Mohd Miswan MF, Othman MS, Muhamad Effendi F, Ibrahim MI, Rozali KN. In this patient, the only sign of the fracture is the thin metaphyseal flake on the anteroposterior view. J Emerg Med. WebThe distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. (B) The lateral view shows posterior displacement and angulation of the distal fragments, appearing similar to a type III supracondylar fracture. 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. If you log out, you will be required to enter your username and password the next time you visit. In supracondylar fractures with medial displacement of the distal fragment, there is often internal rotation, which results in varus if the fracture is oblique. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. To make the diagnosis, it is helpful that the radiologist be familiar with the normal developmental anatomy of the elbow. Unable to process the form. A mini c-arm is utilized to help localize the distal tip of the distal phalanx on both the PA and lateral view. Radiographic findings of proximal radius fractures. Beaty JH, Kasser JR. Rockwood and Wilkins' Fractures in Children. Reduction may be unsuccessful because of soft tissue injury or fracture. See the Medscape Reference article Salter-Harris Fracture Imaging for more information. The assessment should also include finger alignment, ligament integrity, neurovascular status, and flexion and extension of the joints. Reduction is similar to that of a dorsal PIP dislocation if no concomitant injury is present. J Orthop Trauma. 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 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. Unable to load your collection due to an error, Unable to load your delegates due to an error. Radiographic 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. Unauthorized use of these marks is strictly prohibited. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Pathy R, Dodwell ER. Anteroposterior (A) and lateral (B) views of the injured right elbow compared with anteroposterior (C) and lateral (D) views of the uninjured left elbow. Angular deformity also results from rotation at an oblique fracture line. A padded splint can be used to prevent the bone from moving farther out of alignment. Web[2,3]. 2010 Dec 1. Duffy S, Flannery O, Gelfer Y, Monsell F. Eur J Orthop Surg Traumatol. Indirect insults lead to different sequelae that are based on whether the epiphyseal blood supply or metaphyseal Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-41775, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":41775,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/distal-phalanx-fracture/questions/1272?lang=us"}. However, additional morbidity includes a predisposition to subsequent lateral condyle fracture, pain, and late development of posterolateral elbow instability. [45] It has also been suggested that extension force in infants may be more likely to cause a transphyseal fracture than supracondylar fracture. Nondisplaced or minimally displaced (< 2 mm) lateral condyle fractures, may be stratified according to their risk of subsequent displacement. Soft tissues were repaired (Fig. Entrapment is particularly common after an elbow dislocation or subluxation. Transphyseal fracture. 1-6. We propose that fracture stabilization can be performed by the on-call hand resident or fellow in the ER. [12], A study of 62 elementary school baseball players (grades 4-6; ages 9-12 yr) for elbow injuries using MRI found positive findings in 26 (41.9%), all confined to the MCL. Transphyseal fracture. 50:95. Supracondylar fracture. Supracondylar fractures may be complete or incomplete and have a wide range of severity. Baumann angle. It is normal for your finger to be a bit achy and swollen for a couple of months after this type of injury. Finger dislocations can occur at the distal interphalangeal (DIP), proximal interphalangeal (PIP), or metacarpophalangeal (MCP) joints. 2012 Jun. All Rights Reserved. National Library of Medicine Anteroposterior (A) and lateral (B) views of the injured left elbow with anteroposterior (C) and lateral (D) views of the right elbow for comparison. Lateral view demonstrates an abnormal relation of the capitellum to the anterior humeral line, which passes along the anterior margin of the capitellum. This is encouraged before treatment is finalized. (B) Lateral intraoperative image shows reduction and pinning of the fracture, which is well aligned. Radiology of Skeletal Trauma. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Anteroposterior view shows disruption of the medial cortex. Matsuura T, Iwame T, Suzue N, Arisawa K, Sairyo K. Risk factors for shoulder and elbow pain in youth baseball players. Displaced lateral condyle fracture. Failure to treat PIP dislocations appropriately can lead to chronic pain, degenerative changes, and loss of function. Fractures in Children. A modified Gartland type-IV fracture. In this case, the lateral crista is part of the distal fracture fragment, leading to instability of the elbow joint. (2016) Clinical orthopaedics and related research. WebYou have broken your distal phalanx (the end of your finger). History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? Diagnostically, oblique fractures may be demonstrated more easily by use of an AP view with cephalad angulation, which shows the fracture en face. 487-532. Br Med J (Clin Res Ed). The distal phalanx is the most commonly fractured bone in the hand, followed by the metacarpals . [QxMD MEDLINE Link]. 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. When significantly displaced, supracondylar fractures usually have clinically obvious deformity. 179. 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. Subtle olecranon fracture. Anteroposterior view shows a mildly abnormal angular configuration of the lateral aspect of the proximal radial metaphysis. Imaging Pitfalls of the Acutely Traumatized Pediatric Elbow. [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. Reproduced with permission from Soyer AD: Fractures of the Base of the First Metacarpal: Current Treatment Options. MRI could demonstrate the abnormal relationship of the radial head and annular ligament, but such studies are seldom needed. However, this can be challenging for the surgeons schedule, patients schedule, and can also place unnecessary financial burden on the health care system. ("Articular" means "joint.") Displaced proximal radial fracture. 