distal phalanx transphyseal fracture

Displaced lateral condyle fracture. The technique is cost and time effective when treating patients with this type of injury. 2012 Jul-Aug. 32(5):477-82. Kim HH, Gauguet JM. WebThe doctor will take an X-ray of the wrist. Fractures with significant radiological comminution and/or extensive soft tissue injury should be clinically and radiologically reviewed for open fracture. Several bones contribute to thumb function. Your surgeon will discuss with you which option is best for your fracture. Therapy is designed to ensure that you won't overdo it and possibly cause the thumb to come out of alignment, or do too little, which can lead to stiffness of the thumb. Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. This content is owned by the AAFP. 1998. In particular, the internal oblique view has been shown to be better than the AP view for showing the presence of lateral condyle fracture, the degree of displacement, and findings suggesting instability. A role for 3-D kinematic analysis of CT and MRI imaging for evaluation of lateral condyle fracture with nonunion has also been proposed Under conscious sedation and digital block, a Seymour-type exposure3 was utilized to achieve reduction. These injuries should be suspected with gross deformity on inspection of the middle or proximal phalanx. Medial epicondyle fracture with entrapment in an 8-year-old boy. {"url":"/signup-modal-props.json?lang=us"}, Rothe C, Hacking C, Jones J, et al. Any soft tissue and nail bed injuries associated with these fractures must be recognized and treated. Therefore, the flake of bone must represent a fracture fragment. To make the diagnosis, it is helpful that the radiologist be familiar with the normal developmental anatomy of the elbow. 2001 Jan-Feb. 21(1):27-30. Orthop Clin North Am. J Am Acad Orthop Surg. Reduction may be unsuccessful because of soft tissue injury or fracture. 2015;81:296302. WebFractures of distal phalanx Distal Phalanx Tuft Fracture Examination reveals local swelling and tenderness +/- deformity +/- nailbed injury Management consists mainly of treating any associated soft tissue or nailbed injury or tip avulsion. Pulled/nursemaid's elbow. Anteroposterior view shows disruption of the medial cortex. Initially this leaves a wide space between the lateral epicondyle ossification center, which typically has a linear pattern, and the lateral condyle, which can be misinterpreted as an avulsion fracture. 2017. Stress radiographs demonstrating widening of the medial joint space with valgus stress indicate either avulsion of the medial epicondyle or disruption of the ulnar collateral ligament. 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). Case 6: fracture of distal phalanx of great toe, View Mostafa El-Feky's current disclosures, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal. [QxMD MEDLINE Link]. WebPhalangeal fractures are the most common foot fracture in children. The assessment should also include finger alignment, ligament integrity, neurovascular status, and flexion and extension of the joints. Particularly common are those involving the olecranon (shown below), which occur with varus stress applied to a fully extended elbow with the olecranon locked in the olecranon fossa. (A) On the anteroposterior view, the fracture is seen as a longitudinal lucent line through the medial aspect of the proximal ulna. In a transphyseal fracture, the epiphysis is usually medially displaced relative to the metaphysis (see the image below). Pathy R, Dodwell ER. Prognostic Level III. Referral to a hand specialist is required if a fracture is unstable, involves a large portion (greater than 30 percent) of the intra-articular surface, or has significant rotation. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Less often, the distal fragment is displaced laterally, and these fractures tend to have external rotation, producing valgus. The deforming forces that act on the middle phalanx fractures are the FDS and the intrinsic tendons. Anteroposterior (A) and lateral (B) views. Kuhn MA, Ross G. Acute elbow dislocations. In the setting of a nail bed injury, the nail bed repair can be deferred until after the osseous structures have been stabilized. (2019). Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age Prognostic Level III. Often, the capitellum has ossified; in such cases, it may serve as an important marker in the otherwise cartilaginous distal humeral epiphysis. If these fractures are stable, they can be treated nonoperatively with splintage. (2016) Clinical orthopaedics and related research. Lateral and volar PIP dislocations are less common than dorsal injuries. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. The orientation of the fracture line in the sagittal plane has both diagnostic and clinical implications. Splinting in extension for two to three weeks is the typical nonoperative treatment. Radiology of Skeletal Trauma. Unable to process the form. It can take 3 months or more to regain full use of the hand, depending on the severity of the injury. Abnormality of the anterior humeral line indicates distal humeral deformity and, therefore, either an acute or previous fracture. Of 130 patients (mean age, 7.5 yr), 43 (33%) had a radiograph result positive for fracture. Tokarski J, Avner JR, Rabiner JE. Imaging Pitfalls of the Acutely Traumatized Pediatric Elbow. The Elbow: Physeal Fractures, Apophyseal Injuries of the Distal Humerus, Osteonecrosis of the Trochlea, and T-Condylar Fractures. J Pediatr Orthop. Karapinar L, Oztrk H, Altay T, Kse B. Acta Orthop Traumatol Turc. 487-532. The Gartland classification as modified by Wilkins and expanded by Leitch defines extension supracondylar fractures as follows 2017 Feb 20. Beaty JH, Kasser JR. Rockwood and Wilkins' Fractures in Children. 179. This finding must be distinguished from the normal angulation that is usually present at the junction of the radial neck and shaft. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 6. A notchlike defect in the proximal radial metaphysis may be confused with a fracture (see the image below). Supracondylar fractures may be associated with ipsilateral fractures remote from the elbow, most frequently of the distal radius. Disclaimer. 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. The most common of these in the thumb are fractures involving the base of the first metacarpal, affecting the CMC joint where the thumb connects to the wrist: Fractures of the thumb metacarpal can also occur in the long portion of the bone, which is called the metacarpal shaft. Tissue Eng Part B Rev. Pseudo-Galeazzi fracture. 2013 Jan. 61(1):9-17. Therefore, elbow radiographic findings are normal in a pulled elbow. In the series by Jakob et al involving 48 patients with lateral condyle fractures, 20 patients had fractures that were minimally displaced; 28 patients had significant displacement that required surgical reduction and fixation. Rogers LF. Zhou H, Zhang G, Li M, Qu X, Cao Y, Liu X, Zhang Y. J Orthop Surg Res. The articular relations of the medial condyle and proximal ulna are not as easy to evaluate in the immature skeleton. 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. Finger dislocations can occur at the distal interphalangeal (DIP), proximal interphalangeal (PIP), or metacarpophalangeal (MCP) joints. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:427438. For example, the medial epicondyle usually ossifies prior to the trochlea. Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015. Patients should be informed that these fractures are often complicated by hyperesthesia, pain, and numbness for up to six months following the injury.12. As with lateral condyle fractures, medial condyle fractures are often unstable and may be complicated by nonunion. Anteroposterior (A) and lateral (B) views of the injured left elbow with anteroposterior (C) and lateral (D) views of the right elbow for comparison. Kwok IH, Silk ZM, Quick TJ, Sinisi M, MacQuillan A, Fox M. Nerve injuries associated with supracondylar fractures of the humerus in children: our experience in a specialist peripheral nerve injury unit. These may have some angulation but no true displacement of the fracture fragment and no shift of the olecranon. However, this can be challenging for the surgeons schedule, patients schedule, and can also place unnecessary financial burden on the health care system. At her last follow-up 7 months postinjury, she demonstrated radiographic healing of her fracture and returned to full work with only mild limitations in strength and range of motion. (2010) Clinical radiology. This finding is indicative of a nondisplaced fracture. doi: 10.1097/BPO.0000000000001156. [QxMD MEDLINE Link]. Kuoppala E, Parviainen R, Pokka T, Sirvi M, Serlo W, Sinikumpu JJ. Lateral view demonstrates an abnormal relation of the capitellum to the anterior humeral line, which passes along the anterior margin of the capitellum. Common signs of injury are local swelling, erythema, pain, deformity, and tenderness to palpation. Treatment consists of splinting in slight flexion with early range of motion and strengthening exercises. Reduction is often successful without anesthesia. Often associated with nailbed injuries that would require evaluation and repair 4. Appointments 216.444.2606 Appointments & Locations They represent > 50% of all phalangeal fractures and frequently involve the ungual tuft 1. Start appropriate oral antibiotics for any open fractures. J Bone Joint Surg Am. Oblique views may be required to depict these fractures, since some are not apparent on AP views. A 5-year-old boy with previous left distal humeral supracondylar fracture. 