Soft tissue knee injuries

Cite this article as:
Lisa Dann. Soft tissue knee injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25908

Sam, a 12-year-old boy, presents to your department after a soccer blitz. He was tackled, heard a pop, and now can’t weight bear on his right knee.

As popularity and intensity of children’s sports increases there are increased demands placed on children and adolescents. This has resulted in an increased presentation of children like Sam. They can present with knee pain that is traumatic or atraumatic, acute or chronic. Paediatric patients are particularly vulnerable to overuse injuries involving the physes and apophyses due to their inherent weakness (see post, hyperlink article on fractures around knee).

Along with these there has also been an increase in soft tissue injuries. These are seen more commonly in older children/adolescents as their bones become stronger and are less likely to fracture with age.

History/examination

Important points to note on the history include:

  • If there was clear onset of pain
  • Traumatic or atraumatic
  • Duration of pain
  • Previous injury/surgery
  • Site of the pain (try be as specific as possible)
  • Severity of pain
  • Nocturnal pain
  • Systemic symptoms
  • Associated swelling (intermittent or progressive)
  • Contralateral injuries (may result in abnormal gait placing additional pressure on knee)
  • Hip or back pain

Recalling the anatomy of the knee makes evaluating the site of pain easier.  The following make up the knee and all can be can be injured/inflamed and cause pain.

  1. Bones around knee – femur ends at lateral and medial condyles which articulates with tibial plateau and anteriorly the patella unsheathed in the patellar tendon.
  2. Ligaments – anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial and lateral collateral ligaments.
  3. Meniscus – medial and lateral menisci act as shock absorbers and interdigitate into the ACL and PCL for more stability.
  4. Bursae – supra-patellar bursa, infra-patellar bursa, pre-patellar bursa, and pes anserine bursa (medial aspect of knee).
  5. Tendons – quadriceps tendon (inserts into patella), patellar tendon (inserts into tibial tuberosity)
  6. Other – iliotibial band (fibrous support of fascia lata originating at the external lip of iliac crest and inserting into the lateral condyle of the tibia).

Examination in the acute setting is often difficult and may be limited. This is due to swelling, pain and anxiety. Try your best to be as detailed as possible but ensure you note any red flags on examination. These are:

  • Inability to do straight leg raise (extensor mechanism rupture)
  • Ligamentous laxity
  • Catching, locking or giving away (meniscal injury)
  • Inability to fully straighten the knee

After a thorough history and examination you discover he was tackled and the other player’s foot landed on the lateral aspect of his knee. On examination you find a swelling on medial aspect of the knee and laxity of the medial collateral ligament when valgus stress is placed on the right knee.  You clinically diagnose a medial collateral ligament injury. He is placed in a brace and referred to orthopaedic clinic.

Injured ligaments are considered “sprains” and are graded on a severity scale.

  • Grade 1 sprains: The ligament is mildly damaged. It has been slightly stretched, but is still able to help keep the knee joint stable.
  • Grade 2 sprains: The ligament has been stretched to the point where it becomes loose. This is often referred to as a partial tear of the ligament.
  • Grade 3 sprains: This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Ligament specific examinations:

  • Anterior and posterior drawer tests – asses anterior and posterior cruciate ligament integrity.
  • Lachman test – assesses ACL integrity. Most sensitive test for ACL rupture. Non-dominant hand cups and support knee. Ensure quads and hip flexors relaxed for it to work. Dominant hand grasps proximal tibia, knee flexed at 20-30 degrees. Pull sharply. Tibia shouldn’t move much and should have distinct end point.
  • Posterior sag test – patient supine, hip flexed at 45 degrees and knee at 90 degree. Look at knee from lateral position. If PCL damaged you’ll see tibia sagging posteriorly.
  • Varus and valgus stresses – assess integrity of medial and lateral collateral ligaments. Compare both sides for laxity.

Management:

  • Unstable joints require a thorough examination of neurovascular status, orthopaedic consultation and very close follow up.
  • ACL tears often have poor healing abilities and may require surgical repair if injury is significant.
  • PCL is much better at healing itself than ACL and low grade tears are managed non-operatively with grade 3 or higher needing reconstruction.
  • Collateral ligament injuries have good healing potential so rest, ice, bracing and slow advancement of range of motion is the management primarily undertaken.

A short while later one of Sam’s team mates, Patrick, presents to ED. He was also playing in the soccer blitz. He got sudden knee pain when turning and his knee is now locked. Following assessment you suspect a meniscal injury.

Meniscal injuries

Meniscal injuries can be traumatic or atraumatic. Suspect if the knee is locked, there was a twisting mechanism, a tearing sensation, or an effusion.

Specific examinations include:

  • McMurray test – patient supine, hip and knee flexed at 90 degrees. Non-dominant hand placed over joint line. Dominant hand grasps patient’s heel and internally and externally rotates tibia exerting valgus and varus forces while extending the leg. This helps to grind on either the medial or lateral menisci. Pain, popping or clicking is a positive test.
  • Appley compression test – the patient lies prone with the knee bent at 90 degrees. The examiner rotates the leg externally and internally several times under simultaneous vertical pressure. A painful pop can point to a meniscal injury.

Treatment includes physiotherapy to compensate for the tear but surgical management may ultimately be required. Follow up with orthopaedics is required.

Patrick’s sister was also brought for review. She is 15 years old and has been having intermittent knee pain for the last few months but it gets much worse after she plays sports. She also says it really hurt her after the cinema yesterday. You suspect patellofemoral pain syndrome.

Patellofemoral pain syndrome (PFPS)

The pain is frequently described as anterior but is often poorly localised. It may feel like it’s “under” or “around” the patella. Pain is classically exacerbated by prolonged periods of sitting, use of stairs and squatting (theatre sign). Pain may be present for several weeks, exacerbated by activity and relieved after periods of rest. Frequently there is a deterioration in sports performance or inability to participate prompts patients to seek medical review.

Clinical examination should look for gait abnormalities, increased lumbar lordosis, and any asymmetry in hips or lower extremity. It is not uncommon to have reduced flexibility in the hamstrings or quadriceps.

Clarkes sign – positive in PFPS. Patient supine, knee extended. Grab the superior pole to the patella with thumb and index finger and have the patient activate the quadriceps while you inhibit the patellar movement. This causes grinding of the articular surface between patella and femur. Pain is indicative of PFPS.

Investigations are not routinely required. However, knee radiographs may assist in ruling out other conditions such as osteochondritis dissecans of the knee/patella and stress fractures of the patella. Radiographic imaging in PFPS is not diagnostic. It is necessary to combine any findings with your clinical examination.

Management of this is conservative as it is a self-resolving condition. It typically resolves over weeks to months but has been known to take up to two years for complete resolution of symptoms. Management involves reduction in activity (complete cessation usually not required), ice, rest, anti-inflammatory for pain control (short term use), avoidance of aggravating exercises (e.g. squatting) and some find relief with taping/knee-braces. Exercises that strengthen and increase flexibility of the quadriceps, hamstrings, soleus and gastrocnemius muscles are also recommended.

Further specific examinations and possible causes of non-specific knee pain

  • Ask the patient to tighten knee and palpate the quadriceps tendon at superior pole (tenderness indicates possible tendonitis), straight leg raise (assessing quadriceps strength and integrity).
  • Palpate body of patella for tenderness (Sinding-Larsen syndrome) and then patellar tendon and tibial tuberosity (Osgood-Schlatter syndrome).
  • Palpate the medial side of patella (possible inflamed medial plica band) and also palpate the proximal tibial surface (medial anserine bursa- pain, swelling, tenderness may indicate bursitis).
  • Feel under the patella (tenderness on articular surface could indicate patella-femoral syndrome).
  • Lateral – assess for patellar instability (need quadriceps relaxed and knee flexed at 30 degrees). Apprehension indicates patellar laxity and potentially previous dislocation.
  • Joint line – bend the knee and palpate either side slowly and carefully. Try to localize as much as possible. Tenderness may indicate a meniscal tear.
  • Hamstring muscles: With the knee flexed palpate the hamstring muscles. Laterally is the biceps femoris and medially semi-tendinosus and semi-membranosus. Chronic tightness may be the cause of knee pain.
  • Patellar ballottement- effusion

Bottom line

A thorough history and examination can greatly assist in reaching the diagnosis. A correct diagnosis helps to properly counsel patients and appropriately manage their expectations. Without proper treatment, knee injuries can lead to chronic knee problems, early onset arthritis, injury to surrounding tissues, and prolonged healing times. Missed injuries can also cause recurrent cartilage damage, instability in the knee, and unnecessary time away from physical activity. It is our duty to diagnose these injuries in a timely manner and provide appropriate advice, support and follow up.

Below is a useful table outlining the causes of intrinsic knee pain, separated by site of pain on examination (table 1).

References

Finlayson C. Knee injuries in the young athlete. Pediatr Ann. 2014;

Brooke Pengel K. Common overuse injuries in the young athlete. Pediatr Ann. 2014;

Beck NA, Patel NM, Ganley TJ. The pediatric knee: Current concepts in sports medicine. J Pediatr Orthop Part B. 2014. doi:10.1097/BPB.0b013e3283655c94.

Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain. Part II Am Physician. 2003.

PEM Playbook Knee Pain podcast https://pemplaybook.org/podcast/knee-pain/

Tillaux fractures

Cite this article as:
Tadgh Moriarty. Tillaux fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26111

Jenny is a 14-year-old girl who was at soccer training when she had an awkward injury to her left ankle. She was running for the ball when her foot caught in a clump of grass and she externally rotated her leg while her foot remained planted. While the pain was instantaneous, there was very little swelling. Her father has brought her in remarking that ‘it’s probably just a sprain’. But as you call her down to the cubicle to examine her, you think there might be more to it.

Incidence

Tillaux fractures are a type of ‘transitional’ ankle fracture which occur almost exclusively in adolescents. These occur during the unique closure pattern of the distal tibial physis. This closes over an eighteen-month period; first in the middle, then medially and finally laterally. During the closure, this area is vulnerable to these distinctive transitional fractures; the triplane fracture and the Tillaux fracture.

These fractures account for roughly 3% of paediatric ankle fractures. They are seen more commonly in females and tend to occur at slightly different ages depending on gender. It tends to occur later than a triplane fracture; between 12-14 years in girls and 15-18 years in boys.

Mechanism

This Salter-Harris 3 fracture occurs at the anterolateral distal tibial epiphysis. It tends to cause avulsion of the tibial fragment by the tibiofibular ligament; this strong ligament extends from the anterior aspect of the lateral distal tibial epiphysis to the anterior aspect of the fibula. The lack of a fracture through the coronal plane distinguishes this injury from that of a triplane fracture.

This injury pattern occurs usually through a combination of supination and external rotation of the foot in relation to the leg. It usually occurs through low-velocity trauma for example in skateboard accidents or sports with a sliding injury.

Presentation

These injuries are almost exclusively seen in adolescents. Similar to most ankle injuries there will be a history of trauma, symptoms of pain, swelling, and an inability (or painful) weight-bearing.

The clinical exam often reveals localised tenderness to the anterior joint line. This contrasts with a sprain where the tenderness is usually below the joint line. Marked displacement is prevented by the fibula.

Imaging

Do not be misled by lack of swelling – have a low threshold to image injuries which present with an inability to weight bear (at least four steps). When requesting an ankle x-ray AP and lateral views will be included as standard – if you have a high index of suspicion for a Tillaux fracture ask for an oblique or ‘mortise’ view – this can improve your detection by avoiding the obstructed view through the fibula and potentially making the subtle fracture more apparent.

This injury can sometimes have an associated ipsilateral tibial shaft fracture or a proximal fibular injury. During your clinical exam if you illicit tenderness proximal to the ankle, then include a full-length tibia/fibula x-ray with your request.

Does this injury require a CT? Perhaps! See the controversy section below for a more thorough explanation. CT is generally only required by the orthopaedic team to assist with surgical planning.

Image courtesy of Orthobullets.com

Image showing CT scan of same fracture with >2mm displacement courtesy of Orthobullets.com

This injury however often requires a CT scan to assist the orthopaedic team in deciding between conservative and operative management.

A study by Horn et al showed CT as being more sensitive than plain film at detecting fractures with greater than 2mm displacement (the cut-off point adopted for operative fixation).

Treatment

These fractures are important as they involve the weight-bearing surface and can lead to significant morbidity if missed. The treatment of these injuries is not uniform – different methods and cut-offs are described in different case reports and case series. Having that said the current marker for operative versus conservative treatment is the degree of displacement of the fracture fragment.

Those with < 2mm displacement can generally be treated conservatively. This usually involves an above-knee cast for up to 4 weeks (to control the rotational component) followed by either a walker boot or below-knee cast for a further 2-4 weeks. This conservative approach is well documented in having a satisfactory outcome.

Those with displacement >2mm generally require intervention to ensure articular congruity of the joint surface is restored. Intervention can occur in different forms; some may be suitable for a closed reduction under procedural sedation (or general anaesthetic). Different reduction techniques exist however longitudinal traction while the knee is flexed followed by internally rotating a maximally dorsiflexed ankle seems to achieve greater anatomic reduction. A review by Lurie et al concluded those left with a residual gap of more than 2.5mm led to worse functional outcomes. Therefore post-reduction radiological confirmation should show minimal displacement (the figure of <2mm tends to be favoured in the literature) otherwise operative intervention is required. Many orthopaedic surgeons favour CT as the post-reduction imaging modality of choice and then follow this reduction with serial radiographs to confirm maintenance of the reduction over time.

Operative intervention can involve K-wire insertion, use of lag screws or a novel technique involving percutaneously inserted wires with arthroscopic or radiological guidance. This new technique is seen as less invasive and as-effective but is technically complex and demanding. If this injury presents with a neurovascular compromise or critical skin then emergent surgery is indicated. This is, thankfully, rare.

What to tell the patient

Recovery: Both operative and conservative measures tend to require up to 8 weeks of immobilisation followed by a rehab phase. This phase will vary depending on the age of the patient. Most patients have a good outcome with 86% having complete recovery and no sequelae. Very few will have pain or limitation of ankle movement. Late presentation and a non-anatomical reduction will increase the risk of this.

