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Updated: Jun 15 2021

Epiphyseal bracket

  • summary
    • Epiphyseal Bracket is a rare congenital disorder caused by the incomplete development of primary ossification centers that presents with a deformity of the hand or foot. 
    • Diagnosis is made with MRI studies with presence of a longitudinal epiphyseal bracket in the involved digit. 
    • Treatment is usually early surgical physiolysis.
  • Epidemiology
    • Incidence
      • 2-14% of congenital hand and foot deformities
      • 11% of all cases found in the great toe
    • Anatomic location
      • affects the epiphysis of short tubular bones
  • Etiology
    • Pathophysiology
      • incomplete development of primary ossification centers
        • aberrant physeal cartilage extending along the diaphysis interferes with the normal
      • the growth of the abnormal epiphysis leads to a short, wide, triangular or trapezoidal phalanx
      • growth disturbance due to longitudinally oriented cartilaginous bracket
      • growth follows a "C-shaped" curve
    • Genetics
      • autosomal dominant when present in hand
      • otherwise sporadic
    • Associated conditions
      • Rubinstein -Taybi syndrome
      • fibrodysplasia ossificans progressiva
      • hallux varus in feet
      • clindodactyly and polydactyly in hands
      • Apert's syndrome
  • Classification
      • Radiographic Staging
      • Stage 1
      • Delta shaped diaphsyis
      • Radiolucent cartilagenous epiphysis
      • Stage 2
      • Secondary ossification centers at the proximal and distal ends
      • Stage 3
      • Complete ossification of the longitudinal bracket epiphysis along one side of the diaphysis
      • Stage 4
      • Closure of the physis
  • Presentation
    • Physical exam
      • inspection
        • notable deformity of the hand or foot
  • Imaging
    • Radiographs
      • recommended views
        • AP/lateral of hand or foot in question
      • findings
        • involved bone is trapezoidal or triangular in shape
        • "D-shaped" metatarsal
        • wedge-shaped diaphysis of the middle phalanx
    • Ultrasound
      • suspected pre-ossified bracket can be visualized
      • can establish the diagnosis
    • MRI
      • to diagnose longitudinal epiphyseal bracket
  • Treatment
    • Nonoperative
      • splinting
        • indications
          • used in infancy to help loosen the soft tissues prior to surgery
          • some authors consider it not very effective
    • Operative
      • osetotomies (opening or closing wedge)
        • indications
          • longitudinal epiphyseal bracket in older children after closure of the bracket epiphysis
          • helps to correct angulation of the involved bones
      • physiolysis + interposition (PMMA or fat)
        • indications
          • early intervention allows for more correction of angulation and more longitudinal growth
  • Techniques
    • Surgical physiolysis
      • approach the bone of concern
      • mark the border of the bracket at the proximal and distal epiphyses with small gauge needle
      • check placement on fluroscopy
      • sharply resect the border of the bracket
      • protect normal epiphysis at proximal and distal ends
  • Complications
    • Complications with nonoperative treatment
      • structural deformation of the forefoot
      • incomplete longitudinal growth of affected bone
      • clinodactyly at the interphalangeal joint
    • Complications with operative treatment
      • recurrence of deformity
      • incomplete correction of deformity
  • Prognosis
    • Favorable with surgical intervention
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