A fluoroscopic image of the selected needle next to the distal phalanx before insertion can help to confirm the appropriate needle choice. (A) Anteroposterior view. (A) Anteroposterior radiograph shows the displaced lateral condyle and cubitus valgus. LIVIN' ON THE MD EDGE: Drive, Chip, and Putt Your Way to Osteoarthritis Relief, Osteoporosis and Osteopenia: Latest Treatment Recommendations, Osteoporosis: A Bare-Bones Guide to Diagnosis and Treatment. Open fracture of distal phalanx of right little finger; Open mallet fracture of right distal phalanx; Open right little finger mallet fracture; Open right little finger It is normal for your finger to be a bit achy and swollen for a couple of months after this type of injury. Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. This technique has not been previously described in the Orthopedic literature for diverse pattern of fractures of the distal phalanx. In a transphyseal fracture, the epiphysis is usually medially displaced relative to the metaphysis (see the image below). [QxMD MEDLINE Link]. If separation is significant, as shown below, recognition of the fracture is easy, although distinguishing these fractures from supracondylar fractures depends on knowing the characteristic course (see the image below). Normal lines. Anteroposterior view shows a mildly abnormal angular configuration of the lateral aspect of the proximal radial metaphysis. Surgical management is most commonly performed with the aid of an arthrogram. [23] Radiographic evaluation of the amount of displacement is also known to be limited, with many cases showing substantially more displacement by CT than radiography. [Full Text]. Highlight selected keywords in the article text. When the elbow is fully extended, the olecranon becomes locked into the olecranon fossa, making it susceptible to fracture by varus or valgus stress. Between these grooves is the lateral crista of the trochlea, which provides lateral stability to the trochleoulnar joint. Finnbogason T, Karlsson G, Lindberg L, Mortensson W. Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: a prospective radiographic investigation of fracture stability. WebAbstract. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The peak age of occurrence for these fractures is 4-10 years. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. 2016;41:990994. T-condylar fractures may result from flexion or extension injury, with the articular surface of the olecranon acting as a wedge to split the humeral condyles. Surgery for nailbed repair and/or Kirschner wire fixation will be required in more complex cases. Rogers LF. [41] : Stage I fractures have an intact articular surface. [Guideline] Hayes CW, Roberts CC, et al. In most cases, the fracture line then partially traverses the physis and then passes into the cartilaginous distal humeral epiphysis (see the image below). Barton KL, Kaminsky CK, Green DW, et al. Understanding the developmental anatomy of the pediatric elbow helps ensure that normal ossification centers are not misinterpreted as fracture fragments. Subtle lateral condyle fracture. [QxMD MEDLINE Link]. Schubert I, Strohm PC, Zwingmann J. Chicago, IL: Year Book Medical Publishers, Inc; 1985. These fractures may be subtle and have only a linear lucent line through the trabecular region, as shown in the image below. [QxMD MEDLINE Link]. Medial epicondyle avulsion fracture in an 11-year-old girl with an avulsion of part of the left medial epicondyle (A). She underwent irrigation, debridement, and closure of the wound at bedside under digital block. 2016. Metaphyseal fractures [corner fracture]: Commonly affects the distal femur or the proximal tibia (Fig. [19] The acronym CRMTOL describes the usual order of appearance of all 6 elbow centers: capitellum, radial head, medial epicondyle, trochlea, olecranon, and lateral epicondyle. Bone fixation techniques include devices that hold the bone fragments in place either inside the body (internal fixation) or outside the body (external fixation). Digital blocks are readily performed in the ER and typically provide adequate anesthesia for this procedure. Soft-tissue abnormalities (tendon, ligament, nerve, joint recess, and masses) are well-demonstrated with MRI or US. Reduction of a dorsal PIP dislocation should be attempted at the time of injury, if possible, by applying traction and volar pressure on the middle phalanx at the PIP joint (Figure 1). J Bone Joint Surg Am. It is believed that the most common injuries found in association with olecranon fractures are fractures of the proximal radius. However, in approximately 25% of cases, the fracture may