Complications

These are less common than other ankle fractures; delayed or malunion, osteonecrosis of the distal tibial epiphysis, premature growth arrest and compartment syndrome are all very rare occurrences. Early-onset arthritis can occur, those with late presentations or missed fractures are more at risk.

Operative intervention carries the additional (albeit small) risk of physeal damage from direct pressure by blunt instruments and inadvertent damage to the superficial peroneal nerve.

Controversies

Radiological evaluation remains controversial. Plain x-ray usually identifies the transitional fracture, and the degree of displacement. However, CT (ideally with 3D reconstruction) is more accurate in estimating the degree of displacement and fracture separation.

Case courtesy of Dr Yasser Asiri, Radiopaedia.org. From the case rID: 64778

CT can help in identifying the number and position of fragments. The issue of whether CT or MRI alters treatment or prognosis when compared with plain X-ray has not been fully investigated. Limited research has been carried out on whether CT, with its greater accuracy, actually affects treatment or patient outcome. Liporace et al in 2012 found that interobserver and intra-observer agreements about primary treatment plans did not differ significantly between radiography alone and radiography plus CT. This showed that the addition of CT did not actually change the impression about the degree of displacement in each case. This raises the question as to whether CT really alters outcomes despite having perceived greater benefits.

Jenny is found to have significant tenderness about her distal tibia on exam and an x-ray confirms a Tillaux fracture which is minimally displaced. She is placed in an above-knee backslab and referred to the orthopaedic fracture clinic. She is left disappointed that she will miss this season’s matches, but thankfully you didn’t misdiagnose this as a sprain!

References

Orthobullets.com/paediatrics/4028/tillaux-fractures

Wheelers textbook of orthopaedics (updated 2015) Clifford J Wheeless Tintinnali 7th Ed

Tiefenboeck TM, Binder H, Joestil J et al. Displaced juvenile Tillaux fractures: surgical treatment and outcome. Wien Klin Wochenschr. 2017; 129 (5-6):169-175

Rosenbaum AJ, DiPreta JA, Uhl RL. Review of distal tibial epiphysis transitional fractures. Orthopaedics. 2012;35(12):1046-1049

Horn BD, Cristina K, Krug M, Pizzutillo PD, MacEwen GD. Radiologic evaluation of juvenile Tillaux fractures of the distal tibia. J Pediatr Orthopaedics. 2001; 21(2): 162-4

Cooperman DR, Spiegel PG, Laros GS. Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg Am. 1978 Dec. 60 (8):1040-6

Panagopoulos A, van Niekerk L. Arthroscopic assisted reduction and fixation of a juvenile Tillaux fracture. Knee Surg Sports Traumatol Arthrosc 2007;15:415-417

Manderson EL, Ollivierre CO. Closed anatomic reduction of a juvenile tillaux fracture by dorsiflexion of the ankle. A case report. Clin Orthop Relat Res. 1992 Mar. (276):262-6.

Crawford AH Triplane and Tillaux fractres: is a 2mm residual gap acceptable. J Pediatr Orthop. 2012 Jun;32 Suppl1:S69-73

Schlesinger I, Wedge JH. Percutaneous reduction and fixation of displaced juvenile Tillaux fractures: a new surgical technique. J Pediatr Orthopaedics. 1993;13:389-391

Stefanich RJ, Lozman J. The juvenile fracture of Tillaux. Clin Orthopaedics Relat Res. 1986;210:219-227

Kaya A, Altay T, Ozturk H, Karapinar L. Open reduction and internal fixation in displaced juvenile Tillaux fractures. Injury 2007;38:201-205

Choudhry IK, Wall EJ, Eismann EA. Crawford AH, Wilson I. Functional outcome analysis of triplane and tillaux fractyres after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014;34:139-43

Jennings MM, Layaway P, Schubert JM. Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures. J Foot Ankle Surg 2007;46: 376-386

Rockwood and Wilkin’s fractures in children. 6th Edition.2006

Kim JR, Song KH, Song KJ, Lee HS. Treatment outcomes of triplane and Tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010 Mar. 2 (1):34-8

Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 2004 Sep. 183 (3):615-22

Charlton M, Costello R, Mooney JF et al. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthopaedics. 2005;25: 635-640

Liporace FA, Yoon RS, Kubiak EN, Parisi DM, Koval KJ, Feldman DS, et al. Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures?. Orthopedics. 2012 Feb 17. 35 (2):e208-12

Lurie B, Van Rysselberghe N, Pennock AT, Upsani VV. Functional outcomes of Tillaux and triplane fractures with 2-5millimetres of intra articluations gap. J Bone Joint Surg Am. 2020;102:679-686

Rapariz AJ, Avocets G, Gonzalez-Herman P, Texas et al. Distal tibial triplane fractures: long term follow up. J Pediatr Orthopaedics. 1996; 16: 113-118.

Maxilla and zygoma injuries

Cite this article as:
Jessie Lynch. Maxilla and zygoma injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21700

A 2-year-old child called Lucy is brought to your ED by ambulance. She was the right-sided rear seat passenger in a high-speed head-on road traffic collision. The driver of the other car died on impact. She was restrained in a car seat, however, the seatbelt holding the car seat in place had broken and the car seat was thrown forward. She had a 4-minute episode of loss of consciousness. She had a GCS of 14/15 on arrival, she was maintaining her airway and she was haemodynamically stable. She had significant swelling, bruising, and superficial abrasions to the right side of her face, and her right eye was swollen shut.

Facial injuries in children are relatively common. The most common facial injuries encountered in a paediatric population are dental trauma, oral trauma and facial lacerations. Facial fractures, however, are exceedingly rare in this population, with an incidence of <15% in those under the age of 16 years, and only 0.87% – 1% in those under the age of 5 years.

There are a number of factors which make children less prone to facial fractures. These include:

  • Retruded position of the midface relative to the skull
  • Structural stability increased by the presence of tooth buds within maxilla and mandible and lack of sinus pneumatisation
  • A thick layer of adipose tissue coverage
  • More elastic bones and flexible suture lines
  • High level of adult supervision

These factors also make children more prone to greenstick and minimally displaced fractures as opposed to comminuted or complex fractures. These factors become less significant as the child grows older.

History

Common causes of facial fractures include falls, road traffic collisions, sports-related injuries and, less commonly, interpersonal violence. 2.3% of victims of non-accidental injury have facial fractures and the possibility of this should always be taken into account.

Examination

The presence of a midfacial fracture in a child implies that a significant velocity impact has occurred. 40% of children with a midfacial fracture have an associated skull fracture, and associated cervical spine injury is also common. The primary survey should be undertaken following APLS protocols, with particular attention paid to cervical spine immobilisation and airway management. A detailed craniomaxillofacial examination should be performed as part of the secondary survey, after initial stabilisation.

Image from Wikimedia

Fractures of different parts of the face will lead to different clinical signs.

Zygomatic arch and zygomaticomaxillary complex (ZMC) 

The zygomaticomaxillary complex (ZMC) is made up of four parts:

  • lateral orbital wall
  • zygomatic-maxillary junction
  • zygomatic arch
  • orbital floor

An approach to the assessment of ZMC fractures includes:

  • Inspect the orbit. There may be periorbital swelling or ecchymosis, enophthalmos, subconjunctival haemorrhage and diplopia (due to extraocular muscle dysfunction). The orbital examination should also include visual acuity, visual fields and extraocular muscle function.
  • Palpate the facial bones. There may be a palpable depression or step in the infraorbital rim or zygomatic arch as well as tenderness or widening of the frontozygomatic suture.
  • Oral assessment. There may be trismus (lock jaw) and bruising and tenderness of the upper buccal sulcus.
  • Infraorbital nerve assessment, documenting any paraesthesia.

Maxilla

Maxillary fractures are classified according to the Le Fort classification system*

  1. Le Fort I: A horizontal fracture through the floor of maxillary sinuses with the teeth contained within the detached fragment. Only palate moves.
  2. Le Fort II: A fracture which can be one-sided or bilateral fracture through the maxilla extending into the floor of the orbit, the nasal cavity and hard palate. This results in a pyramidal shaped fracture.
  3. Le Fort III: A fracture through the orbits in which the entire maxilla and one or more facial bones, the entire midface, becomes separated from the base of the skull. This is called craniofacial disjunction.

*Rene Le Fort was a French physician at the turn of the 20th century. He discovered that the midface tended to fracture in three different ways when traumatising cadavers in quite gruesome, but scientifically important, ways.

Clinical signs of Le Fort fractures are much the same signs as for ZMC and zygomatic arch fractures but signs are, for the most part, bilateral. Facial asymmetry, flattening or elongation may be evident in older children.

Management

Manage pain with non-pharmacologic and pharmacological measures. Oral and intravenous analgesia may be required but avoid intranasal analgesia in case of fracture.

Investigations

Facial bone x-rays may give you some valuable information, but the caveat is that they can be difficult to interpret in children. If you have a high clinical suspicion of a facial bone fracture, a CT scan is the imaging modality of choice and can be argued to be the cornerstone of investigation for facial bone fractures in children.

A chest x-ray may be indicated to exclude aspiration of foreign bodies or dental fragments.

Specific treatment

All fractures should be discussed with the local maxillofacial service and/or ophthalmology if orbital involvement is present. A formal ophthalmological review should be carried out as early as is feasible in children with any suspected midfacial fracture.

Most greenstick or minimally displaced fractures can be managed conservatively with soft diet, advice not to blow nose or hold nose closed while sneezing, antibiotic prophylaxis and a nasal decongestant.

There is no clear consensus on the best choice of antibiotic for facial fractures, and there is much variety among papers. The most commonly used would appear to be co-amoxiclav, cefuroxime, and clindamycin in penicillin-allergic patients.

Surgical intervention range from an intraoral approach for minimally displaced zygoma fractures to open reduction and internal fixation for comminuted fractures.

Potential complications, including mal/non-union, are less common in paediatric patients than in adults.

The do not miss bits

  • Reduced or lost vision, severe eye pain or proptosis of the globe are all features of retro-orbital haemorrhage, an ophthalmological emergency which requires immediate surgical intervention to avoid permanent blindness.
  • Although facial fractures are rare in children they have the potential to cause significant disruption to future growth, function & cosmesis and thus it is vital that they are recognised.
  • It takes significant velocity to cause a facial fracture in a child, and examination & investigations must be thorough to identify any other potential injuries. Consideration should be given to the possibility of non-accidental injury when assessing a child with a facial fracture.

Lucy’s CT brain & c-spine showed no significant abnormalities. CT facial bones showed a minimally displaced fracture of the frontal process of the right zygoma. She was reviewed by ophthalmology & maxillofacial specialists & was treated conservatively with oral antibiotics with a soft diet until her fracture had healed.

Selected references

Alcalá-Galiano A,  Arribas-García IJ,  Martín-Pérez MA, et al. Paediatric Facial Fractures: Children Are Not Just Small Adults. RadioGraphics. 2008; 28:441-461

Kumaraswamy SV, Madan N, Keerthi R, Singh DS. Paediatric injuries in maxillofacial trauma: a 5 year study. J Maxillofac Oral Surg. 2009; 8(2):150-153

Braun TL, Xue AS, Maricevich RS. Differences in the Management of Paediatric Facial Trauma. Semin Plast Surg. 2017;31:118-122

Cole P, Kaufman Y, Hollier LH. Managing the Pediatric Facial Fracture. Craniomaxillofac Trauma Reconstruction. 2009;2:77-84

Kidd AJ, Beattie TF, Campbell-Hewson G. Facial injury patterns in a UK paediatric population aged under 13 years. Emergency Medicine Journal. 2010;27:603-606

Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofac Trauma Reconstr. 2015;8(1):64–78

The Royal Children’s Hospital Melbourne.The Paediatric Trauma Manual. Maxillofacial Injury. https://www.rch.org.au/trauma-service/manual/maxillofacial-injury/

Finger Tips – tendons and ligaments

Cite this article as:
Sinead Fox + Kate Jackson. Finger Tips – tendons and ligaments, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25422

Little fingers get everywhere, and injuries are common. The mechanism of injury tends to be age-dependent with the under-fives magnetically drawn to door hinges and the over-fives more likely to do some damage during higher impact sport. Below are a few common injuries of the tendons and collateral ligaments of the fingers that you might come across in PED.

  • Ensure adequate analgesia prior to assessment, occasionally the administration of a local anaesthetic is required… don’t forget bubbles too!
  • As tendon/ligament injuries may not occur in isolation, an assessment must include inspection, palpation, (look, feel, move!), assessment of vascular structures, and testing of motor and sensory functions.
  • Children typically tend to display hand dominance between the ages of 2-4 years old; if the child is old enough make sure to record hand dominance in the medical or nursing notes.
  • In older children/adolescents document details of sport participation/ hobbies/professional goals as these may be taken into account by hand surgeons when considering treatment options.

Part 1: Flexor tendon injuries

Anatomy

There are two flexor tendons for each finger and one for the thumb.

The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) are the flexor tendons of the fingers, and the flexor pollicis longus (FPL) is the only thumb flexor.

The flexor tendons travel distally from the forearm through the carpal tunnel and are named based on the forearm muscles from which they arise.

The flexor digitorum profundus (think profound i.e. deep) arise from the deeper layer of the flexor muscles. The flexor pollicis longus tendon of the thumb also arises from the deeper muscle layer. The flexor digitorum superficialis (think superficial) is the continuation of the more superficial layer.

  • FDP inserts at the base of the distal phalanx and flexes the DIP joint (tip: FDP is at the point of the finger).
  • The FDS tendon divides into two slips that wrap around the FDP to insert into the sides of the middle phalanx. FDS flexes the PIP joint.

The Pulley System

The flexor tendons are enclosed in a synovial sheath that lubricates them and minimizes friction.

It is organized into segments of transverse fibres forming annular pulleys (annular means ring-like; think of the ring-like lesions of annular eczema) and oblique fibres comprising cruciate pulleys (cruciate means crossed, like the cruciate ligaments of the knees).

There are three cruciate pulleys (C1-3) and five annular pulleys (A1-5) pulleys. These pulleys keep the flexor tendons close to the bone and prevent bowstringing of the tendon.

The pulley system

Evaluation

Closed flexor tendon injuries are usually caused by forced extension of the finger in active flexion. The child may present with reduced flexion of the finger or pain when bending the finger and there may be localized swelling or open wounds.

