Even incomplete fractures often have enough disruption in 1 of the cortices (usually the anterior cortex) to make diagnosis easy (see the image below). 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. Shrader MW. eCollection 2021. Instr Course Lect. Hand Clin. 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. (C) Arteriogram shows abrupt termination of contrast in the brachial artery proximal to the level of transection, suggesting spasm and thrombosis. The effect of humeral length visualized on the x-ray. On the lateral view, the distal ulnar epiphysis is largely obscured by the distal radius. 2017 Feb 20. Monteggia variant. This injury is commonly referred to as jersey finger.11 Examination of the affected finger demonstrates the inability to flex the finger at the DIP joint. [QxMD MEDLINE Link]. J Bone Joint Surg Am. Dynamic assessment with US is effective for diagnosing nerve or muscle subluxation. However, unlike supracondylar fractures, lateral condyle fractures are seldom associated with fractures remote from the elbow. The fracture originates in the lateral aspect of the distal humeral metaphysis and passes obliquely to the physis. Decompress associated subungual hematoma with 18-gauge needle placed through the nail. However, such an injury may be suggested by localized tenderness and soft tissue swelling and by the presence of a posterolateral elbow dislocation. 1964. 2001 May. ACR Appropriateness Criteria chronic elbow pain. Pseudo-Galeazzi fracture. In most cases, patients with transphyseal fractures have a good prognosis, although correct diagnosis may be problematic. As a result, accurate and timely radiographic interpretation is essential for alerting the clinical staff to the features of the fractures and the need for orthopedic treatment. WebFractures of the distal phalanx are the most common fractures in the hand. [41]. 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. Subtle olecranon fracture. An 18-month-old child with buckle-type distal humeral supracondylar fracture and an associated distal radial metaphyseal buckle fracture. 398-9. WebA distal radius fracture almost always occurs about 1 inch from the end of the bone. As with lateral condyle fractures, medial condyle fractures are often unstable and may be complicated by nonunion. These injuries are due to valgus rather than varus stress and distract the physis starting medially. 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 radial head ossification center is initially oval and subsequently becomes flattened and disk shaped. Fractures and dislocations of the elbow region. Rykiel H. Levine, Lisa A. Foris, Trevor A. Nezwek, Muhammad Waseem. In some cases, cubitus varus results from medial comminution and collapse. Richard M Shore, MD is a member of the following medical societies: American Roentgen Ray Society, American Society for Bone and Mineral Research, International Skeletal Society, Society for Pediatric Radiology, Society of Nuclear Medicine and Molecular ImagingDisclosure: Nothing to disclose. 17.1 ). [QxMD MEDLINE Link]. 171:243-245. A radial fracture with apex anterior angulation is present. 2012 Feb. 20(2):69-77. [QxMD MEDLINE Link]. If there is instability or significant rotation, referral to a hand surgeon is required. It also aids recognition of an injury when the pattern is altered. [QxMD MEDLINE Link]. In the radiographic evaluation of pediatric elbow trauma, it is important to assess the status of the medial epicondyle, particularly after an elbow dislocation. The history should include mechanism of injury, timing and progression of symptoms, hand dominance, and any previous finger injury. Although only a very thin sliver of bone may be viewed, it represents the small ossified portion of the entire distal fragment that is mostly cartilage (see the image below). Anteroposterior (A) and lateral (B) views. In long-term follow-up, mean carrying angle was 50% more in injured elbows (21) than in uninjured elbows (14). 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. [35], The rate of flexion-type fractures has been estimated to be 1.2%. In these cases, only the radial head is still in alignment with the capitellum. 88(5):980-5. J Orthop Trauma. In this patient, the uninjured right elbow has a Baumann angle of 12, and the previously injured left elbow has a Baumann angle of only 2, suggesting 10 of varus deformity of the left distal humerus. See the Medscape Reference article Salter-Harris Fracture Imaging for more information. 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. With subtle fractures, the fracture line may be initially seen through only a portion of the metaphysis. Displacement of the lateral trochlear ridge has also resulted in elbow joint instability with dislocation of the olecranon laterally and posteriorly. Often, the capitellum has ossified; in such cases, it may serve as an important marker in the otherwise cartilaginous distal humeral epiphysis. Supracondylar fracture. Supracondylar Fractures of the Distal Humerus. With medial displacement or medial comminution, loss of support for the medial aspect of the distal fragment allows the distal fragment to shift into varus alignment. 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. Olecranon fractures are often associated with other injuries. 2015;81:296302. Both direct and indirect findings are helpful in the radiographic diagnosis of supracondylar fractures. Bouton D, Ho CA, Abzug J, Brighton B, Ritzman TF. Some fractures may be caused indirectly, from twisting or even from strong muscle contractions, as might occur in wrestling, hockey, football, and skiing. 50:95. [40]. Valgus may also result from malunion, and varus deformity may be caused by malunion or stimulation of growth of the lateral condylar physis. Medial epicondyle avulsions may include separation of the entire medial epicondyle from the metaphysis, avulsion of only part of the medial epicondyle (see the image below), or avulsion of the epicondyle together with a small portion of the adjacent metaphysis. Invariably, the capitellum is the first secondary center to ossify, usually followed by the medial epicondyle, the trochlea, and the lateral epicondyle. Broken fingers generally heal well after treatment and rehabilitation. A fluoroscopic image of the selected needle next to the distal phalanx before insertion can help to confirm the appropriate needle choice. Radiographic In a meta-analysis of 5154 supracondylar fractures in children, nerve injury occurred in 11%. 