Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. Anteroposterior (A) and lateral (B) views show significant lateral and posterior displacement of a distal fragment. However, in approximately 25% of cases, the fracture may be subtle. In children, the ligaments are generally stronger than the bone; therefore, avulsion fractures occur more frequently than ligamentous injury. (A) Anteroposterior view shows a varus deformity of the distal humerus from a prior supracondylar fracture that has fully healed. Philadelphia, PA: JB Lippincott; 1983. This typically occurs several years after the injury. 2017 Mar 20. These fractures are commonly classified as intra- or extra-articular. [Simple elbow dislocations in children : Systematic review and meta-analysis]. More distally (D and E), there is reconstitution of the radial and ulnar arteries from collaterals that supply the palmar arch. Radiographically occult bone abnormalities can be detected with MRI, CT, or bone scintigraphy. 1-6. Elhusseiny K, El-Sobky TA. However, distal pulses remained absent. T-condylar fracture in 15-year-old youth. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New ZealandDisclosure: Nothing to disclose. 56(4):688-703. In the radiographic evaluation of pediatric elbow trauma, it is important to assess the status of the medial epicondyle, particularly after an elbow dislocation. This relation should be examined on a frontal view as well. J Pediatr Orthop. The frequency of olecranon fractures on follow-up may suggest the occult nature of these fractures. However, such an injury may be suggested by localized tenderness and soft tissue swelling and by the presence of a posterolateral elbow dislocation. The needle can be chosen based on the measurement of the isthmus of the distal phalanx on the lateral view on the injury radiographs. Rykiel H. Levine, Lisa A. Foris, Trevor A. Nezwek, Muhammad Waseem. Note the normal position of the medial epicondyle in left elbow, which is not seen in the right elbow. Similar to lateral condyle fractures, the fracture continues through the epiphysis, but it cannot be seen in this patient because the entire trochlea is still cartilage and has not yet become ossified. Evaluation of displacement of the medial epicondyle may also be aided by recent data regarding the position of the normal medial epicondyle relative to other distal humeral landmarks. There are pros and cons to all treatment options. In most cases, the fracture line then partially traverses the physis and then passes into the cartilaginous distal humeral epiphysis (see the image below). J Bone Joint Surg Br. 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. Fractures in Children. [Closed reduction and percutaneous pinning with three Kirschner wires in children with type III displaced supracondylar fractures of the humerus]. WebThe majority of fractures of the distal phalangeal diaphysis are closed and either undisplaced, or minimally displaced. 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 1978 Jul. A notchlike defect in the proximal radial metaphysis may be confused with a fracture (see the image below). 2018 May/Jun;38(5):e262-e266. Anteroposterior (A) and lateral (B) views show combined fractures of the distal humeral lateral condyle and olecranon process of the ulna. [41]. 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. The most common complication is cubitus varus caused by a malunion, osteonecrosis of the medial condyle, or growth arrest. The bones. Arthritis can result in limited joint motion and pain in the joint. 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. In children, an ulnar fracture often is manifested by plastic bowing without a discrete fracture line, as shown in the image below. doi: 10.1097/BPO.0000000000001156. ("Articular" means "joint.") A 5-year-old boy with previous left distal humeral supracondylar fracture. The chronologic order of appearance of elbow ossification centers is as follows: capitellum, radial head, medial epicondyle, trochlea, olecranon, and lateral epicondyle at 1, 5, 7, 10, 10, and 11 years, respectively. Common complications of these injuries are: altered sensitivity (numbness, hyperesthesia, tenderness) cold sensitivity (cold intolerance) restriction of DIP joint movement Fractures with significant radiological comminution and/or extensive soft tissue injury should be clinically and radiologically reviewed for open fracture. Normal articulation of the medial condyle and proximal ulna is maintained. [Full Text]. 37 (6): 1791-1812. 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. However, because the lateral epicondyle is the last center in the elbow to ossify, most pediatric patients with lateral condyle fractures have elbows that are too immature to have a lateral epicondyle ossification center. All of the bones in the thumb are susceptible to fracture. Vertically oriented fracture begins along the medial aspect of the distal humeral metaphysis and extends to the growth plate. The decision to remove the pin at this time point was based on the absence of tenderness at the fracture site and stable appearance on x-rays. WebYou have broken your distal phalanx (the end of your finger). WebPhalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits for fractures in the United States. Place in stack splint for protection and pain control for 3 to 4 weeks. The Gartland classification as modified by Wilkins and expanded by Leitch defines extension supracondylar fractures as follows Unable to process the form. In the setting of a nail bed injury, the nail bed repair can be deferred until after the osseous structures have been stabilized. 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. Rotator Cuff and Shoulder Conditioning Program. A pulled elbowis a distraction injury. 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. Displaced proximal radial fracture. Several bones contribute to thumb function. Low incidence of flexion-type supracondylar humerus fractures but high rate of complications. Between these grooves is the lateral crista of the trochlea, which provides lateral stability to the trochleoulnar joint. If extensive loss of motion persists, referral is recommended. WebA distal radius fracture almost always occurs about 1 inch from the end of the bone. modify the keyword list to augment your search. Finger and metacarpal fractures are the most common sports-related fractures in adults and adolescents.1,2 If not treated properly, finger fractures and dislocations can have significant consequences, including poor function, chronic pain, stiffness, and deformity.3 The goal of management is return to normal function and activity. 