The FDS and FDP tendons should be tested individually; it is not enough just to observe the child make a fist as tendon injuries can be easily overlooked or missed.

  • To check FDS function, hold all adjacent fingers in extension and then release the finger you want to assess. Ask the child to flex the free digit at the PIP joint.
  • To examine the FDP, hold the middle phalanx in extension and ask the child to flex the DIP joint.
Testing FDP
Testing FDS

Examination Pearls

Tendon function can be difficult to assess in a very young or uncooperative child. In these circumstances observation of digital cascade and wrist tenodesis can be useful physical examination tools to assess tendon integrity of hand and fingers.

  1. Digital Cascade

When the child’s hand is in a resting position, the fingers should have a natural cascade of progressively increasing flexion from the index finger through to the little finger.

The digital cascade
  1. Wrist Tenodesis

Squeezing the forearm muscles while observing the fingers can also be used to assess flexor tendon continuity. If flexor tendons are intact, the child’s fingers should flex when the forearm muscles are squeezed.

Wrist tenodesis

A: Extending the wrist flexes the fingers. With intact flexor tendons and a relaxed or distracted patient, passive wrist extension results in finger flexion. If flexor tendons are damaged then the injured finger(s) will rest in an extended position when the wrist is extended.

B: Flexing the wrist extends the fingers. Similarly, with intact extensor tendons, passive wrist flexion results in finger extension. If the extensor tendons are damaged, the injured finger(s) will rest in a flexed position when the wrist is flexed.

Wound Exploration

It is important to remember that tendons move; looking into a wound and seeing an intact tendon does not exclude a tendon injury. If the wound is sustained while the finger is flexed and the finger is examined while it is extended, the level of the tendon injury will not correspond to the level of the skin laceration. Therefore it is important to ask the parent or older child/adolescent about finger position at the time of the injury and put the injured digit through a passive range of movement while examining the wound.  If you are in doubt or cannot rule out a tendon injury refer the patient to the local hand surgery team.

Classification

The sites of the flexor tendon injuries are divided into five zones.

*The term ‘No Man’s Land’ was coined by hand surgeon Mr. Sterling Bunnell in 1918 because at that time it was felt no man (or woman) should attempt repair within this zone due to the complexities of the anatomy and risk of adverse outcomes. While this belief is no longer a common practice, it highlights the intricacies of surgical repair within this zone.

Jersey finger (Zone 1 injury)

Juno is a fifteen-year-old girl who is attending ED with an injury to her left ring finger. She was playing rugby earlier today and her hand got caught in another player’s jersey during a tackle. On examination, you note swelling, bruising, and tenderness to the volar base (on the palmar side) of her distal phalanx on her left ring finger. When you lie her left hand flat on a table with the palm facing upwards and hold the middle phalanx of her ring finger in extension she is unable to flex her distal phalanx at the DIP joint. She also can’t bend the DIP joint when trying to make a fist. You correctly identify that she has an injury to her FDP tendon and make the diagnosis of Jersey Finger. You send Juno to X-ray to assess for a fracture.

Mechanism

Disruption of the FDP tendon is known as Jersey finger. This injury is caused by the forced extension of the DIP joint during active flexion. It commonly occurs when an athlete’s finger catches in another player’s jersey, usually while playing a tackling sport such as rugby or American football. For those that prefer more solo pursuits, it can also be caused by an overly tight crimp grip in climbers.

 

Presentation

A patient with Jersey finger may present with pain and swelling to the volar (the palmar) aspect of the DIP joint and the finger will be extended at rest. The ring finger is commonly affected. The integrity of the FDP should be evaluated as outlined above. An injured FDP will produce very restricted or no movement. An x-ray should be performed to rule out an avulsion fracture at the volar base of the distal phalanx.

X-ray demonstrating an avulsion fracture at the base of the distal phalanx of the little finger in Jersey Finger. Case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 26251
The clinical appearance of Jersey Finger. Case courtesy of Dr Salem Bauones, Radiopaedia.org. From the case rID: 26251
Jersey finger – disruption of insertion of FDP

Treatment

Early referral to a hand surgeon for assessment and appropriate treatment is paramount.

Operative: The majority of these cases require surgical intervention to reattach the tendon to prevent tendon retraction and optimize function. The prognosis for patients with jersey finger worsens if treatment is delayed and severe tendon retraction is present.

Non- Operative: A partial tear may be managed conservatively (splinting, NSAIDS, physiotherapy). However, from a PED perspective, these injuries should be considered surgical cases until deemed otherwise by a hand specialist.

You do not identify a fracture on Juno’s X-ray and you refer her to the Plastic Surgery team for prompt review as it is possible she may require surgery to repair her FDP tendon.

…A quick overview of Trigger thumb

Trigger thumb, although uncommon, maybe a reason for presentation to the PED, typically when a child is 2 years old. Paediatric Trigger thumb results from a mismatch in the size of the Flexor Pollicis Longus (FPL) and the first annular pulley (A1) disrupting normal tendon gliding. Children find it difficult to extend the IP joint of the thumb, with clicking or snapping felt or heard. Some patients even have a fixed flexion deformity at the IP joint. Characteristically, a palpable mass is felt at the level of the MCP joint crease on the volar (palmar) surface of the thumb representing a nodule in the FPL as well as thickening of the flexor tendon sheath. This is commonly referred to as ‘Notta’s Node’.

Its aetiology is poorly understood. Historically, trigger thumb was thought to be congenital, however, this is controversial and an argument exists that trigger thumb is an acquired condition. Diagnosis is usually based on clinical exam. X-rays or alternate imaging is rarely indicated, although parents will occasionally try attribute symptoms to a recent history of trauma. This is usually a red herring!

Paediatric trigger thumb can be managed surgically or conservatively with splinting and a physiotherapy regime – sometimes it can spontaneously resolve, although the spontaneous resolution of paediatric trigger thumb can be less likely after 2 years old. Surgical release of the first annular pulley may be offered as a treatment option to restore thumb IP joint movement if there is a fixed flexion deformity beyond the age of 12 months or if conservative management fails.

 

Part 2: Extensor Tendon Injuries

Anatomy

Distal to the MCP joint, the common extensor tendon divides into three slips: one central and two lateral bands. The central slip inserts at the base of the middle phalanx and the two lateral bands extend along the radial and ulnar margins of the middle phalanx to converge at the distal third of the middle phalanx to form the terminal extensor tendon, which inserts at the base of the distal phalanx. The central slip extends the middle phalanx at the PIP joint level and the terminal extensor tendon extends the DIP joint. The Extensor Pollicis Longus (EPL) extends the thumb at the IP joint.

Extensor tendon anatomy

Evaluation

The extensor tendons are assessed by applying pressure to the dorsum (back) of the finger while the patient is attempting active extension.

Testing extensor tendons

To test the Extensor Pollicis Longus (EPL), ask the patient to place their hand flat on a table and lift up their thumb against resistance.

Testing EPL

Classification

The extensor mechanism can be divided into 9 anatomical zones. Odd-numbered zones are located over joints, and even-numbered zones are located over bones. Tendon injuries can be categorized according to these anatomical zones.

Extensor tendon zones

A little nugget: an easy way to recall the extensor zones is to remember the odd numbers (I, III, and V) are at the joints (DIPJ, PIPJ, and MCPJ).

Injuries in zone 1 (the DIP joint) and zone III (the PIP joint) cause some unique injury patterns which we’ll explore below.

The thumb has a unique classification system as it has one fewer phalanx.

Mallet Finger: zone I injury (Baseball Finger)

Isabelle is an 8-year-old girl who was playing with her twin sister, Sophie, in their bedroom while their Mummy and Daddy were busy working from home in another room. Sophie accidentally closed the bedroom door catching Isabelle’s finger in the hinge side of the door. In ED you see that Isabelle’s right, dominant index finger is bruised and swollen at the DIP joint and there is a superficial abrasion to the dorsum of the DIP joint. Isabelle’s point of maximal tenderness is to the DIP joint. You try your best to assess finger function but Isabelle is crying and says she is too sore to move her fingers. But you note that the index finger appears flexed at the DIP joint and you suspect a Mallet injury. You give Isabelle analgesia and refer her for an x-ray.

Mechanism

Mallet finger is a partial or complete avulsion of the terminal extensor tendon from its insertion on the distal phalanx, commonly resulting from sudden flexion of an extended DIP joint. It can also occur secondary to a crushing mechanism.

Presentation

Mallet finger can be an open or closed injury with or without a fracture. Patients present with a flexion deformity at the distal phalanx and an inability to extend finger at DIP joint. The DIP joint can be swollen and ecchymosed.

Mallet finger

In children, this injury typically occurs due to an avulsion fracture of the distal phalangeal epiphysis, the insertion point of the terminal extensor tendon.

Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 12227

Classification

Mallet fingers can be described using a classification scheme (I through IV) developed by Doyle (1993).

Classification of Mallet finger

Treatment

Early referral to a hand surgeon for assessment and advice regarding appropriate treatment is essential.

Non-operative: Closed acute injuries with or without fractures can be managed with 6-8 weeks of extension splinting at DIP joint, followed by gentle active flexion ROM.

A 2004 Cochrane review found insufficient evidence to support the use of any particular splint when treating mallet injuries; all achieve similar outcomes. However, patient compliance is vital to a successful outcome.

Operative:

Open injuries are treated by surgical repair.

Closed injuries may be considered for surgical management if there is joint subluxation or an avulsion fracture of more than 30-50% of the articular surface.

Complications: Swan-neck deformity

Correct management of an acute mallet injury is critical as a poorly managed or untreated chronic terminal extensor tendon injury can lead to swan-neck deformity.

Swan-neck deformity is caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint hyperextension.

It takes a while before Isabelle and her Mum return to the ED from X-ray. Fortunately, the analgesia seems to have had some effect and Isabelle is more relaxed. You review the X-ray and do not identify a fracture. On examination, you confirm there is a flexion deformity at the DIP joint and note that Isabelle is unable to actively extend at the DIP joint. Suspecting a mallet injury, you apply an extension splint and refer Isabelle to plastics. They opt to treat the injury conservatively with an extension splint at the DIP joint for 6 weeks. They give Mum and Isabelle careful advice about compliance with splinting and give her an appointment for follow up in out-patients.

Central Slip Injuries: zone III injury

Michael is a 15-year-old talented basketball player. He was playing in a school league basketball final three days ago, when he felt a sudden sharp pain in his left middle finger after a failed attempt at catching the ball. He played until the end of the game but attended a minor injuries unit the following day as his finger was swollen and painful at the PIP joint. After a normal X-ray, he was diagnosed as having a soft tissue injury and discharged home with his fingers buddy-strapped. However, his pain has not improved and he’s still unable to fully extend his finger at the PIP joint, so his dad brings him to your ED. He has a digital copy of the X-Ray for you to review.

Mechanism

Central slip injuries are extensor tendon injuries at the middle phalanx most often resulting from forced flexion of an extended PIP joint, a mechanism commonly seen in basketball players. Other injuries that can accompany central slip disruption include volar (palmar) dislocations of the PIP joint, dorsal avulsion fractures of the base of the middle phalanx, and lacerations to the dorsal surface of PIP joint.

Presentation

The PIP joint may be swollen and bruised. The area of maximal tenderness is generally over the dorsal aspect of the PIP joint.

Closed central slip injuries can be easily missed or misdiagnosed as a sprain or soft tissue injury as there is no wound and sometimes no abnormality seen on X-ray.

The physical examination can be challenging- some patients have no loss of active extension at the PIP joint as extension is still provided by the lateral bands of the extensor tendon despite the disruption of the central slip. Even when there is a loss of extension, this can be overlooked or attributed to pain. (Don’t forget to provide adequate analgesia prior to assessment!)

These pitfalls can be avoided by maintaining a high index of suspicion for a central slip injury and undertaking a careful examination including Elson’s test to establish the integrity of the central slip, especially in the patient who presents with a painful, swollen PIP joint without gross deformity. Occasionally, ring blocks are required to allow a proper assessment of ROM.

Elson’s Test

  • Ask the patient to bend the affected PIP joint 90° over the edge of a table and ask them to extend the middle phalanx against resistance.
  • If the central slip is intact (negative test), extension is strong and the DIP remains floppy because the extension force is now placed entirely on maintaining extension of the PIP and the lateral bands cannot act distally in this position.
  • When a rupture of the central slip is present (positive test) there will be weak PIP extension, and the DIP will extend abnormally and become rigid.

There is also a modified version of Elson’s test that can be used. Here’s how the Modified Elson’s Test is done:

  • Ask the patient to place their injured and uninjured contralateral fingers knuckle to knuckle in 90 degree PIP flexion, with the middle phalanges pressed against each other. The patient is then asked to extend both DIP joints.
  • Negative test (normal)- DIP joints symmetrically flexed.
  • A positive test (central slip injury)- Injured DIP joint extends more (See diagram below).
The modified Elson’s test. A) Uninjured fingers show a symmetric inability to straighten the DIP joint when the middle IP joints are flush against each other. B) In a central slip injury, the DIP joint is pathologically straightened, which is seen in the left hand in this example. From AliEM.com (Illustration by David Ting)

This video from Brian Lin demonstrates both tests beautifully.

These tests can be limited by pain and the patient’s ability to co-operate, if a closed central slip injury is suspected then the PIP joint should be splinted in an extension and follow up in a hand clinic arranged.

Treatment

Early referral to a hand surgeon for assessment and advice regarding appropriate treatment is essential.

Non Operative:

  • Closed injuries
  • Extension splinting of the PIP joint for up to 6 weeks to allow central slip restoration

Operative: Surgical treatment reserved for

  • Open injuries
  • Displaced avulsion fractures of the middle phalanx
  • PIP instability
  • Failed non-surgical treatment

Complications: Boutonnière deformity

Failure to recognize and treat a central slip injury in the ED may result in a problematic Boutonnière deformity later on.

Boutonnière deformity is characterized by flexion of the PIP joint and hyperextension of the DIP joint. It develops secondary to loss of extension force on the PIP joint, with volar subluxation of the lateral bands and subsequent DIP joint hyperextension.

