Updated: 1/13/2019

Epiphyseal bracket

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Introduction
  • Longitudinal epiphyseal bracket (Delta Phalanx)
    • a congenital disorder affecting the epiphysis of short tubular bones
    • incomplete development of primary ossification centers
    • aberrant physeal cartilage extending along the diaphysis interferes with the normal longitudinal growth
    • epiphysis extends along the phalangeal base, up along the diaphysis, and then across the distal surface of the phalanx
  • Epidemiology
    • incidence
      • 2-14% of congenital hand and foot deformities
      • 11% of all cases found in the great toe
  • Pathophysiology
    • 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
  • Prognosis
    • favorable with surgical intervention
Classification
 
 Radiographic Staging
Stage I  • Delta shaped diaphsyis
 • Radiolucent cartilagenous epiphysis
 
Stage II  • Secondary ossification centers at the proximal and distal ends

Stage III  • Complete ossification of the longitudinal bracket epiphysis along one side of the diaphysis
Stage IV  • 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
 

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