1/14/2010
Written By: Lynn M. Lindaman, Lindaman Orthopaedics
Category: Health & Fitness  

The structure and physiology of the immature hand has very significant influences on the types of injuries these athletes receive and the management of these injuries.  The athlete's hand may be skeletally immature well up into the high school years.  One factor that most everyone is aware of in the immature hand is the presence of growth plates, or physes.  The ligaments and tendons tend to insert on the epiphyseal portion of the bone.  In the immature skeleton the tendons and ligaments are stronger than the physis so that any force applied to the bone or joint will cause the physis to fail before the ligaments fail.  Adolescents athletes don't sprain, they break. 

In dealing with hand injuries, the primary bones we will be talking about are the fingers (phalanges).  The fingers are a frequent location of injuries in many sports.  The majority of these injuries are to the base of the finger (proximal phalanx) or the tip of the finger (distal phalanx).  The injury to the tip of the finger often results in the distal phalanx being snapped down suddenly.  The athlete will then notice that while they can flex the joint (DIP joint), they can't straighten it out.  This leads to the impression that the joint is sprained or that tendon that extends the tip of the finger is torn off the bone, as happens in adults.  In actuality, the tendon is still attached, but the distal phalanx has broken through the growth plate.
 

If left alone the fracture will heal, but will be in a permanently bent position.  Because of this, the fracture must be put back into position (reduced) and held there until the fracture heals.  This can usually be accomplished quite easily with a simple splint.   The one red flag would be if there is bleeding at the base of the finger nail as this would indicate that it is actually an Open Fracture.   This would then require surgical treatment to properly reduce the fracture and clean it out to prevent infection.

The situation is actually worse in the slightly older athlete where the growth plate is closing, but isn't quite closed yet.  In these instances the tendon actually pulls part of the epiphysis off.   This type of fracture disrupts the joint surface and upon healing will result in a permanently stiff and painful joint.  This requires a more accurate reduction and possibly stabilizing it with pins or screws.

Another common fracture occurs at the base of the proximal phalanx, the part of the finger where it connects with the hand.  This is frequently seen at the little finger where it is bent off to the side.   While this may be much more dramatic looking than the distal phalanx fracture, it really is much less serious.  It does need to be reduced into a reasonably, but not perfectly, straight position.  Here is where the immature and growing nature of the bone is beneficial.  Because of the soft bone in this area, the bone merely wrinkles in on itself and so is quite stable when it is straightened.  I like to compare it to squashing a Styrofoam cup, while the sides wrinkle in, it is still quite stable and can support itself.  As such, all the protection that the fracture needs until it is healed is "Buddy Taping".
  

In addition, because of the rapid healing of this age athlete, the bone is usually healed in a month, and during this time the athlete is usually able to fully participate in sports as long as the finger is buddy taped.

When dealing with finger injuries to High School age and younger athletes it is probably best to remember that if the finger is swollen or bruised it is most likely broken, not “jammed”.  While most fractures can be dealt with fairly quickly and simply and the athlete returned to action rapidly, open fractures and fractures into the joint frequently need surgical managements.