Your video is converting and might take a while Feel free to come back later to check on it. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible.
PMID: 22465516. A combination of anteroposterior and lateral views may be best to rule out displacement. A fracture, or break, in any of these bones can be painful and impact how your foot functions. Patients with lesser toe fractures with angulation of more than 20 in the dorsoplantar plane, more than 10 in the mediolateral plane, or more than 20 rotational deformity should also be referred.6,23,24. Fractures of multiple phalanges are common (Figure 3). Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. Pearls/pitfalls. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Lightly wrap your foot in a soft compressive dressing. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. A 55 year-old woman comes to you with 2 months of right foot pain. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. 11(2): p. 121-3. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49)
Because it is the longest of the toe bones, it is the most likely to fracture. Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Some metatarsal fractures are stress fractures. It ossifies from one center that appears during the sixth month of intrauterine life. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. J AmAcad Orthop Surg, 2001. Methods: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Referral is indicated if buddy taping cannot maintain adequate reduction. Injuries to this bone may act differently than fractures of the other four metatarsals. For several days, it may be painful to bear weight on your injured toe. Foot fractures are among the most common foot injuries evaluated by primary care physicians. METHODS: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Healing of a broken toe may take 6 to 8 weeks. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. (Left) The four parts of each metatarsal. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Differential Diagnosis The same mechanisms that produce toe fractures. When this happens, surgery is often required. Lesser toe fractures are about twice as common as great toe fractures.23,24 The great toe has an increased role in weight bearing and balance; thus, injury to the great toe is associated with higher morbidity.6,24, The primary goals of treating toe fractures include reestablishing and maintaining alignment, regaining range of motion, and preventing complications. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. At the conclusion of treatment, radiographs should be repeated to document healing. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. myAO. In most cases, a fracture will heal with rest and a change in activities. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. This is called internal fixation. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. This webinar will address key principles in the assessment and management of phalangeal fractures. (OBQ05.226)
abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. The skin should be inspected for open fracture and if . Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). While celebrating the historic victory, he noticed his finger was deformed and painful. An X-ray can usually be done in your doctor's office. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Fracture Fixation, Internal Bone Plates Fracture Fixation Bone Nails Fracture Fixation, Intramedullary Bone Screws Bone Wires Range of Motion, Articular Hemiarthroplasty Arthroplasty Casts, Surgical Treatment Outcome Arthroplasty, Replacement Internal Fixators Retrospective Studies Bone Transplantation Reoperation Injury . Phalangeal fractures are the most common foot fracture in children. Diagnosis is made with plain radiographs of the foot. The nail should be inspected for subungual hematomas and other nail injuries. Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Tang, Pediatric foot fractures: evaluation and treatment. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. All the bones in the forefoot are designed to work together when you walk. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Returning to activities too soon can put you at risk for re-injury. See permissionsforcopyrightquestions and/or permission requests. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. Most fractures can be seen on a routine X-ray. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful.
These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Foot fractures range widely in severity, prognosis, and treatment. Content is updated monthly with systematic literature reviews and conferences. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Hatch, R.L. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Taping may be necessary for up to six weeks if healing is slow or pain persists. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. Radiographs are shown in Figure A. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. (Kay 2001) Complications: If the wound communicates with the fracture site, the patient should be referred. While many Phalangeal fractures can be treated non-operatively, some do require surgery. (OBQ11.63)
Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. This is called a "stress fracture.". Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. In some cases, a Jones fracture may not heal at all, a condition called nonunion. Fractures can also develop after repetitive activity, rather than a single injury. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Patients with Jones fractures should be referred if there is more than 2 mm of displacement, if conservative therapy is ineffective after 12 weeks of immobilization and radiography reveals nonunion, or if the patient is an athlete or is highly active.2,13,2022, Toe fractures are the most common fractures of the foot.23,24 Most fractures involve minimal displacement and are treated nonsurgically. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Vollman, D. and G.A. 21(1): p. 31-4. ClinPediatr (Phila), 2011. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. Surgical fixation involves Kirchner wires or very small screws. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. All rights reserved. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. Plate fixation . In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. Epidemiology Incidence Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Patients with intra-articular fractures are more likely to develop long-term complications. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. Your foot may become swollen and discolored after a fracture. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Surgery is not often required. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. (OBQ05.209)
Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Although tendon injuries may accompany a toe fracture, they are uncommon. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. angel academy current affairs pdf . and S. Hacking, Evaluation and management of toe fractures. While on call at the local rural community hospital, you're called by an emergency medicine colleague. The metatarsals are the long bones between your toes and the middle of your foot. If you need surgery it is best that this be performed within 2 weeks of your fracture. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Physical examination reveals marked tenderness to palpation. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. They typically involve the medial base of the proximal phalanx and usually occur in athletes. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; Petnehazy, T., et al., Fractures of the hallux in children. All Rights Reserved. High-impact activities like running can lead to stress fractures in the metatarsals. The proximal phalanx is the toe bone that is closest to the metatarsals. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. Because it is the longest of the toe bones, it is the most likely to fracture. This webinar will address key principles in the assessment and management of phalangeal fractures.
In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. All material on this website is protected by copyright. (Right) The bones in the angled toe have been manipulated (reduced) back into place. (OBQ09.156)
24(7): p. 466-7. Ulnar gutter splint/cast. Toe and forefoot fractures often result from trauma or direct injury to the bone. The fractures reviewed in this article are summarized in Table 1. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. Copyright 2016 by the American Academy of Family Physicians. He came to the ER at that point to be evaluated. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. fractures of the head of the proximal phalanx. Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. In many cases, a stress fracture cannot be seen until several weeks later when it has actually started to heal, and a type of healing bone called callus appears around the fracture site. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Diagnosis is made with plain radiographs of the foot. Pediatr Emerg Care, 2008. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. Shaft. This information is provided as an educational service and is not intended to serve as medical advice.
The most common injury in children is a fracture of the neck of the talus. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. Hand (N Y). Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Treatment is generally straightforward, with excellent outcomes. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease).
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