be subtle. However, additional morbidity includes a predisposition to subsequent lateral condyle fracture, pain, and late development of posterolateral elbow instability. [QxMD MEDLINE Link]. J Pediatr Orthop. Related letter: Proper Technique for Reduction of Metacarpophalangeal Dislocations. Radiology of Skeletal Trauma. Varus stress fractures may be associated with a lateral condyle fracture or a lateral dislocation of the radial head (type 3 Monteggia fracture/dislocation). Bright RW, Burstein AH, Elmore SM. A major complication of a radial neck fracture is limitation of motion at the proximal radioulnar joint, which mostly limits supination. Some fractures may be caused indirectly, from twisting or even from strong muscle contractions, as might occur in wrestling, hockey, football, and skiing. (2019). Curr Opin Pediatr. The distal phalanx is the most commonly fractured bone of the hand. J Shoulder Elbow Surg. The bones of the hand and wrist are shown in the figure ( figure 1 ). Philadelphia, PA: JB Lippincott; 1983. Caffey's Pediatric X-Ray Diagnosis. The distal interphalangeal joints are formed by the articulations between the heads of the middle phalanges and the bases of the distal phalanges. Front Pediatr. The Difficult Supracondylar Humerus Fracture: Flexion-Type Injuries. 198:214-219.e2. Lateral condyle and olecranon fractures. ACR Appropriateness Criteria chronic elbow pain. 29 (4): 519-34. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. The olecranon apophysis fuses in an anterior-to-posterior direction; radiographs may reveal a residual posterior cleftlike lucency with well-defined sclerotic margins. These injuries resemble Salter-Harris type I, III, and II fractures, respectively, though the Salter-Harris classification is usually applied to injuries of the epiphyses rather than those of the apophyses. 2013 Jan. 61(1):9-17. Fredric A Hoffer, MD, FSIR Affiliate Professor of Radiology, University of Washington School of Medicine; Member, Quality Assurance Review Center Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. On an anteroposterior view obtained after reduction of the lateral condyle fracture (C), the olecranon fracture is more obvious. However, this can be challenging for the surgeons schedule, patients schedule, and can also place unnecessary financial burden on the health care system. 50:95. WebTransphyseal fracture of the distal humerus. Int Orthop. The age at which ossification centers are first seen varies considerably; maturation usually proceeds earlier in girls than in boys. The risk of subluxation and instability is higher with larger volar plate fractures.8 Referral to a hand specialist is indicated if more than 30 percent of the volar intra-articular surface is involved, or if subluxation or instability of the PIP joint is detected.9 Flexion and extension at the PIP joint should be evaluated following successful reduction of a dislocation. The most common fracture seen is a tuft fracture. With the elbow fully extended, or hyperextended with relative ligamentous laxity during childhood, the olecranon acts as a fulcrum to transmit the load into a bending force on the distal humerus in the supracondylar region. This injury is commonly referred to as jersey finger.11 Examination of the affected finger demonstrates the inability to flex the finger at the DIP joint. Cost and complications of percutaneous fixation of hand fractures in a procedure room versus the operating room. 2. Flexion injury is often from a fall on a flexed elbow, whereas extension injury is often from a fall on a slightly flexed and outstretched arm, with the coronoid process acting as the wedge. Features that help in distinguishing between transphyseal and lateral condyle fractures include alignment of the radiocapitellar joint and the direction of displacement. J Hand Surg Eur Vol. [QxMD MEDLINE Link]. A dorsal PIP dislocation often leads to obvious dorsal deformity of the middle phalanx and volar plate tenderness. 187:812-817. (2006) Clinics in sports medicine. Become a Gold Supporter and see no third-party ads. 1982. As in all cases of trauma, the importance of recognition of open distal phalanx fractures is due to the increased risk of contamination and, hence, infection. Lateral condyle fracture passing through the ossified portion of the capitellum. Compare these images with the lateral view of the contralateral elbow (C), which shows the anterior humeral line passing normally through the middle third of the capitellum. Unfortunately, access to procedure rooms and appropriate surgical instrumentation may not be possible at all health care facilities. See Instructions for Authors for a complete description of levels of evidence. WebDistal phalanx fractures are often seen following crush injuries of the fingertips at home or in the work-place. Lateral condyle fracture with instability. [22]. government site. Although it is important to differentiate medial condyle fractures from medial epicondyle fractures, the distinction is not always easy to make with radiographs. Unauthorized use of these marks is strictly prohibited. 