Overall, many thumb fractures have good outcomes after appropriate treatment. 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. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Rogers LF, Malave S Jr, White H, Tachdjian MO. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. If you log out, you will be required to enter your username and password the next time you visit. The presence of a joint effusion does not specifically indicate that a fracture is present, but a joint effusion does signal that a fracture is likely; in such cases, a careful search is required. Please confirm that you would like to log out of Medscape. [22]. Song KS, Kang CH, Min BW, Bae KC, Cho CH. 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. Rarely, a Salter-Harris type IV fracture extends vertically through the metaphysis and epiphysis, crossing the physis. Initial lateral view (A) shows an abnormal anterior humeral line indicative of a fracture. Stage II fractures extend through the articular surface, allowing for a small amount of displacement of the distal fragment and olecranon shift. Elbow fractures are the most common type of fractures in children, primarily occurring from a fall on an outstretched hand. Fractures of the proximal phalanx can be complex owing to forces exerted on the fracture fragments by multiple muscles and tendons which often result in angular This information is provided as an educational service and is not intended to serve as medical advice. This topic will review the evaluation and management of toe fractures in adults. Surgery does have some potential complications, which could include infection, wound issues, or failure of the surgery to hold alignment. 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. These injuries are due to valgus rather than varus stress and distract the physis starting medially. Skaggs DL, Hale JM, Bassett J, et al. Anteroposterior (A) and lateral (B) views. The flexor digitorum superficialis (FDS) attaches to the palmar surface of the middle phalanx and is the primary flexor of the PIP joint. A delay in treatment may make it more difficult to align the bones properly and may lead to a poor outcome. 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. 7. van Leeuwen WF, van Hoorn BT, Chen N, et al. Some distraction fractures of the olecranon may be subtle, whereas others may have significant proximal displacement of the fracture fragment. You will likely wear a cast or splint for 2 to 6 weeks after surgery. (2017) RadioGraphics. However, lateral condyle fractures may be complicated by instability (see the image below), avascular necrosis, and malunion or nonunion, which are more problematic for lateral condyle fractures than supracondylar fractures. In 55-85% of patients, the radial head is anteriorly dislocated, with an associated apex anterior ulnar fracture (Monteggia type 1 injury). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins; 2010. The distal phalanx is the most commonly fractured bone in the hand, followed by the metacarpals . 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. FOIA WebTransphyseal Fracture of the Distal Humerus. [15] : Initial evaluation of chronic elbow pain should begin with radiography. Following reduction of a proximal interphalangeal dislocation, short-term splinting in flexion with early active range of motion and strengthening is preferable to prolonged immobilization. Metaphyseal fractures [corner fracture]: Commonly affects the distal femur or the proximal tibia (Fig. It can take 3 months or more to regain full use of the hand, depending on the severity of the injury. The bones of the hand and wrist are shown in the figure ( figure 1 ). The olecranon is often ossified from 2 secondary centers that should not be confused with fracture fragments. Reduction is similar to that of a dorsal PIP dislocation if no concomitant injury is present. Like the metacarpal, the distal and proximal phalanges can fracture near/into a joint or in the shaft of the bone. JAMES R. BORCHERS, MD, MPH, AND THOMAS M. BEST, MD, PhD. A major complication of a radial neck fracture is limitation of motion at the proximal radioulnar joint, which mostly limits supination. 2009 Sep. 91(9):2188-93. [QxMD MEDLINE Link]. Medially, the trochlear notch articulates with a corresponding ridge along the ulna. As in all cases of trauma, the importance of recognition of open distal phalanx fractures is due to the increased risk of contamination and, hence, infection. 1990. The most common follow-up fractures were olecranon (N=23, 72%), coronoid process (N=4, 13%), and supracondylar (N=3, 9%). Anteroposterior view shows disruption of the medial cortex. Fractures and dislocations of the elbow region. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. J Hand Surg Br. [32] If this does not adequately restore circulation, vascular repair, usually following arteriography, may be needed. Because several secondary ossification centers exist in the elbow, a small flake of bone adjacent to the metaphysis may be misinterpreted as a developmental center, such as the lateral epicondyle. Please enable scripts and reload this page. The benefits of early range of motion following relocation of a dorsal PIP dislocation are debated. In general, medial condyle fractures (Salter-Harris type IV injuries) have larger metaphyseal components than medial epicondyle fractures that involve the metaphysis have. [QxMD MEDLINE Link]. This joint sits between the proximal phalanx and a bone in the hand called the first metacarpal. Check for errors and try again. Other injuries that may be confused with lateral condyle fractures include supracondylar fracture, true Salter-Harris type II fracture, and, in young infants, separation of the distal humeral epiphysis (transphyseal fracture, Salter-Harris type I). A volar dislocation (Figure 2) can be accompanied by avulsion of the central slip extensor mechanism of the PIP. You will likely need to wear the cast for at least 4 to 6 weeks. J Bone Joint Surg. 