Pediatric Phalangeal Neck Fractures: To Fix or Not to Fix?

Pediatric phalangeal neck fractures occur distal to the collateral ligament recess, often with apex volar angulation. These fractures are at an increased risk for various complications including malunion, nonunion, stiffness, and osteonecrosis. The Al-Qattan classification system categorizes these fractures into three types: type I fractures are nondisplaced, type II fractures are displaced while maintaining cortical contact, and type III fractures lack cortical contact with associated malrotation or partial amputation. Type I fractures are typically managed nonsurgically. Recent reports have shown that minimally displaced type II fractures can also be successfully managed nonsurgically. However, type II fractures with greater than 30° of angulation, 25% translation, and/or clinical malrotation or deviation warrant surgical intervention via closed reduction and percutaneous pinning. Open reduction is reserved for open fractures or when closed reduction techniques fail. Open reduction is associated with higher complication rates and poorer overall outcomes. Unsatisfactory outcomes are common in fractures with poor prognostic factors, including vascular compromise, concurrent distal epiphyseal or juxtaphyseal fractures, comminution of the phalangeal head, open fractures, and all type III fractures. Phalangeal neck fractures require special attention and should be managed using an algorithmic approach to optimize outcomes and mitigate complications.