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https://upload.orthobullets.com/topic/4013/images/transphyseal fracture.jpg
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Introduction
  • Epidemiology  
    • incidence
      • 3-6% of all pediatric elbow injuries
      • high index of suspicion for child abuse
    • demographics
      • M:F = 3:1
      • most common in 10-15 year olds
      • very rare in younger children < 3 years old
    • locations
      • transphyseal fracture more common 
  • Pathophysiology
    • mechanism of injury
      • fall onto an outstretched hand
    • pathoanatomy
      • classically thought to be a combination of
        • supinated forearm and 
        • elbow extended or partially flexed (posterior dislocation)
      • relatively small coronoid process in children cannot resist proximal and posterior displacement of ulna
  • Associated conditions
    • traumatic
      • child abuse
        • high index of suspicion for child abuse
      • avulsion of the medial epicondyle 
        • is the most common associated fracture
        • incarcerated intra-articular bone fragment may block reduction
      • fractures of proximal radius, olecranon and coronoid process
      • neurovascular injury
        • brachial artery and median nerve
          • may be stretched over displaced proximal fragment
        • ulnar nerve
          • at risk with associated medial epicondyle avulsions
          • most common neuropathy
    • congenital
      • dislocation of radial head 
Classification
  • Anatomic classification
    • based on the position of the proximal radio-ulnar joint in relation to the distal humerus
    • includes
      • posterior or posterolateral (most common)
      • anterior (rare)
      • medial
      • lateral
Presentation
  • Symptoms
    • painful and swollen elbow
    • attempts at motion are painful and restricted
  • Physical exam
    • inspection
      • elbow held in flexion
      • forearm appears to be shortened from the anterior and posterior view
    • palpation
      • distal humerus creates a fullness within the antecubital fossa
    • essential to perform neurovascular examination 
Imaging
  • Radiographs
    • required views
      • AP and lateral radiograph of elbow
      • comparison radiographs of the contralateral elbow may be helpful
    • findings
      • look for fractures of medial epidcondyle, coronoid, proximal radius
      • high index of suspicion for transphyseal (distal humerus epiphyseal separation) fractures in very young children (<3 years old) 
Treatment
  • Nonoperative
    • closed reduction, brief immobilization with early range of motion  
      • indications
        • dislocation that remains stable following reduction
        • indicated in the majority of cases
      • reduction technique (see below)
      • brief immobilization
        • immobilization should be minimized to 1- 2 weeks to minimize risk of stiffness
      • early therapy
        • encourage early active range of motion
  • Operative
    • open reduction 
      • indications
        • open dislocation
        • incarcerated medial epicondyle or coronoid process in the joint
        • failure to obtain or maintain an adequate closed reduction
        • significant joint instability 
Technique
  • Closed reduction technique
    • closed reduction performed using gradual traction and flexion for posterior dislocations
    • post-reduction films should be reviewed to rule out presence of entrapped bone fragment 
  • Open reduction
    • approach
      • depends on reason for blocked reduction
        • elbow medial approach   
          • indicated if medial epicondyle avulsion with incarcerated fragment is blocking reduction
Complications
  • Stiffness
    • most common 
      • due to prolonged immobilization
  • Heterotopic ossification
  • Neurologic injuries
    • usually transient
    • ulnar nerve most commonly affected
  • Loss of terminal flexion or extension
  • Chronic instability (recurrent dislocations)
 

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