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. [QxMD MEDLINE Link]. Oman Med J. Therefore, the flake of bone must represent a fracture fragment. Malays Fam Physician. In a Monteggia fracture type 3, the radial head is dislocated, primarily laterally and slightly anteriorly. An ulna fracture with apex anterior angulation is present. A study by Garon et al1 assessed the cost of performing percutaneous fixation of hand fractures in a procedure room versus an OR. On the anteroposterior view (C), the fracture may clearly be seen to extend all of the way across the metaphysis. Clipboard, Search History, and several other advanced features are temporarily unavailable. Type B fractures are similar, other than the fracture line can be traced to the physis. Displaced, oblique, or spiral fractures are inherently unstable and should be referred to a hand specialist.3. Often associated with nailbed injuries that would require evaluation and repair 4. Alternatively, it may result from excessive muscular activity, often in association with throwing. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. The frequency of olecranon fractures on follow-up may suggest the occult nature of these fractures. 2018 May/Jun;38(5):e262-e266. Saper MG, Pierpoint LA, Liu W, Comstock RD, Polousky JD, Andrews JR. Although acute nerve injury is rare, elbow deformity following lateral condyle fracture may lead to ulnar neuritis (tardy ulnar palsy), a late complication (average interval from injury = 22 years). The technique is cost and time effective when treating patients with this type of injury. These fractures are usually Salter-Harris type II injuries that include a metaphyseal fragment of variable size. 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. The capitellum develops as a single smooth center, whereas trochlear ossification most often has a fragmented and irregular appearance. Baumann angle. Careers. With complete fractures, the fracture line and displacement are obvious. The age at which ossification centers are first seen varies considerably; maturation usually proceeds earlier in girls than in boys. WebDistal phalangeal enchondromas are rare and often difficult to differentiate from epidermal cysts, glomus tumor and osteoid osteoma. [QxMD MEDLINE Link]. Treatment of phalangeal fractures. [QxMD MEDLINE Link]. Become a Gold Supporter and see no third-party ads. 2015; Accessed: May 30, 2016. Fredric A Hoffer, MD, FSIR Affiliate Professor of Radiology, University of Washington School of Medicine; Member, Quality Assurance Review Center 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. 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. no financial relationships to ineligible companies to disclose. Under conscious sedation and digital block, a Seymour-type exposure3 was utilized to achieve reduction. T-condylar fracture in 15-year-old youth. 8600 Rockville Pike 56(4):688-703. Medial condyle fracture with markedly rotated distal fragment in a 7-year-old boy. [26] . 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. 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. (A) Note the avulsion of the medial epicondyle, which projects just distal to the trochlea on the anteroposterior view. Salter-Harris type IV fracture. These fractures are commonly classified as intra- or extra-articular. [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. J Pediatr. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. [1] Although lateral soft tissue swelling may be prominent, clinically evident deformity is less common in lateral condyle fracture compared with supracondylar fracture. 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 64B:256. It occurs due to injury or weakened bones. People with a history of bone disease or calcium deficiency are especially at risk for thumb fractures. Fracture rotation can be difficult to assess radiologically and is best assessed on clinical examination. 2016 May 11. National Guideline Clearinghouse. 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. The distal humeral articular surface has several grooves and ridges that are important in determining anatomic stability after a fracture. 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. Despite its frequency, there is no clear consensus on the proper treatment of mallet fractures. [QxMD MEDLINE Link]. Although the majority of distal phalanx fractures can be treated nonsurgically with external immobilization, particular injury patterns such as fracture dislocations, transverse fracture patterns, and open physeal fractures (Seymour fractures), may warrant further stabilization. Distraction stress on the olecranon may occur from falling on an arm with the elbow partially flexed so that acute hyperflexion stress is applied against the triceps. 128(1):145-50. The fracture is almost always about 1 inch from the end of the bone. Several bones contribute to thumb function. Some transphyseal fractures include a small portion of the metaphysis as shown in the image below; such a finding is helpful in recognizing that a fracture is present. Olecranon fracture. 2005;39(1):23-9. 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. 2010 Apr-May. J Emerg Med. (2013) Hand clinics. A mini c-arm is utilized to help localize the distal tip of the distal phalanx on both the PA and lateral view. According to the authors, referral to a nerve specialist following supracondylar fractures is recommended in cases of complete nerve palsy, a positive Tinel sign, or neuropathic pain or vascular compromise. The alignment was confirmed by clinical examination and fluoroscopy. The fractured medial epicondyle may become entrapped in the elbow joint, representing a major complication. 