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. Less frequently (4 of 48 in Jakob's series), the fracture passes through the lateral aspect of the metaphysis, crosses the physis, and continues through the ossified capitellum, with the typical radiographic appearance of a Salter-Harris type IV fracture (see the image below). 2008 Apr. Typically, none of these centers is ossified at birth. J Orthop Trauma. These ossification centers vary not only with regard to the age of the patient at the time of development but also with regard to their radiographic appearances. 1964. [QxMD MEDLINE Link]. A positive elbow ultrasound had a sensitivity of 98% and a specificity of 70%. Carpenter S, Rohde RS. Orthop Clin North Am. With subtle fractures, the fracture line may be initially seen through only a portion of the metaphysis. On the lateral view, cortical disruption is usually seen posteriorly rather than anteriorly as in supracondylar fractures. Both direct and indirect findings are helpful in the radiographic diagnosis of supracondylar fractures. Case Report: Locking Plate for Cubitus Varus Correction in a 7-Year-Old Girl With Osteogenesis Imperfecta. Caffey's Pediatric X-Ray Diagnosis. A 5-year-old child with type III supracondylar fracture and brachial artery injury. Most cases of isolated radial head dislocation in children are likely to actually be Monteggia fracture/dislocation with a subtle ulnar bowing fracture. Fredric A Hoffer, MD, FSIR Affiliate Professor of Radiology, University of Washington School of Medicine; Member, Quality Assurance Review Center The double density caused by such overlap may simulate a flake of bone, with lucency of the physis simulating an adjacent fracture line. Saeed W, Waseem M. Fracture, Elbow. The .gov means its official. These may have some angulation but no true displacement of the fracture fragment and no shift of the olecranon. Note the presence of the normal trochlear ossification center in this patient, which was not present in the younger patient. In most cases, patients with transphyseal fractures have a good prognosis, although correct diagnosis may be problematic. [22] Nonunion has been considered to be more of a problem in patients with minimally displaced fractures than in patients with significant displacement, presumably because the lack of surgical fixation allows a small amount of motion and because of the development of fibrocartilage between the fragments. The physician will examine the injury, take a medical history, and order X-rays of the injury. New York: Churchill Livingstone. 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. Lateral condyle fracture. The smooth end of the ulna is the metaphysis ending at the physial fracture. Data is temporarily unavailable. J Bone Joint Surg Am. Curr Opin Pediatr. Elbow dislocation accounts for approximately 5% of elbow injuries in children. In the setting of a nail bed injury, the nail bed repair can be deferred until after the osseous structures have been stabilized. Radiographic findings that indicate transphyseal fracture rather than dislocation include maintenance of normal radiocapitellar relations and medial displacement of the forearm bones. Abnormality of the anterior humeral line indicates distal humeral deformity and, therefore, either an acute or previous fracture. Distal phalanges are the most exposed phalanges and are, therefore, fractured more often than other hand fractures. Radiographic findings in lateral condyle fracture. 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. 39(2):155-61, v. [QxMD MEDLINE Link]. The pin was removed at her 6-week follow-up, at which time there was some early consolidation of the fracture on imaging. Shrader MW. In a Monteggia fracture type 3, the radial head is dislocated, primarily laterally and slightly anteriorly. Pain and swelling: Take your normal painkillers if you are in pain. These injuries should be suspected with gross deformity on inspection of the middle or proximal phalanx. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. The most common of these in the thumb are fractures involving the base of the first metacarpal, affecting the CMC joint where the thumb connects to the wrist: Fractures of the thumb metacarpal can also occur in the long portion of the bone, which is called the metacarpal shaft. Tissue Eng Part B Rev. eCollection 2021. Olecranon fractures are often associated with other injuries. (A) Anteroposterior view. Injury, postreduction, and follow-up x-rays are shown in Figure 3. (B) On the lateral view, a small fracture line is present at the tip of the proximal ulna, and subtle discontinuity of the posterior cortex is seen. A needle is selected that is of sufficient length to traverse the distal phalanx and cross the DIP joint into the middle phalanx for improved stability of the temporary fixation. Sep 2006. Observations concerning fractures of the lateral humeral condyle in children. Salter-Harris type IV fracture. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). With complete fractures, the fracture line and displacement are obvious. Edmonds EW. Radiology. At her last follow-up 7 months postinjury, she demonstrated radiographic healing of her fracture and returned to full work with only mild limitations in strength and range of motion. J Pediatr Orthop. (A) Anteroposterior radiograph shows the displaced lateral condyle and cubitus valgus. Distal phalanx fracture. Radiograph anteroposterior view taken in the day of the trauma. [QxMD MEDLINE Link]. 