doi:10.5455/handmicrosurg.5246
ABSTRACT Fractures involving the entire distal humerus are uncommon injuries and are usually seen in infants and neonates. Their occurrence in older children is uncommon and is mostly limited to children younger than seven years. Epiphyseal sep- aration of the distal humerus usually follows an extension pattern, in which the distal fragment is posteriorly displaced. Anteromedial displacement is extremely rare and is considerably rarer in 8-year-old children. This case report describes this extremely rare injury pattern in an 8-year-old girl and provides relevant details of its management.
Key words: Elbow, injury, fracture, epiphyseal separation, distal humerus, pediatric
Anteromedial epiphyseal separation of the distal humerus in an 8-year-old girl: A case report and literature review of a rare injury pattern
Ganesh Singh Dharmshaktu
Introduction Epiphyseal separation of the distal humerus is an
uncommon injury that is often complicated by mis- diagnosis and neglect. The radiological absence of ossification centers in the skeleton of children makes the diagnosis of this injury difficult. The Salter-Harris classification system, which is widely used for physeal injuries, categorizes such separations as type 1 inju- ries. However, many books contain separate chapters
dedicated to distal humeral epiphysis because such injuries are critical and are associated with long-term complications requiring accurate diagnoses [1]. Frac- tures involving the entire distal humerus mainly occur in children aged less than 6–7 years [2]. Anatomical factors such as the V-shaped arrangement of the distal humeral physis in older children reduce the chance of physeal separation [3]. These injuries are similar to su- pracondylar fractures in older children because the hy-
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India Ganesh Singh Dharmshaktu, MS, Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India e-mail: drganeshortho@gmail.com August 23, 2018 / October 09, 2018
Author affiliations : Correspondence :
Received / Accepted :
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eJM eJManager OPEN ACCESS
perextension following the fall that causes the fracture as mentioned above often causes epiphyseal separation in younger children [3]. The majority of these injuries are of the extension type, in which the distal epiphy- seal fragment is posteriorly displaced [1,3]. Another possible reason for epiphyseal separation in younger children is the proximal placement of the physeal line to the olecranon fossa; thus, the hyperextension force is mainly exerted on the olecranon fossa, resulting in physeal separation [4]. Although epiphyseal separation is commonly observed in young children, it may some- times be observed in children older than 6–7 years. This case report describes this rare injury pattern (i.e., anteromedial displacement) in an 8-year-old girl.
Case Report An 8-year-old girl presented to our department
with an injury to her right elbow one day after a fall on an outstretched hand. She was provided with an arm pouch sling at a primary care center before being referred to us. Swelling and pain over the affected el- bow were noted, and the distal neurovascular status ap- peared intact on clinical evaluation. No open wound or abrasion was noted, and she underwent to emergency radiography. Orthogonal radiographs revealed an an- teromedial shift of the distal humeral physis along with the capitellum, trochlea, and medial epicondyle. The
radiocapitellar and proximal radioulnar relationships were maintained (Figure 1). Elbow dislocation was not detected, but epiphyseal separation was suspect- ed; an attempt to reduce the separation resulted in the correction of the deformity in the lateral view, but the deformity was still partially observable in anteropos- terior views (Figure 2a). She was advised to undergo computed tomography (CT) to accurately delineate the injury more accurately. The findings revealed the physeal separation of the distal humerus along with the medial epicondyle and the thin rim of the metaphyseal bone. The findings were suggestive of complete epiphy- seal separation on the medial side and indicated that anterior displacement was reduced. The deformity was more accurately depicted in 3D reconstructed images (Figures 3a, 3b). Operative fixation was planned after
Figure 1. Radiograph showing the separation and displacement of distal humeral epiphysis along with lateral and medial condylar region medially and anteriorly in orthogonal views.
Figure 2. Radiograph showing closed reduction with favorable out- comes in the lateral view but an inadequate reduction in the coronal plane (a). Postoperative radiograph showing favorable reduction and fixation with crossed K-wires.
Anteromedial epiphyseal separation
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informed consent was obtained from her parents, and the surgery was performed as per the standard proto- col. The lateral approach, which is used for managing supracondylar fractures, was used for the surgery. Sat- isfactory reduction of the injury was achieved owing to appropriate soft tissue handling, and the reduction was confirmed on an image intensifier. Two crossed K-wires
Figure 3. CT 3D reconstructed images showing injury details from the posterior (a) and from anterior (b) aspects. A rim of metaphyseal bone is also present along with the distal fragment.
Figure 4. Radiograph before wire removal at three weeks postopera- tively showing favorable union and healing of the injury.
were used to fix the fracture, and the final reduction was assessed on an image intensifier before the application of a well-padded long plaster splint (Figure 2b). The surgery was uneventful. The distal neurovascular status was intact in the postoperative period, and the patient was advised to perform the active range of motion ex- ercises for her fingers throughout the treatment period. Stitches were removed on the 10th day, and the plaster was removed four weeks after the radiograph showed satisfactory healing of the injury (Figure 4). The wires were also removed on that day, and after three more weeks, active physiotherapy was initiated so that the patient could regain the full range of elbow motion. The outcome was excellent, and no recent or remote complications were noted in the 18-month follow-up. However, considering the possibility of potential com- plications such as deformities or growth disturbances, cases of such fractures should be followed up at least until skeletal maturity is achieved; therefore, periodic we conduct evaluations of our case.
