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Updated: Oct 9 2022

Distal Humerus Physeal Separation - Pediatric

3.8

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  • 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
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