However, the trochlea does not become ossified before the medial epicondyle. This motion causes the ulna to fracture and contact the proximal radius, forcing the radial head to become dislocated from the capitellum. Lateral condyle fracture. In a meta-analysis of 5154 supracondylar fractures in children, nerve injury occurred in 11%. 2012 Feb. 20(2):69-77. Chicago, IL: Year Book Medical Publishers, Inc; 1985. 65 (10): 773-80. Posterolateral elbow dislocation. Rather, only deformity is observed, as demonstrated by the anterior humeral line. [QxMD MEDLINE Link]. Note the comminuted fracture of the distal phalanx of the fourth toe Fig.2. The distal fracture fragment is displaced laterally and posteriorly. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. With complete fractures, the fracture line and displacement are obvious. Anteroposterior (A) and lateral (B) views. Supracondylar fracture. Fractures of the lateral condyle are the second most common elbow fracture in children, accounting for 15-20%. Once the fracture has healed, it is very important to follow all therapy instructions to improve motion in the thumb. 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. 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. Silverman FN. Understanding the developmental anatomy of the pediatric elbow helps ensure that normal ossification centers are not misinterpreted as fracture fragments. [3] Clinical feature of these lesions are variable, the glomus tumor present changes in pain severity depending on temperature. 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. This technique has not been previously described in the Orthopedic literature for diverse pattern of fractures of the distal phalanx. This website also contains material copyrighted by 3rd parties. Stability of the reduction is assessed by gentle active flexion of the involved finger; the joint should be stable through flexion and extension. It is also called nursemaid's elbow and other names; it usually results from a sudden pull on the hand. 41 (7):1453-1461. The peak age is 5-7 years, and the nondominant arm is involved more frequently than the dominant arm. Of 130 patients (mean age, 7.5 yr), 43 (33%) had a radiograph result positive for fracture. Tokarski J, Avner JR, Rabiner JE. Orthop Clin North Am. The radial head ossification center is initially oval and subsequently becomes flattened and disk shaped. Medial epicondyle avulsion fracture in an 11-year-old girl with an avulsion of part of the left medial epicondyle (A). Transcondylar fracture with typical posterior and medial displacement of the distal fragment. Distal phalanx fractures are stable and can be treated with simple splinting of the DIP joint only. 1. Other fractures that may be associated with elbow dislocations include fractures of the proximal radius, particularly fractures in which the radial head is markedly displaced and rotated into the coronal plane; fractures of the lateral condyle; and remote fractures in the same extremity, most often the distal radius and ulna. Mallet fractures (mallet finger) occur at the insertion of the terminal finger extensor mechanism into the dorsal portion of the distal phalanx. Successful management is dependent on an early and accurate diagnosis of the injury, through clinical and radiologic evaluation. (C) Arteriogram shows abrupt termination of contrast in the brachial artery proximal to the level of transection, suggesting spasm and thrombosis. This joint sits between the proximal phalanx and a bone in the hand called the first metacarpal. Although not routinely acquired, this view may be useful when a fracture is highly suspected but is not found on standard views. A 13-year-old youth with nonunion of lateral condyle fracture and subsequent ulnar neuropathy. Type A fractures have no or minimal gap at their lateral aspect and cannot be traced all of the way to the physis. Thumb Fractures - OrthoInfo - AAOS [QxMD MEDLINE Link]. Distal [QxMD MEDLINE Link]. Supracondylar fractures may be complete or incomplete and have a wide range of severity. Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. This content is owned by the AAFP. 2008 Apr. Rotator Cuff and Shoulder Conditioning Program. The medial epicondyle is included in the distal fragment. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. See Instructions for Authors for a complete description of levels of evidence. Crush injuries often have associated soft-tissue However, such an injury may be suggested by localized tenderness and soft tissue swelling and by the presence of a posterolateral elbow dislocation. Fracture of the medial condyle is an uncommon injury in children. 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. Copyright 2012 by the American Academy of Family Physicians. 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. 2015; Accessed: May 30, 2016. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. 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. Therefore, elbow radiographic findings are normal in a pulled elbow. [18]. Normal articulation of the medial condyle and proximal ulna is maintained. 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. On exam, the dislocation was unable to be reduced. 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. 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. See permissionsforcopyrightquestions and/or permission requests. Distal phalanx or tuft fractures: Closed with minimal to no displacement: Inherently stable Often have an associated subungual hematoma that may need evacuated (see Other Procedures ) for pain control Ice for swelling and pain control 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. The possibility of concomitant fracture or soft tissue injury must be considered, especially if relocation is unsuccessful. 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. The most common direction of displacement is posterior or posterolateral (see the images below), although lateral and anterior dislocations also occur. This is encouraged before treatment is finalized. She was started on a home exercise program at that time. (2019). fractures [35], The rate of flexion-type fractures has been estimated to be 1.2%. Treatments usually include splints or surgery, for more severe fractures. Treatment of unstable distal phalanx fractures by Follow-up anteroposterior (C) and lateral (D) views demonstrate the fracture better. 1998. [23] Radiographic evaluation of the amount of displacement is also known to be limited, with many cases showing substantially more displacement by CT than radiography. Instr Course Lect. 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. WebDistal Phalanx Fractures Tuft Fracture (crush injury) Soft tissue injury is often more obvious; Xray required to detect underlying fracture Management consists mainly of Careers. Saper MG, Pierpoint LA, Liu W, Comstock RD, Polousky JD, Andrews JR. Check for errors and try again. The history should include mechanism of injury, timing and progression of symptoms, hand dominance, and any previous finger injury. This finding must be distinguished from the normal angulation that is usually present at the junction of the radial neck and shaft. WebType 4: 4A, transphyseal fracture in children. Alternatively, it may result from excessive muscular activity, often in association with throwing. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Management of finger injuries begins with closed reduction of the fracture or dislocation, if indicated. Tuft fracture (Figure 3) is the most common type of distal phalanx fracture. Lateral view demonstrates an abnormal relation of the capitellum to the anterior humeral line, which passes along the anterior margin of the capitellum. With subtle fractures, the fracture line may be initially seen through only a portion of the metaphysis. Initial anteroposterior (A) and lateral (B) views show a nondisplaced lateral condyle fracture. Radiographic evaluation with a minimum of three views (commonly anteroposterior, true lateral, and oblique) is required if any fracture or dislocation is suspected.4. 23 (3):318-26. The bones. [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. It can take 3 months or more to regain full use of the hand, depending on the severity of the injury. Sep 2006. Traditional treatment following reduction of uncomplicated dorsal PIP joint dislocations is splinting for one to two weeks followed by buddy taping for another one to two weeks. Fracture J Pediatr Orthop. In one study, 7 out of 606 supracondylar humeral fractures were flexion-type injuries.
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