A 16 year old male's mother called over this president's weekend with "an emergency". Her son was playing basketball indoors and injured his great toe. She explained there was lots of bleeding and the nail was partially avulsed.

I met them at my office. I will present only the pertinent info for the sake of brevity.

There was a subungual hematoma and bleeding was by the eponychium. X-rays were taken which revealed a fracture at the physeal plate with dislocation. I anesthesized the digit, removed the nail plate and cleaned it.

Although, there was bleeding there the nail bed appeared well coapted if you will.

I, explained to the parents this was an open fracture and their child would need antibiotics.

The next step was deciding what to do with the fracture/dislocation. Since, the patient was numb. Attempts were made to relocate. On the  DP view one can see there was transverse disclocation as well as sagittal plane deviation as seen on the lateral. I was able to relocate the digit on the transverse plane, and somewhat in the sagittal plane.

The question I pose at this point is: Would you be satisfied with the correction? At this point would you cast the patient or would you opt to bring the child to the OR to attempt further reduction and try to close the dorsal gapping? How would analyze the risk reward ratio? If one decides they would attempt further correction - kindly be specific and detail exactly how you would achieve this.

The case is ongoing - and I appreciate any and all opinoins. There is a good review article on this in JAPMA 1988, but unfortunately, my hospital starts with the 1998 versions and so I have yet to get my hands on the article.salter1                                     

In the picture to my left this is the original x-ray. Hopefully, some of you have IPADS and can enlarge the pictures, or explain to me how I can enlarge them for you to view.salter2

In this second view one can see I was able to reduce the fracture somewhat, leaving some dorsal gaping about 3 maybe 4 mm.

salternormalThis 3rd view is the normal contralateral side.

 

 

 

salterpost

 

Here again, on the left I made another attempt but it does not appear to be closing down anymore. I am not sure why the DP comes out blank when I try and transfer it here, but the DP position is pristine and not displaced at all.

Based on the x-ray on the left - the question I ask, cast immobilization or attempt a K-wire "joystick" type of maniupation?

What do my peers think?Again, thank you all in advance for any commentary.

  • Comments (20)
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  • 'Peds are half as big as adults,  and heal twice as fast' is my memory aid.  I would expect healing in 3-4 weeks, but remodeling of bone continues for a year.

  • Quote:

    Dr Bates - thanks, yes I decided, he's fixated. But, you bring up a good point. So, now that he has crossed kwire e with one nice reduction and in a bk cast, how long would one keep the cast on? The pins in? Typically, you hear it takes bone 6-8 weeks to heal, but pedis and growth plates heal faster...so, on average....what do you guys think? I was wondering this as I was driving home.


    Jeff,

    After reading about the operation I can't help but think my towel clamp method would not have been so radical a departure. Perhaps we have a different concept / application in mind, in terms of technique. In any event, glad the job worked out well.

    7-10 days after reduction a callus formation is well established and any residual deformity well tolerated and, as has been mentioned, remodelling potential is good with up to 2 years growth remaining. The only concern is for rotational malalignment, but even then, residual deformity in toes is more acceptable than major lower extremity bones.

    Healing is usually complete by 4 weeks. Juking notwithstanding .....

     

