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. Carpenter S, Rohde RS. WebTransphyseal 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. While previously supracondylar fractures were more frequent in boy than in girls, this discrepancy has diminished. Imaging in Pediatric Elbow Trauma - Medscape Proximal radial fractures in children are frequently associated with other injuries; such injuries most frequently involve the olecranon. Treatment following simple reduction is also similar to that following PIP dislocation. distal phalanx fractures Tuft fracture ( Figure 3 ) is the most common type of distal phalanx fracture. If the medial epicondyle is not seen in its normal anatomic position, it should be searched for elsewhere, including within the elbow joint. 2010 Dec 1. While transphyseal distal humerus fractures are rare, the true incidence may be Medial epicondyle fracture with distal displacement of a fracture fragment. A nondegenerative injury was seen in 27.5%, and 67.9% were degenerative injuries. 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. 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. How displaced are "nondisplaced" fractures of the medial humeral epicondyle in children? 1-6. 2008 Apr. However, unlike supracondylar fractures, lateral condyle fractures are seldom associated with fractures remote from the elbow. Distal phalanges are the most exposed phalanges and are, therefore, fractured more often than other hand fractures. The fracture then propagates through the physis and eventually passes into the metaphysis, producing a typical Salter-Harris appearance. However, distal pulses remained absent. Recognizing that the forearm is not aligned with the humerus on plain radiography can aid in the diagnosis of the injury. Displaced fractures of the neck of the radius. The lateral epicondyle may arise as either a single elongated center or as multiple centers of ossification. [QxMD MEDLINE Link]. Follow-up anteroposterior (C) and lateral (D) views demonstrate the fracture better. 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 See Instructions for Authors for a complete description of levels of evidence. 2008 Apr. Epiphyseal-plate cartilage. Type A fractures have no or minimal gap at their lateral aspect and cannot be traced all of the way to the physis. Therefore, the flake of bone must represent a fracture fragment. Place in stack splint for protection and pain control for 3 to 4 weeks. The corresponding ages at which the ossification centers of the proximal forearm bones appear are 4.5 years for the radial head and 9 years for the olecranon. 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. [20, 27, 1]. A 19-month-old male presented to the ED with an open fracture dislocation of his middle finger distal phalanx after his finger was caught inside a door hinge. 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. [QxMD MEDLINE Link]. A dorsal PIP dislocation is the most common type of finger dislocation. You may be trying to access this site from a secured browser on the server. [28] With greenstick fractures, cortical disruption is seen on the tensile side (usually the anterior cortex), and they may be accompanied by cortical buckling of the compression side (usually the posterior cortex). Such complications include nonunion or fibrous union. Fractures of the medial epicondyle account for 10-15% of elbow fractures in children. 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. The other bones of the thumb the distal phalanx and proximal phalanx are also susceptible to fractures. 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. Normal lines. Radiography also helps identify volar fracture of the middle phalanx and other associated injuries. WebDistal phalanx 1. In cases in which the radial head is not yet ossified, this injury cannot be distinguished from a true Monteggia fracture/dislocation by use of plain radiographs. Plain radiographs form the mainstay of imaging distal phalanx fractures. Common signs of injury are local swelling, erythema, pain, deformity, and tenderness to palpation. With the elbow fully extended, or hyperextended with relative ligamentous laxity during childhood, the olecranon acts as a fulcrum to transmit the load into a bending force on the distal humerus in the supracondylar region. Orthop Clin North Am. Radiocapitellar alignment remains normal. Elbow dislocations are usually readily apparent on radiographs. When the proximal radius and ulna return to normal position, the capitellum may shear off the radial head, leaving it posteriorly displaced. Author disclosure: No relevant financial affiliations to disclose. You may search for similar articles that contain these same keywords or you may 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). Finger fractures and dislocations may occur during daily activities, such as work, but usually occur during participation in sporting activities. The age at which ossification centers are first seen varies considerably; maturation usually proceeds earlier in girls than in boys. Avulsion fractures of the medial epicondyle may occur before ossification, and they cannot be detected on plain radiographs. 295(6590):109-10. JAMES R. BORCHERS, MD, MPH, AND THOMAS M. BEST, MD, PhD. Fredric A Hoffer, MD, FSIR is a member of the following medical societies: Children's Oncology Group, Radiological Society of North America, Society for Pediatric Radiology, Society of Interventional RadiologyDisclosure: Nothing to disclose. Simplistically, a Monteggia fracture/dislocation may be thought of as the result of a force that dislocates the radial head and simultaneously fractures the ulna in the same direction. Common complications of these injuries are: altered sensitivity (numbness, hyperesthesia, tenderness) cold sensitivity (cold intolerance) restriction of DIP joint movement For reprint requests, or additional information and guidance on the techniques described in the article, please contact Rebecca G. Burr, MD, at [emailprotected] or by mail at Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center Maywood, IL 60153. Although posteriorly displaced lateral condyle fractures may show an abnormal relationship between the anterior humeral line and the capitellum, this finding is not as useful in lateral condyle fractures as in supracondylar fractures. In particular, the internal oblique view has been shown to be better than the AP view for showing the presence of lateral condyle fracture, the degree of displacement, and findings suggesting instability. It is normal for your finger to be a bit achy and swollen for a couple of months after this type of injury. 