These injuries resemble Salter-Harris type I, III, and II fractures, respectively, though the Salter-Harris classification is usually applied to injuries of the epiphyses rather than those of the apophyses. Radiographic findings that indicate transphyseal fracture rather than dislocation include maintenance of normal radiocapitellar relations and medial displacement of the forearm bones. Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. This website also contains material copyrighted by 3rd parties. In young patients with a nonossified or only partially ossified trochlea, the epiphyseal component of the fracture is not visible, and only the metaphyseal flake is identifiable. Open fracture of distal phalanx of right little finger; Open mallet fracture of right distal phalanx; Open right little finger mallet fracture; Open right little finger In those cases in which vascular injury is recognized, reduction usually corrects the vascular abnormality, and hence reduction and pinning should not be delayed for arteriographic assessment. (A) Note the avulsion of the medial epicondyle, which projects just distal to the trochlea on the anteroposterior view. doi: 10.1097/BPO.0000000000001156. 3rd ed. (B) The ulnar fracture has apex lateral angulation and is well aligned on the lateral view. Results of a three-dimensional computed tomography analysis. Note the pseudoarthrosis of the distal phalanx of the fourth toe Fig.3. The double density caused by such overlap may simulate a flake of bone, with lucency of the physis simulating an adjacent fracture line. The mechanisms of dislocation include a fall on an outstretched arm with the elbow partially flexed and forced hyperextension, although both mechanisms more frequently result in fractures than in dislocations. 17.1 ). [45] It has also been suggested that extension force in infants may be more likely to cause a transphyseal fracture than supracondylar fracture. On exam, the dislocation was unable to be reduced. This is sometimes called a tuft fracture Healing: This normally takes approximately 4-6 weeks to heal. A 20-G needle was used to reduce and stabilize her fracture with the same technique described in case 1, although was not advanced through the DIP joint in this case. Fractures at the base of the distal phalanx are often unstable due to the fact these are the insertions sites for both the flexor and extensor tendon, however splinting of these fractures, granted they are closed has favorable outcomes 3. Most medial epicondyle fractures are avulsion injuries caused by traction from the ulnar collateral ligament or the forearm flexor muscles that arise from the medial epicondyle. Distal Phalanx Fractures Peterson JJ, Bancroft LW. Transphyseal Fracture of the Distal Humerus - PubMed 2017 Jun. Case 6: fracture of distal phalanx of great toe, View Mostafa El-Feky's current disclosures, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal. 2008;1:97102. 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). Patients should be informed that these fractures are often complicated by hyperesthesia, pain, and numbness for up to six months following the injury.12. For these fractures, the lateral crista of the trochlea is intact, maintaining stability of the elbow joint. Typical supracondylar fracture. The radial head epiphysis may show displacement with varying amounts of shift and angulation that may lead to limitation of motion of the proximal radioulnar joint. See permissionsforcopyrightquestions and/or permission requests. More laterally, the capitellotrochlear sulcus separates the humeral articular surface of the radius from that of the ulna. MRI could demonstrate the abnormal relationship of the radial head and annular ligament, but such studies are seldom needed. Medial condyle fracture. Federal government websites often end in .gov or .mil. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. With complete fractures, the fracture line and displacement are obvious. 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. modify the keyword list to augment your search. Morewood DJ. These are often easier to treat than fractures involving the joint. For surgeons with CRPP experience, there is a low learning curve for this bedside procedure. The 2 major complications of supracondylar fractures in children are cubitus varus (see images below), which is relatively common, and vascular injury, which is uncommon but has considerable morbidity when present. (A) On the anteroposterior view, the fracture is seen as a longitudinal lucent line through the medial aspect of the proximal ulna. Combined lateral condyle and olecranon fractures. 2016 Apr. [Closed reduction and percutaneous pinning with three Kirschner wires in children with type III displaced supracondylar fractures of the humerus]. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. 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. 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. Medial epicondyle fracture with entrapment in an 8-year-old boy. Fractures and dislocations of the elbow region. The lucent cleft in the fracture fragment is the normal olecranon growth plate. from the American Academy of Orthopaedic Surgeons, The flexor pollicis longus (FPL), which runs along the palm side of the thumb and allows you to bend your thumb. 