Discussion Epiphyseal separation of the distal humerus is an
uncommon injury, and many of these injuries are asso- ciated with birth-related trauma. Child abuse is another crucial etiology; thus, the identification of other inju- ries and proper documentation and reporting is neces- sary in cases of these injuries. Nearly half of the children with these injuries, who are younger than two years, have experienced abuse [5]. Based on the presence of the ossification centre of the lateral condyle epiphysis, DeLee classified children with these injuries into the following age groups: up to 12 months (group A), 12 months-3 years (group B), and 3-7 years (group C) [6]. The comparison of the contralateral radiographs is a method that can help clinicians make definitive diag- noses in suspected cases and the proximal radioulnar and humeral relationship should be carefully observed.
An extremely rare case of a flexion-type injury with the anterior displacement of the distal fragment has been reported previously [7]. In our literature re-
Dharmshaktu GS
115 | Hand and Microsurgery Year 2019 | Volume 8 | Issue 2 | 113-117
Anteromedial epiphyseal separation
view, we could not find cases with anteromedial dis- placement. This injury pattern and the uncommon age of our patient make our case unique.
In separation injuries, joint congruity and the range of motion are minimally affected; thus, favorable outcomes are expected [3,8]. Common complications include cubitus varus and osteonecrosis of the troch- lea [9]. Closed reduction can be performed in younger children with only medial displacement, but with mini- mal tilting, because future remodeling provides favora- ble results. Because our patient was older and the injury involved complete displacement, we preferred surgical intervention for more accurate fixation to prevent ep- iphyseal damage. Avascular necrosis of the medial hu- meral condyle is associated with later cubitus varus [10]. In our case, no complication was noted, and this may be because we did not make vigorous reduction attempts pre- and intraoperatively. Moreover, careful handling of soft tissues was ensured in addition to the early initiation of active exercises. In many cases, sep- aration injuries may be missed if radiographic assess- ment alone is used for diagnosis; ultrasonography is a highly useful adjunct to reduce the number of misdiag- nosed cases [11]. According to the literature, most of these injuries occur in younger children or even new- borns [12]. Scant information is available on the prev- alence of these injuries and their management in older children, and this may be due to their rarity. Our case highlights that careful assessment prevents these inju- ries from being missed and that imaging studies should be conducted to more accurately delineate injuries on cases of suspected separation injury. Standard man- agement practices for supracondylar fractures produce favorable outcomes if conducted with minimal manip- ulation and if regular follow-up is performed. However, long-term follow-up (until adulthood) is required to assess these injuries and complications, such as growth problems or deformities.
Conflict of interest statement The authors have no conflicts of interest to declare.
References 1. Glotzbecker MP, Kasser JR. Distal humeral phy-
seal, medial condyle, lateral epicondylar, and other uncommon elbow fractures. In: Flynn JM, Skaggs DL, Waters PM, (eds.) Rockwood and Wilkins’ Fractures in Children. Wolters Kluwer Health, Philadelphia, 2015:725-50.
2. Ashurst APC. An Anatomical and Surgical Study of Fractures of the Lower End of the Humerus. Lee & Debugger, Philadelphia, PA, 1910.
3. Abe M, Ishizu T, Nagaoka T, Onomura T. Epi- physeal separation of the distal end of the humer- al epiphysis: a follow-up note. J Pediatr Orthop 1995;15:426-34.
4. Dameron TB Jr. Transverse fractures of distal hu- merus in children. Instr Course Lect 1981;30:224- 35.
5. Nimkin K, Kleinman PK, Teeger S, Spevak MR. Distal humeral physeal injuries in child abuse: MR imaging and ultrasonography findings. Pediatr Ra- diol 1995;25:562-5.
6. DeLee JC, Wilkins KE, Rogers LF, Rockwood CA. Fracture-separation of the distal humeral epiphy- sis. J Bone Joint Surg Am 1980;62:46-51.
7. Berman JM, Weiner DS. Neonatal fracture separa- tion of the distal humeral chondroepiphysis: a case report. Orthopedics 1980;3:875-9.
8. de Jager LT, Hoffman EB. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Br 1991;73:143-6.
9. Yoo CI, Suh JT, Suh KT, Kim YJ, Kim HT, Kim YH. Avascular necrosis after fracture-separation of the distal end of the humerus in children. Orthopedics 1992;15:959-63.
10. Oh CW, Park BC, Ihn JC, Kyung HS. Fracture sep- aration of the distal humeral epiphysis in children younger than three years old. J Pediatr Orthop 2000;20:173-6.
11. Supakul N, Hicks RA, Caltoum CB, Karmazyn B. Distal humeral epiphyseal separation in young
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children: An often-missed fracture-Radiographic signs and ultrasound confirmatory diagnosis. Am J Roentgenol 2015;204:192-8.
12. Gigante C, Kini SG, Origo C, Volpin A. Transphy- seal separation of the distal humerus in newborns. Chinese J Traumatol 2017;20:183-6.
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