Full text can be accessed at http://jhs.sagepub.com/content/38/8/903.full.pdf+htmlFive patients under 4 years of age with 180 degrees rotational deformity of a proximal phalangeal neck fracture are described. All cases resulted from a direct shear force to the bone coupled with a sharp withdrawal reaction of the hand. All of the children were successfully treated with open reduction and internal fixation but only after fruitless attempts at closed manipulation and an initial lack of recognition of the severity of the fracture. Each child achieved a full functional recovery of the finger with clinical and radiological union at 4 weeks.