Extensor mechanism over the finger. A) Intact central slip and lateral band mechanism. B) Disrupted central slip leading to a Boutonnière’s deformity. after ALiEM.com

On examination, you note swelling and bruising to the PIP joint. Michael tells you that he is maximally tender on palpation to the dorsal surface of his PIP joint. He is able to partially extend his finger at the PIP joint but using Elson’s test you note weak PIP extension, and an abnormally extended and rigid DIP joint. You diagnose a central slip injury and explain the diagnosis to Michael and his dad before referring Michael to the plastic surgery team for assessment. Plastics treat Michael in an extension splint for 6 weeks to allow central slip restoration.

Part 3: Collateral Ligament Injuries

Anatomy

The collateral ligaments stabilize the phalanges laterally at the DIP, PIP and MCP joints.

Mechanism

Forced ulnar or radial deviation of any of the IP joints can cause partial or complete collateral ligament tears.

Presentation

Collateral ligament injuries of the fingers present as tenderness on palpation overlying affected ligament, swelling and sometimes bruising.

Evaluation

The integrity of a collateral ligament is assessed by applying valgus and varus stress to the involved joint with the joint in full extension and with the joint in 30 degrees of flexion. Compare the laxity of the injured finger with an unaffected finger. Increased laxity or lack of an endpoint signify an injury.

An x-ray should be performed to out-rule an avulsion fracture at the insertion site of the ligament.

Treatment

If the joint is stable and no large fracture fragments are identified, the injury can be treated with buddy strapping.

Treatment Pearl: Buddy strapping

If the ring finger is involved, it should be secured to the little finger as the little finger is naturally extended and easily injured if exposed.

Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb / Gamekeeper’s Thumb)

Tess was very excited as she stepped out onto the fresh crunchy snow all kitted up and raring to go. However, she didn’t count on it being so slippery and fell more or less right away whilst holding her ski poles. She had a lot of pain in her thumb and it looked a bit swollen.

It sounds like Tess has Skier’s Thumb, which is an injury to the ulnar collateral ligament of the MCP joint of the thumb.

Ulnar collateral injury

Mechanism

This injury is usually caused by forced abduction or extension at the MCP joint, typically falling onto an outstretched hand with something in the palm, falling onto an abducted thumb or as a result of a ball or object striking the ulnar aspect of the thumb during sports. This force stretches or tears the ulna collateral ligament, resulting in complete or partial rupture of the and can be associated with an avulsion fracture.

Presentation

Pain, swelling, and bruising are usually noted over the ulnar aspect (the index finger side) of the MCP joint of the thumb. The patient will also be tender on palpation to this area. Occasionally, a mass or a lump can be felt at the site of tenderness, which may suggest a Stener Lesion*. In severe ulnar collateral ligament injuries, the proximal phalanx may become subluxed with radial deviation on the metacarpal head.

*Stener Lesion

  • Normally, the ulnar collateral ligament lies deep to the adductor pollicis tendon.
  • A Sterner Lesion can form when a torn UCL becomes displaced superficially to adductor pollicis longus.
  • The presence of a Stener Lesion is an indication for surgical repair of this injury.

Evaluation

Evaluation of an ulnar collateral ligament injury involves valgus stress (radial deviation) testing of the joint at neutral and 30 degrees of flexion at MCP joint of the thumb. Compare the patient’s injured with their uninjured thumb to find out what is normal for that child. Hold the base of the thumb then apply sideways (lateral) pressure to the tip of the thumb. Increased laxity or lack of an endpoint signify an injury. It may be kindest to put in a ring block to prevent guarding due to pain, to increase the accuracy of the exam.

Functionally it’s important to test the (in)ability to grasp between thumb and finger. A stable pinch mechanism depends on the integrity of the radial collateral ligament of the index finger and the UCL of the thumb.

An X-ray should be performed to out-rule an avulsion fracture.  If an avulsion fracture is present, this will be seen at the ulnar corner of the base of the proximal phalanx. Ultrasound or MRI may be used to identify a tear to the UCL or diagnose the presence of a Stener Lesion.

Avulsion fracture to ulnar corner of proximal phalanx of thumb. Courtesy of Orthobullets.com

Treatment

Non- operative: A partial UCL rupture may be treated conservatively. Conservative management involves immobilization of the MCP joint in a thumb spica cast or thermoplastic thumb splint.

Operative: Complete UCL rupture or the presence of Stener Lesion are indications for surgical repair. Early immobilization with a thumb spica will also prevent further damage and make it more comfortable for the child while awaiting surgical review.

Tess’ thumb is very bruised and extremely tender. You pop in a ring block and with valgus stress you can tell there is increased laxity compared to the other side. There’s no fracture on x-ray. You refer Tess to your colleagues in plastics, who, after an ultrasound, diagnose a partial rupture of her ulnar collateral ligament. Her thumb’s immobilised in a thumb spica. 6 months later she’s back on the slopes!

Selected References

Allan, C. H. (2005). Flexor tendons: anatomy and surgical approaches. Hand clinics21(2), 151-157.

Armstrong, M. B., & Adeogun, O. (2009). Tendon injuries in the pediatric hand. Journal of Craniofacial Surgery20(4), 1005-1010.

Avery, D. M., Inkellis, E. R., & Carlson, M. G. (2017). Thumb collateral ligament injuries in the athlete. Current reviews in musculoskeletal medicine10(1), 28-37.

Dorani, B. (2020). Soft Tissue Injuries of the Hand. Retrieved from https://www.rcemlearning.co.uk/reference/soft-tissue-injuries-of-the-hand/#1583314733632-1b04992c-edab

Elson, R. A. (1986). Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. The Journal of bone and joint surgery. British volume68(2), 229-231.

Forward, K. E., Yazdani, A., & Lim, R. (2017). Mallet Finger in a Toddler: A Rare But Easily Missed Injury. Pediatric emergency care33(10), e103-e104.

Guly, H.R. (1991). Missed tendon injuries. Archives of Emergency Medicine, (8), 87-91.

Handoll, H. H., & Vaghela, M. V. (2004). Interventions for treating mallet finger injuries. Cochrane Database of Systematic Reviews, (3).

Hatch, D. (2019). Extensor Tendon Injuries. Retrieved from https://www.orthobullets.com/hand/6028/extensor-tendon-injuries

Kalainov, D. M., Hoepfner, P. E., Hartigan, B. J., Carroll IV, C., & Genuario, J. (2005). Nonsurgical treatment of closed mallet finger fractures. The Journal of hand surgery30(3), 580-586.

Leggit, J., & Meko, C. J. (2006). Acute finger injuries: part I. Tendons and ligaments. American family physician73(5), 810-816.

Lo, I. & Richards, R.S. (1995). Combined Central Slip and Volar Plate Injuries at the PIP Joint. Journal of Hand Surgery, 20B (3), 390-391.

Matzon, J. L., & Bozentka, D. J. (2010). Extensor tendon injuries. The Journal of hand surgery35(5), 854-861.

Nugent, N., & O’Shaughnessy, M. (2011). Closed central slip injuries–a missed diagnosis?, Irish Medical Journal, 104 (8):248-250.

Perron, A. D., Brady, W. J., Keats, T. E., & Hersh, R. E. (2001). Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand. The American journal of emergency medicine19(1), 76-80.

Ritting, A. W., Baldwin, P. C., & Rodner, C. M. (2010). Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clinical Journal of Sport Medicine20(2), 106-112.

Shah, A. S., & Bae, D. S. (2012). Management of pediatric trigger thumb and trigger finger. JAAOS-Journal of the American Academy of Orthopaedic Surgeons20(4), 206-213.

Sheth, U. (2019). Mallet Finger. Retrieved from https://www.orthobullets.com/hand/6014/mallet-finger

Sullivan, M. A., Cogan, C. J., & Adkinson, J. M. (2016). Pediatric hand injuries. Plastic Surgical Nursing36(3), 114-120.

Thurston, M. and Dawes, L. et. al. Gamekeeper Thumb. Retrieved from https://radiopaedia.org/articles/gamekeeper-thumb

Wahba, G., & Cheung, K. (2018). Pediatric hand injuries: Practical approach for primary care physicians. Canadian Family Physician64(11), 803-810.

Yoon, A. P., & Chung, K. C. (2019). Management of acute extensor tendon injuries. Clinics in plastic surgery46(3), 383-391.

Elbow dislocations

Cite this article as:
Becky Platt. Elbow dislocations, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28344

You are called to assess 14-year old Oliver who has presented to your ED by ambulance with an elbow injury.  He dived to make a save while playing football and landed on his outstretched hand.  He reports feeling a click in his elbow, followed by excruciating pain.  He was given methyoxyflurane in the ambulance which has helped. 

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

Oliver’s elbow looks significantly swollen, deformed and bruised.  You feel for a radial pulse – it’s there – and  undertake a neurovascular assessment, which is intact.  You prescribe him some intranasal fentanyl and order AP and lateral x-Rays of his elbow.

The elbow is an incredibly stable joint due to the way the humerus and ulna articulate (giving anterior-posterior and varus-valgus stability), strengthened by the medial and lateral collateral ligaments and the joint capsule.  Muscles and tendons further strengthen this ring.  A significant amount of force is needed to dislocate the elbow. 

Traumatic dislocation of the elbow is rare in the paediatric population comprising only 3-6% of all childhood elbow injuries, but the most common large joint dislocation (Lieber et al., 2012).  It is usually the result of a fall onto an outstretched hand, often with a large amount of force involved.  

Clinically, it is obvious that there is significant injury around the elbow; this is not something you will miss or be tempted not to x-ray.  Displaced supracondylar fractures can sometimes be confused with elbow dislocation as both present with a grossly swollen elbow and significant pain.  A quick and easy way to distinguish the two clinically is to palpate for the equilateral triangle formed by the olecranon and the two epicondyles: this is lost in elbow dislocation as the humerus creates a fullness in the antecubital fossa. There is no need to check movements in a deformed elbow but be sure to undertake a neurovascular assessment as a priority.  

The easiest way to classify simple elbow dislocations is by describing the direction of ulna dislocation in relation to the distal humerus.

Classification of elbow dislocations

90% of paediatric elbow dislocations are postero-lateral with the radiographic appearance as below:

But beware: elbow dislocations rarely present in isolation.  They often coexist with other elbow injuries. Associated fractures are likely to occur prior to closure of the epiphyses; when they are closed, collateral ligaments are likely to be ruptured (Lieber et al., 2012). The most common associated fracture is a medial epicondyle avulsion which can become incarcerated in the joint – scrutinize the elbow x-rays for associated fractures. This illustrates the importance of knowing CRITOE.

Elbow dislocation with medial epicondyl avulsion from Orthobullets.com. The white arrow points to the avulsed medial epicondyl while the red arrow shows where it has been avulsed from.

Oliver returns from x-ray and you review his films. You note the posterior dislocation but cannot see any associated fractures on Oliver’s films. You contact your orthopaedic team for further assistance.

Management

Many elbow dislocations reductions can be carried out in the emergency department with adequate muscular relaxation and appropriate analgesia.  A reasonable amount of force is often required to achieve reduction using traction on the forearm with counter-traction around the elbow.  This should be carried out or supervised by a clinician experienced in the procedure. 

Common pitfalls in elbow reduction

Be very careful to conduct a thorough neurovascular assessment before attempting reduction. The brachial artery and median nerve may become stretched over the displaced proximal ulna and ulnar nerve can become damaged when medial epicondyle avulsions complicate elbow dislocations. If a deficit is found after reduction you need to know whether it was present before you attempted relocation…

And if you can’t reduce the dislocation go back and have another look at the x-ray – it could be due to an avulsed medial epicondyle in the joint. Any elbow dislocation with an incarcerated piece of avulsed bone in the joint must be reduced in theatre and not in the ED.

Complications

Possible complications following elbow dislocation include residual limitation of the range of movement, recurrent instability, neurovascular injury, avascular necrosis of the epiphyses and degenerative arthritis. Early diagnosis and stable reduction, with fixation of concomitant fractures if necessary, are generally associated with better outcomes.  For the Emergency department clinician, it is therefore critical that children with this injury are assessed and managed with the minimum possible delay, ensuring that associated fractures are recognised and managed appropriately.

After sedation with ketamine, Oliver’s elbow is reduced in the department with a satisfying clunk signifying reduction.  His elbow is put through a full range of movement to test joint stability and an above elbow backslab applied.  You order repeat x-Rays to evaluate the position and to check for the joint spacing and any fracture fragments within the joint as this would require surgical intervention.  The post-reduction films are good and Oliver’s neurovascular assessment remains normal and he leaves your ED with a follow-up appointment in fracture clinic in a week’s time.

References

Cadogan, M. (2019) Elbow Dislocation https://lifeinthefastlane.com/elbow-dislocation/

Edgington, J. (2018) Elbow Dislocation – Pediatric.  

https://www.orthobullets.com/pediatrics/4013/elbow-dislocation–pediatric

Lieber, J., Zundel, S., Luithle, T., Fuchs, J., & Kirschner, H-J. (2012) Acute traumatic posterior elbow dislocation in children.  Journal of Pediatric Orthopaedics B. 21(5) 474-481

Rasool, M. N. (2004). Dislocations of the elbow in children. The Journal of Bone and Joint Surgery, 86, 1050–1058. 

Sibenlist, S. & Biberthaler, P. (2019) Simple Elbow Dislocations in Biberthaler, P., Sibenlist, S. & Waddell, J.P. Acute Elbow Trauma.  Fractures and dislocation injuries (eBook).  Springer

Sofu, H., Gursu, S., Camurcu, Y., Yildirim, T., & Sahin, V. (2016). Pure elbow dislocation in the paediatric age group. International Orthopaedics, 40(3), 541–545

Radial head and neck fractures

Cite this article as:
Becky Platt. Radial head and neck fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21165

Aisha is 10 years old. She loves gymnastics but today, during a cartwheel, she injured her right elbow.  Aisha is cradling her right arm in her left hand and is reluctant to move it, despite having had ibuprofen at home.  

 

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

 

On examination, you note swelling around the elbow, especially on the lateral aspect.  Aisha has tenderness particularly over the radial head and complains of pain on any movement especially supination and pronation.  She has normal sensory and motor function of radial, ulnar and median nerves and normal pulses, colour and capillary refill time to her hand. You prescribe further analgesia, apply a broad arm sling for comfort and order lateral and AP x-rays of her elbow.

