A 38-year-old right hand dominant female presented to the ED after sustaining an open fracture of the left small finger distal phalanx when it was caught in the rotary blade of a bread cutter at work. Ultrasonography-guided closed reduction in the treatment of displaced transphyseal fracture of the distal humerus. Medial condyle fracture with markedly rotated distal fragment in a 7-year-old boy. A pulled elbowis a distraction injury. Milch II lateral condyle fracture with elbow dislocation, frontal (A) and lateral (B) views. Please enable it to take advantage of the complete set of features! It usually involves injury to the volar plate and may include a volar plate avulsion fracture. Reduction of a dorsal PIP dislocation should be attempted at the time of injury, if possible, by applying traction and volar pressure on the middle phalanx at the PIP joint (Figure 1). Anteroposterior (A) and lateral (B) views. A more recent article on common finger fractures and dislocations is available. WebTransphyseal fracture of the distal humerus. Fig.1. This motion causes the ulna to fracture and contact the proximal radius, forcing the radial head to become dislocated from the capitellum. Rotator Cuff and Shoulder Conditioning Program. An avulsion fracture (Figure 5) typically results from forced hyperextension of a flexed DIP joint. The medial and lateral columns are more separated proximally than distally. Note the presence of the normal trochlear ossification center in this patient, which was not present in the younger patient. Supracondylar fracture. Distal phalanges are the most exposed phalanges and are, therefore, fractured more often than other hand fractures. Unable to process the form. The peak age of occurrence for these fractures is 4-10 years. Supracondylar fracture. When the elbow is fully extended, the olecranon becomes locked into the olecranon fossa, making it susceptible to fracture by varus or valgus stress. In some patients, impaction of the epiphysis on the medial aspect of the metaphysis may cause growth plate injury, leading to subsequent varus deformity (see the image below). Anteroposterior (A) and lateral (B) views. 2015; Accessed: May 30, 2016. [QxMD MEDLINE Link]. The presence or absence of an intra-articular component, degree of comminution, and fracture displacement should be assessed when formulating a report. WebFractures of the distal phalanx are the most common fractures in the hand. A modified Gartland type-IV fracture. Typically, an 18 (outer diameter 1.270mm) or 20-G needle (outer diameter 0.908mm) can be used for an adult. Treatment is generally straightforward, with excellent outcomes. Fat-suppressed T2-weighted coronal MRI shows that the fracture extends through the metaphysis into the epiphysis, although the articular surface remains intact. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. In addition to a transverse or oblique component through the supracondylar region, the distinguishing aspect of T-condylar fracture is a sagittally oriented component that extends to the articular surface, splitting the medial and lateral condyles. Accessibility Imaging Pitfalls of the Acutely Traumatized Pediatric Elbow. You may search for similar articles that contain these same keywords or you may [18]. 2009 Sep. 91(9):2188-93. It is imperative that extension is maintained at all times during treatment because any flexion can affect healing and may extend the treatment period. 5 The mechanism of fracture is usually a crush injury. Extreme tenderness when the thumb is touched, A misshapen or deformed look to the thumb, Test the tendons and nerves of the thumb to make sure there are no other associated injuries, Look for injuries to the other digits and the rest of the hand, Stress the ligaments of the thumb to make sure they are strong and have no evidence of injury. Cubitus varus has also been recognized to result from posttraumatic trochlear deformity, which is likely due to avascular necrosis of the trochlear ossific nuclei or ischemic injury of growth plate chondrocytes following distal humeral fractures, most commonly supracondylar fractures. Although not directly analogous, this is one example of the cost disparities associated with performing a procedure in the ER versus OR. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Cost and complications of percutaneous fixation of hand fractures in a procedure room versus the operating room. Dislocations of the MCP joint are usually dorsal.6 Simple dislocations do not involve soft tissue structures and are reduced using the same technique as with dorsal PIP dislocations. Referral to a hand specialist is needed if a dislocation cannot be reduced; is unstable following reduction; or involves significant ligament, tendon, or soft tissue injury. [9, 5, 20, 21, 22, 23, 24, 25, 26, 1], Supracondylar fractures are the most common elbow fracture in children, accounting for 50-60% of all elbow fractures. 2007;27:154157. Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age Prognostic Level III. [36, 37]. An end-result study. Radiographic findings that indicate transphyseal fracture rather than dislocation include maintenance of normal radiocapitellar relations and medial displacement of the forearm bones. Zhou H, Zhang G, Li M, Qu X, Cao Y, Liu X, Zhang Y. J Orthop Surg Res. Transphyseal fractures of the distal humerus typically occur in children younger than 3 years secondary to birth trauma, nonaccidental trauma, or a fall from a small Nonoperative treatment is based on immobilization of the DIP joint in extension, leaving the PIP joint free. John J Grayhack, MD, MS Associate Professor of Orthopedics, Northwestern University, The Feinberg School of Medicine; Consulting Surgeon, Department of Surgery, Division of Orthopedic Surgery, Ann and Robert H Lurie Children's Hospital of Chicago J Bone Joint Surg Am. Bookshelf Okumura Y, Maldonado N, Lennon K, McCarty B, Underwood P, Nelson M. Point-of-Care Ultrasound: Sonographic Posterior Fat Pad Sign: ACase Report and Brief Literature Review. There are pros and cons to all treatment options. Medial epicondyle fractures in children. It is also referred to as the terminal phalanx. On follow-up, additional fractures were seen in 32 of the children, and of these, 25 had a different type of fracture than that identified on the initial radiographs. Song KS, Kang CH, Min BW, Bae KC, Cho CH. Injury, postreduction, and follow-up x-rays are shown in Figure 3. Skeletal Radiol. J Trauma. Distal In addition to the findings in the multiple ossification centers described above, other normal findings may simulate pathology. 2001 Jan-Feb. 21(1):27-30. This is sometimes called a tuft fracture Healing: This normally takes approximately 4-6 weeks to heal. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. They represent > 50% of all phalangeal fractures and frequently involve the ungual tuft 1. Schubert I, Strohm PC, Zwingmann J. In the study, after clinical examination and before radiography, pediatric emergency physicians performed elbow US of the posterior fat pad and determined whether radiography was required. Wolters Kluwer Health, Inc. and/or its subsidiaries. If the capitellum is not yet ossified and hence cannot be used to evaluate elbow alignment, the direction of displacement of the forearm bone relative to the distal humeral metaphysis may be useful in distinguishing transphyseal fracture from elbow dislocation. Although it is important to differentiate medial condyle fractures from medial epicondyle fractures, the distinction is not always easy to make with radiographs. Radiography and referral are recommended for reduction requiring anesthesia and for open reductions.7 Following a simple MCP reduction, radiography is needed to assess congruity of the joint. 1975 Dec. 57(8):1087-92. Some common finger fractures can be treated conservatively with appropriate reduction and immobilization. (A) Lateral view of initial radiographs shows type III supracondylar fracture with marked posterior and proximal displacement of the distal fragment. The consequences of pin placement. In 94% of supracondylar fractures, an abnormally posterior position of the capitellum is demonstrated by passage of the anterior humeral line anterior to the middle third of the capitellum. According to Rabiner et al, ultrasonography is highly sensitive for elbow fractures, and a negative ultrasound may reduce the need for radiographs in children with elbow injuries. A subsequent anteroposterior view (C) shows lateral displacement of a distal fragment. [QxMD MEDLINE Link]. 2005;39(1):23-9. Like the metacarpal, the distal and proximal phalanges can fracture near/into a joint or in the shaft of the bone. [41] : Stage I fractures have an intact articular surface. All rights reserved. Management of vascular injuries in displaced supracondylar humerus fractures without arteriography. 3rd ed. Pain and swelling: Take your normal painkillers if you are in pain. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. Pain and swelling: Take your normal painkillers if you are in pain. Treatment of mallet fracture using a percutaneous fixation technique with an 18-gauge needle. Anteroposterior (A) and lateral (B) views. Displaced, oblique, or spiral finger fractures should be referred to a hand surgeon. Incidence of pin track infections in childrens fractures treated with Kirschner wire fixation. The characteristic location of the olecranon ossification centers, their smooth uninterrupted cortical margins, and the typical appearance of the partially fused physis help in distinguishing olecranon ossification from fractures at that site. When significantly displaced, supracondylar fractures usually have clinically obvious deformity. You may need surgery to treat the thumb fracture, depending on the location of the break, the alignment of the broken bone, and the amount of movement between the fragments. MRI coronal T2* gradient echo (B) and axial fat suppressed T2-weighted (C) images better show the extent of the fracture through the cartilaginous aspect of the medial epicondyle. A corrective lateral closing wedge osteotomy can be performed to restore a nearly normal carrying angle. J Pediatr Orthop. In the sagittal plane, the fracture may be transverse of oblique, extending upward from anterior to posterior. 1999 Oct. 81(10):1429-33. [Guideline] Hayes CW, Roberts CC, et al. Hence, lateral condyle fractures are Salter-Harris type IV injuries, even though they often have the radiographic appearance of a Salter-Harris type II injury. [29, 30] : Type 1 - Fractures with no or minimal posterior displacement or angulation of the distal fragment such that the anterior humeral line still intersects part of the capitellum, Type 2 - Fractures with more posterior displacement or angulation, but with an intact posterior cortex; type 2 fractures have been divided into type 2A, with no rotation or translation, and type 2B, with some rotation or translation in addition to posterior displacement and angulation, Type 3 - Fractures with displacement and complete cortical disruption (see the image below), Type 4 - Fractures with displacement, complete cortical disruption, and complete loss of the periosteal hinge anteriorly and posteriorly leading to multidirectional instability. (2006) Clinics in sports medicine. Radiology of Skeletal Trauma. 