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Introduction
  • Also called transphyseal distal humerus fracture
  • Epidemiology
    • demographics
      • typically seen in children under the age of 3
  • Mechanism
    • can happen during vaginal delivery 
      • from force of labor or obstetric maneuvers
        • especially traumatic delivery and shoulder dystocia
    • 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
  • Associated conditions
    • abuse or battered child syndrome (up to 50%) 
  • Prognosis
    • often missed diagnosis as very difficult to diagnose
      • >50% missed by radiologist

Classification
  • Salter Harris classification
    • older children (>3y) have Salter Harris II injuries
      • metaphyseal piece attached to distal fragment
    • younger children (<3y) have Salter Harris I injuries
      • pure physeal
    • rare cases have intra-articular extension (Salter Harris III or IV)
Presentation
  • History
    • birthing process (see above)
    • fall from height (bed, chair, down stairs)
    • another child jumps/falls on younger child's elbow
    • suspect nonaccidental trauma if 
      • unwitnessed injuries 
      • inconsistent explanations
      • history of multiple injuries, burns, bites, bruising
  • Physical exam
    • inspection
      • pseudoparalysis / diminished spontaneous movement
    • neurovascular
      • rarely neurovascular compromise
Imaging
  • Radiographs 
    • recommended views
      • AP and lateral centered on the  elbow 
      •  
        • "baby gram" (radiograph of entire extremity) often miss diagnosis
      • stress radiographs may be helpful to clarify the diagnosis
      • skeletal survey if child-abuse suspected
    • findings
      • in infant only sign may be posteromedial displacement of the radial and ulnar shafts relative to the distal humerus   
      • 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, will be aligned with radius shaft, making diagnosis definitive
  • Ultrasound
    • indications
      • uncertain diagnosis
    • advantage
      • no need for sedation
    • 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
    • disadvantage
      • requires sedation
  • Elbow arthrography
    • indications
      • uncertain diagnosis
    • 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 scuffing of articular cartilage when posterolateral portal is used
      • inject equal parts saline:contrast 
      • bring 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
Differentials
  • Elbow dislocation
    • almost never happens in <3 yrs because physis is weaker than bone-ligament interface, predisposing to physeal fracture rather than ligament disruption/dislocation
  • Other fractures
    • often misdiagnosed (or delayed diagnosis up to 1 week) as supracondylar, condyle, epicondyle fractures
Treatment
  • Nonoperative
    • limited role because most fractures are displaced
    • posterior long arm splint then long arm casting x 2-3wk
      • indications
        • nondisplaced fractures
        • late presenting fractures
          • treat nonop initially 
          • deformity will persist/develop, requiring osteotomy in future
  • Operative
    • closed reduction and pinning 
      • pinning is necessary to ensure adequate reduction, which may be lost with casting alone once swelling subsides
      • indications
        • displaced fractures
Technique
  • Closed reduction and pinning
    • general anesthesia
    • 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
    • use elbow arthrogram to aid
    • parameters
      • 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
    • bend / cut pins, splint the arm
    • postop care
      • admit overnight 24h for IV antibiotics, observe for compartment syndrome
      • see 1 week postop
      • see 3 weeks postop with radiographs and remove pins in office
        • allow active ROM at that time
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)
    • treatment
      • lateral closing wedge osteotomy
  • Medial condyle AVN
  • 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 >5yo
        • larger extremity
        • child more cooperative
 

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