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Which of the following injuries shown in Figures A-E is most commonly the result of child abuse?
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Of the fractures shown, distal humerus physeal separation (Figure D) has the highest association with child abuse.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis of a displaced humeral physeal separation can be a difficult diagnosis to make. Sometimes stress radiographs are necessary for the diagnosis. In infants without ossification the only sign may be posteromedial displacement of the radial and ulnar shafts relative to the distal humerus.
Shrader et al. report elbow fractures in children are extremely common and make up approximately 15% of all fractures in pediatric patients. The distal humerus makes up approximately 85% of all elbow fractures in children. They report the most common fractures of the distal humerus in children are supracondylar humerus fractures, lateral condyle fractures, medial epicondyle fractures, and transphyseal humerus fractures.
Figure D is an AP radiograph showing a distal humerus physeal separation. Notice the posteromedial displacement of the radial and ulnar shafts relative to the distal humerus.
Answer 1: Figure A shows an example of a Monteggia fracture.
Answer 2: Figure B shows an example of a pediatric proximal femur fracture.
Answer 3: Figure C shows an example of Toddler's fracture.
Answer 5: Figure E shows an example of a supracondylar humerus fracture.
Orthop. Clin. North Am.. 2008 Apr;39(2):163-71, v. PMID: 18374807 (Link to Abstract)
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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:
High risk of tardy ulnar nerve palsy
High association with child abuse
High risk of cubitus varus deformity
High risk of subsequent avascular necrosis of the medial condyle
The clinical presentation and radiographs are consistent with a distal humeral physeal separation (transphyseal fracture). This is supported by the radiograph which shows posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. Posteromedial displacement is most common. This injury pattern is associated with child abuse, and may lead to cubitus varus deformity or avascular necrosis of the medial condyle. Tardy ulnar nerve palsy is not associated with transphyseal fractures, and is more commonly seen following lateral condyle fracture nonunions and cubitus valgus.
Radiographs of a distal humeral physeal separation can appear like an elbow dislocation when none of the secondary ossification centers have yet developed. In the child with a visible ossification center at the capitellum, a true elbow dislocation will have disruption of the radiocapitellar line and transphyseal separation of the distal humerus will not.
The article by Skaggs notes that child abuse should be suspected in each of these cases as they occur in children less than 3 years of age and occur from a shearing mechanism. The displacement is almost always posteromedial.
The level 4 study by Oh et al. found that 7 of 12 young children with transphyseal fractures developed cubitus varus deformity regardless of treatment and 6 had evidence of AVN of the medial condyle. Transphyseal fractures are either Salter I injuries or can be associated with a metaphyseal fragment (Salter-Harris Type II) that can range in size from a small fragment to a large Thurston-Holland fragment.
Oh CW, Park BC, Ihn JC, Kyung HS
J Pediatr Orthop. 2000 Mar-Apr;20(2):173-6. PMID: 10739277 (Link to Abstract)
Oh, JPO 2000
J Am Acad Orthop Surg. 1997 Nov;5(6):303-312. PMID: 10797226 (Link to Abstract)
Skaggs, JAAOS 1997
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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?
Open reduction and internal fixation
Closed reduction and percutaneous pinning
Closed reduction and casting
Closed reduction and hinged external fixation
The patient's age and radiograph are consistent with a distal humeral physeal separation and is most appropriately treated with closed reduction and percutaneous pinning. Interpretation of this radiograph is difficult because the distal aspect of the humerus is cartilaginous and is not visible on x-ray, and at this age none of the secondary ossification centers have yet developed. Of note, this fracture pattern is associated with child abuse, and should alert the evaluating physician to evaluate for potential abuse scenarios.
The first ossification center to appear is the capitellum, which doesn’t take place until 1-2 years of age. Nonetheless, the diagnosis can be delineated. In this radiograph, the radial head is not dislocated, and it has moved as a unit with the ulna. Two other options (distal humerus physeal separation and elbow dislocation) are difficult, if not impossible, to distinguish from each other radiographically before ossification of the capitellum. However, transphyseal fractures are frequently associated with a metaphyseal fragment (Salter-Harris Type II) that can range in size from a small flake to a large Thurston-Holland fragment, and in these radiographs, a fragment does appear on the radiograph, especially on the lateral view (not shown). Additionally, elbow dislocations are exceedingly rare in this age group. Therefore, the diagnosis is distal humerus physeal separation.
Accurate diagnosis of distal humerus physeal separation is important because these injuries commonly result in a cubitus varus deformity and avascular necrosis of the medial humeral condyle, and they are often the result of child abuse.
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