29 (4): 519-34. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. Identify direction (dorsal, volar, lateral), Check for neurovascular status and soft tissue injuries (volar plate in dorsal dislocation, central slip in volar dislocation), Volar: Splint in extension if there is an associated central slip, Check for neurovascular status and soft tissue injuries, Obtain postreduction radiographs (soft tissue injuries often impede reduction), Splint and early range of motion for simple dislocations, Splint for two to four weeks followed by range of motion; hyperesthesia, pain, and numbness common for up to six months following injury, Assess for inability to extend at DIP joint, Radiographs show a bony fragment at dorsal surface of the proximal distal phalanx, Splint DIP joint in extension for eight weeks, Assess for inability to flex at the DIP joint, Radiographs show a bony fragment at volar surface of the proximal distal phalanx, Referral recommended (possible flexor digitorum profundus retraction). Medial epicondyle avulsion fracture with entrapment in an older patient. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. Percutaneous pinning of distal phalanx fractures in the ED using an 18- or 20-G hypodermic needle is an effective treatment with minimal early complications. government site. Instr Course Lect. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. WebAbstract. WebDistal Phalanx Fractures Tuft Fracture (crush injury) Soft tissue injury is often more obvious; Xray required to detect underlying fracture Management consists mainly of [22]. FOIA Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. to maintaining your privacy and will not share your personal information without 2016 May 11. Loss of thumb function due to a fracture can affect your ability to grasp items, and certain types of thumb fractures can increase the risk of arthritis later in life. 2. JB Lippincott. What is the Distal Phalanx. Goto A, Murase T, Moritomo H, Oka K, Sugamoto K, Yoshikawa H. Three-dimensional invivo kinematics during elbow flexion in patients with lateral humeral condyle nonunion by an image-matching technique. J Pediatr Orthop. HHS Vulnerability Disclosure, Help Because the entrapped medial epicondyle is positioned just distal to the medial side of the distal humeral metaphysis, it may be misinterpreted as the ossification center for the trochlea. Orthop Clin North Am. Treatment of a mallet fracture includes splinting the distal interphalangeal joint in extension; various splint types are of equal benefit. Since relatively little growth occurs at the distal humerus, angular deformity in most cases is not due to growth disturbance, but rather malunion of varus deformity. Anteroposterior (A) and lateral (B) views. 1978 Jul. (A) Anteroposterior view shows a varus deformity of the distal humerus from a prior supracondylar fracture that has fully healed. They will also: If the bone fragments of the fracture have not moved (displaced) very much, or if the break is located in the middle (shaft) of the bone, your surgeon may be able to treat the thumb fracture without surgery using a specially designed cast (spica cast) to hold the bone fragments in place. However, distal pulses remained absent. Treatments usually include splints or surgery, for more severe fractures. Subtle cortical deformity also may be present medially or laterally, which may be associated with varus or valgus deformity. Barton KL, Kaminsky CK, Green DW, et al. To limit these complications, we wanted to explore the benefits of using locked extra-articular DIP pinning. JAMES R. BORCHERS, MD, MPH, AND THOMAS M. BEST, MD, PhD. We introduce a technique to stabilize diverse fractures of the distal phalanx in the emergency department (ED) utilizing a hypodermic 18- or 20-G needle. Although the radiologic diagnosis of lateral condyle fracture depends on plain radiographic findings, MRI, arthrography, or ultrasonography (US) may be useful in the further evaluation of the fractures, particularly with regard to the course of the fracture through the cartilaginous epiphysis, as shown below. [QxMD MEDLINE Link]. Distal phalanx fracture. When the cast is removed, your doctor may recommend hand therapy to restore movement to your hand. Br Med J (Clin Res Ed). More distally (D and E), there is reconstitution of the radial and ulnar arteries from collaterals that supply the palmar arch. Lateral condyle fracture. WebPhalangeal fractures are the most common foot fracture in children. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. Monteggia fracture/dislocation involves dislocation of the radial head accompanied by fracture of the proximal or mid ulna, with the apex of the ulnar fracture pointing in the same direction as the radial head dislocation. WebDisplaced phalangeal neck fractures may be missed because the fracture may be confused with a distal physis, a minor avulsion fracture, or even a nondisplaced fracture if adequate lateral and oblique films are not obtained. The bones of the hand and wrist are shown in the figure ( figure 1 ). These deformities may cause posttraumatic arthritis with pain and diminished range of motion, which are often not correctable. Normal radiographic findings that may simulate nontraumatic pathology include a radial tuberosity that appears as a lytic lesion when viewed en face (see the image below) and the olecranon fossa of the distal humerus, which may be unusually large and lucent. They are frequently related to sports, with lesions such as the mallet finger and the Jersey finger. In most patients, the fracture is a Salter-Harris type I injury, passing entirely through the growth plate. 