Ho-Jung Kang, et al. Fig. 5. Intraoperative findings of proximal phalangeal neck fracture. Central tendon insertion was mobilized with a rubber band. Internal fixation was done by criss- cross 23 gauge needle fixation. growth and proximal interphalangeal joint swell- ing was present in four patients, but none had any functional disturbance. No pin site infections or osteonecrosis of the phalangeal head occurred. DISCUSSION Neck fracture of the proximal phalanx of the finger is a relatively uncommon injury and occurs almost exclusively in children. Leonard and Dubrovnik,10 in a review of 263 finger fractures in children, found that 38 (15%) were fractures of the phalangeal neck. Of 38 patients, nine required open reduction and internal fixation, either for dorsal displacement with volar angulation of the head or for 180 proximal rotation of the head. The current authors have seen 248 finger fractures in children. Of those fractures, 27 were proximal phalangeal neck fractures (10.9%). Surgery was performed in 24 patients. In the current study, closed reduction and pinning with splint immo- bilization was used only for the patients who had less than 5 angulation deformity after closed reduction, without rotational deformity. Advanta- geously, stabilization of the fracture by percutane- ous pinning allows the patient to move the small joints of the injured digit during fracture healing to prevent stiffness. Therefore, closed reduction and internal fixation are recommended as the initial treatment. Closed reduction may be diffi- Yonsei Med J Vol. 46, No. 4, 2005 cult if there is displacement with some degree of rotation of the fractured fragment (Type II & III). Dixon and Moon11 reported that, in children, the volar plate could roll on itself, causing 90 rota- tion of the condylar fragment which then is en- trapped in the capsule and collateral ligaments. This fracture may easily be overlooked because of obscure radiographic findings and a lack of finger deformity. The fractured distal fragment is usually cartilaginous and may be radiolucent. The ossified portion of the distal fragment is usually small. Because the phalangeal neck fractures have a ten- dency to rotate dorsally, with the intact collateral ligaments acting as the pivot point, the proximal and distal fragments can overlap each other and be missed on normal AP radiographs. Thus, the true lateral view is more helpful in diagnosing phalangeal neck fractures. In the current study, seven patients who visited private clinics when initially injured received closed reduction and splint immobilization. Six patients were transferred to the author's institu- tion because of late recognition of fracture frag- ment displacement or rotation. Two patients' parents did not recognize the finger deformity or fracture at the time of initial injury. On average, the patients visited the author's institution 5 weeks after the trauma. The initial finger radio- graphs showed shortened phalangeal length with minimal AP displacement and 180 rotation of the head on lateral projection. Hastings and Simmons6 reported that operative treatment was needed for patients with displacement greater than 5 angula- tion, displacement of more than 2 mm radiograph- ically, or any clinical evidence of malrotation or angulation. They argued that the most common causes of malunion were reliance on inadequate radiographic views, failure to critically evaluate for rotational alignment with the digit in full flexion, inadequate immobilization of the frac- tures, or an assumption that the fracture would always remodel. In the hand, growth plates nor- mally exist only in the proximal end of phalanges, the proximal end of thumb metacarpal, and the distal end of the finger metacarpals. The literature reports a limited potential for remodeling after fractures of the neck of the proximal phalanx because of the distance of the fracture from the physis. If treated unreduced, these fractures may