88(5):980-5. Typical supracondylar fracture. 2018 Jul. Carpenter S, Rohde RS. Radiographic evaluation with a minimum of three views (commonly anteroposterior, true lateral, and oblique) is required if any fracture or dislocation is suspected.4. The distal humeral articular surface has several grooves and ridges that are important in determining anatomic stability after a fracture. 83-A(5):735-40. The https:// ensures that you are connecting to the This finding is indicative of a nondisplaced fracture. The needle should be advanced across the DIP into the middle phalanx and this position should be confirmed with the mini c-arm. A pulled elbowis a distraction injury. In this patient, the uninjured right elbow has a Baumann angle of 12, and the previously injured left elbow has a Baumann angle of only 2, suggesting 10 of varus deformity of the left distal humerus. 2001 Jan-Feb. 21(1):27-30. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNDE1ODIyLW92ZXJ2aWV3. The extensor pollicis longus (EPL), located on the back side of the thumb, which allows you to straighten your thumb. 1999 Oct. 81(10):1429-33. Referral is recommended for fracture involving greater than 30 to 40 percent of the intra-articular surface, if reduction is difficult or unsuccessful, or if the patient is unable to achieve full extension following reduction. Like the metacarpal, the distal and proximal phalanges can fracture near/into a joint or in the shaft of the bone. The long finger is the most Int Orthop. The proximal radius has normal angulation between the neck and shaft, with the neck angulated laterally and slightly anteriorly relative to the shaft, which should not be confused with a fracture. Lateral condyle fractures may be associated with other elbow fractures. Ultrasound evaluation of the ulnar collateral ligament of the elbow: Which method is most reproducible?. 45 (2):140-144. By Gregory Rubin, DO rubinsportsmed.com Case Conclusion The lateral epicondyle usually fuses to the distal humeral epiphysis (lateral condyle) before fusing to the metaphysis. Supracondylar fracture. Treatment consists of splinting in slight flexion with early range of motion and strengthening exercises. Richard M Shore, MD is a member of the following medical societies: American Roentgen Ray Society, American Society for Bone and Mineral Research, International Skeletal Society, Society for Pediatric Radiology, Society of Nuclear Medicine and Molecular ImagingDisclosure: Nothing to disclose. 34 (4):300-6. The anterior humeral line may be extremely useful in the diagnosis of supracondylar fracture. Pediatric Elbow Injuries. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. 4. Dislocations of the DIP joint are often associated with trauma and may have associated fractures and soft tissue injury.7 A simple dorsal DIP dislocation should be evaluated with radiography to assess for fracture. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. In supracondylar fractures with medial displacement of the distal fragment, there is often internal rotation, which results in varus if the fracture is oblique. Dorsal dislocation of the proximal interphalangeal joint is the most common type of finger dislocation. 2018 Jan. [QxMD MEDLINE Link]. J Bone Joint Surg Am. Examples of entrapment of the medial epicondyle in a young child, before ossification of the trochlea occurs, and of entrapment in an older child, after trochlear ossification has occurred, are presented (see the images below). The radial head epiphysis may show displacement with varying amounts of shift and angulation that may lead to limitation of motion of the proximal radioulnar joint. Matsuura T, Iwame T, Suzue N, Arisawa K, Sairyo K. Risk factors for shoulder and elbow pain in youth baseball players. If an associated radial fracture is not identified, a careful search should be made for a radiocapitellar dislocation or subluxation. [QxMD MEDLINE Link]. 