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. [QxMD MEDLINE Link]. Supracondylar fractures may be associated with ipsilateral fractures remote from the elbow, most frequently of the distal radius. [QxMD MEDLINE Link]. 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. 1. Displaced proximal radial fractures may result from transient posterior elbow dislocation. WebFractures of the distal phalanx are the most common fractures in the hand. The age at which ossification centers are first seen varies considerably; maturation usually proceeds earlier in girls than in boys. [41] Because the distal humerus has a broader base at the physis than in the region of the olecranon fossa where supracondylar fractures occur, there is more contact between the fragments, and hence less tilting. A Monteggia variant has fractures of the radius and ulna. Radiographic findings in supracondylar fracture. 187:812-817. When the valgus force is removed, the medial epicondyle may then become entrapped as the medial joint space closes. Reduction may be unsuccessful because of soft tissue injury or fracture. Olecranon avulsion fracture. Supracondylar Fractures of the Distal Humerus. Failure of the radiocapitellar line to pass through the capitellum indicates radiocapitellar dislocation. Transphyseal fractures of the distal humerus typically occur in children younger than 3 years secondary to birth Curr Rev Musculoskelet Med. Orthop Clin North Am. Fractures of the radial head epiphysis are uncommon in children. 4. 45 (2):140-144. Table 1 summarizes the evaluation and management of finger dislocations and fractures. More laterally, the capitellotrochlear sulcus separates the humeral articular surface of the radius from that of the ulna. WebTransphyseal distal humerus fractures typically occur in children younger than 3 years secondary to birth trauma, nonaccidental trauma, or a fall from a small height. A broken thumb can be a serious problem. 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. 1978 Jul. Monteggia fracture type I. Lateral view of injured forearm (A) shows anterior dislocation of the radial head and convex anterior bowing of the ulna, which is most apparent when compared with the contralateral uninjured forearm (B). 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. 1992:753. (B) On the frontal view, radial tuberosity is clearly recognizable. [46] Some proximal radial fractures may result in abnormal articulation of the radial head and capitellum and therefore are fracture/dislocations. These cases include greenstick and plastic bowing fractures. Alternatively, it may result from excessive muscular activity, often in association with throwing. Less often, the distal fragment is displaced laterally, and these fractures tend to have external rotation, producing valgus. Demonstration of normal alignment between the proximal radius and the capitellum (radiocapitellar line) and normal alignment of the proximal radius and ulna with each other are the keys to differentiating transphyseal fracture from elbow dislocation. Tuft fracture (Figure 3) is the most common type of distal phalanx fracture. Lateral view in a patient with osteogenesis imperfecta who has had bilateral recurrent fractures in the same region. 2017. John J Grayhack, MD, MS is a member of the following medical societies: American Academy of Orthopaedic SurgeonsDisclosure: Nothing to disclose. Although the annular ligament becomes transiently interposed between the radial head and capitellum, this movement does not cause recognizable widening of the radiocapitellar joint. (A) Anteroposterior, (B) oblique, and (C) lateral views show markedly rotated distal fracture fragment of this medial condyle fracture. Anteroposterior (A) and lateral (B) views show significant lateral and posterior displacement of a distal fragment. Indirect insults lead to different sequelae that are based on whether the epiphyseal blood supply or metaphyseal They are frequently related to sports, with lesions such as the mallet finger and the Jersey finger. Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine With such bending, the joint capsule applies a tension force to the anterior cortex of the distal humerus, accounting for the frequent anterior position of the lucent fracture line. WebYou have broken your distal phalanx (the end of your finger). The orientation of the fracture line in the sagittal plane has both diagnostic and clinical implications. 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 There is an area of webbing between the thumb and first finger that allows you to spread your thumb out to grasp an object. An anteroposterior tomogram (D) obtained at that time shows both the displacement and the course of the fracture line through the epiphysis to the articular surface of the trochlea. 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. This is encouraged before treatment is finalized. Common complications of these injuries are: altered sensitivity (numbness, hyperesthesia, tenderness) cold sensitivity (cold intolerance) restriction of DIP joint movement 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 The fracture then propagates through the physis and eventually passes into the metaphysis, producing a typical Salter-Harris appearance. In most cases, lateral condyle fractures are distraction injuries from the forearm extensors, usually as a result of acute varus stress applied to an extended elbow. Kwok IH, Silk ZM, Quick TJ, Sinisi M, MacQuillan A, Fox M. Nerve injuries associated with supracondylar fractures of the humerus in children: our experience in a specialist peripheral nerve injury unit. Fractures of the lateral condyle are the second most common elbow fracture in children, accounting for 15-20%. The distal phalanx is the most commonly fractured bone of the hand. The position of the tiny ossification center for the capitellum suggests that it is displaced posteriorly; this is confirmed on the arthrogram (C). J Pediatr Orthop. Disclaimer. 