Radial head and neck fractures comprise around 5% of all elbow injuries in children, with a peak at 9-10 years of age. They normally result from a FOOSH (‘fall onto an outstretched hand’).  Fractures through the radial head are rare in children: more commonly the physis (the growth plate: the disc of cartilage between the epiphysis and metaphysis), or radial neck will be involved.

 

Radial Neck fractures

Radial neck fractures can generally be diagnosed on lateral and AP elbow x-ray.  It’s useful to remind yourself of the elbow anatomy prior to looking at the x-ray so that you know what you’re looking for.  It’s really important to appreciate that part of the radial neck sits outside of the capsule. Most radial neck fractures occur at the level of the annular ligament, which forms a collar around the radial neck to anchor it to the ulna.

Elbow ligaments. From RCEM Learning

This means that not all radial neck fractures have a joint effusion. Don’t be fooled by a lateral elbow x-ray without a fat pad sign – this just means there’s no joint effusion; it doesn’t mean there isn’t a radial neck fracture.

The appearance can be quite subtle, so it’s useful to remind yourself what the radial neck looks like on a normal X-ray:

Normal radial neck. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 24158

In particular, notice how the contours of the radial neck form smooth curves, as above. These smooth curves are lost in radial neck fracture:

Radial neck fracture. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 42688

 

Mildly angulated radial neck fracture (black arrow) and posterior fat pad (white arrow). Reproduced with permission from Emery et al. Ped Rad. 2016; 46:61-6

How are radial neck fractures classified?

Radial neck fractures were classified by O’Brien (1965)  as follows:

Type I: <30 degrees displacement

Type II: 30-60 degrees displacement

Type III: >60 degrees displacement

O’Brien’s classification of radial neck fractures. From Orthobullets

 

Other radial neck classifications have been described so, to avoid confusion, it’s probably safest to describe the degree of displacement rather than the classification type, especially as displacement of radial neck fractures in children is uncommon.

 

How should radial neck fractures be managed?  

Most paediatric radial neck fractures are type I: undisplaced or minimally displaced.  These do really well with conservative management with immobilization in a collar and cuff.  Those with displacement of >30 degrees tend to have a worse outcome and should be referred to orthopaedics as reduction, and possible internal fixation will be required.

 

Which children need to be discussed with the orthopaedic team before they go home?

  • Any displaced radial neck fractures
  • Any radial neck fractures with a second elbow injury

 

Radial neck fractures – do not miss…

30-50% of children with a proximal radial fracture have another fracture – examine the child and their x-rays very carefully.  Having a second injury is associated with a poorer outcome. The most common associated injuries are:

  • elbow dislocations
  • medial epicondyle fractures
  • olecranon fractures

 

Radial neck fractures can also be associated with compartment syndrome of the forearm, although thankfully this is rare.   Compartment syndrome is a limb-threatening condition caused by increased pressure within the closed space of a muscular compartment which causes compression of the nerves, muscles, and vessels within the compartment.  Untreated, this can lead to ischaemic injury within 4-8 hours.

 

Assessing for compartment syndrome – the 5 Ps

  • Pain – the most important indicator.  Often diffuse and progressive, not resolved by analgesia, worsened by passive flexion of the injury.
  • Pallor – assess distal to the injury.  Dusky or cool skin (compared to the other side) or delayed capillary return.
  • Pulse – weak or absent pulse indicates poor perfusion,
  • Paralysis – assess active movement of the wrist and fingers.  This may cause pain but the purpose is to assess ability to move.
  • Paraesthesia – ask about pins and needles or a feeling of the hand “falling asleep”.  Assess sensation with light touch or using an object such as a pen lid.

Any concerns about potential compartment syndrome must be escalated to an ED or orthopaedic senior without delay as this is a time-critical situation.

 

Radial Head fractures

Like radial neck fractures, radial head fractures are also most often due to a FOOSH.  Unlike radial neck fractures, radial head fractures typically occur after the proximal radial physis has closed so are more common in older children. They are usually clearly visible on x-ray and the majority are undisplaced and respond well to conservative management in a collar and cuff or sling.  Displaced fractures of the radial head are rare and will need an urgent orthopaedic referral.

Radial head fracture. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 24158

 

 

Aisha returns from X-Ray and you spot an undisplaced fracture of the radial neck, visible on the AP and lateral views.  You remember that associated fractures are common and so have a careful look for other injuries and check the epiphyses using the CRITOE rule.  Aisha has an isolated, non-displaced radial neck fracture with no other injuries: you pop her in a collar and cuff and organize virtual fracture clinic follow up.  You make sure to give her and her family advice about analgesia and signs of any neurovascular compromise before they leave.

 

References

Barclay, T. (2019) Elbow Joint. Innerbody https://www.innerbody.com/image/skel14.html

Davies, F., Bruce, C. E., & Taylor-Robinson, K. J. (2011). Emergency Care of Minor Trauma in Children. London: Hodder & Stoughton.

De Mattos, C. B., Ramski, D. E., Kushare, I. V., Angsanuntsukh, C., & Flynn, J. M. (2015). Radial Neck Fractures in Children and Adolescents. Journal of Pediatric Orthopaedics, 36(1), 6-12.

Edgington, J. & Andras, L. (2018) Radial head and neck fractures – pediatric https://www.orthobullets.com/pediatrics/4011/radial-head-and-neck-fractures–pediatric

Emery, K. H., Zingula, S. N., Anton, C. G., Salisbury, S. R., & Tamai, J. (2016). Pediatric elbow fractures: a new angle on an old topic. Pediatric Radiology, 46(1), 61–66.

Gaillard, F. https://radiopaedia.org/articles/radial-head-fractures?lang=us Accessed 23/06/2019

Gomes, C. & Lowsby, R. (2018) Elbow Injuries.  RCEM Learning https://www.rcemlearning.co.uk/reference/elbow-injuries/

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. The Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Lampert, L. (2016). Compartment Syndrome – The 5 Ps. Ausmed. Retrieved from https://www.ausmed.com/cpd/articles/compartment-syndrome

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Nickson, C. (2018) Compartment Syndrome. Life in the Fast Lane https://lifeinthefastlane.com/compartment-syndrome/

O’Brien, P.I. (1965) Injuries involving the proximal radial epiphysis.  Clinical Orthopaedic related Research, 41, 51-58.

Shabtai, L., & Arkader, A. (2016). Percutaneous reduction of displaced radial neck fractures achieves better results compared with fractures treated by open reduction. Journal of Pediatric Orthopaedics, 36(4), S63–S66.

Tan, B. H., & Mahadev, A. (2011). Radial neck fractures in children. Journal of Orthopaedic Surgery (Hong Kong), 19(2), 209–212.

Olecranon fractures

Cite this article as:
Becky Platt. Olecranon fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21080

14-year old Noah was rocking on his chair while daydreaming his way through a maths lesson this morning… and fell off.  He reports that he landed directly on his left elbow and that it has been painful throughout the day.  He attends your ED this afternoon with his unamused mother.

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

You ensure Noah has been given analgesia before examining him.  His pain score is 5 and he seems comfortable after paracetamol and ibuprofen when his arm is resting.  His elbow is notably bruised and swollen. He is particularly tender over the olecranon and any movement is painful.  His neurovascular status is normal with good radial and ulnar pulses, normal sensation in the radial, ulnar and median nerve distributions and as he’s able to make the rock, paper, scissors and ok hand signs, you’re happy he has full motor function.  You order AP and lateral films of his elbow and pop him in a broad arm sling for comfort before sending him round for his x-rays.

Epidemiology and mechanism of injury

Olecranon fractures in children are rare, comprising around 5% of elbow fractures. Compare this with supracondylar fractures which comprise over half of all elbow fractures in the paediatric population. Olecranon fractures may result from a fall onto an outstretched hand (FOOSH), direct trauma or, occasionally, a stress fracture from repetitive throwing motion in athletes.

They can be classified according to the Mayo classification.

Examination findings

In addition to pain, there will almost certainly be generalised swelling around the elbow, usually with visible evidence of trauma, such as bruising or abrasion, over the olecranon process.  Point tenderness over the olecranon is often a feature, but the degree of swelling can sometimes make this difficult to appreciate.  Inability to fully extend the elbow is common, and pain on extension, supination and pronation is expected.  In those with comminuted or significantly displaced fractures it may be possible to feel crepitus over the olecranon.

Radiology

Interpreting children’s elbow x-rays can be mind boggling. Epiphyses ossify at different rates and so it can be easy to confuse a normal olecranon epiphysis with a fracture.  The olecranon epiphysis normally appears around 9 years and fuses at 15-17 years.   Be sure to refer to the CRITOE rules and if you’re not sure whether you’re seeing a normal epiphysis or a fracture, seek senior advice.  The olecranon can be best assessed on the lateral film.

This x-ray shows a normal olecranon epiphysis:

Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 26814

Some olecranon fractures are obvious…

…but some can be incredibly subtle as illustrated in this series from Radiology Assistant:

Some olecranon fractures may only be visible on one view.  This may be the AP or the lateral.  The below elbow x-rays show a transverse olecranon fracture visible on the AP view only (arrow).  Note the raised anterior and posterior fat pads on the lateral view.  And an extra bonus point to those who spotted the subtle radial neck fracture.

Management

The majority of olecranon fractures (around 80%) are either undisplaced or minimally displaced (less than 2mm); these can be managed conservatively with an above elbow back-slab with good functional outcome.

Minimally displaced (<2mm) fracture in a 7 year old, requiring conservative management only. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 23650

Complications

In children with a displaced olecranon fracture, there is risk of complications including delayed or non-union, ongoing elbow stiffness and impaired function.  Refer any child who has an olecranon fracture with these features as they’re likely to require surgical intervention:

  • >2-4mm displacement
  • angulation of >30°
  • intra-articular involvement
  • extensor mechanism disruption
  • instability on extension
  • comminution

Olecranon fracture with >30 degrees of displacement, requiring surgical fixation. From Orthobullets.com.

The practitioner seeing injured children in the ED must be aware of the potential for these.  Displaced olecranon fractures can cause growth disturbances resulting in fixed flexion deformity of the elbow joint and associated morbidity into adulthood.

The ulnar nerve is particularly at risk of injury with olecranon fracture. Ensure you carry out a thorough neurovascular assessment, in particular checking sensation over the little finger and that the small muscles of the hand are functioning normally (the “scissors” sign).

A significant proportion of olecranon fractures are associated with concomitant injury, including radial neck fracture and /or supracondylar fracture and any co-existing injury is prognostic for poorer outcome.  When interpreting the x-ray, it is important therefore to have a systematic approach.

Bullets of wisdom 

  • Don’t confuse an unfused olecranon epiphysis with a fracture
  • But don’t forget that olecranon fractures can be subtle – maintain a high index of suspicion in children with direct trauma and inability to extend their elbow
  • Olecranon fractures are sometimes only visible on one view and this can be the lateral or the AP
  • Displaced fractures can have devastating consequences and must be referred to orthopaedics as they may need surgical intervention
  • Document neurovascular status and be sure to check ulnar nerve function
  • And look for a concomitant radial neck or supracondylar fracture

Noah returns from X-Ray and you review his films. He has a posterior fat pad sign and on closer scrutiny you spot an intra-articular fracture of the olecranon. You recognise that this type of fracture can be associated with complications and refer him to the orthopaedic team.  You ensure that his pain score and neurovascular status are being assessed regularly.

 

References

Cabanela M.E. & Morrey B.F. (1993) The Elbow and Its Disorders. 2nd ed. Philadelphia, PA, USA: WB Saunders cited in Sullivan, C. W., & Desai, K. (2019). Classifications in Brief: Mayo Classification of Olecranon Fractures. Clinical Orthopaedics and Related Research, 477(4), 908–910.

Caterini, R., Farsetti, P., DʼArrigo, C., & Ippolito, E. (2002). Fractures of the Olecranon in Children. Long-Term Follow-Up of 39 Cases. Journal of Pediatric Orthopaedics B, 11(4), 320–328.

Corradin, M., Marengo, L., Andreacchio, A., Paonessa, M., Giacometti, V., Samba, A., … Canavese, F. (2016). Outcome of isolated olecranon fractures in skeletally immature patients: comparison of open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. European Journal of Orthopaedic Surgery and Traumatology, 26(5), 469–476.

Degnan, A. J., Ho-Fung, V. M., Nguyen, J. C., Barrera, C. A., Lawrence, J. T. R., & Kaplan, S. L. (2019). Proximal radius fractures in children: evaluation of associated elbow fractures. Pediatric Radiology, 1–8.

Edgington, J. & Andras, L. (2019) Olecranon fractures – pediatric https://www.orthobullets.com/pediatrics/4010/olecranon-fractures–pediatric?expandLeftMenu=true

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Pace, A., Gibson, A., Al-Mousawi, A., & Matthews, S. J. (2005). Distal humerus lateral condyle mass fracture and olecranon fracture in a 4-year-old female – Review of literature. Injury Extra, 36(9), 368–372.

Perkins, C. A., Busch, M. T., Christino, M. A., Axelrod, J., Devito, D. P., Fabregas, J. A., … Willimon, S. . (2018). Olecranon fractures in children and adolescents: outcomes based on fracture fixation. Journal of Children’s Orthopaedics, 12, 497–501.

Rath, N. K., Carpenter, E. C., Ortho, F., & Thomas, D. P. (2011). Traumatic Pediatric Olecranon Injury. A Report of Suture Fixation and Review of the Literature. Pediatric Emergency Care, 27(12), 1167–1169.

Medial epicondylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Medial epicondylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21036

In this section we will mainly discuss medial epicondylar fractures. Medial condylar fractures are a rare pattern of fracture and managed in a similar manner to lateral condylar fractures. It is important to differentiate between medial condylar and epicondylar fractures as condylar fractures are intra-articular and require urgent open reduction and internal fixation.

Lateral condylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21030

Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…

 

Epidemiology 

This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.

 

History 

The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.

 

Examination

Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.

Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.

It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.

Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.

 

Investigations

AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.

The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.

The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.

The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.

 Lateral condyle fractures can be classified depending on their x-ray appearances.

 

Classification

There are several different classification methods. The most common classifications as below.

Milch Classification
Type 1 The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2 The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.

