the fracture-dislocation of the PIP joints would occur in the flexed PIP joint by hitting the softball as shown in Fig. 6.

Fig. 6.

Injury mechanism of the present case. A The soft ball hit the dorsal aspect of the flexed proximal interphalangeal (PIP) joint and axial force was applied to the joint. B The PIP joint dislocated dorsally. C The broken palmar epiphysis of the middle phalanx turned upside-down when the dislocated PIP joint returned to the original position

Testa et al. reported a similar Salter-Harris type III fracture-dislocation of the thumb interphalangeal joint in a 9-year-old boy [11]. However, to the best of our knowledge, no study has reported this type of fracture-dislocation of the PIP joint. In the present case, the patient had a habit of placing his right hand under the softball in the left-hand softball globe when catching a ball, which would be a predisposing finger position to the reported type of the fracture-dislocation considering that both fracture-dislocation of the 2nd and 3rd PIP joints exhibited the similar radiological and surgical findings. Therefore, paediatric softball and baseball players, especially beginners like the present case, should avoid this habit of catching a ball.

Various types of surgical procedures, including closed reduction and percutaneous pinning, external fixation, open reduction with or without internal fixation and hemiarthroplasty have been reported for the treatment of fracture-dislocation of the PIP joint [2, 12, 13]. However, there is still no consensus on the best surgical management of these fracture-dislocations. In the present case, the displaced epiphysis of the middle phalanx involved less than 30% of the PIP joint [14], and the stability of the fragment was confirmed intraoperatively during ROM of the PIP joint. In addition, the epiphysis fragment was so small that internal fixation was not performed. At the midterm follow-up examinations, the patient was free from symptoms and was able to play softball, although plain radiography showed early closure of the growth plate of the 2nd middle phalanx. Closed reductions were attempted several times before surgery of the fracture-dislocation of the 2nd PIP joint while no closed reduction was performed at the time of fracture-dislocation of the 3rd PIP joint. In addition, two incisions were created during surgery of the 2nd PIP joint while one incision was made for the 3rd PIP joint. These differences might contribute to the development of isolated premature physeal closure of the 2nd middle phalanx. Although no definitive conclusions on the optimal surgical treatment of Salter-Harris type III fracture-dislocation of the 2nd or 3rd PIP joint can be drawn from this case report, this case report will be helpful for orthopaedic surgeons who treat similar cases in the future. Careful long-term follow-up is mandatory to clarify the efficacy of this surgical treatment.

Conclusion

We presented a case in which irreducible Salter-Harris type III fracture-dislocations of the 2nd and 3rd PIP joints were treated by open reduction without internal fixation. At the midterm follow-up examinations (7 years after surgery for the 2nd PIP joint and 5 years after surgery for the 3rd PIP joint), the patient was free from symptoms and was able to play softball, although plain radiography showed early closure of the growth plate of the 2nd middle phalanx.

Abbreviations

PIP

Proximal interphalangeal

SH

Salter-Harris

CT

Computed tomography

ROM

Range of motion; 2nd, second; 3rd, third

Authors’ contributions

TO, MN and TY collected the data. TO and TY mainly drafted the manuscript, and TT, EC and NK supervised it. All authors had complete access to all data used in this study and take responsibility for its accuracy. All authors have read and approved the final manuscript.

Funding

The authors received no external funding for this study.

Data availability

All data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Written informed consent for participation was obtained from the patient and his parents.

Consent for publication

Written informed consent for publication was obtained from the patient and his parents.

Competing interests

The authors declare no competing interests.