4B, hyperflexion injury with fracture of articular surface of 20% to 50%. The needle was manually rotated to advance it through the fracture and across the DIP joint into the middle phalanx. With complete fractures, the fracture line and displacement are obvious. The other bones of the thumb the distal phalanx and proximal phalanx are also susceptible to fractures. Anteroposterior view shows an obvious lateral condyle fracture with lateral displacement of the fragment, rotation, and downward displacement caused by muscular traction. Stage III fractures have significant displacement, usually laterally and proximally, leading to translocation of the olecranon and radial head. They are frequently related to sports, with lesions such as the mallet finger and the Jersey finger. Finger dislocations should be reduced as quickly as possible and concurrent soft tissue injuries treated appropriately. http://www.guideline.gov/content.aspx?id=49910&search=elbow, American Society for Bone and Mineral Research, Society of Nuclear Medicine and Molecular Imaging. Overall, many thumb fractures have good outcomes after appropriate treatment. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. [28] See the images below. Avulsion fractures of the medial epicondyle may occur before ossification, and they cannot be detected on plain radiographs. J Bone Joint Surg Am. WebTransphyseal Fracture of the Distal Humerus. [QxMD MEDLINE Link]. All fingernail beds should point toward the thenar eminence. J Pediatr Orthop. On the initial anteroposterior view (B), the fracture is subtle and is seen only medially. Mallet fractures (mallet finger) occur at the insertion of the terminal finger extensor mechanism into the dorsal portion of the distal phalanx. WebA distal radius fracture almost always occurs about 1 inch from the end of the bone. 2007 Jan. 89(1):58-63. 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. The fracture extends through the metaphysis and into the epiphysis, typically arising just above the medial epicondyle and extending to the trochlear groove, as shown in the image below. Become a Gold Supporter and see no third-party ads. A 13-year-old youth with nonunion of lateral condyle fracture and subsequent ulnar neuropathy. Normal radiographic findings that may simulate nontraumatic pathology include a radial tuberosity that appears as a lytic lesion when viewed en face (see the image below) and the olecranon fossa of the distal humerus, which may be unusually large and lucent. 2nd ed. WebA broken finger is a common bone break. Note the abnormal relation of anterior humeral line on the lateral view. 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. J Bone Joint Surg. [41] : Stage I fractures have an intact articular surface. 1) and a protective splint was placed. WebDistal phalanx 1. However, such an injury may be suggested by localized tenderness and soft tissue swelling and by the presence of a posterolateral elbow dislocation. [22] Nonunion has been considered to be more of a problem in patients with minimally displaced fractures than in patients with significant displacement, presumably because the lack of surgical fixation allows a small amount of motion and because of the development of fibrocartilage between the fragments. 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. 30(3):253-63. [5] Because supracondylar fractures may be oriented obliquely on the lateral view, coursing proximally from anterior to posterior, an AP view with cephalad angulation of the x-ray beam may help to better demonstrate such a fracture. Medially, the trochlear notch articulates with a corresponding ridge along the ulna. The anterior fat pad is demonstrated and is abnormally elevated. In one study, 7 out of 606 supracondylar humeral fractures were flexion-type injuries. In children, an ulnar fracture often is manifested by plastic bowing without a discrete fracture line, as shown in the image below. 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. WebType 4: 4A, transphyseal fracture in children. Check for errors and try again. The distal fracture fragment is displaced laterally and posteriorly. Nondisplaced or minimally displaced (< 2 mm) lateral condyle fractures, may be stratified according to their risk of subsequent displacement. 25 (3): 527-42, vii-viii. In most patients, the fracture is a Salter-Harris type I injury, passing entirely through the growth plate. [QxMD MEDLINE Link]. Medial epicondyle fracture with distal displacement of a fracture fragment. 56(4):688-703. When the medial epicondyle is pulled downward (distally) by the forearm flexor muscles, it may enter the medial joint space. