Pediatric emergency medicine trisk 3467 3467
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Fractures of the distal humeral physis in children under the age of 3
years, and especially infants under the age of 1 year, should raise
concern for possible abuse.
Radiographic diagnosis of humerus physeal fractures is difficult as the
distal humerus and proximal radius and ulna have not yet ossified.
To distinguish distal humeral physeal separation from elbow dislocation,
one should note that displacement of the proximal radius and ulna is
usually posterior and medial in the former. With dislocation, the
proximal radius and ulna are typically displaced posterolaterally, and
the relationship between proximal radius and lateral condyle epiphysis
is disrupted.
Separation of the distal humerus physis is an infrequently seen elbow injury in
the pediatric ED and the diagnosis is frequently missed leading to delays in
diagnosis. Most injuries involving the entire distal humeral physis occur before
age 7. Recognition is both difficult and important, especially in infants, in whom
this particular injury is often the result of physical abuse. The proposed
mechanism in abused children is forceful twisting of the arm that shears off the
distal epiphysis. Elbow swelling, pain, and disuse of the extremity, but without
significant deformity, in the setting of a FOOSH are the usual history and
examination. With significant displacement, the appearance may mimic that of an
elbow dislocation. Dislocations more commonly occur in early adolescence than
in children less than 7 years old. Radiographic diagnosis requires recognition of
subtle displacement and may necessitate comparison views. In the normal
relationship, the shaft of the ulna should align with the shaft of the humerus on
the anteroposterior view, whereas the ulna will be medial on the AP view
compared with this injury. With clinical concern, ultrasound may be a useful
adjunct. Given the frequent need for reduction and pinning, all suspected
epiphyseal separations of the distal humerus merit immediate orthopedic referral.
MRI or ultrasound studies may be necessary to define the extent of damage to the
cartilaginous structures. The risk of avascular necrosis and growth disturbance
increases with delay in diagnosis.
Olecranon Fractures
CLINICAL PEARLS AND PITFALLS
