As with lateral condyle fractures, medial condyle fractures are often unstable and may be complicated by nonunion. Thumb Fractures - Emergency Department 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. Salter-Harris fracturesare a group childhood injuries where a fracture involves the physis. Anteroposterior (A) and lateral (B) views show combined fractures of the distal humeral lateral condyle and olecranon process of the ulna. [Full Text]. The elbow is the most frequently dislocated joint in children, whereas in adults, dislocations of the shoulder and interphalangeal joints of the fingers are more common. In addition to a transverse or oblique component through the supracondylar region, the distinguishing aspect of T-condylar fracture is a sagittally oriented component that extends to the articular surface, splitting the medial and lateral condyles. 2015;81:296302. Most cases of isolated radial head dislocation in children are likely to actually be Monteggia fracture/dislocation with a subtle ulnar bowing fracture. 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. T-condylar fractures may result from flexion or extension injury, with the articular surface of the olecranon acting as a wedge to split the humeral condyles. Overall, many thumb fractures have good outcomes after appropriate treatment. Distal Phalanx Fracture A broken thumb can be a serious problem. Beaty JH, Kasser JR. You are being redirected to J Pediatr Orthop. Since Milch II lateral condyle fractures separate the lateral crista of the trochlea (lateral trochlear ridge) from the rest of the trochlea, there may be accompanying elbow dislocation through loss of lateral support for the olecranon process (see the image below). Vertically oriented fracture begins along the medial aspect of the distal humeral metaphysis and extends to the growth plate. 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. Karapinar L, Oztrk H, Altay T, Kse B. Acta Orthop Traumatol Turc. A variety of 18- and 20-G short hypodermic needles are available in all practice settings. 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). 88(5):980-5. Subtle lateral condyle fracture. {"url":"/signup-modal-props.json?lang=us"}, Rothe C, Hacking C, Jones J, et al. Anteroposterior (A) and lateral (B) views show significant lateral and posterior displacement of a distal fragment. In most cases, lateral condyle fractures are distraction injuries from the forearm extensors, usually as a result of acute varus stress applied to an extended elbow. A 20-G needle is typically used in pediatric injuries as well, however a smaller needle could be considered occasionally for smaller patients. In the remainder of patients, fractures/dislocations are divided equally between posterior (Monteggia type 2 injury) and lateral (Monteggia type 3 injury) dislocation of the radial head. [46] Some proximal radial fractures may result in abnormal articulation of the radial head and capitellum and therefore are fracture/dislocations. Displaced proximal radial fractures may result from transient posterior elbow dislocation. (D) Postoperative anteroposterior radiograph shows improved alignment and healing. 2017. Start appropriate oral antibiotics for any open fractures. This content is owned by the AAFP. Hand Clin. 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. 2002 Mar-Apr. Oman Med J. At surgical exploration, the brachial artery was transected at the level of the fracture. Injuries of the fingers and thumb in the athlete. Common complications of these injuries are: altered sensitivity (numbness, hyperesthesia, tenderness) cold sensitivity (cold intolerance) restriction of DIP joint movement In particular situations, such as with young children, conscious sedation can be provided by ED physicians to make the procedure more tolerable. The flexor digitorum superficialis (FDS) attaches to the palmar surface of the middle phalanx and is the primary flexor of the PIP joint. DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. Curr Opin Pediatr. Subtle cortical deformity also may be present medially or laterally, which may be associated with varus or valgus deformity. However, the adjacency of fracture margins for the metaphysis and capitellum poses the risk of focal physial closure. However, this finding may cause the injury to be confused with a lateral condyle fracture. The incidence of distraction fractures is particularly high in patients with osteogenesis imperfecta, including patients with relatively normal-appearing bones and few fractures elsewhere (see the image below). In searching for subtle fractures, knowing their expected location is essential. Stress radiographs demonstrating widening of the medial joint space with valgus stress indicate either avulsion of the medial epicondyle or disruption of the ulnar collateral ligament. [28] See the images below. One patient did experience stiffness of the injured finger which improved with therapy. The peak age of occurrence for these fractures is 4-10 years. Anteroposterior view shows the lateral condyle with a fracture line passing through the metaphysis and capitellum, crossing the growth plate. Rabiner JE, Khine H, Avner JR, Friedman LM, Tsung JW. J Shoulder Elbow Surg. However, such an injury may be suggested by localized tenderness and soft tissue swelling and by the presence of a posterolateral elbow dislocation. ("Articular" means "joint.") Joint effusion is more likely to be present with medial condyle fractures, although joint effusions may be seen with medial epicondyle avulsion fractures. Fractures of the proximal ulna are uncommon in children, accounting for 6% of elbow fractures. Supracondylar fracture. Rarely, a Salter-Harris type IV fracture extends vertically through the metaphysis and epiphysis, crossing the physis. 