  • Dieter - you got me curious, so I googled as well, now I know why he re- dislocated,,,,,,,,,glad I put that cast on.
  • Dr Bates - thanks, yes I decided, he's fixated. But, you bring up a good point. So, now that he has crossed kwire e with one nice reduction and in a bk cast, how long would one keep the cast on? The pins in?Typically, you hear it takes bone 6-8 weeks to heal, but pedis and growth plates heal faster...so, on average....what do you guys think? I was wondering this as I was driving home.
  • Alex- great minds think alike. I am reading your post, now that I am home after the procedure. So, I could not reduce the fracture/dislocation with my hand. The technique used (and with the help of 2 excellent residents) we used a central k-wire as a "joystick" to help maneuver the distal fragment out of a plantarflexed position and into better alignment,Then, ran a second k-wire directly under it (the first one was shot slightly plantar and so I didn't want to use it as a fixating wire but instead converted it to a joystick. We then used a third kwire to cross the second one and pulled the joystick out.This followed with a below knee cast where I casted over the big toe completely.I have some fluoroscopy pics I can share, I'll try to put them up tomorrow.I was happy with the outcome, and again, must compliment Dr.'s Patel and Markowitz for their excellent help.Incidently, I was going to give the Chinese finger traps a try, they had them, but they would not fit over the great toe. Instead, I gave them to the residents as "trophies" for their excellent help.
  • I hope you documented the "juking" & tricks while on crutches as well as the fact that the kid was stepped on in school.....you know, in the event that he bends or breaks the K-wire you are going to put into his toe!

    I wish you luck on this one, sounds like it's going to be a fun time dealing with compliance issues. Given the history, it may not be a bad idea to below the knee cast this kid after fixation with a couple of inches of cast extension beyond the toes to protect the K-wire. In the event that you weren't planning on fixating this, since you are going to take it into the operating room for the reduction, might as well fixate it anyway. The fact that it displaced post reduction is an indication of the instability of the fracture & it almost begs for fixation.

  •  I have no idea what that is and was scared to ask why he was "juking" on crutches.

    Not up to speed with latest street parlance, but curious all the same I googled the term ... so, anyway - you don't want to know

  • I can not enlarge the xray.  My understanding is if there are 2 years of growth remaining a Salter Harris I or II  can remodel if in anatomical plane.  Bone callous forms much faster in peds than adults so decide and act  soon if you decide to manipulate.

  • Dieter - I am with Alex on this one...towel clamp for amputation and maybe maybe to hold a fracture in place....but not in this case....which incidently on follow up, I was informed the toe was stepped on and bumped at school. I was also imformed the patient is a "pro" with the crutches and could do all kinds of "jukes". I have no idea what that is and was scared to ask why he was "juking" on crutches. I have never seen anyone have so much fun on crutches as this patient. I think he is having too much fun

    ....after taking x-ray whatever correction was there is no longer there. (not sure if it was the fact he was stepped on, bumped the toe or the juking..so the plan is to go to the OR...

    I am hoping to reduce the toe and reapproximate, If i get it like last time with the dorsal gapping closed down a mm or 2 , I think I will be happy. Will keep you posted.

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    Dieter - I'd be as conservative as possible with pediatric cases; hence - no towel clamp. Also - I'd never use a towel clamp on a toe / phalanx unless I was amputating it - too traumatic in my opinion. I think Jeff Played it quite right.

    The "Chinese Finger Trap" method I don't think wound have worked here since I believe there wouldn't be much of a musculo-tendinus component to the injury / resultant deformity. The finger traps work well if you want to distract a joint & reduce the musculo-tendinus influences (which relax over time as passive stretching is applied).

    Just my $0.02 on your treatment rationale


    .



    Dr. Estrada,

    Thank you for your comments. Appreciated and duly noted.

    I have trained and worked with orthopedists. The towel clamp is a  feathery touch .. comparatively speaking ;-)

    But this would depend on the size of the digit involved.  I have used the towel clamp, when required to do so. On fifth digits too. I have had no adverse sequela, from doing so. Works for me.

    I take your point about pediatric cases. On the other hand, peds heal well too! Ultimately it is a judgment call, best made by the Attending. And after examination and assessment of the digit, to know if the tissue can handle this approach.

    I am less inclined to shy away from a smooth K-wire, or two; this will have no dramatic effect on the growth plate. A threaded K-wire is more likely to be injurious.

    The enemy of good is better: a comment I first heard from instructors here in the US. But never in Europe.

    Let it be, or do more: have an honest discussion of the risks:benefits with the patient / parent. That would be my approach. 

    ~DJF

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