4(1):25-9. Web[2,3]. When associated with a crush injury, open fracture is more likely. [QxMD MEDLINE Link]. Olecranon avulsion fracture. Finger fractures involving greater than 30 percent of the intra-articular surface should be referred to an orthopedic or hand surgeon. HHS Vulnerability Disclosure, Help Other views may also be helpful, such as the internal oblique view for lateral condyle fractures. WebDistal phalanx 1. Lateral condyle and olecranon fractures. Case Report: Locking Plate for Cubitus Varus Correction in a 7-Year-Old Girl With Osteogenesis Imperfecta. [QxMD MEDLINE Link]. 2. 3. 1990. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. This is sometimes called a tuft fracture Healing: This normally takes approximately 4-6 weeks to heal. Rarely, a Salter-Harris type IV fracture extends vertically through the metaphysis and epiphysis, crossing the physis. Stabilization is often achieved with splinting. 1. Intra-articular fractures are often complicated and unstable and should be referred to a hand specialist.3 Extra-articular fractures may be nondisplaced or displaced. Because the lateral crista of the trochlea is often included in the fracture fragment, the elbow joint loses lateral support in lateral condyle fractures. 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. The concave head of the radius articulates with the capitellum, which is the convex lateral articular surface of the distal humerus. 2001 Jan-Feb. 21(1):27-30. Most frequently, the thumb, the middle finger, or somewhat less often, the index finger is injured. This website also contains material copyrighted by third parties. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. (2010) Clinical radiology. Some distraction fractures of the olecranon may be subtle, whereas others may have significant proximal displacement of the fracture fragment. John J Grayhack, MD, MS is a member of the following medical societies: American Academy of Orthopaedic SurgeonsDisclosure: Nothing to disclose. Elbow fractures include supracondylar, lateral condyle, medial condyle, radial head and neck, and olecranon. Distal phalanx fractures are among the most common fractures in the hand. Sinikumpu JJ, Pokka T, Victorzon S, Lindholm EL, Serlo W. Paediatric lateral humeral condylar fracture outcomes at twelve years follow-up as compared with age and sex matched paired controls. Medial epicondyle avulsion fracture in an 11-year-old girl with an avulsion of part of the left medial epicondyle (A). Prompt and accurate diagnosis of a transphyseal distal humerus fracture is crucial for a 2. In addition, elbow US took a median of 3 minutes, while elbow radiography took a median of 60 minutes. Epub 2021 Mar 20. 2008 Apr. 1982. Entrapment of the medial epicondyle may be difficult to detect on the frontal view; such entrapment is often better depicted on the lateral view. This rotation allows for supination and pronation of the forearm and depends on proper motion of the proximal radioulnar joint (the third articulation of the elbow) and on the normal mobility of the forearm and wrist. 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. The fracture extends through the metaphysis and into the epiphysis, typically arising just above the medial epicondyle and extending to the trochlear groove, as shown in the image below. In fact, Monteggia variant and pseudo-Galeazzi injuries are forearm fractures involving both bones, with 1 of the fractures occurring so close to the joint that a dislocation is erroneously suggested. If these fractures are stable, they can be treated nonoperatively with splintage. Ann Emerg Med. 22(2):188-93. Although the Baumann angle does not define the true carrying angle of the elbow, it uses radiographically identifiable landmarks and is useful in comparison with the contralateral elbow. 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. A major complication of a radial neck fracture is limitation of motion at the proximal radioulnar joint, which mostly limits supination. The physial line is also located more proximally in infants, predisposing them to a physial fracture from a force that would have caused a supracondylar fracture in an older child. 487-532. Share cases and questions with Physicians on Medscape consult. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Finger dislocations can occur at the distal interphalangeal (DIP), proximal interphalangeal (PIP), or metacarpophalangeal (MCP) joints. If separation is significant, as shown below, recognition of the fracture is easy, although distinguishing these fractures from supracondylar fractures depends on knowing the characteristic course (see the image below). Your surgeon may use one of several operative fixation techniques to realign the bone fragments. Central slip injury can lead to the inability to extend the finger at the PIP joint and hyperflexion or boutonnire deformity over time.11 These injuries should be splinted for six weeks in full PIP extension to avoid chronic deformity at the PIP joint.11 Volar PIP dislocations are more difficult to reduce and results should be confirmed with postreduction radiography. Exam and imaging revealed an oblique distal phalanx fracture with an associated volar laceration and nail bed injury. There is a theoretical risk that open bore needles could incur higher rates of pin tract infections than standard k-wires due to increased implant surface area, but this was not seen in our patient population. Wolters Kluwer Health Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure fractures of the elbow in children. Successful management is dependent on an early and accurate diagnosis of the injury, through clinical and radiologic evaluation. The stability of the distal fragment is partly determined by whether the fracture extends all the way to the articular surface or whether a cartilaginous hinge remains intact to help prevent motion of the fracture fragment. 39(2):155-61, v. [QxMD MEDLINE Link]. 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%. Therefore, the trochlea should not be seen unless the medial epicondyle is identified as well. Typical supracondylar fracture.