summary Distal Humerus Physeal Seperations are traumatic fractures usually seen in children under the age of three and are often associated with child abuse. Diagnosis can be made with plain radiographs of the elbow. Treatment is usually operative closed reduction and percutaneous pinning Epidemiology Demographics typically seen in children under the age of 3 although variations can be seen in older children (see below) Etiology Mechanism vaginal delivery (birth fracture) from force of labor or obstetric maneuvers shoulder dystocia and traumatic delivery are at higher risk cesarean section from excessive traction nonaccidental trauma rotational force / twisting fall on outstretched hand with elbow extended Pathoanatomy physis is biomechanically the weakest location in distal humerus it is also referred to as a transphyseal distal humerus fracture Associated conditions abuse or battered child syndrome (up to 50%) Classification Salter-Harris classification older children (>3y) have Salter-Harris II injuries metaphyseal fragment attached to distal fragment younger children (<3y) have Salter-Harris I injuries pure physeal injury rare cases have intra-articular extension (Salter-Harris III or IV) can be difficult to differentiate from a lateral condyle fracture Displacement of the distal fragment most commonly posteromedial rarely can be anterior Presentation History birthing process (see above) fall from height (bed, chair, down stairs) typically onto extended elbow another child jumps/falls on a child's elbow nonaccidental trauma unwitnessed injuries inconsistent explanations history of multiple injuries, burns, bites, bruising skin lesions are most common findings in nonaccidental trauma Physical exam inspection pseudoparalysis / diminished spontaneous movement swelling or ecchymosis neurovascular rarely neurovascular compromise Imaging Radiographs recommended views AP and lateral centered on the elbow "baby gram" (radiograph of entire extremity) or forearm/arm radiographs can lead to missed diagnosis stress radiographs may be helpful to clarify the diagnosis skeletal survey if child abuse suspected findings posteromedial displacement of the radial and ulnar shafts relative to the distal humerus may be the only finding in infants forearm not aligned with humeral shaft soft tissue swelling, joint effusion (posterior fat pad) anterior fat pad may be absent if capitellar ossification center is present, it will be aligned with radius shaft, making diagnosis definitive Ultrasound indications uncertain diagnosis advantage no need for sedation disadvantage need experiences technician findings static exam detect separation of epiphysis from metaphysis by noting lack of cartilage at distal humeral metaphysis dynamic exam detect instability of epiphysis relative to metaphysis MRI not routinely used disadvantage requires sedation in young children Elbow arthrography indications uncertain diagnosis often combined with CRPP in OR findings visualization of entire distal articular surface and proximal radius technique posterolateral approach or direct posterior approach direct posterior into olecranon fossa recommended in young children to prevent iatrogenic damage to the articular cartilage when posterolateral portal is used inject equal parts saline:contrast bring elbow through range of motion if pinning is needed, arthrogram aids visualization of pin starting points on capitellum aids assessment of quality of reduction by seeing anterior humeral line intersecting capitellum advantage if performed under anesthesia in OR, can perform reduction and stabilization simultaneously if needed Differential Elbow dislocation almost never happens in <3 yrs because distal humerus physis is weaker than bone-ligament interface, predisposing to physeal fracture rather than ligament disruption/dislocation typically distal fragment is displaced posterolaterally with elbow dislocations Other fractures often misdiagnosed (or delayed diagnosis up to 1 week) as supracondylar, condyle, epicondyle fractures Treatment Nonoperative posterior long arm splint then long arm casting x 2-3 weeks indications limited role because most fractures are displaced nondisplaced fractures late presenting fractures treat nonoperatively initially deformity will persist/develop, requiring osteotomy in future Operative closed reduction and pinning indications displaced fractures (most) pinning is necessary to ensure adequate reduction, which may be lost with casting alone once the swelling subsides technique combined with elbow arthrogram to determine direction of initial displacement and adequate reduction