1975 Dec. 57(8):1087-92. [9, 10, 11], A review of medical records of 462 children (median age, 6 yr) with elbow fractures identified the most common fractures as supracondylar (N=258, 56%), radial neck (N=80, 17%), and lateral condylar (N=69, 15%). (A) Anteroposterior, (B) oblique, and (C) lateral views show markedly rotated distal fracture fragment of this medial condyle fracture. You may search for similar articles that contain these same keywords or you may F. Thumb fractures 1. 2015 Aug 28. 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. See Instructions for Authors for a complete description of levels of evidence. Note the small fragment of metaphysis attached to the medial epicondyle; this finding indicates a Salter-Harris type II injury. The fractured medial epicondyle may become entrapped in the elbow joint, representing a major complication. Donnelly L, Klostermeier T, Klosterman L. Traumatic elbow effusions in pediatric patients: are occult fractures the rule?. [QxMD MEDLINE Link]. Radiographic findings of proximal radius fractures. Fractures of the lateral condyle are the second most common elbow fracture in children, accounting for 15-20%. no financial relationships to ineligible companies to disclose. 1978 Jul. Soft tissues were repaired (Fig. Medscape Education. 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. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma. Unstable distal phalanx fractures are typically treated by pinning of the distal phalanx or the distal interphalangeal joint (DIP). Distal 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. CT may be helpful to further assess the nature of the fracture. Management of vascular injuries in displaced supracondylar humerus fractures without arteriography. Our patients experienced no pin tract infections, nail defects, or sensation issues. Transphyseal Distal [QxMD MEDLINE Link]. Phalanx Fractures Like the metacarpal, the distal and proximal phalanges can fracture near/into a joint or in the shaft of the bone. Rykiel H. Levine, Lisa A. Foris, Trevor A. Nezwek, Muhammad Waseem. 3. Dorsal dislocation of the proximal interphalangeal joint is the most common type of finger dislocation. Characteristics ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. WebA distal radius fracture almost always occurs about 1 inch from the end of the bone. Distal Fracture You will likely need to wear the cast for at least 4 to 6 weeks. Recently, it has been suggested that at least 7 cm of the humeral shaft should be visualized and that using the medial or lateral cortices of the distal humeral diaphysis rather than the center of the shaft to define the humeral axis led to a more reproducible measurement of Baumann angle. [36, 37]. Beaty JH, Kasser JR. Rockwood and Wilkins' Fractures in Children. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Results of a three-dimensional computed tomography analysis. More distally (D and E), there is reconstitution of the radial and ulnar arteries from collaterals that supply the palmar arch. [QxMD MEDLINE Link]. These hinge joints allow flexion and extension and are reinforced by plantar ligaments, as well as by medial and lateral collateral ligaments. Edmonds EW. The bones of the thumb have several important ligaments at each joint that both allow for motion of the joint and keep the joint stable so it does not dislocate: Several other tendons/muscles allow the thumb to move in virtually all directions. Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Angular deformity also results from rotation at an oblique fracture line. For patient information resources, see eMedicineHealth's First Aid and Injuries Center, as well as Broken Elbow and Elbow Dislocation. 2008 Feb. 24(1):139-52. Avulsion fractures of the medial epicondyle may occur before ossification, and they cannot be detected on plain radiographs. Typical supracondylar fracture. WebA broken finger is a common bone break. T-condylar fractures are uncommon in pediatric patients, particularly prior to skeletal maturity, although they may be misdiagnosed as other elbow injuries with clinical presentation often similar to supracondylar fracture and radiographs that may be confused with supracondylar, lateral condyle, or medial condyle fractures. Philadelphia:. Nonoperative treatment is based on immobilization of the DIP joint in extension, leaving the PIP joint free. 2016 May 11. The proximal radius and ulna maintain a normal relationship with respect to the epiphysis; hence, the forearm bones are also displaced relative to the humeral metaphysis. Imaging in Pediatric Elbow Trauma - Medscape Although the radiologic diagnosis of lateral condyle fracture depends on plain radiographic findings, MRI, arthrography, or ultrasonography (US) may be useful in the further evaluation of the fractures, particularly with regard to the course of the fracture through the cartilaginous epiphysis, as shown below. Goto A, Murase T, Moritomo H, Oka K, Sugamoto K, Yoshikawa H. Three-dimensional invivo kinematics during elbow flexion in patients with lateral humeral condyle nonunion by an image-matching technique. Monteggia variant. Elbow fractures are the most common type of fractures in children, primarily occurring from a fall on an outstretched hand. Recognizing that the forearm is not aligned with the humerus on plain radiography can aid in the diagnosis of the injury. 