|Year : 2022 | Volume
| Issue : 3 | Page : 57-59
Transphyseal fracture of distal humerus
Department of Paediatric Orthopaedics, CMC, Vellore, Tamilnadu, India
|Date of Submission||29-Mar-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||25-May-2022|
Professor and Head, Department of Paediatric Orthopaedics, #1106, Paul Brand Building, Christian Medical College & Hopsital, vellore, Tamilnadu 632004
Source of Support: None, Conflict of Interest: None
Distal humeral physeal seperations are a rare and clinically important injury. It can be misinterpreted due to the unossified nature of the distal humeral physis. The appropriate management and imaging guidelines have been included for better management of this entity which carries a good prognosis.
Keywords: Transphyseal distal humerus, Transphyseal elbow fracture, Physeal seperation
|How to cite this article:|
Palocaren T. Transphyseal fracture of distal humerus. J Orthop Assoc South Indian States 2022;19, Suppl S1:57-9
Transphyseal fracture of distal humerus (TFDH), also known as fracture separation of distal humerus or epiphysiolysis of distal humerus, is an uncommon injury mostly seen in children below 3 years of age. The most common mechanism of injury is fall on outstretched hand, hyperextension, and rotatory mechanism. It can be misdiagnosed as an elbow dislocation on plain radiographs and can be very often missed. Since elbow dislocation is very uncommon below the age of 3 years as the cartilaginous physis is weaker than the bone–ligament interface, ligament injuries and dislocations are almost unheard of, below the age of 3.
Physeal separation is known to occur during vaginal delivery or cesarean section if excessive force is used. This should be suspected if there is elbow swelling in the neonatal period as it can be missed initially. Nonaccidental trauma or fall on outstretched hand with the elbow extended has also been reported and rarely following septic arthritis.
| Diagnosis|| |
Radiography is the initial imaging modality for elbow trauma. However, since almost all or most of the distal humerus is made up of unossified cartilage, it is easy to miss the diagnosis unless a high degree of suspicion is present. In the series by Supakul et al., 9/16 were missed by radiography highlighting the need for good-quality orthogonal radiographs. Often, oblique radiographs are obtained and the posterior displacement is missed [Figure 1]a, [Figure 1]b and [Figure 2]a, [Figure 2]b.
|Figure 1: (a) DeLee group A with displaced metaphyseal spike. (b) DeLee group A with minimally displaced metaphyseal spike|
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Ultrasound is noninvasive, cheap, and inexpensive and should be preferred to magnetic resonance imaging (MRI), which needs sedation or anesthetic. Very few case reports are present which use ultrasound to diagnose this injury, but the series by Supakul et al. has proved that systematic use of ultrasound is valuable for definitive diagnosis.
Arthrography by the posterior or posterolateral approach can be used to diagnose this entity. Equal volumes of dye and normal saline can be mixed and injected directly posteriorly into the olecranon fossa or into the soft pad (posterolateral approach) [Figure 3].
| Classification|| |
DeLee et al. have classified this injury into three types [Figure 4].
|Figure 4: DeLee classification (modified). (a) Transphyseal fracture of distal humerus with no capitellar secondary ossification center and no metaphyseal spike; (b) transphyseal fracture of distal humerus with metaphyseal spike smaller than secondary ossification center of the capitellum; (c) transphyseal fracture of distal humerus with bigger metaphyseal spike than secondary ossification center|
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The role of nonsurgical management is limited as most of the fractures are displaced. However, for undisplaced or minimally displaced fractures, 2–3 weeks of above elbow cast after a few days in a slab for the swelling to reduce will be adequate.
Most displaced fractures will need to be reduced and pinned with 1.5 mm K-wires [Figure 5]. Arthrogram is done and the direction of displacement is noted. Closed reduction is carried out, and 2–3 divergent K-wires are inserted from the lateral side in a retrograde manner ensuring good spread and divergence and engaging both the cortices. The anterior humeral line should bisect the capitellum and no malrotation should be accepted.
| Complications|| |
Complications associated with TFDH are cubitus varus, compartment syndrome, and growth disturbance.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Abzug JM, Ho CA, Ritzman TF, Brighton BK. Transphyseal fracture of the distal humerus. J Am Acad Orthop Surg 2016;24:e39-44.
Zhou W, Canavese F, Zhang L, Li L. Functional outcome of the elbow in toddlers with transphyseal fracture of the distal humerus treated surgically. J Child Orthop 2019;13:47-56.
Sabat D, Maini L, Gautam VK. Neonatal separation of distal humeral epiphysis during caesarean section: A case report. J Orthop Surg (Hong Kong) 2011;19:376-8.
Mathew DK, Gangadharan S, Krishnamoorthy V, Shanmughanathan R. Anterior physeal separation of distal humerus: Report of a rare case with review of literature. Indian J Orthop 2021;55:208-12.
Supakul N, Hicks RA, Caltoum CB, Karmazyn B. Distal humeral epiphyseal separation in young children: An often-missed fracture-radiographic signs and ultrasound confirmatory diagnosis. AJR Am J Roentgenol 2015;204:W192-8.
Ruo GY. Radiographic diagnosis of fracture-separation of the entire distal humeral epiphysis. Clin Radiol 1987;38:635-7.
DeLee JC, Wilkins KE, Rogers LF, Rockwood CA. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Am 1980;62:46-51.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]