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Prompt and accurate diagnosis of a transphyseal distal humerus fracture is crucial for a Normal proximal radial metaphyseal notch. On follow-up, additional fractures were seen in 32 of the children, and of these, 25 had a different type of fracture than that identified on the initial radiographs. Donnelly L, Klostermeier T, Klosterman L. Traumatic elbow effusions in pediatric patients: are occult fractures the rule?. J Shoulder Elbow Surg. 17.1 ). Medial epicondyle avulsion fracture in an 11-year-old girl with an avulsion of part of the left medial epicondyle (A). Salter-Harris type IV fracture. [QxMD MEDLINE Link]. The detection of these fractures requires a high index of suspicion and comparison with the noninjured elbow. Cubitus varus has also been recognized to result from posttraumatic trochlear deformity, which is likely due to avascular necrosis of the trochlear ossific nuclei or ischemic injury of growth plate chondrocytes following distal humeral fractures, most commonly supracondylar fractures. This humeroulnar or trochleoulnar joint is a hinged articulation that essentially permits motion in a single plane, allowing flexion and extension. Although the anterior fat pad may be seen without an effusion, it should not be elevated to this degree. There is an area of webbing between the thumb and first finger that allows you to spread your thumb out to grasp an object. On the lateral view, the distal ulnar epiphysis is largely obscured by the distal radius. With medial displacement or medial comminution, loss of support for the medial aspect of the distal fragment allows the distal fragment to shift into varus alignment. The patient saves significant time by undergoing the procedure in the ER as well by avoiding the additional time to be indicated for the procedure, whether urgent or as an outpatient. Anteroposterior (A) and lateral (B) views. Displaced, oblique, or spiral finger fractures should be referred to a hand surgeon. Detection of an elbow dislocation should alert the radiologist to carefully search for the other injuries. Become a Gold Supporter and see no third-party ads. Place in stack splint for protection and pain control for 3 to 4 weeks. However, the trochlea does not become ossified before the medial epicondyle. Some distraction fractures of the olecranon may be subtle, whereas others may have significant proximal displacement of the fracture fragment. It is important that such entrapment be recognized; the diagnosis may be made on the basis of radiographic findings. Referral is recommended for complicated injuries. Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures. 4. The age at which ossification centers are first seen varies considerably; maturation usually proceeds earlier in girls than in boys. Failure to identify and appropriately treat these fractures can lead to long-term reduced function and disability. Incidence of unsuspected fractures in traumatic effusions of the elbow joint. Instr Course Lect. [QxMD MEDLINE Link]. [41]. In addition, elbow US took a median of 3 minutes, while elbow radiography took a median of 60 minutes. Lateral view shows the posterior fat pad, which is always abnormal when seen with the elbow positioned in right-angle flexion. At the time the article was last revised Craig Hacking had no recorded disclosures. The effect of humeral length visualized on the x-ray. Typical supracondylar fracture. [1] Although lateral soft tissue swelling may be prominent, clinically evident deformity is less common in lateral condyle fracture compared with supracondylar fracture. 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. In these cases, only the radial head is still in alignment with the capitellum. Distal phalanx fractures represent common sports and work-related injuries, accounting for approximately half of all hand fractures [ 1-3 ]. 3rd ed. A similar situation occurs in the wrist in children; that is, a fracture through the distal ulnar physis may occur in association with a distal radial diaphyseal fracture and result in a pseudo-Galeazzi injury (see the image below). [17]. Anteroposterior (A) and lateral (B) views. 1. You are being redirected to However, additional morbidity includes a predisposition to subsequent lateral condyle fracture, pain, and late development of posterolateral elbow instability. Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. The distal phalanx is the most commonly fractured bone of the hand. When the elbow is fully extended, the olecranon becomes locked into the olecranon fossa, making it susceptible to fracture by varus or valgus stress. 9 (1):7030. In particular situations, such as with young children, conscious sedation can be provided by ED physicians to make the procedure more tolerable. They are intra-articular injuries in which the fracture extends through the epiphysis, across the physis and through the metaphysis. WebThe distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. [35], The rate of flexion-type fractures has been estimated to be 1.2%. [QxMD MEDLINE Link]. The medial epicondyle usually develops as a single center. You will likely need to wear the cast for at least 4 to 6 weeks. All rights reserved. 