“One Note Higher”: A Unique Pediatric Hand Fracture

CASE PRESENTATION: An otherwise healthy, 12-year-old male presented to the emergency department after a fall down the stairs in which he landed on his right hand. Radiographs demonstrated a Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation, also known as an “extra-octave“ fracture. Orthopedic surgery was consulted and the fracture was reduced and placed in a short-arm cast. The patient was discharged and scheduled for orthopedic follow-up. DISCUSSION: A Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation is referred to as an “extra-octave” fracture due to the advantage a pianist would gain in reach of their fifth phalanx if not reduced. However, reduction is needed if the fracture is displaced and can be achieved by several described methods including the “90-90” or “pencil” methods followed by cast or splint application. Percutaneous pinning is rarely needed. Complications include flexor tendon entrapment, collateral ligament disruption, and malunion leading to a “pseudo-claw” deformity. We recommend that all extra-octave fractures receive orthopedic follow-up in one to two weeks or sooner if severely displaced.