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