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. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Saeed W, Waseem M. Fracture, Elbow. (A) Anteroposterior view. The presence or absence of an intra-articular component, degree of comminution, and fracture displacement should be assessed when formulating a report. 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. Jie C. Nguyen, B. Keegan Markhardt, Arnold C. Merrow, Jerry R. Dwek. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. 4). Olecranon fractures are often associated with other injuries. Failure of the radiocapitellar line to pass through the capitellum indicates radiocapitellar dislocation. Kim HT, Song MB, Conjares JN, Yoo CI. For surgeons with CRPP experience, there is a low learning curve for this bedside procedure. Shrader MW. A dorsal PIP dislocation is the most common type of finger dislocation. 37 (6): 1791-1812. 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. If an associated radial fracture is not identified, a careful search should be made for a radiocapitellar dislocation or subluxation. The overall sensitivity of elbow US was 88%. AJR. In young patients, alignment of the radiocapitellar joint is evaluated by using the radiocapitellar line, whereas in the more mature skeleton, articulating surfaces of the radial head and capitellum are revealed directly. In addition, traction from the common extensor muscles leads to rotation so that the cartilage-covered articular surface of the fractured lateral condyle is in contact with the metaphysis, leading to nonunion if not corrected. [QxMD MEDLINE Link]. (B) Lateral view. There is a theoretical risk that open bore needles could incur higher rates of pin tract infections than standard k-wires due to increased implant surface area, but this was not seen in our patient population. A broken thumb can be a serious problem. In transphyseal fracture, the distal humeral epiphysis and forearm bones are usually displaced medially, whereas in true elbow dislocations, the radius and ulna are dislocated either laterally and posteriorly (in children >2 y) or primarily posteriorly (in children < 2 y). The double density caused by such overlap may simulate a flake of bone, with lucency of the physis simulating an adjacent fracture line. This is particularly helpful in the distal tibia when the plain film can under-estimate the complexity and severity of a distal tibial injury. Displaced fractures of the neck of the radius. Treatment is generally straightforward, with excellent outcomes. MRI coronal T2* gradient echo (B) and axial fat suppressed T2-weighted (C) images better show the extent of the fracture through the cartilaginous aspect of the medial epicondyle. [24], Complications of medial epicondyle fracture. For patient information resources, see eMedicineHealth's First Aid and Injuries Center, as well as Broken Elbow and Elbow Dislocation. In addition to the findings in the multiple ossification centers described above, other normal findings may simulate pathology. Localized soft tissue swelling is usually present. (A) Anteroposterior view shows vertically oriented fracture separating the medial and lateral condyles. CT scan performed two months after the trauma. 92(17):2785-91. 2017 Aug. 46 (8):1081-1085. 2015; Accessed: May 30, 2016. Radiographs showed a physeal injury of the distal phalanx with an The thumb also has several nerves that give you feeling and blood vessels that provide the thumb with blood flow. Unable to load your collection due to an error, Unable to load your delegates due to an error. Lattanza LL, Keese G. Elbow instability in children. 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. Entrapment of the medial epicondyle may be difficult to detect on the frontal view; such entrapment is often better depicted on the lateral view. In some cases, widening of the physis and displacement of the medial epicondyle may be quite subtle, and comparison views of the contralateral elbow may be useful. ("Articular" means "joint.") [31] Cubitus varus may be evaluated with the use of the Baumann angle, which is determined by lines drawn along the axis of the humeral shaft and the physis for the capitellum. Morewood DJ. The flexor digitorum superficialis (FDS) attaches to the palmar surface of the middle phalanx and is the primary flexor of the PIP joint. An anteroposterior tomogram (D) obtained at that time shows both the displacement and the course of the fracture line through the epiphysis to the articular surface of the trochlea. Injury and follow-up x-rays are shown in Figure 2. For those injuries that include a small portion of the metaphysis, care must be taken to distinguish medial epicondyle fracture (usually an extraarticular injury) from medial condyle fracture, which extends to the articular surface.
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