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Introduction
  • Overview
    • a distal humerus physeal separation is a traumatic fracture usually seen in children under the age of three and is often a birth fracture related to delivery.
      • the fracture pattern should raise suspicion of child abuse.
      • treatment is usually operative closed reduction and pinning.
    • it is also referred to as a transphyseal distal humerus fracture
  • Epidemiology
    • demographics
      • typically seen in children under the age of 3
      • although variations can be seen in older children (see below)
  • 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
  • Associated conditions
    • abuse or battered child syndrome (up to 50%) 
  • 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
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 Diagnosis 
  • 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. 
 

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(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? Review Topic

QID: 954
FIGURES:
1

Open reduction and internal fixation

8%

(116/1490)

2

Closed reduction and percutaneous pinning

53%

(790/1490)

3

Closed reduction and casting

37%

(546/1490)

4

Functional bracing

1%

(22/1490)

5

Closed reduction and hinged external fixation

1%

(11/1490)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.120) Which of the following injuries shown in Figures A-E is most commonly the result of child abuse? Review Topic

QID: 4480
FIGURES:
1

Figure A

7%

(321/4540)

2

Figure B

5%

(211/4540)

3

Figure C

14%

(621/4540)

4

Figure D

71%

(3224/4540)

5

Figure E

3%

(144/4540)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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: Review Topic

QID: 940
FIGURES:
1

High risk of tardy ulnar nerve palsy

33%

(736/2233)

2

Posteromedial displacement

4%

(88/2233)

3

High association with child abuse

13%

(301/2233)

4

High risk of cubitus varus deformity

21%

(461/2233)

5

High risk of subsequent avascular necrosis of the medial condyle

29%

(641/2233)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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