 

Milch Classification

 

Jakob Classification
Stage 1 <2mm displacement, which indicates intact cartilaginous hinge
Stage 2 2-4mm of displacement
Stage 3 >4mm displacement with rotation of the fragment

 

Jakob Classification

 

Immediate treatment in the ED

Provide immediate adequate analgesia to the child prior to any examination or investigation.

If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.

Keep the child nil by mouth as they may need urgent surgery.

 

Treatment following imaging

Treatment depends on the degree of displacement of the fracture.

Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.

 

Jakob classification Treatment option Follow up
Stage 1 (<2mm of displacement) Conservative management with immobilisation with above elbow cast to 90 degrees. Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation) These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation. 3-6 weeks in above-elbow cast and orthopaedic follow up.

 

Areas of controversy

Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.

 

Potential complications

This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.

The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:

  • Stiffness is the most common complication, usually fully resolving by 48 weeks.
  • Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
  • Non-union is more likely when delayed union occurs.
  • Cubitus valgus deformity occurs with lateral physeal growth arrest.
  • Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
  • Avascular necrosis may develop 1-3 years after the fracture.

Image from wikimedia.org

 

Do not miss bits

Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.

  

William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.

 

 

References

Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.

 

Finger injuries: basics and bones

Cite this article as:
Sinead Fox. Finger injuries: basics and bones, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27577

Introduction

Injuries to the hand are frequent in the paediatric population and are a common reason for presentation to the PED. Despite the frequency of these presentations, assessment and management of hand and finger injuries can be challenging. But never fear! DFTB have come to the rescue with a comprehensive two-part series related to the assessment and management of paediatric hand and finger injuries including some handy tips.

This first post will cover an overview of the basic anatomy of the hand, professional lingo as well as history taking and the clinical examination. Documentation essentials and common phalangeal and metacarpal fractures seen in PED will also be covered.  

First, let’s take a look at the basic anatomy of the bones of the hand.

Outlines the bones of the hand

Professional Lingo: Get to know your pinkie from your pointer!

Although it is helpful to know your pinkie from your pointer when talking to children, it is also important to have knowledge of the professional language used to document and describe hand injuries appropriately. This is not only important from a medico-legal point of view but having the ability to describe the exact location of clinical findings in professional terms makes communication and referral to specialist services much easier.

Clinical History/Documentation Essentials: Take a HAND history

H-          How the injury happened? Ask about mechanism of injury including the environment in which the injury was obtained.

              Hobbies. Ask about the child’s hobbies, sports, activities, career aspirations (in older child) as these may impact on management.

A-          Altered sensations. Ask about any altered sensations such as paraesthesia which could indicate a nerve injury.

N-          Needles/Needs Tetanus? Ask about vaccinations, is the child’s Tetanus vaccination up to date, especially relevant if open wounds or animal/human bites are present.

NAI        Like all paediatric injuries consider the possibility of NAI, especially in the younger child. A comprehensive history is essential to detect the possibility of intentional injury from physical abuse or an unintentional injury as a result of neglect. Consider injuries that are self-inflicted in the older child/adolescent age group.

D-          Dominance. Ask and record the child’s hand dominance as this can impact injury management.

Physical exam – look, feel, move

Clinical assessment of hand injuries involves a systematic exam of both hands including inspection, palpation, and range of motion (ROM).

1. Look

  • Once the child has received appropriate analgesia and you have established a rapport with the child and their parent, begin by looking at the hand without touching, observe the child’s hand at rest and play, involve a play specialist if available- they always bring the right amount of magic to get even the sorest of little hands and fingers moving!
  • Look for bruising, swelling, abrasions or open wounds. Assess for nail bed injuries.
  • Check for any clinical deformities including a rotational deformity which may not become apparent until the child makes a fist. Minimally displaced fractures may be clinically significant if they result in a rotational deformity, so it is vital to routinely assess for same. It is good practice to include the presence or absence of a rotational deformity in your documentation.
Rotational deformity – the normal cascade should point to the thenar eminence

2. Feel

  • Examine the child’s unaffected hand first and keep the child chatting throughout the exam, it helps reduce the child’s anxiety and allows the child to build trust in you.
  • Remember to examine the whole hand. It is important to develop a systematic approach to the examination of the hand including palpation of the wrist, carpal bones (including anatomical snuff box and scaphoid tubercle) metacarpals, metacarpophalangeal joints (MCPJs), phalanges, proximal interphalangeal joints (PIPJs) and distal interphalangeal joints (DIPJs).  Systematic palpation of the entire hand can help localise underlying fractures and concomitant injuries.
  • Evaluate and document neurovascular status.

Examination Pearl: The Wrinkle Test

Neurological assessment in young children or children/adolescents with difficulties communicating can be particularly challenging as they may be unable to report the presence or absence of sensation. The wrinkle test measures autonomic function of peripheral nerves via placement of the child’s hand in warm water for 10 minutes, wrinkles on the fingers indicate intact neurological function.

3. Move

  • Getting a child to move an injured hand can be challenging but certain familiar gestures such as high fives, thumbs up or fist bumps can be used to assess active range of movement in a young or uncooperative child.
  • A game of paper, rock, scissors is a fun and systematic way to test peripheral nerves in children with upper limb injuries. 
  • Be vigilant for tendon injuries. Check out the DFTB finger tendon and ligament injuries post for further details and clinical pearls related to the assessment of specific tendon functions. These functional tests should be included in every clinical examination of an injured hand.

Phalangeal Fractures

Approximately 20% of hand injuries in children are fractures. In particular, the phalanges are the most frequently injured bones of the hand with distal phalangeal and proximal phalangeal base fractures being the most commonly diagnosed fractures.

Proximal phalangeal base fractures

It’s a sunny June afternoon and Patrick a 9-year-old boy is brought to your ED by his Dad. Patrick reports it is the last day of school term before the summer holidays, he tells you he was so excited that when the final bell rang he threw his book bag in the air but, as the bag landed his left little finger got caught in the strap. It sounds like his finger was forcefully abducted by the weight of the bag. He shows you his swollen, bruised, and painful pinkie.  

Mechanism

Typically, proximal phalangeal base fractures result from a finger being abducted beyond acceptable limits of the MCP joints.

Presentation

A child with a proximal base phalangeal fracture will typically present with swelling, ecchymosis, and focal tenderness on palpation to base of proximal phalanx. A displaced fracture to the base of the proximal phalanx can cause malrotation of the finger. A significantly displaced fracture or a fracture that causes a rotational deformity requires closed reduction to correct the deformity.

Imaging

Oblique, PA, and lateral X-rays of the injured fingers should be obtained. True lateral X-ray is the most effective way to examine joint congruity. Angulation of proximal phalanx fractures is best seen on the lateral projection.

Salter-Harris Classification

Fractures involving the physis are described by the Salter-Harris Classification system as types I-V.  Salter- Harris type II fractures of the proximal phalanx are a common type of finger fracture in children.

  • Salter-Harris type I fractures involve only the physis and can be difficult to diagnose because X-Rays typically appear normal unless there is displacement.
  • Salter-Harris type II fractures involve extension through the physis and metaphysis.
  • Salter-Harris type III fractures extend through the physis and epiphysis.
  • Salter-Harris type IV fractures extend through the physis, metaphysis and epiphysis.
  • Salter-Harris type V fractures involve crush injuries that shatter the physis. 

Treatment

Non- Operative: Un-displaced or minimally displaced Salter-Harris type I or II fractures of the proximal phalanx without clinical deformity are usually managed with buddy taping to an adjacent finger for support and encouragement of early range of motion, typically for 3-4 weeks.

For displaced Salter Harris type II fractures of the proximal phalanx closed reduction can be carried out in ED. Depending on the age and preference of the child, closed reduction can be performed using a ring block +/- procedural sedation. The proximity of the physis assures a high degree of remodelling. The ED practitioner’s thumb or a cylindrical object such as a pen or pencil can be used to achieve adequate reduction. Post reduction stability is maintained by buddy tapping +/- splinting.

Operative: Severely displaced, unstable or open fractures require evaluation by a hand surgeon.

X-ray shows a displaced Salter-Harris type II fracture to the base of Patrick’s proximal phalanx. There is a rotational deformity on clinical exam. You reduce the fracture in ED using a ring block and Nitrous Oxide. On reassessment post reduction the clinical deformity is corrected and check X-rays are satisfactory. You discharge Patrick home with his finger buddy taped and arrange follow up in an outpatient clinic.  

Phalangeal shaft, neck and condylar fractures

Phalangeal shaft fractures

Treatment for fractures along the shaft of the phalanges is dictated by the orientation of the fracture as well as the degree of angulation on initial presentation. Clinical exam is also extremely important as even innocuous appearing fractures along the phalangeal shaft can be clinically significant if they cause a rotational deformity of the injured digit. A rotational deformity must be corrected as failure to do so can lead to long term functional impairments for the child.

Non operative: For length stable fractures with minimal displacement, buddy taping to an adjacent finger for support and to allow early range of motion can be an effective treatment for approximately 3-4 weeks.

Operative: Oblique or spiral fractures requiring closed reduction need more rigid immobilisation such as an ulnar or radial guttar splint or cast. Alignment of these fractures can be difficult to maintain and fixation is often required; surgical opinion is advised.

Surgery is also indicated in cases of open or severely displaced fractures or where there is instability post-reduction.

X-ray of long oblique proximal phalanx shaft fracture Courtesy of Orthobullets: https://www.orthobullets.com/hand/6114/phalanx-fractures

Phalangeal neck fractures

Neck fractures of the proximal and middle phalanges are classic paediatric injuries, rarely seen in adults. They typically result from a crush injury to the finger such as a child getting the finger caught in a closing door.

Non operative: Non-displaced fractures to the neck of the proximal or middle phalanges can usually be managed safely by immobilizing the digit for 3-4 weeks.

Operative: Surgical consultation is recommended for any displaced neck fractures as these are inherently unstable and require close follow up.

Condylar fractures

The condyles are a pair of tuberosities that form the distal articular surfaces of the proximal and middle phalanges. Condylar fractures are intra-articular fractures and can be unstable, therefore surgical consultation is recommended as these fractures require meticulous reduction to ensure proper joint congruity.

Volar plate avulsion injuries

Tori is a 14-year-old girl and a talented soccer goalie. She reports that while trying to save a penalty, her right middle finger was forcefully hyperextended and is now very painful. She shows you her right middle finger which is swollen and bruised at the PIPJ.

An overview of volar plate injuries

The volar plate lies between the flexor tendons and the palmar PIPJ capsule. It originates from the proximal phalanx and inserts into the middle phalanx. The volar plate contributes to the stability of the PIPJ by preventing hyperextension of the PIPJ.  Volar plate injuries encompass a spectrum of soft tissue injuries and can occur with an avulsion fracture at the volar base of the middle phalanx.  Subluxation or dislocation of the PIPJ may also occur.

Mechanism

Volar plate injuries are commonly caused by forced, sudden hyperextension injuries of the PIPJ, seen typically in older children/adolescents involved in hand/contact sports. Occasionally volar plate injuries can be caused by a crush injury to the digit.

Presentation

Diagnosis of a volar plate injury is based on history and clinical examination. Typically, there is swelling of the PIPJ. Bruising to the volar surface of the PIPJ is sometimes observed. Maximal tenderness on palpation is over the volar PIPJ and the patients may report pain on passive hyperextension of the PIPJ. The collateral ligaments should be tested as with collateral ligament injuries to check stability of the PIPJ.

 X-rays may reveal an avulsion fracture at the base of the volar surface of the middle phalanx and can help identify PIPJ subluxation or dislocation.

Case courtesy of Dr Mohammad A. ElBeialy, Radiopaedia.org. From the case rID: 46050

Treatment

Non- operative: A stable joint without a large avulsion fracture (<40% of articular segment) and/or a reducible fracture with 30 degrees of flexion is usually managed conservatively with splinting. In less severe injuries the injured finger can be buddy taped.

Operative: Surgical opinion should be sought if there is instability of the PIPJ or there is a large avulsion fracture.

When you examine Tori’s hand there is an isolated injury to Tori’s right middle finger as evidenced by swelling, bruising and tenderness to the PIPJ. Although active ROM is painful, Tori is able to fully extend and flex the finger. X-ray demonstrates a small avulsion fracture to the volar base of the middle phalanx on her right middle finger and you correctly diagnose her with a volar plate injury. Tori’s injury is stable and suitable for buddy taping to allow for early range of motion and prevent stiffness.

Distal Phalangeal Fractures

Distal tuft fracture

Khalid is a 2-year-old boy. He is brought to ED by his Mum as he caught his right index finger in the hinge side of a closing door. You examine his hands and note swelling and erythema to the distal phalanx of his right index finger. There is no nail bed injury or open wounds and he is moving the finger freely as you observe him playing with a toy tractor which was kindly supplied by the PED play specialist. His Mum appears more upset than he is, so you calmly reassure her that a serious finger injury is unlikely but an X-ray is required to rule out a fracture.

Mechanism

Distal tuft fractures are common in the toddler or pre-school age groups and typically occur as a result of direct crush injuries such as getting little fingers caught in a closing door.

Presentation

A concomitant nail bed laceration or pulp laceration may be present in children who have a distal tuft fracture. In this case the fracture is classed as an open fracture and opinion should be sought from Plastic Surgery Team. Check out the DFTB post on fingertip injuries for more information related to the assessment and management of nail bed injuries. Be alert for injury to flexor/extensor tendons.

Treatment

Non-Operative: Most children who have a closed distal tuft fracture are treated conservatively with splinting or buddy taping.

Operative: Surgical treatment is reserved for patients with distal tuft fractures who have nail bed injuries, subtotal/total amputations, or an unstable transverse fracture pattern.

X-ray demonstrates an un-displaced tuft fracture. You buddy tape Khalid’s fingers and reassure Mum that the fracture is small and unlikely to cause Khalid any functional problems.

Seymour fractures

Jordan is a 12-year-old boy who is brought to the PED with an injury to his left thumb. During a rugby match he was tackled to the ground and an opposition player stood on his thumb. He shows you a swollen, bruised partially flexed thumb. There is blood at the proximal nail fold and the nail plate is partially avulsed. The finger is visibly contaminated with dirt and soil from the rugby pitch, so you irrigate it with saline prior to X-ray and check that Jordan’s vaccination status is up to date.

