Operative Treatment for Proximal Phalangeal Neck Fractures of the Finger in Children heal with angular deformity and a bony block to flexion.7,9,12 To prevent such deformity, we per- formed surgical treatment for anatomical reduc- tion. Simmons and Peters12treated three children with such malunions using the volar approach with incision of the accessory collateral ligaments to provide exposure. A power burr was used to extensively resect the bony block, with average gain of 42 degrees of flexion at the proximal interphalangeal joint for their patients. Early open reduction or closed reduction and percutaneous pinning of the fracture generally yield better results than attempts to correct the malunion later.13 We proposed that the indications for open reduction are the failure of closed reduction as an initial treatment, an unstable fracture that was not maintained after reduction, or a malunited frac- ture due to the failure of conservative treatment and gross rotational deformity of the nail plane in full grip. In open reduction for malunited cases, osteoclasis must be performed to obtain accept- able range of motion 6 weeks after the initial injury. In our study, malunion of the fracture, due to late recognition of fracture fragment displace- ment and rotation, was found in 6 cases, which were treated between 4 and 6 weeks after the initial injury. All of them required open reduction and internal fixation, including osteoclasis or osteotomy. In some of the children, the affected phalanges were so small that Kirschner's wire was sometimes inadequate for fixation.14 In those cases, we used 23-gauge needles as fixation ma- terial. Criss-cross needle fixation was adequate for the union. The initial X-ray, and especially the true lateral view, must be carefully examined. We recom- mend performing the dorsal midline incision and occasionally the parasagittal incision through the transverse retinacular ligament for accurate rota- tional alignment. Twenty-three gauge, criss-cross fixation needles can be best used for younger children or small fracture fragments. The best results can only be obtained with early active motion exercise and restoration of the plane of motion and the axis of rotation. REFERENCES 1. De Jonge JJ, Kingma J, Van Der Lei B, Klasen HJ. Phalangeal fractures of the hand. An analysis of gender and age-related incidence and etiology. J Hand Surg 1994;19B:168-70. 2. Schenck RR. Classification of fractures and dislocations of the proximal interphalangeal joint. Hand Clin 1994; 10:179-85. 3. Worlock PH, Stower MJ. The incidence and pattern of hand fractures in children. J Hand Surg 1986;11B:198- 200. 4. Campbell RM Jr. Operative treatment of fractures and dislocations of the hand and wrist region in children. Orthop Clin North Am 1990;21:217-43. 5. Barton NJ. Fractures of the phalanges of the hand in children. Hand 1979;2:134-43. 6. Hastings H 2nd, Simmons BP. Hand fractures in children. A statistical analysis. Clin Orthop 1984;188: 120-30. 7. Mintzer CM, Waters PM, Brown DJ. Remodelling of a displaced phalangeal neck fracture. J Hand Surg 1994; 19:594-6. 8. Wood VE. Fractures of the hand in children. Orthop Clin North Am 1976;7:527-42. 9. Al-Qattan MM. Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg 2001;26:112-21. 10. Leonard MH, Dubravcik P. Management of fractured fingers in child. Clin Orthop 1970;73:160-8. 11. Dixon GL, Moon NF. Rotational supracondylar frac- tures of the proximal phalanx in children. Clin Orthop 1972;83:151-6. 12. Simmons BP, Peters TT. Subcondylar fossa reconstruc- tion for malunion of fractures of the proximal phalanx in children. J Hand Surg 1987;12:1079-82. 13. Newington DP, Craigen MA. Bennet GC. Children's proximal phalangeal neck fractures with 180 degrees rotational deformity. J Hand Surg 1995;20:353-6. 14. Vandenberk P, De Smet L, Farby G. Finger fractures in children treated with absorbable pins. J Pediatr Orthop 1996;5:27-30. Yonsei Med J Vol. 46, No. 4, 2005