533-93. distal phalanx fracture; percutaneous pinning; emergency department; hypodermic needle. The thumb also has several nerves that give you feeling and blood vessels that provide the thumb with blood flow. The possibility of concomitant fracture or soft tissue injury must be considered, especially if relocation is unsuccessful. In transphyseal fractures, radiocapitellar alignment remains normal, whereas in lateral condyle fractures, the distal fragment is often displaced or rotated, as described above, with alteration of the radiocapitellar alignment. The solid anterior humeral line is drawn along the anterior cortex of the distal humeral metaphysis and should pass through the middle third of the capitellum. Semin Ultrasound CT MR. 2018 Aug. 39 (4):384-396. Bouton D, Ho CA, Abzug J, Brighton B, Ritzman TF. In some cases, the fracture may extend into the metaphysis, producing a Salter-Harris type II injury. On the frontal view, supracondylar fractures typically extend transversely through the metaphysis across the region of the olecranon fossa. Federal government websites often end in .gov or .mil. In some cases, cubitus varus results from medial comminution and collapse. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. WebINTRA ARTICULAR DISTAL HUMERUS FRACTURE 24546 Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation when performed; with intercondylar extension PELVIC RING ACETABULUM BICONDYLAR TIBIAL PLATEAU 27536 Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without Note the comminuted fracture of the distal phalanx of the fourth toe Fig.2. Reproduced with permission from Soyer AD: Fractures of the Base of the First Metacarpal: Current Treatment Options. sharing sensitive information, make sure youre on a federal These fractures are caused by an axial load to the tip of an extended finger, leading to forced flexion at the DIP joint.11 A mallet fracture includes a bone fragment attached to the terminal extensor mechanism (Figure 4). 2. Other injuries that may be confused with lateral condyle fractures include supracondylar fracture, true Salter-Harris type II fracture, and, in young infants, separation of the distal humeral epiphysis (transphyseal fracture, Salter-Harris type I). [33] For extension fractures, the anterior interosseous branch of the median nerve is most frequently injured, whereas with the rare flexion type supracondylar fractures, the ulnar nerve is most often involved. Central slip injury can lead to the inability to extend the finger at the PIP joint and hyperflexion or boutonnire deformity over time.11 These injuries should be splinted for six weeks in full PIP extension to avoid chronic deformity at the PIP joint.11 Volar PIP dislocations are more difficult to reduce and results should be confirmed with postreduction radiography. Pain and swelling: Take your normal painkillers if you are in pain. Other views may also be helpful, such as the internal oblique view for lateral condyle fractures. We propose that fracture stabilization can be performed by the on-call hand resident or fellow in the ER. If the fracture extends into the joint, it is called an intra-articular fracture; if it does not, it is called an extra-articular fracture. Radiographic findings in supracondylar fracture. Graham T, Evans P Maschke S. Operative treatment of selected fractures of the childs hand. Middle finger distal interphalangeal (DIP) joint fracture dislocation following reduction of DIP joint, spanning 20-G needle, and soft tissue repair. [QxMD MEDLINE Link]. With such bending, the joint capsule applies a tension force to the anterior cortex of the distal humerus, accounting for the frequent anterior position of the lucent fracture line. For the normal elbow (B), note the normal position of the medial epicondyle along the medial aspect of the distal humeral metaphysis. 12 (1):26-28. A joint effusion helps in suggesting a subtle fracture; lateral soft tissue swelling localizes the region to be examined most carefully. For more information, please refer to our Privacy Policy. After spontaneous reduction, prior elbow dislocation may be suggested by the identification of the fractures described above. In other patients, the fracture is best seen at the proximal tip of the olecranon metaphysis, as depicted in the image below. Olecranon fracture. A systematic physical examination is imperative to avoid complications and poor outcomes following these injuries. Compare the simultaneous view of the uninjured right elbow (B) and a previous view of the left elbow obtained when the patient was 10 years of age (C). Lateral view demonstrates an abnormal relation of the capitellum to the anterior humeral line, which passes along the anterior margin of the capitellum. The risk of a thumb fracture can be lessened by using protective taping, padding, or other equipment. Posterolateral elbow dislocation, lateral view. Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures. Displacement of the radial head may be marked, usually with the head displaced distally, and its articular surface may be rotated into the coronal plane posteriorly. The distal fracture fragment is displaced laterally and posteriorly. If the fracture extends into the joint, it is called an intra-articular fracture; if it does not, it is called an extra-articular fracture. Lateral view shows the 2 lines used for radiographic analysis in patients with elbow trauma. The presence of a metaphyseal flake fracture is not specific because some medial epicondyle avulsions extend into the metaphysis as a Salter-Harris type II fracture. Anteroposterior view shows the lateral condyle with a fracture line passing through the metaphysis and capitellum, crossing the growth plate. Milch II lateral condyle fracture with elbow dislocation, frontal (A) and lateral (B) views. At surgical exploration, the brachial artery was transected at the level of the fracture. The much less common flexion-type supracondylar fracture is usually caused by a direct blow to the posterior aspect of the elbow, usually from a fall onto the elbow. 474 (11): 2531-2537. WebDistal Phalanx Fractures Tuft Fracture (crush injury) Soft tissue injury is often more obvious; Xray required to detect underlying fracture Management consists mainly of A 19-month-old male presented to the ED with an open fracture dislocation of his middle finger distal phalanx after his finger was caught inside a door hinge. However, these injuries have marked medial soft tissue swelling compared with the lateral soft tissue findings with lateral condyle fracture. J Bone Joint Surg Am. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. 4C, hyperextension injury with fracture of the articular surface usually greater than 50% with early or late This site needs JavaScript to work properly. 30(3):253-63. Failure to treat PIP dislocations appropriately can lead to chronic pain, degenerative changes, and loss of function. They are intra-articular injuries in which the fracture extends through the epiphysis, across the physis and through the metaphysis. These injuries function as ligament injuries and are often treated as such. Functional outcome of the elbow in toddlers with transphyseal fracture of the distal humerus treated surgically. J Am Acad Orthop Surg 2016;24 (2):e39e44. It is also referred to as the terminal phalanx. It is imperative that extension is maintained at all times during treatment because any flexion can affect healing and may extend the treatment period. Imaging Pitfalls of the Acutely Traumatized Pediatric Elbow. Stage II fractures extend through the articular surface, allowing for a small amount of displacement of the distal fragment and olecranon shift. The presence of a joint effusion does not specifically indicate that a fracture is present, but a joint effusion does signal that a fracture is likely; in such cases, a careful search is required. J Pediatr. Note the normal position of the medial epicondyle in left elbow, which is not seen in the right elbow. The mean annual incidence was 0.8 per 105. Kim HT, Song MB, Conjares JN, Yoo CI. Some institutions attempt to circumvent these challenges by running a dedicated procedure room within the emergency room (ER) for these procedures. Initial anteroposterior (A) and lateral (B) views show a nondisplaced lateral condyle fracture. 1995 Jul-Aug. 15(4):422-5. Note the pseudoarthrosis of the distal phalanx of the fourth toe Fig.3. The proximal radius and ulna maintain a normal relationship with respect to the epiphysis; hence, the forearm bones are also displaced relative to the humeral metaphysis. Medial epicondyle fractures are 3 times more common in boys than girls and tend to occur in older children more often than supracondylar or lateral condyle fractures, with a peak age of 11-12 years, although younger children may also be affected. [18]. MRI, US, or arthrography may be used to directly depict the relationship of the cartilaginous distal humeral epiphysis to the metaphysis (see the image below). In most patients, the medial epicondyle is extra-articular; therefore, a joint effusion is not present. F. Thumb fractures 1. Fractures and dislocations involving the distal phalanx are frequently treated with immobilization, however particular injury patterns warrant additional stabilization. 