Mechanism

A Seymour fracture is an injury unique to children. This fracture pattern is usually caused by a crush injury and results in an angulated Salter-Harris type I or Salter-Harris type II fracture with an associated nail bed injury. It is important to recognise this fracture pattern as early referral to a hand surgeon is important to avoid complications.

Presentation

The typical presentation is a swollen, bruised, and painful finger flexed at the DIPJ. There may be blood under the nail or the nail plate can be completely avulsed proximally causing it to sit superficial to the eponynchial fold (aka proximal nail fold). Soft tissue (often the germinal matrix of the nail) can become interposed in the fracture which prevents fracture reduction and healing.

Imaging

PA X-ray views of the injured finger often appear normal. Lateral view X-ray are used to confirm the diagnosis.

Pro tip! Because of the flexed appearance at the DIPJ, a Seymour fracture can be misinterpreted as bony mallet injury; however a mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not enter DIPJ).

Treatment

Non-Operative: Closed injuries are managed with closed reduction and splinting. The child may be followed up with a weekly X-ray to ensure maintenance of fracture reduction.

Operative: Substantive injuries require open reduction and nail bed repair.

Bottom Line

It is important to seek surgical opinion regarding the management of Seymour fractures as if left untreated possible complications include osteomyelitis, malunion, and pre-closure of the physis.

Jordan’s x-ray shows an angulated Salter-Harris type II fracture to the distal phalanx and you correctly diagnose a Seymour fracture. You refer Jordan to the plastic surgery team who decide to take Jordan to theatre to ensure a thorough washout and repair of the nail bed injury.

Metacarpal Fractures

Katie is a 15-year-old girl who presents to your ED with her father. Her father reports that she had an argument with her Mum and punched a wall at home, he also reports that this is not the first time an incident like this has occurred. Katie shows you her right hand which is grossly swollen and bruised over the dorsal surface. There are no open wounds and she reports focal tenderness on palpation to her 5th metacarpal bone. There is an obvious loss of knuckle height and rotational deformity to her little finger. During the exam she is visibly withdrawn and quiet and you are suspicious that there is more than a hand injury bothering Katie.  

Mechanism

Metacarpal fractures are common in adolescent athletes. The most common type of metacarpal fracture is the so-called ‘‘boxer’s fracture’’, which involves the neck of the ring or small finger metacarpal. This injury usually occurs as a result of direct bony trauma when the child/adolescent strikes a fixed object such as a wall with a closed fist or is struck on a fisted hand with an object such as a bat/hurl/hockey stick for example.

Presentation

The child/adolescent will usually present with bruising, swelling and diffuse pain over the dorsum of the hand. There may be loss of knuckle prominence. Be vigilant for rotational deformity; no degree of malrotation is acceptable.

Ensure to evaluate skin integrity over the injured area, check for and document the presence of open wounds; consider the possibility that these could be so-called ‘’fight bites’’ and will require antibiotics. Substantial injuries or infected open wounds require a surgical opinion as these may require admission for IV antibiotic cover and washout in theatre. Check integrity of flexor/extensor tendons in the presence of open wounds. Remember to check Tetanus vaccination status.

A child/adolescent who presents to the PED with a hand injury because of a fight or an injury mechanism such as puching a wall requires special attention- screening for mental health and/or social problems is paramount. Involvement of medical social worker teams or mental health teams may be necessary. The HEEADSSS screening tool may be useful to guide this line of inquiry.  

Treatment

Treatment is generally based on the level of injury (e.g. head, neck, shaft and base) and clinical findings (rotational deformities, open wounds, fracture stability).  

Un-displaced stable fractures of the neck or shaft (2nd-5th metacarpals)

Non-operative: Can be treated in rest volar splint/back -slab and followed up in clinic

Angulated neck of metacarpal fractures

Most common is fracture of 5th metacarpal or  ‘‘Boxer’s fracture’’

Treatment guided by degree of angulation. Seek surgical opinion

Non-operative: Closed reduction in PED using nerve block +/- procedural sedation and immobilisation in cast

Operative: Surgery may be required in the presence of open wounds, suspected tendon injuries or if angular deformity is substantial and/ or there is a rotational deformity on clinical exam.

Case courtesy of Dr Benoudina Samir, Radiopaedia.org. From the case rID: 23848

Displaced intra articular, unstable, comminuted or unstable fractures

Operative: These fractures all require surgical referral

Metacarpal head fracture (intra-articular) Courtesy of Orthobullets: https://www.orthobullets.com/hand/6037/metacarpal-fractures

Thumb metacarpal fractures

Thumb metacarpal base fractures require surgical opinion. Disruption of carpometacarpal (CMC) joint congruity can result in significant functional impairments for a child/adolescent particularly loss or limitation of pincer or power grip.

Specific names are given to fractures of the base of the 1st metacarpal

  • Bennett fracture: defined as an intra-articular 2-part fracture of the base of 1st metacarpal bone *(see also Reverse Bennett fracture below)
  • Rolando fracture: similar to Bennett fracture but prognosis is worse. Defined as a comminuted intra-articular fracture of the 1st metacarpal, producing at least 3 parts.

X-ray demonstrates a severely angulated fracture to the neck of Katie’s 5th metacarpal bone. Taking this into consideration and the presence of rotational deformity, you refer her to the hand surgery team for management. They decide to admit her for manipulation under anaesthetic (MUA). While awaiting admission you get the opportunity to establish a rapport and talk to Katie about her mental health. You use the HEEADSSS screening tool to guide your inquiry. She reveals information about difficulties at home related to her mother’s substance abuse and reports that she has been missing a lot of school due to bullying. Katie agrees that she needs help dealing with these issues and you refer her to the inpatient mental health team with her permission. Her dad is also informed.

*Reverse Bennett fracture dislocation

An intra-articular fracture dislocation of the base of 5th metacarpal bone is called a reverse Bennett fracture. This fracture pattern is inherently unstable and referral to hand specialist is essential.

Reverse Bennett fracture dislocation Case courtesy of Dr Alborz Jahangiri, https://radiopaedia.org/cases/reverse-bennett-fracture-dislocation-1

References

Andy Neill. AFEM 033 | Hand: Lingo and soft tissues. Retrieved from https://litfl.com/bscc/clinical-anatomy/hand-anatomy/

Abzug, J. M., Dua, K., Bauer, A. S., Cornwall, R., & Wyrick, T. O. (2016). Pediatric phalanx fractures. Journal of the American Academy of Orthopaedic Surgeons24(11), e174-e183.

Sullivan, M. A., Cogan, C. J., & Adkinson, J. M. (2016). Pediatric hand injuries. Plastic Surgical Nursing36(3), 114-120.

Wahba, G., & Cheung, K. (2018). Pediatric hand injuries: Practical approach for primary care physicians. Canadian Family Physician64(11), 803-810.

Weber, D. M., Seiler, M., Subotic, U., Kalisch, M., & Weil, R. (2019). Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. Journal of Hand Surgery (European Volume)44(6), 640-647.

Apophysitis

Cite this article as:
Stephen Gilmartin. Apophysitis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24364

David is a 12-year-old boy who attends the emergency department complaining of bilateral heel pain. His pain has been getting gradually worse over the past month. He is a keen footballer, but his symptoms have gotten to the stage where he is now unable to play through his pain.

 

Apophysitis is a term used to describe a group of overuse traction injuries which commonly cause pain in adolescents. We have all heard of Osgood Schlatter disease. It is the most common form of apophysitis. Other anatomical areas that are commonly affected include the inferior pole of patella (Sinding-Larsen-Johansson), calcaneal tuberosity (Sever’s), medial epicondyle of the elbow (within spectrum of Little League elbow) and various sites on the pelvis. They’re subtly different from osteochondrosis, which is instead due to changes in the epiphyseal ossification centre.

An apophysis is an area of bony growth separate to the ossification centres. It acts as a site of tendon or ligament attachment and will eventually fuse with the bone as the body matures. Rapid growth and relative bone weakness combined with repetitive movements cause increased traction forces at the point of attachment. The apophysis is the weakest point in the muscle-tendon-bone junction; repeated strain at this point leads to bone fragmentation and micro-separation. This abnormal growth leads to swelling and pain at the site. Similar overuse injuries result in tendon and muscle injuries in adults.

Apophysitis is most common during ages of peak growth i.e. between 10-14 years in girls and 12-16 years in boys. Apophysitis is traditionally more common in boys, but the incidence is growing in girls. This is likely linked to increasing sports participation rates among girls of this age. The mean age of onset is younger in girls due to the earlier appearance of the ossification centres. Earlier fusion leads to the cessation of symptoms at a younger age in girls when compared to boys. In lower limb apophysitis, up to 50% of patients will experience bilateral symptoms.



 

Let’s take a look at some x-rays

This 11-year-old male basketball player has been complaining of heel pain. His ankle x-ray shows increased density of the calcaneal apophysis, typically seen in children between 7 and 14 years with Sever’s Disease. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation.

Case courtesy of Dr Dinesh Brand, Radiopaedia.org. From the case rID: 60324

 

This 12-year-old female long-distance runner complains of anterior knee pain, localised to the inferior aspect of her patella. Her lateral knee x-ray shows dystrophic ossification of the inferior patella with subtle thickening of proximal patellar tendon. These changes are consistent with a diagnosis of Sinding-Larsen-Johansson.

Sinding-Larsen-Johansson. Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 6323

 

This 13-year-old female volleyball player presents with progressive pain over her tibial tuberosity. Her pain is exacerbated by jumping. Her lateral knee x-ray shows fragmentation of apophysis with overlying soft tissue swelling, classic for Osgood Schlatter Disease. Some isolated fragmentation can be normal at the tibial tuberosity.

Osgood Schlatter’s Disease. Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9740

 

This 11-year-old boy presents to the ED with worsening elbow pain. He is an avid cricket player and is trying to make his county underage team but finds his pain much worse while bowling. His AP elbow x-ray shows widening of the physis at the medial epicondyle. This is consistent with a diagnosis of Little League Elbow. You may also see fragmentation.

Little League Elbow from Orthobullets

 

This is an MRI of a 14-year-old male long-distance runner complaining of anterior hip pain. His pain is becoming increasingly worse on running and is now affecting his times. MRI shows bone marrow and surrounding soft tissue oedema at the anterior superior iliac spine involving the sartorius muscle origin without separation as may occur in an acute avulsion injury. This is consistent with ASIS (anterior superior iliac spine) apophysitis. Plain radiographs are usually normal or may only show subtle changes of pelvic apophysitis.

ASIS apophysitis. Case courtesy of Dr Chris O’Donnell, Radiopaedia.org. From the case rID: 31877

 

History and exam

Apophysitis has a typical history and the diagnosis is largely based on an accurate history and exam. An adolescent will present with gradual onset focal pain over the involved site. They are typically highly active and may be going through an acute increase in there training levels. They may be currently progressing to higher levels of sport or competing in multiple sports at multiple grades. The initial symptom will be pain present at the start of physical activity. In the early stages the pain will often subside once the child has fully warmed up, only to return once they have cooled down. As the process progresses the child will have persisting symptoms throughout physical activity and the pain will eventually result in total cessation of activity.

Clinical examination will reveal point tenderness over the affected site. There may be mild swelling over the area. Pain will be reproduced by resisted contraction of the affected muscle, e.g. resisted plantar flexion of the ankle in Sever’s disease and resisted knee extension in Osgood-Schlatter’s. A good way to assess this is to ask the patient to demonstrate actions which exacerbate their pain.

 

Differential diagnosis

Alternative diagnoses and investigations should be considered if there are any concerning features on history or exam. Atypical features on presentation are:

  • Sudden onset pain
  • Pyrexia
  • Non-weightbearing
  • History of trauma
  • Point of tenderness or age of patient not typical for apophysitis.

The most common differential diagnoses are osteomyelitis, avulsion fractures, osteochondritis, stress fractures and malignancy. Investigations should be performed in accordance with suspected differential diagnosis.

The below cases and accompanying images highlight the need for you have possible alternative diagnoses in the back of your mind. The patient should be presenting with gradual onset pain, over an apophysis site, at the appropriate age (10-16) for apophysitis. A history which includes high levels or sudden increase in activity can be helpful. Any atypical features should be actively sought out.

 

This elbow x-ray is from a 13-year-old male baseball pitcher attending with sudden onset medial elbow pain. The medial epicondyle is displaced with a sliver adjacent bone, representing a medial epicondyle avulsion fracture. There is marked adjacent soft tissue swelling and joint effusion. Compare this to the Little League elbow x-ray.

Medial epicondyl avulsion fracture. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 41533

 

A 10-year-old female basketball player attended with sudden onset knee pain following a fall. The x-ray shows a bone fragment avulsed from inferior patella at point of tendon insertion with moderate overlying soft tissue swelling: a patella sleeve fracture. This contrasts with the findings of dystrophic ossification of Sinding-Larsen-Johansson.

Patella sleeve fracture. Case courtesy of Dr Yuan Ling, Radiopaedia.org. From the case rID: 69680

 

A 13-year-old female long jumper attends with anterior knee pain following a fall resulting in forced flexion of their flexed knee. She has significant pain and is unable to straight leg raise. Her x-ray shows displacement of tibial tuberosity with significant overlying soft tissue swelling: an avulsion fracture of the tibial tuberosity. Compare this to the typical radiographic features of fragmentation and mild swelling observed in Osgood-Schlatter disease.

Tibial tuberosity avulsion fracture. Case courtesy of Radiopaedia.org. From the case rID: 12022

 

A 13-year-old girl presents with worsening ankle/heel pain over the last week. Her pain is exacerbated on while running and playing football. She has been pyrexic over the past 24 hours and is now unable to weight bear. The x-ray of her ankle shows diffuse soft tissue swelling abutting the distal end of her fibula. There is suspicious erosion of distal fibular cortex. These findings are suspicious for osteomyelitis of the distal fibula.

Osteomyelitis of the distal fibula. Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 10046

 

An 8-year-old boy attends with gradual onset knee pain while running. He begins to notice some associated swelling. His mother feels he is becoming increasingly lethargic. Lateral x-ray shows sclerotic lesion involving the dia-metaphyseal region of the tibia with a wide zone of transition and characteristic “Sunburst ” type of periosteal reaction seen in osteosarcomas.