2019 Feb 1;13(1):47-56. doi: 10.1302/1863-2548.13.180156. 3. Anterior displacement of most of the distal ulna relative to the wrist is due to a distal ulnar growth plate fracture, with anterior displacement of the metaphysis relative to the epiphysis, which still articulates normally with the wrist. Wheeler DK, Lindscheid RL. Referral to a hand specialist is required if a fracture is unstable, involves a large portion (greater than 30 percent) of the intra-articular surface, or has significant rotation. Note the normal position of the medial epicondyle in left elbow, which is not seen in the right elbow. 2016 Apr. All of the bones in the thumb are susceptible to fracture. Distal phalanx fractures are stable and can be treated with simple splinting of the DIP joint only. This humeroradial or radiocapitellar joint permits the radius to flex and extend relative to the humerus and to rotate throughout elbow flexion and extension. Between these grooves is the lateral crista of the trochlea, which provides lateral stability to the trochleoulnar joint. Richard M Shore, MD Professor, Department of Radiology, Northwestern University, The Feinberg School of Medicine; Head, Division of General Radiology and Nuclear Medicine, Ann and Robert H Lurie Children's Hospital of Chicago The fracture is almost always about 1 inch from the end of the bone. In young patients, alignment of the radiocapitellar joint is evaluated by using the radiocapitellar line, whereas in the more mature skeleton, articulating surfaces of the radial head and capitellum are revealed directly. 1998. Medial epicondyle fracture with entrapment in an 8-year-old boy. Burr, Rebecca G. MD; Burnham, Robert R. Jr MD; Fishman, Felicity G. MD, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL. A physical examination is crucial in the assessment of finger injuries. Reduction is often successful without anesthesia. 1992:753. Salter-Harris type IV injuries will often follow typical location patterns and most commonly involve the distal radius, phalanges and distal tibia. A biomechanical and histological analysis of failure modes. 7th Ed. Epub 2017 Sep 28. Weband phalanx fracture consolidation (Fig. More laterally, the capitellotrochlear sulcus separates the humeral articular surface of the radius from that of the ulna. (2010) Clinical radiology. (A) Anteroposterior, (B) oblique, and (C) lateral views show markedly rotated distal fracture fragment of this medial condyle fracture. Zorrilla S de Neira J, Prada-Caizares A, Marti-Ciruelos R, Pretell-Mazzini J. Supracondylar humeral fractures in children: current concepts for management and prognosis. With plastic bowing, no discrete fracture line is present. Matsuura T, Iwame T, Suzue N, Arisawa K, Sairyo K. Risk factors for shoulder and elbow pain in youth baseball players. Bone fixation techniques include devices that hold the bone fragments in place either inside the body (internal fixation) or outside the body (external fixation). Posterolateral elbow dislocation. It is also called nursemaid's elbow and other names; it usually results from a sudden pull on the hand. When no displacement is present, findings indicating a lateral condyle fracture may be subtle. Radiographs showed a physeal injury of the distal phalanx with an Normal articulation of the medial condyle and proximal ulna is maintained. Our patients experienced no pin tract infections, nail defects, or sensation issues. Invariably, the capitellum is the first secondary center to ossify, usually followed by the medial epicondyle, the trochlea, and the lateral epicondyle. The distal fracture fragment is displaced laterally and posteriorly. If extensive loss of motion persists, referral is recommended. Klatt JB, Aoki SK. Injury to soft tissue can also lead to hyperesthesia, cold sensitivity, and nail abnormalities.4 Fixation with previously described techniques, most frequently CRPP with k-wires, involves overutilization of hospital resources by requiring the procedure be done in an operative room. Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. Wolters Kluwer Health Normal lines. J Am Acad Orthop Surg. [QxMD MEDLINE Link]. The other bones of the thumb the distal phalanx and proximal phalanx are also susceptible to fractures. This typically occurs several years after the injury. This is encouraged before treatment is finalized. J Bone Joint Surg. 2018;13:428434. Edmonds EW. Prognostic Level III. On an anteroposterior view obtained after reduction of the lateral condyle fracture (C), the olecranon fracture is more obvious. WebThe doctor will take an X-ray of the wrist. Saeed W, Waseem M. Fracture, Elbow. Most patients with lateral condyle fractures are younger, and the epiphyseal extension of the fracture is within the growth cartilage and thus not identifiable on plain radiographs. Unable to process the form. Transphyseal fracture (also called transcondylar fracture) is a fracture through the distal humeral physis that separates the entire distal humeral epiphysis from the metaphysis. Initial lateral view (A) shows an abnormal anterior humeral line indicative of a fracture.