65:371-8. She was started on a home exercise program at that time. Initial anteroposterior (A) and lateral (B) views show a nondisplaced lateral condyle fracture. Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015. Krengel WF 3rd, Wiater BP, Pace JL, Jinguji TM, Bompadre V, Stults JK, et al. 2015 Sep;99 Suppl 1:S99-105. Fractures of the radial head epiphysis are uncommon in children. Reliability of a modified Gartland classification of supracondylar humerus fractures. Although infection rates following CRPP with k-wires are low in both children and adults,57 infection rates after CRPP with open bore needles has not been reported previously. 2017 Feb 20. J Hand Surg Eur Vol. While transphyseal distal humerus fractures are rare, the true incidence may be However, these injuries have marked medial soft tissue swelling compared with the lateral soft tissue findings with lateral condyle fracture. Dislocations often are associated with fractures, most often involving the medial epicondyle and coronoid process of the ulna. [22]. 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. Initially this leaves a wide space between the lateral epicondyle ossification center, which typically has a linear pattern, and the lateral condyle, which can be misinterpreted as an avulsion fracture. Complications of lateral condyle fracture. Unlike supracondylar fractures, vascular and neurologic complications are extremely rare with lateral condyle fractures. 4C, hyperextension injury with fracture of the articular surface usually greater than 50% with early or late More distally (D and E), there is reconstitution of the radial and ulnar arteries from collaterals that supply the palmar arch. Some common finger fractures can be treated conservatively with appropriate reduction and immobilization. (A) On the lateral view, the radial tuberosity is seen en face and appears as a lytic defect. Lateral view demonstrates an abnormal relation of the capitellum to the anterior humeral line, which passes along the anterior margin of the capitellum. Management of supracondylar humerus fractures in children: current concepts. Particularly common are those involving the olecranon (shown below), which occur with varus stress applied to a fully extended elbow with the olecranon locked in the olecranon fossa. A variety of treatment modalities exist for distal phalanx fractures including closed reduction and splinting, closed reduction and percutaneous pinning (CRPP), and open fixation. Radiographic J Bone Joint Surg. A 5-year-old child with type III supracondylar fracture and brachial artery injury. 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. See the image below. The most common complication is cubitus varus caused by a malunion, osteonecrosis of the medial condyle, or growth arrest. Available at http://www.guideline.gov/content.aspx?id=49910&search=elbow. The incidence of distraction fractures is particularly high in patients with osteogenesis imperfecta, including patients with relatively normal-appearing bones and few fractures elsewhere (see the image below). A radial fracture with apex anterior angulation is present. Stability of the reduction is assessed by gentle active flexion of the involved finger; the joint should be stable through flexion and extension. John J Grayhack, MD, MS is a member of the following medical societies: American Academy of Orthopaedic SurgeonsDisclosure: Nothing to disclose. Lateral condyle fracture. J Pediatr Orthop. 3. [QxMD MEDLINE Link]. Fracture rotation can be difficult to assess radiologically and is best assessed on clinical examination. 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. Elbow dislocation accounts for approximately 5% of elbow injuries in children. (2017) RadioGraphics. In young children in whom the distal humeral epiphysis is not yet ossified, this malalignment of the forearm bones and the distal humeral metaphysis may be mistaken to indicate an elbow dislocation. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Displaced fractures of the neck of the radius. If the medial epicondyle is not seen in its normal anatomic position, it should be searched for elsewhere, including within the elbow joint. Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. Traditional treatment following reduction of uncomplicated dorsal PIP joint dislocations is splinting for one to two weeks followed by buddy taping for another one to two weeks. 1. Weband phalanx fracture consolidation (Fig. With some proximal radial fractures, no displacement of the epiphysis occurs; detection of the fracture depends on the metaphyseal component, which may show only subtle abnormal angular deformity, as in the image below. Duffy S, Flannery O, Gelfer Y, Monsell F. Eur J Orthop Surg Traumatol. Assessment of stability is necessary for appropriate management of dislocated joints. WebTransphyseal fracture of the distal humerus. (2019). 23 (3):318-26. WebThe doctor will take an X-ray of the wrist. A modified Gartland type-IV fracture. Graham T, Evans P Maschke S. Operative treatment of selected fractures of the childs hand. [41] See the image below. Obstetric traumatic separation of the distal humeral epiphysis is a rare injury that follows a traumatic delivery, often secondary to an abnormal presentation.1, 2 In a historical review of 30 years of experience, Madsen 3 documented only one case of distal humeral epiphysis separation in 105,119 neonates. Dislocations are described as dorsal, volar, or lateral depending on the direction of the middle phalanx to the proximal phalanx. For those injuries that include a small portion of the metaphysis, care must be taken to distinguish medial epicondyle fracture (usually an extraarticular injury) from medial condyle fracture, which extends to the articular surface. J Pediatr Orthop. Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine Salter-Harris IV injuries typically have a poor prognosis due to interruption of the proliferative and reserve cartilage zones often leading to altered joint mechanics and functional impairment and as such orthopedic evaluation and subsequent operative intervention are often required 1,2. (B) Lateral view. The authors recommend that the pin remain in place for 4 weeks in pediatric patients and for 4 to 6 weeks in adults, using clinical and radiographic healing as a guide for removal. (B) Subsequent radiograph shows abnormality of the medial condyle and varus deformity from a growth plate injury. Check for errors and try again. When the proximal radius and ulna return to normal position, the capitellum may shear off the radial head, leaving it posteriorly displaced. Reduction is similar to that of a dorsal PIP dislocation if no concomitant injury is present. 1998. However, caution should be taken where there is partial overlap of the capitellum with the metaphysis. 1995 Jul-Aug. 15(4):422-5. The goals of this simple intervention are to decrease unnecessary burden on the health care system, provide better care to patients, and potentially improve outcomes for patients with this type of injury. To limit these complications, we wanted to explore the benefits of using locked extra-articular DIP pinning. The distal humeral articular surface has several grooves and ridges that are important in determining anatomic stability after a fracture. Because of the risk of tendon retraction and the need for surgical treatment, patients with flexor digitorum profundus avulsion fractures should be referred to a hand specialist. J Hand Surg Br. Unauthorized use of these marks is strictly prohibited. Fractures of the distal humerus include supracondylar fracture, lateral condyle fracture, medial epicondyle fracture, medial condyle fracture, and transphyseal (transcondylar fracture), and T-condylar fracture. Direct growth plate insults occur most commonly with Salter-Harris fractures, and injuries that allow the transphyseal communication of vessels are at a higher risk for subsequent transphyseal bone bridge formation. 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. Salter-Harris fracturesare a group childhood injuries where a fracture involves the physis. Splinting in extension for two to three weeks is the typical nonoperative treatment. Fractures of the proximal ulna are uncommon in children, accounting for 6% of elbow fractures. Prior literature has demonstrated effective stabilization of mallet fractures with hypodermic needles2; however, the utility of this technique for other fracture patterns have not been discussed. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Conversely, ulnar fractures in a child are often accompanied by a radial fracture or dislocation, even if the ulnar fracture is a relatively subtle greenstick injury. Dislocations of the DIP joint are often associated with trauma and may have associated fractures and soft tissue injury.7 A simple dorsal DIP dislocation should be evaluated with radiography to assess for fracture. With acute valgus stress, the medial side of the elbow joint is opened. Battle J, Carmichael KD. 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. The mean annual incidence was 0.8 per 105. [QxMD MEDLINE Link]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Some distraction fractures of the olecranon may be subtle, whereas others may have significant proximal displacement of the fracture fragment. Webfollowing insertion of orthopedic implant, joint prosthesis or bone plate - see Fracture, following insertion of orthopedic implant, joint prosthesis or bone plate; in (due to) - see Fracture, pathological, due to, neoplastic disease; pathological (cause unknown) - see Fracture, pathological; breast bone - see Fracture, sternum; bucket handle (semilunar 22(2):188-93. Lastly, mini c-arms are now widely available in EDs. In addition to the findings in the multiple ossification centers described above, other normal findings may simulate pathology. If the fracture extends into the joint, it is called an intra-articular fracture; if it does not, it is called an extra-articular fracture. National Guideline Clearinghouse. [9, 10, 11], A review of medical records of 462 children (median age, 6 yr) with elbow fractures identified the most common fractures as supracondylar (N=258, 56%), radial neck (N=80, 17%), and lateral condylar (N=69, 15%). Soft-tissue abnormalities (tendon, ligament, nerve, joint recess, and masses) are well-demonstrated with MRI or US. Growth Plate [38]. Pediatric Elbow Injuries. J Pediatr Orthop. See the image below. Rha E, Lee M, Lee J, et al. Pseudo-Galeazzi fracture. The deforming forces that act on the middle phalanx fractures are the FDS and the intrinsic tendons. 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).