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. In a meta-analysis of 5154 supracondylar fractures in children, nerve injury occurred in 11%. Posterolateral elbow dislocation, lateral view. [QxMD MEDLINE Link]. The elbow should be well visualized in all patients who have an ulnar injury, with or without an associated radial fracture. The position of the tiny ossification center for the capitellum suggests that it is displaced posteriorly; this is confirmed on the arthrogram (C). Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: It usually involves injury to the volar plate and may include a volar plate avulsion fracture. Anteroposterior (A) and lateral (B) views of the injured left elbow with anteroposterior (C) and lateral (D) views of the right elbow for comparison. (B) On the lateral view, a small fracture line is present at the tip of the proximal ulna, and subtle discontinuity of the posterior cortex is seen. 2016 Jan. 46 (1):61-6. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 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. The mean annual incidence was 0.8 per 105. Jpn J Radiol. A radial fracture with apex anterior angulation is present. The assessment should also include finger alignment, ligament integrity, neurovascular status, and flexion and extension of the joints. Abzug JM, O'TYoole RV, Paryavi E, Sterling R. Are orthopaedic residents competent at performing basic nonoperative procedures in an unsupervised setting? In these cases, only the radial head is still in alignment with the capitellum. Once the fracture has healed, it is very important to follow all therapy instructions to improve motion in the thumb. Shukla M, Keller R, Marshall N, Ahmed H, Scher C, Moutzouros VB, et al. Several bones contribute to thumb function. Supracondylar fracture. Transphyseal Distal 2021 Jul;31(5):871-881. doi: 10.1007/s00590-021-02932-2. Fractures of the medial epicondyle account for 10-15% of elbow fractures in children. In most cases, the fracture line then partially traverses the physis and then passes into the cartilaginous distal humeral epiphysis (see the image below). Growth Plate Normal proximal radial metaphyseal notch. [QxMD MEDLINE Link]. 2018 Jul. [QxMD MEDLINE Link]. Classification of fractures of the thumb. The capitellum and radiocapitellar joint are best seen on the radiocapitellar view. Fracture of the medial condyle is an uncommon injury in children. The distal humerus has 4 secondary ossification centers: those for the capitellum and trochlea (which form the articular surfaces) and those for the medial and lateral epicondyles. We describe a technique to stabilize fractures of the distal phalanx using an 18- or 20-G hypodermic needle in the emergency department setting. Treatment of phalangeal fractures. Distal phalanx fracture. 8600 Rockville Pike Flynn JC, Richards JF Jr, Saltzman RI. You will likely wear a cast or splint for 2 to 6 weeks after surgery. When significantly displaced, supracondylar fractures usually have clinically obvious deformity. The double density caused by such overlap may simulate a flake of bone, with lucency of the physis simulating an adjacent fracture line. A local joint block can be considered if significant pain impedes reduction. [1] Although lateral soft tissue swelling may be prominent, clinically evident deformity is less common in lateral condyle fracture compared with supracondylar fracture. Some institutions attempt to circumvent these challenges by running a dedicated procedure room within the emergency room (ER) for these procedures. 1. [1, 2, 3, 4] The evaluation of pediatric elbow radiographs in the setting of acute trauma may be challenging for many emergency department physicians, orthopedic surgeons, and radiologists. Proper Technique for Reduction of Metacarpophalangeal Dislocations. A variety of treatment modalities exist for distal phalanx fractures including closed reduction and splinting, closed reduction and percutaneous pinning (CRPP), and open fixation. Bone Joint J. Treatment of a mallet fracture includes splinting the DIP joint in extension for eight weeks. Of 130 patients (mean age, 7.5 yr), 43 (33%) had a radiograph result positive for fracture. These fractures often demonstrate only a subtle subcortical fracture line along the lateral aspect of the metaphysis, as shown below. If the thumb fracture involves a joint, there is an increased tendency to develop arthritis in the long term even if the fracture is treated perfectly. The effect of humeral length visualized on the x-ray. Middle and proximal phalanx fractures are often associated with trauma. A fracture of the thumb can be held in proper alignment using external fixation. [5] Because supracondylar fractures may be oriented obliquely on the lateral view, coursing proximally from anterior to posterior, an AP view with cephalad angulation of the x-ray beam may help to better demonstrate such a fracture. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. Finger fractures involving greater than 30 percent of the intra-articular surface should be referred to an orthopedic or hand surgeon. 2012 Jun;26(6):657-60. (2016) Clinical orthopaedics and related research. Note associated proximal radial metaphyseal fracture. Elbow dislocations are usually readily apparent on radiographs.
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