3. However, widening of the joint space may be difficult to evaluate in patients in whom the elbow is immature; in such cases, the largely cartilaginous trochlea makes the normal gap between the distal humerus and ulna appear quite wide. Other causes of transphyseal fractures of the distal humerus include nonaccidental trauma and fall from a low level height [4-7]. It is believed that the most common injuries found in association with olecranon fractures are fractures of the proximal radius. We introduce a technique to stabilize diverse fractures of the distal phalanx in the emergency department (ED) utilizing a hypodermic 18- or 20-G needle. Of 130 patients (mean age, 7.5 yr), 43 (33%) had a radiograph result positive for fracture. Such distraction injuries may arise from valgus stress applied to an extended elbow or muscular stress. Supracondylar fracture. Our patients experienced no pin tract infections, nail defects, or sensation issues. The anterior fat pad is demonstrated and is abnormally elevated. Radiography (commonly anteroposterior, true lateral, and oblique views) is required in the evaluation of finger fractures and dislocations. In 55-85% of patients, the radial head is anteriorly dislocated, with an associated apex anterior ulnar fracture (Monteggia type 1 injury). 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. [Closed reduction and percutaneous pinning with three Kirschner wires in children with type III displaced supracondylar fractures of the humerus]. They found that the total cost of supplies and nonphysician labor was $432.31 per OR case and $179.59 per procedure room. With type C fractures, the fracture line remains is as wide medially as laterally. Tendon Avulsion Injuries of the Distal Phalanx The possibility of concomitant fracture or soft tissue injury must be considered, especially if relocation is unsuccessful. 7. van Leeuwen WF, van Hoorn BT, Chen N, et al. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. Entrapment of the medial epicondyle may be difficult to detect on the frontal view; such entrapment is often better depicted on the lateral view. A study showed an increase in range of motion and intrinsic muscle strength following four weeks of splinting with daily active exercise compared with immobilization alone.10 For uncomplicated dorsal PIP dislocations, short-term splinting in flexion with early active range of motion and strengthening is preferable to immobilization.5,10. 1988;13:350352. Initial lateral view (A) shows an abnormal anterior humeral line indicative of a fracture. If an associated radial fracture is not identified, a careful search should be made for a radiocapitellar dislocation or subluxation. 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. Fractures and dislocations involving the distal phalanx are frequently treated with immobilization, however particular injury patterns warrant additional stabilization. Donnelly L, Klostermeier T, Klosterman L. Traumatic elbow effusions in pediatric patients: are occult fractures the rule?. Transphyseal fractures most often occur in young children (< 2 y); they are reportedly associated with birth injury and child abuse. Olecranon avulsion fracture. Krengel WF 3rd, Wiater BP, Pace JL, Jinguji TM, Bompadre V, Stults JK, et al. Radiographic findings in supracondylar fracture. Anteroposterior (A) and lateral (B) views. In addition to the elbow dislocation, avulsion of the medial epicondyle is noted projecting posterior to the capitellum. Note the small fragment of metaphysis attached to the medial epicondyle; this finding indicates a Salter-Harris type II injury. Distal Phalanx Fractures Instr Course Lect. Before In addition, traction from the common extensor muscles leads to rotation so that the cartilage-covered articular surface of the fractured lateral condyle is in contact with the metaphysis, leading to nonunion if not corrected. 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. Clin Orthop. 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. Treatment consists of splinting in slight flexion with early range of motion and strengthening exercises. WebThe doctor will take an X-ray of the wrist. Localized soft tissue swelling is usually present. Fractures in Children. Medial epicondyle fractures 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. J Bone Joint Surg Am. 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. However, these injuries have marked medial soft tissue swelling compared with the lateral soft tissue findings with lateral condyle fracture. This complication is usually caused by malalignment of the radial head and neck; more severe limitation of motion may result from radioulnar synostosis. For these fractures, the lateral crista of the trochlea is intact, maintaining stability of the elbow joint. All rights reserved. Your message has been successfully sent to your colleague. In the coronal plane, the fracture line extends transversely across the metaphysis at the level of the olecranon fossa. Varus stress fractures may be associated with a lateral condyle fracture or a lateral dislocation of the radial head (type 3 Monteggia fracture/dislocation). Prognostic Level III. The consequences of pin placement. Techniques in Orthopaedics36(4):514-516, December 2021. These fractures usually have anterior displacement of the distal fragment. 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]. Chondral and osteochondral abnormalities can be further evaluated with MRI or CT. The addition of arthrography is helpful, especially for detecting intra-articular bodies. Please confirm that you would like to log out of Medscape. The anterior humeral line may be extremely useful in the diagnosis of supracondylar fracture. Web26785 Open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, each Depth of Plunge CPT Description 23515 Open treatment of clavicular fracture, with or without internal or external fixation 23615 Open treatment of proximal humeral (surgical or anatomical neck) fracture, with or The flexor digitorum profundus tendon inserts at the volar surface of the distal phalanx. Some fractures may be caused indirectly, from twisting or even from strong muscle contractions, as might occur in wrestling, hockey, football, and skiing. 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. Following reduction, the DIP joint remained unstable. Transphyseal Distal 32(4):373-7. Skaggs DL, Hale JM, Bassett J, et al. This information is provided as an educational service and is not intended to serve as medical advice. Please enable it to take advantage of the complete set of features! Referral for surgical management of mallet fractures has been suggested for those involving greater than 30 percent of the intra-articular surface and for those associated with volar subluxation of the distal phalanx.16,17 Nevertheless, a study of 22 mallet fractures involving greater than 30 percent of the joint space reported that patients with volar subluxation and displaced fragments after splinting had no difference in pain and function than those without these features.18 Conservative therapy for all mallet fractures is preferable as first-line treatment and may have outcomes similar to those of surgical treatment.19,20 Consultation with a hand surgeon is recommended if the physician is uncomfortable with the management of more complicated mallet fractures.