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. The identification of a proximal radial fracture should alert the examiner to carefully search for other injuries. 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. MRI is useful in identifying medial epicondyle fractures prior to ossification of the medial epicondyle and for delineating the full extent of the cartilaginous fracture in children with a small medial epicondyle ossification center. Other views may also be helpful, such as the internal oblique view for lateral condyle fractures. The flexor digitorum profundus tendon inserts at the volar surface of the distal phalanx. Philadelphia:. [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. 1975 Dec. 57(8):1087-92. 1991:528. In addition to the findings in the multiple ossification centers described above, other normal findings may simulate pathology. They represent > 50% of all phalangeal fractures and frequently involve the ungual tuft 1. Kirschner wire pin site infection in hand and wrist fractures: incidence rate and risk factors. The majority of distal phalanx fractures are minimally displaced and may be treated conservatively. These fractures are usually Salter-Harris type II injuries that include a metaphyseal fragment of variable size. Orthop Clin North Am. 533-93. The fracture originates in the lateral aspect of the distal humeral metaphysis and passes obliquely to the physis. Avulsion fractures of the medial epicondyle may occur before ossification, and they cannot be detected on plain radiographs. One patient did experience stiffness of the injured finger which improved with therapy. The most common follow-up fractures were olecranon (N=23, 72%), coronoid process (N=4, 13%), and supracondylar (N=3, 9%). 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). With healing, sclerosis is demonstrated across the entire metaphysis, indicating the full extent of the fracture (see the image below). The avulsed proximal fracture fragment is proximally retracted by the triceps muscle. An 18-month-old child with buckle-type distal humeral supracondylar fracture and an associated distal radial metaphyseal buckle fracture. Copyright 2023 American Academy of Family Physicians. Olecranon fracture. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. In general, medial condyle fractures (Salter-Harris type IV injuries) have larger metaphyseal components than medial epicondyle fractures that involve the metaphysis have. 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. Fracture is at the tip of the ossified portion of the olecranon process. Subtle cortical deformity also may be present medially or laterally, which may be associated with varus or valgus deformity. 1995 Jul-Aug. 15(4):422-5. 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. The mean annual incidence was 0.8 per 105. 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. All rights reserved. 2012 Jul-Aug. 32(5):477-82. (A) Anteroposterior radiograph shows avulsion and distal displacement of a portion of the left medial epicondyle ossific nucleus. The proximal radius has normal angulation between the neck and shaft, with the neck angulated laterally and slightly anteriorly relative to the shaft, which should not be confused with a fracture. Ossification of the elbow region is complex, but knowledge of it is essential in analyzing elbow trauma in children. Almost most distal phalanx fractures can be treated nonsurgically with splinting, a small subset warrant internal fixation to potentially avoid adverse outcomes. [QxMD MEDLINE Link]. Medial epicondyle avulsion fracture in an 11-year-old girl with an avulsion of part of the left medial epicondyle (A). [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. The frequency of olecranon fractures on follow-up may suggest the occult nature of these fractures. 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. The thumb also has several nerves that give you feeling and blood vessels that provide the thumb with blood flow. (A) Anteroposterior view. J Pediatr Orthop. Because the lateral crista of the trochlea is often included in the fracture fragment, the elbow joint loses lateral support in lateral condyle fractures. These may have some angulation but no true displacement of the fracture fragment and no shift of the olecranon. Sep 2006. 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. Abzug JM, O'TYoole RV, Paryavi E, Sterling R. Are orthopaedic residents competent at performing basic nonoperative procedures in an unsupervised setting? Distraction may also result from the ulnar collateral ligament with elbow dislocation or subluxation, which accounts for approximately half of medial epicondyle fractures in children. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. She was started on a home exercise program at that time. 1992:753. 2015;81:296302. The physician will examine the injury, take a medical history, and order X-rays of the injury. While previously supracondylar fractures were more frequent in boy than in girls, this discrepancy has diminished. Management of finger injuries begins with closed reduction of the fracture or dislocation, if indicated. Proper Technique for Reduction of Metacarpophalangeal Dislocations. Radiocapitellar alignment remains normal. 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. Passage of the anterior humeral line either anterior to the capitellum or through the anterior third of the capitellum demonstrates that the capitellum is positioned too far posteriorly; this finding indicates a distal humeral fracture. 2007 Jan. 89(1):58-63. 2017. Medial condyle fracture with markedly rotated distal fragment in a 7-year-old boy. A 4-year-old child with medial epicondyle fracture. In a transphyseal fracture, the epiphysis is usually medially displaced relative to the metaphysis (see the image below). 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. When no displacement is present, findings indicating a lateral condyle fracture may be subtle. HHS Vulnerability Disclosure, Help Rha E, Lee M, Lee J, et al. 2015 Aug 28. [QxMD MEDLINE Link]. 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. doi: 10.1097/BPO.0000000000001156. 1974 Jun. 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. [QxMD MEDLINE Link]. [16], Tokarski et al found that use of conventional radiography may be reduced in patients with a low clinical concern for fracture and normal elbow ultrasound. 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.
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