1990. All rights reserved. In a meta-analysis of 5154 supracondylar fractures in children, nerve injury occurred in 11%. Displacement of the radial head may be marked, usually with the head displaced distally, and its articular surface may be rotated into the coronal plane posteriorly. Elbow US combined with clinical suspicion for fracture had a sensitivity of 100%. A study by Garon et al1 assessed the cost of performing percutaneous fixation of hand fractures in a procedure room versus an OR. [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. In supracondylar fractures with medial displacement of the distal fragment, there is often internal rotation, which results in varus if the fracture is oblique. Transphyseal fractures of the distal humerus typically occur in children younger than 3 years secondary to birth In most cases, patients with transphyseal fractures have a good prognosis, although correct diagnosis may be problematic. 2018 Sep. 33 (5):444-446. Treatment of a mallet fracture includes splinting the DIP joint in extension for eight weeks. These fractures are [15] : Initial evaluation of chronic elbow pain should begin with radiography. In the series by Jakob et al involving 48 patients with lateral condyle fractures, 20 patients had fractures that were minimally displaced; 28 patients had significant displacement that required surgical reduction and fixation. Anteroposterior (A) and lateral (B) views. Often, the capitellum has ossified; in such cases, it may serve as an important marker in the otherwise cartilaginous distal humeral epiphysis. Careers. A 4-year-old child with medial epicondyle fracture. [QxMD MEDLINE Link]. Injury, postreduction, and follow-up x-rays are shown in Figure 3. 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, lucent fracture line extending through metaphysis, across physis and into the epiphysis, angulation, displacement and rotation may occur, adjacent soft tissue swelling and joint effusion may be noted, CT imaging has a role in evaluating the degree of displacement and anatomic extent of Salter-Harris type IV fractures and can subsequently guide operative intervention, CT imaging can also be incorporated to evaluate focal osseous bridging across the physis during the healing process (most common in Salter-Harris IV and V injuries), 1. A staging system for displacement of lateral condyle fractures is as follows Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. 2015; Accessed: May 30, 2016. 7. van Leeuwen WF, van Hoorn BT, Chen N, et al. Referral is recommended for fracture involving greater than 30 to 40 percent of the intra-articular surface, if reduction is difficult or unsuccessful, or if the patient is unable to achieve full extension following reduction. Elbow fractures include supracondylar, lateral condyle, medial condyle, radial head and neck, and olecranon. Radiography (commonly anteroposterior, true lateral, and oblique views) is required in the evaluation of finger fractures and dislocations. PMC Jpn J Radiol. Weband phalanx fracture consolidation (Fig. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. The vast majority (98%) of supracondylar fractures are extension injuries that result from a fall on an outstretched arm. 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. There is an area of webbing between the thumb and first finger that allows you to spread your thumb out to grasp an object. With subtle fractures, the fracture line may be initially seen through only a portion of the metaphysis. In children younger than 5 years, the annular ligament is relatively loose, allowing the radial head to be pulled through it when acute traction is suddenly placed on a pronated forearm (which is the usual position of the forearm when a child is being pulled along by an adult). In young people, such fractures typically occur in high-energy accidents, such as http://www.guideline.gov/content.aspx?id=49910&search=elbow, American Society for Bone and Mineral Research, Society of Nuclear Medicine and Molecular Imaging. 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. Additional investigation with a larger cases series may be warranted to further evaluate outcomes and complications. 2017. J Emerg Med. Compare the simultaneous view of the uninjured right elbow (B) and a previous view of the left elbow obtained when the patient was 10 years of age (C). Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Supracondylar fracture. The elbow should be well visualized in all patients who have an ulnar injury, with or without an associated radial fracture. People with a history of bone disease or calcium deficiency are especially at risk for thumb fractures. 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. The dashed radiocapitellar line is drawn through the radial neck and should pass through the capitellum. [6] Cubitus varus after supracondylar fractures is relatively common and had previously been considered to be primarily a cosmetic problem. Metaphyseal fractures can be undetectable clinically and show only in bone survey. These may have some angulation but no true displacement of the fracture fragment and no shift of the olecranon. Complications of lateral condyle fracture. The capitellum develops as a single smooth center, whereas trochlear ossification most often has a fragmented and irregular appearance. Although the proximal radius is the most common site of elbow fracture in adults, it accounts for only 5% of elbow fractures in children. [47]. Sep 2006. 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. [Guideline] Hayes CW, Roberts CC, et al. Bookshelf 22(2):188-93. Flexion injury is often from a fall on a flexed elbow, whereas extension injury is often from a fall on a slightly flexed and outstretched arm, with the coronoid process acting as the wedge. Radiographic findings of proximal radius fractures. 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. The anterior humeral line may be extremely useful in the diagnosis of supracondylar fracture. Chicago, IL: Year Book Medical Publishers, Inc; 1985. 2016. 2005;39(1):23-9. [QxMD MEDLINE Link]. Lateral view in a patient with osteogenesis imperfecta who has had bilateral recurrent fractures in the same region. Bone Joint J. Check for errors and try again. Failure to identify and appropriately treat these fractures can lead to long-term reduced function and disability. 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.
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