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
Key words: Elbow, injury, fracture, epiphyseal separation, distal
Anteromedial epiphyseal separation of the distal humerus in an
8-year-old girl: A case report and literature review of a rare
Ganesh Singh Dharmshaktu
Introduction Epiphyseal separation of the distal humerus is
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 . Frac- tures involving the entire distal
humerus mainly occur in children aged less than 6–7 years .
Anatomical factors such as the V-shaped arrangement of the distal
humeral physis in older children reduce the chance of physeal
separation . 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: [email protected]
August 23, 2018 / October 09,
Author affiliations : Correspondence :
Received / Accepted :
© 2019 Turkish Society for Surgery of the Hand and Upper Exremity
eJM eJManager OPEN ACCESS
perextension following the fall that causes the fracture as
mentioned above often causes epiphyseal separation in younger
children . 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
. 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
Hand and Microsurgery | 114www.handmicrosurgeryjournal.com
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
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 . 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) . 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
An extremely rare case of a flexion-type injury with the anterior
displacement of the distal fragment has been reported previously
. In our literature re-
115 | Hand and Microsurgery Year 2019 | Volume 8 | Issue 2 |
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
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 . 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 . 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 . According to the
literature, most of these injuries occur in younger children or
even new- borns . 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.
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