2012. A 20-G needle was used to reduce and stabilize her fracture with the same technique described in case 1, although was not advanced through the DIP joint in this case. Anteroposterior views of the injured left elbow (A) compared with the uninjured right elbow (B). Jpn J Radiol. Stabilization is often achieved with splinting. J Bone Joint Surg Br. Dislocations of the MCP joint are usually dorsal.6 Simple dislocations do not involve soft tissue structures and are reduced using the same technique as with dorsal PIP dislocations. Screening was performed using low-magnetic-field (0.2-T) MRI. In searching for subtle fractures, knowing their expected location is essential. The distal ulnar epiphysis is best depicted on the anteroposterior view, on which it is seen to overlap the ulnar metaphysis. A study showed an increase in range of motion and intrinsic muscle strength following four weeks of splinting with daily active exercise compared with immobilization alone.10 For uncomplicated dorsal PIP dislocations, short-term splinting in flexion with early active range of motion and strengthening is preferable to immobilization.5,10. Angular deformity also results from rotation at an oblique fracture line. Your surgeon will discuss with you which option is best for your fracture. In most patients, the fracture is a Salter-Harris type I injury, passing entirely through the growth plate. 1. The first metacarpal is connected to the wrist by the carpometacarpal (CMC) joint, which sits between the metacarpal and a carpal bone called the trapezium. Distal phalanx fracture. Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015. In a meta-analysis of 5154 supracondylar fractures in children, nerve injury occurred in 11%. Referral is recommended for complicated injuries. Okamoto Y, Maehara K, Kanahori T, Hiyama T, Kawamura T, Minami M. Incidence of elbow injuries in adolescent baseball players: screening by a low field magnetic resonance imaging system specialized for small joints. official website and that any information you provide is encrypted In general, medial condyle fractures (Salter-Harris type IV injuries) have larger metaphyseal components than medial epicondyle fractures that involve the metaphysis have. Ossification of the elbow region is complex, but knowledge of it is essential in analyzing elbow trauma in children. 2017 Feb 20. She was started on a home exercise program at that time. DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Transphyseal fractures of the distal humerus typically occur in children younger than 3 years secondary to birth Salter-Harris type IV fractures are relatively uncommon injuries that occur in children. The most common follow-up fractures were olecranon (N=23, 72%), coronoid process (N=4, 13%), and supracondylar (N=3, 9%). Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. This relation should be examined on a frontal view as well. The most common direction of displacement is posterior or posterolateral (see the images below), although lateral and anterior dislocations also occur. 2010 Dec 1. [45] It has also been suggested that extension force in infants may be more likely to cause a transphyseal fracture than supracondylar fracture. The concave head of the radius articulates with the capitellum, which is the convex lateral articular surface of the distal humerus. Although the radiologic diagnosis of lateral condyle fracture depends on plain radiographic findings, MRI, arthrography, or ultrasonography (US) may be useful in the further evaluation of the fractures, particularly with regard to the course of the fracture through the cartilaginous epiphysis, as shown below. Almost most distal phalanx fractures can be treated nonsurgically with splinting, a small subset warrant internal fixation to potentially avoid adverse outcomes. Supracondylar Fractures of the Distal Humerus. In cases in which the radial head is not yet ossified, this injury cannot be distinguished from a true Monteggia fracture/dislocation by use of plain radiographs. Additional investigation with a larger cases series may be warranted to further evaluate outcomes and complications. 65:371-8. If you log out, you will be required to enter your username and password the next time you visit. Simplistically, a Monteggia fracture/dislocation may be thought of as the result of a force that dislocates the radial head and simultaneously fractures the ulna in the same direction. Elbow US combined with clinical suspicion for fracture had a sensitivity of 100%. Often, the capitellum has ossified; in such cases, it may serve as an important marker in the otherwise cartilaginous distal humeral epiphysis. Postreduction radiography can be used to assess alignment. Curr Rev Musculoskelet Med. Prompt and accurate diagnosis of a transphyseal distal humerus fracture is crucial for a

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