2019 Feb 1;13(1):47-56. doi: 10.1302/1863-2548.13.180156. The technique is cost and time efficient with minimal early complications. Does using the medial or lateral humeral line improve reliability of Baumann angle measurement on plain x-ray? A staging system for displacement of lateral condyle fractures is as follows 533-93. The ulna articulates with the humerus at the trochlea, which is the grooved and rounded medial articular portion of the distal humerus. People with a history of bone disease or calcium deficiency are especially at risk for thumb fractures. The fractured medial epicondyle may become entrapped in the elbow joint, representing a major complication. The much less common flexion-type supracondylar fracture is usually caused by a direct blow to the posterior aspect of the elbow, usually from a fall onto the elbow. Following reduction, the DIP joint remained unstable. [QxMD MEDLINE Link]. This content is owned by the AAFP. [31] Cubitus varus may be evaluated with the use of the Baumann angle, which is determined by lines drawn along the axis of the humeral shaft and the physis for the capitellum. and transmitted securely. The olecranon apophysis fuses in an anterior-to-posterior direction; radiographs may reveal a residual posterior cleftlike lucency with well-defined sclerotic margins. 32(4):373-7. Acta Orthop Belg. The anterior humeral line may be extremely useful in the diagnosis of supracondylar fracture. Vascular injury may be a severe complication of supracondylar fractures, usually occurring with significant posterior displacement of the distal fragment, with the brachial artery injured by the sharp distal end of the proximal fracture fragment. 30(3):253-63. What is the Distal Phalanx. Such distraction injuries may arise from valgus stress applied to an extended elbow or muscular stress. 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 height. At the time the article was last revised Mostafa El-Feky had 98-B (6):851-856. The Milch classification scheme for lateral condylar fractures defines a type I fracture as one that passes through the distal humeral epiphysis lateral to the lateral crista of the trochlea, in most cases passing through the ossified capitellum. All of the bones in the thumb are susceptible to fracture. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Several bones contribute to thumb function. Thus, lateral displacement of the proximal forearm bones is seen in lateral condyle fracture, rather than medial displacement, which is typically seen in transphyseal fractures. 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. Salter-Harris type I fractures that pass entirely through the physis of the olecranon apophysis may occur, but they are relatively uncommon. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. [1, 2, 3, 4] The evaluation of pediatric elbow radiographs in the setting of acute trauma may be challenging for many emergency department physicians, orthopedic surgeons, and radiologists. The possibility of concomitant fracture or soft tissue injury must be considered, especially if relocation is unsuccessful. (A) Lateral view of initial radiographs shows type III supracondylar fracture with marked posterior and proximal displacement of the distal fragment. T-condylar fracture in 15-year-old youth. MeSH Zhou H, Zhang G, Li M, Qu X, Cao Y, Liu X, Zhang Y. J Orthop Surg Res. Kuoppala E, Parviainen R, Pokka T, Sirvi M, Serlo W, Sinikumpu JJ. Lateral view shows the posterior fat pad, which is always abnormal when seen with the elbow positioned in right-angle flexion. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. 2015; Accessed: May 30, 2016. 41 (7):1453-1461. Therapy is designed to ensure that you won't overdo it and possibly cause the thumb to come out of alignment, or do too little, which can lead to stiffness of the thumb. In the absence of associated microvascular injury, most fractures can be stabilized nonurgently and subsequently scheduled for surgery on an outpatient basis. [QxMD MEDLINE Link]. Conventional, magnetic resonance, or CT arthrography may be helpful in searching for a cartilaginous entrapped medial epicondyle in patients in whom the medial epicondyle is intra-articular. Cubitus varus. 2016. Master Techniques in Orthopaedic Surgery: The Hand. [QxMD MEDLINE Link]. Valgus stress fractures may be associated with a compression fracture of the radial neck or avulsion of the medial epicondyle. If the medial epicondyle is not seen in its normal anatomic position, it should be searched for elsewhere, including within the elbow joint. 2020 Dec 1;15(1):575. doi: 10.1186/s13018-020-02118-2. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New ZealandDisclosure: Nothing to disclose. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:427438. [QxMD MEDLINE Link]. Developing strength in the hands through exercise and getting proper nutrition can also provide some protection. These deformities may cause posttraumatic arthritis with pain and diminished range of motion, which are often not correctable. Appointments 216.444.2606 Appointments & Locations Diagnostic difficulties stem both from the complex developmental anatomy of the elbow and from significant differences between children and adults in the patterns of injury after elbow trauma. Epub 2021 Mar 20. You are being redirected to In one study, alltType A fractures were stable, whereas 17% of type B fractures and 42% of type C fractures showed subsequent displacement. 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 The medial and lateral columns are more separated proximally than distally.
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