Osteosarcoma of the tibia. Case courtesy of Dr Iqbal Naseem, Radiopaedia.org. From the case rID: 22814

 

Investigations

Despite the diagnosis being clinical, a baseline x-ray is often useful. An x-ray can help ensure there is no avulsion fracture and a study by Rachel et al found x-rays changed management in up to 5% of patients with Sever’s disease.

Findings of apophysitis can vary on imaging and some patients may not show any radiological changes on plain films. The typical x-ray findings include increased density and fragmentation at secondary ossification centres. Overlying soft tissue swelling can often be seen. MRI will reveal increased fluid signal, apophyseal oedema and fragmentation.

This lateral plain film view shows the calcaneal apophysis with high density and fragmentation consistent with Sever’s disease.

Sever’s on x-ray. Case courtesy of Dr Fateme Hosseinabadi , Radiopaedia.org. From the case rID: 69971

Compare the x-ray to this MRI image showing oedema and fragmentation at the calcaneal apophysis and extending into the adjacent calcaneal tuberosity. These findings are commonly seen in patients with Sever’s disease.

Sever’s on MRI. Case courtesy of Dr Paulo A Noronha, Radiopaedia.org. From the case rID: 63302

 

Treatment

Apophysitis is a self-limiting process. Most patients will return to full activity following 4-6 weeks of rest or reduced activity. Despite successful return to activity, patients may continue to experience some symptoms. The symptoms will cease definitively once growth centres fuse.

The focus of treatment should be to reduce symptoms sufficiently to allow continued sports participation.

Strategies shown to improve recovery are

  • analgesia
  • activity modification
  • muscle stretching and strengthening programmes

Other therapies which have little evidence but may be helpful in some cases include

  • ice application
  • foot orthotics or heel raises in Sever’s disease
  • taping or bracing

There is no place for surgery in the standard treatment of apophysitis. Any short-term benefit observed from surgery cannot be justified when weighed against the potential damage to an immature skeleton. Surgery may be considered an option if there is a displaced avulsion fracture or a loose body in an affected joint.

 

Prevention

Apophysitis is a largely preventable process and as a result recent focus has been placed on both primary and secondary prevention programmes. It can be difficult at an individual level to make changes as these patients tend to be highly active and competitive people. This has seen some youth sport bodies enforcing limits on game participation and mandatory rest to avoid repetitive strain.

Simple advice to give parents and children include:

  1. Encourage 1-2 days off from competitive sport per week
  2. Encourage 2-3 months off from each sport per year
  3. Participate on only one team per sport
  4. Avoid early sport specialisation
  5. Avoid increasing levels of training by more than 10% from one week to the next
  6. Maintain good sleep, hydration and dietary habits.

 

Take home tips

  • Apophysitis has a typical history of gradual onset pain over an apophysis in highly active adolescents.
  • It is a self-limiting process but can cause debilitating pain.
  • Treatment should focus on analgesia, activity modification and muscle stretching programmes.
  • Symptoms will resolve definitively once ossification centres fuse.

 

Not to miss bits

  • Any atypical features should be investigated appropriately. The area around the apophysis is a common site for avulsion fractures, osteomyelitis and malignancy.
  • These patients are high risk for other overuse injuries. All patients should be given secondary prevention advice.

 

And our favourites, the controversies

  • Despite the diagnosis being clinical, baseline x-rays can be useful to out-rule other differential diagnoses.
  • There is little evidence displaying additional benefit for treatment with taping or splints.
  • Custom orthotics can be useful for patients suffering from Sever’s Disease.

 

David undertook a month long physio led programme of activity modification and muscle stretching. He was given secondary prevention advice to avoid overtraining. He is now back to symptom free football participation.  

 

References

Brenner, J. S. (2007). Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics, 119(6), 1242 LP – 1245

Elengard, T., Karlsson, J., & Silbernagel, K. G. (2010). Aspects of treatment for posterior heel pain in young athletes. Open Access Journal of Sports Medicine, 1, 223–232.

Fleisig, G. S., Andrews, J. R., Cutter, G. R., Weber, A., Loftice, J., McMichael, C., Hassell, N., & Lyman, S. (2011). Risk of serious injury for young baseball pitchers: a 10-year prospective study. The American Journal of Sports Medicine, 39(2), 253–257.

Frush, T. J., & Lindenfeld, T. N. (2009). Peri-epiphyseal and Overuse Injuries in Adolescent Athletes. Sports Health, 1(3), 201–211.

Gregory, B., & Nyland, J. (2013). Medial elbow injury in young throwing athletes. Muscles, Ligaments and Tendons Journal, 3(2), 91–100.

Guldhammer, C., Rathleff, M. S., Jensen, H. P., & Holden, S. (2019). Long-term Prognosis and Impact of Osgood-Schlatter Disease 4 Years After Diagnosis: A Retrospective Study. In Orthopaedic Journal of Sports Medicine (Vol. 7, Issue 10, p. 2325967119878136).

James, A. M., Williams, C. M., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review.” Journal of Foot and Ankle Research, 6(1), 16.

Rachel, J. N., Williams, J. B., Sawyer, J. R., Warner, W. C., & Kelly, D. M. (2011). Is Radiographic Evaluation Necessary in Children With a Clinical Diagnosis of Calcaneal Apophysitis (Sever Disease)? Journal of Pediatric Orthopaedics, 31(5).

Ramponi, D. R., & Baker, C. (2019). Sever’s Disease (Calcaneal Apophysitis). Advanced Emergency Nursing Journal, 41(1), 10–14.

Vaishya, R., Azizi, A. T., Agarwal, A. K., & Vijay, V. (2016). Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus, 8(9), e780–e780.

Wiegerinck, J. I., Zwiers, R., Sierevelt, I. N., van Weert, H. C. P. M., van Dijk, C. N., & Struijs, P. A. A. (2016). Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial. Journal of Pediatric Orthopaedics, 36(2).

Cairns G, Owen T, Kluzek S, et al. Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport & Exercise Medicine 2018

Cairns, G., Owen, T., Kluzek, S., Thurley, N., Holden, S., Rathleff, M. S., & Dean, B. J. F. (2018). Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport &amp;Amp; Exercise Medicine, 4(1), e000383.

 

Osteochondrosis

Cite this article as:
Stephen Gilmartin. Osteochondrosis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25054

The Limp family arrive at the emergency department with two of their children. Katie is a 10-year-old complaining of right foot pain.  The pain has been getting worse over the past month and she is now beginning to develop some stiffness.  She is a keen athlete and trains five times per week.  Her younger brother Michael is a six-year-old attending with progressive left hip pain.  Both children’s injuries were atraumatic, and they are systemically well.

 

Introduction

Osteochondrosis is a disorder of bone growth primarily involving the ossification centres at the epiphysis.  It commonly begins in childhood and results in osteonecrosis of the growth plate.  This can lead to altered bone and cartilage formation beyond the growth plate.

Although often confused with apophysitis, which is more clearly due to traction overuse injuries, osteochondrosis is often described as idiopathic osteonecrosis as there has been no definite cause found.  There have been some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis.

 

 

 

History and examination

Osteochondrosis presents in a similar fashion independent of location.  The symptoms will have a subacute onset with one or more of; joint pain, swelling or dysfunction.  The patient may comment on symptoms worsening while stressing the site during activity.  This is typical in throwing or gymnastics for Panner disease and weight-bearing activities such as running and jumping in lower limb osteochondrosis.

The joint involved may have mild swelling and tenderness.  Other common findings are stiffness and a reduced range of motion. Active children will often seek medical attention once their pain and stiffness begin to affect sporting performance.

Important points to establish on history and exam are no sudden pain, absence of temperature and no systemic complaints. This will help you to consider important differentials including osteomyelitis, malignancy and stress fractures.

 

Investigations

X-ray is the diagnostic tool of choice. Findings depend on anatomical location and the stage of disease.  Each location has its own radiological criteria which can be quickly referenced online.  MRI may be required in certain cases if the diagnosis remains unclear following initial imaging. Early typical x-ray findings are potentially normal. Radiological findings tend to show:

Initial findings

  • Irregular epiphyseal growth
  • Flattening of the epiphysis
  • Soft tissue swelling

As disease progresses

  • Sclerosis
  • Fragmentation
  • Joint destruction

Blood tests have no role in the diagnosis of osteochondrosis but will aid the work-up of possible differentials including infection and malignancy.

 

Perthes Disease

A 10-year-old boy presents to the ED with progressive left leg pain.  It has been progressing over the past few months with normal knee x-ray.  The pain is now becoming localised to the hip. He has a hip x-ray performed which shows flattening of the femoral head with widening of the femoral neck.  There is increased joint space and sclerosis at the physis.  His x-ray shows advanced Perthes disease.

Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 5978

 

Panner Disease

A 13-year-old cricket player attends with elbow pain.  The pain started gradually while bowling.  He is now complaining of stiffness and pain which is affecting his performance. His x-ray shows irregularity of the capitellum with associated sclerosis. These findings are consistent with a diagnosis of Panner disease.

Image source Orthobullets.com

 

Freiberg’s Disease

A 15-year-old female runner presents complaining of progressive forefoot pain while training.

Her x-ray shows widening of the metatarsophalangeal joint.  There is flattening of the metatarsal head with cystic lesions.  These findings are seen in Freiberg disease. Progressive disease will show sclerosis and increased cortical thickening.

Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9296

 

Kohler Disease

A 9-year-old presents with worsening left foot pain.  X-ray reveals thinning and sclerosis of the navicular bone.  This is typical for Kohler disease.  You may see fragmentation in advanced cases.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 18657

 

Treatment

Osteochondrosis is self-limiting and the bone will eventually revascularize to a certain extent.  The goal of therapy is to facilitate maximal revascularisation while minimising long term symptoms.

An appropriate treatment plan should be decided on a case by case basis and in conjunction with orthopaedics, physiotherapists and the patient themselves.  Although there is limited evidence to guide the type and length of treatment, there are some factors which can help guide clinicians.

  • Radiological stage: There are radiological staging criteria unique to each form of osteochondrosis. These categorise disease progression on x-ray.
  • Joint function: Patients range of motion and stiffness should be assessed. If there is a significant loss of joint function the patient should be treated more aggressively to prevent progression
  • Patient symptoms: If the patient’s pain is significant, they may need some immobilisation to aid with pain prior to progression of their rehabilitation.
  • Age at presentation: as a rough rule of the thumb, the younger the patient’s bone age the more likely they are to respond to conservative management.

Three broad treatment strategies exist.

Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physiotherapy programme can help to strengthen the area and improve joint function.  This approach is suitable for patients with minimal symptoms and early changes of disease progression on x-ray.

Immobilisation:  Immobilisation can be beneficial for patients with significant pain or more advanced changes on x-ray.  This may be in the form of a cast, walking boot or splint depending on the area involved.  This needs to be weighed up against the risk of worsening joint stiffness.

Surgery:  It is very rare if ever that patients will require surgery.  When used it is only in advanced stages of disease and when appropriate conservative management has proved ineffective. Surgical options include osteotomy, arthroplasty and physeal drilling.

 

Prognosis

Osteochondrosis is a self-limiting pathological process. Patients will usually show full clinical and radiological recovery if diagnosed and treated early. Despite this, some patients will continue to have long term pain and stiffness; this can occur despite appropriate treatment plans.

This is especially true for Perthes Disease patients have a high risk of arthritis and subsequently requiring a total hip replacement. One case series found that >50% of all Perthes Disease patients will require total hip replacement with the mean age of initial total hip replacement of 37.8 years.

Bone age of <6 years and <50% femoral head involvement have been shown to be good prognosticating factors for Perthes.

 

The Limps are delighted with your assessment.  Katie has been diagnosed with Kohler Disease.  You place her in a boot for 4 weeks for symptoms management.  Following this she undergoes a specific return to activity regime to manage her training load and recovery.  She is totally symptom-free at 6 months.

Michael is lucky that his diagnosis of Perthes was made early.  His x-ray shows he is in the early stages with minimal femoral head involvement and good femoral head coverage.  He is started on a physio programme with closely monitored clinical and radiographic assessment until full recovery.

 

Take homes

  • Osteochondrosis is an idiopathic osteonecrosis affecting children
  • It is diagnosed with a combination of accurate history and typical radiograph findings
  • Early diagnosis and treatment can aid a complete recovery
  • Bone age <6 years, <50% of femoral head involved and good femoral head coverage are good prognosticating factors for Perthes disease

Not to miss bits

  • Differential diagnoses including malignancy and infection may present similarly
  • Common systemic causes of osteonecrosis should not be missed i.e. haematological (sickle cell, malignancy), Rheumatological (SLE).
  • Although the pathophysiology of osteochondrosis is self-limited. If not treated promptly it can result in long term morbidity.

Controversies

  • Potential causative factors include genetic links and repetitive activity.
  • There are no firm directives regarding the length of treatments including immobilisation.
  • Benefits of surgery are variable and need to be considered on a case by case basis.

 

Selected references

Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–618.

Claessen, F. M. A. P., Louwerens, J. K. G., Doornberg, J. N., van Dijk, C. N., Eygendaal, D., & van den Bekerom, M. P. J. (2015). Panner’s disease: literature review and treatment recommendations. Journal of Children’s Orthopaedics, 9(1), 9–17.

Terjesen, T., Wiig, O., & Svenningsen, S. (2010). The natural history of Perthes’ disease. Acta Orthopaedica, 81(6), 708–714.

Talusan, P. G., Diaz-Collado, P. J., & Reach, J. S. (2013). Freiberg’s Infraction: Diagnosis and Treatment. Foot & Ankle Specialist, 7(1), 52–56.

Olstad, K., Ekman, S., & Carlson, C. S. (2015). An Update on the Pathogenesis of Osteochondrosis. Veterinary Pathology, 52(5), 785–802.

Joseph, B. (2015). Management of Perthes’ disease. Indian Journal of Orthopaedics, 49(1), 10–16.

Masrouha, K. Z., Callaghan, J. J., & Morcuende, J. A. (2018). Primary Total Hip Arthroplasty for Legg-Calvé-Perthes Syndrome: 20 Year Follow-Up Study. The Iowa Orthopaedic Journal, 38, 197–202.

Chan, J. Y., & Young, J. L. (2019). K&#xf6;hler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.