Technique Closed Reduction and Pinning approach general anesthesia use elbow arthrogram to determine direction of displacement reduction maneuver gentle traction (very little force required) distal fragment may sometimes be grasped between index finger and thumb and reduced to humeral shaft correction of translation/malrotation elbow flexion acceptable parameters (similar to supracondylar humerus fractures) no cubitus varus anterior humeral line should bisect capitellum no malrotation pinning 2 or 3 x 0.062inch K wires these larger pins help prevent loss of reduction from lateral side, retrograde fashion divergent engage both cortices good spread at fracture site then perform live fluoroscopy through range of motion and slight varus/valgus stress to ensure no loss of reduction immobilization bend / cut pins splint the arm postoperative care admit overnight to observe for compartment syndrome (may not be necessary in all cases) see 1 week postoperatively with radiographs to ensure no loss of reduction see 3 weeks postoperatively with radiographs and remove pins in office allow full active ROM at that time physical therapy is rarely needed typically follow patients for 2-4 years after injury to ensure there is no growth arrest, deformity, or osteonecrosis (see below) Complications Cubitus varus up to 70% have this complication more common than with supracondylar fractures cause AVN of medial condyle malunion (common because of missed diagnosis, or loss of reduction) growth arrest treatment lateral closing wedge osteotomy Medial or lateral condyle AVN may lead to fishtail deformity seen in all distal humerus fractures Loss of motion usually no functional limitation Growth disturbance progressive cubitus varus joint irregularities angular deformity limb-length discrepancy treatment observe initially, undertake surgery when > 5 years old larger extremity child more cooperative can address all deformities in one surgery. Prognosis Often missed diagnosis as very difficult to diagnose up to 50% missed by radiologist In patients with early recognition and prompt treatment, outcomes are very good
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next (OBQ18.50) An 8-month-old boy was brought in by his parents for refusing to use his right arm after a fall off of the couch earlier in the evening. The patient's hand is otherwise well-perfused. Current imaging is shown in Figure A. After immobilization of the extremity which of the following is the next best step in treatment? QID: 212946 FIGURES: A Type & Select Correct Answer 1 Magnetic resonance imaging (MRI) of the elbow 6% (111/1902) 2 Computed tomography (CT) of the elbow 3% (57/1902) 3 CT of the head 2% (40/1902) 4 Emergent fixation in the operating room 20% (385/1902) 5 Contacting child protective services 68% (1290/1902) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.120) Which of the following injuries shown in Figures A-E is most commonly the result of child abuse? QID: 4480 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 7% (371/5450) 2 Figure B 5% (257/5450) 3 Figure C 14% (782/5450) 4 Figure D 71% (3846/5450) 5 Figure E 3% (169/5450) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.68) A 7-month-old girl cries when the mother touches her swollen left elbow. Figure A displays a series of radiographs. In Figure A, the images labeled A and B show the painful left elbow, while C and D are of the contralateral, non-injured elbow. What is the most appropriate treatment? QID: 954 FIGURES: A Type & Select Correct Answer 1 Open reduction and internal fixation 7% (175/2614) 2 Closed reduction and percutaneous pinning 54% (1407/2614) 3 Closed reduction and casting 37% (968/2614) 4 Functional bracing 1% (38/2614) 5 Closed reduction and hinged external fixation 1% (16/2614) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.54) A 10-month-old child fell off of the couch and has left elbow pain and swelling. A radiograph is shown in Figure A. All of the following are characteristics of this injury pattern EXCEPT: QID: 940 FIGURES: A Type & Select Correct Answer 1 High risk of tardy ulnar nerve palsy 33% (921/2816) 2 Posteromedial displacement 5% (127/2816) 3 High association with child abuse 14% (386/2816) 4 High risk of cubitus varus deformity 20% (563/2816) 5 High risk of subsequent avascular necrosis of the medial condyle 29% (807/2816) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
All Videos (0) Podcasts (1) Pediatrics⎪Distal Humerus Physeal Separation - Pediatric Orthobullets Team Pediatrics - Distal Humerus Physeal Separation - Pediatric Listen Now 18:42 min 3/9/2020 348 plays 5.0 (1)