Distal Humeral Epiphyseal Separation in Young Children: An Often-Missed Fracture—Radiographic Signs and Ultrasound Confirmatory Diagnosis

Abstract

OBJECTIVE. Distal humeral epiphyseal separation is rare and often misdiagnosed. The purpose of this study was to summarize an experience with radiography and ultrasound of distal humeral epiphyseal separation. MATERIALS AND METHODS. The records of all children younger than 36 months with the diagnosis of distal humeral epiphyseal separation from 2006 to 2013 were identified. Medical and imaging records were reviewed for diagnosis with radiography and ultrasound, cause, treatment, and follow-up. The initial diagnosis, relation of the radius and ulna to the distal humerus, presence of other fractures, and signs of elbow effusion were evaluated. RESULTS. Sixteen patients (10 boys, six girls; mean age, 8.6 months) were evaluated for distal humeral epiphyseal separation. All patients had elbow radiographs. Fifteen (94%) patients had medial and six (38%) had posterior displacement of the radius and ulna. The diagnosis was missed on radiographs of nine (56%) patients. Ultrasound was performed for 12 patients and showed distal humeral epiphyseal separation in all. In 10 (63%) patients, one or more additional humeral fractures were found: bucket-handle fractures in five patients and condylar avulsion fracture in six patients. In the six (38%) patients younger than 1 month, distal humeral epiphyseal separation was secondary to birth trauma. In 4 of the 10 (40%) older patients, nonaccidental trauma was diagnosed. All patients underwent follow-up with a pediatric orthopedist and had full range of motion. Two patients had mild varus deformities. CONCLUSION. The diagnosis of distal humeral epiphyseal separation is often missed on radiographs. Radiologists should be aware that posteromedial displacement of the radius and ulna in young children is highly suggestive of distal humeral epiphyseal separation and that the diagnosis can be confirmed with ultrasound.

Transphyseal separation of the distal humerus in newborns

“…In 2009 Jacobsen et al 4 reviewed a series of 6 neonatal chondroepiphyseal injury in addition to 22 previous cases reported in the literature. Since then there have been only 14 cases further quoted 5, 7, 8, 9, 10, 11, 12, 20…”

“…In a historical review of 30 years of experience, Madsen 3 documented only one case of distal humeral epiphysis separation in 105,119 neonates. In the literature there is only sporadic cases or small case series reported 4, 5, 6, 7, 8, 9, 10, 11, 12. This lesion may be easily missed at birth, due to clinical and radiographic difficulty in diagnosis 13 .…”

“…For these reasons, to confirm the diagnosis, many authors have suggested further investigations, such as sonography,5, 6, 7 MRI15, 16 and arthrography 17, 18. Till date the management of this lesion is not yet well established though most authors agree that the outcomes are satisfactory 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14…”

MR imaging for detection of trampoline injuries in children

“…Another limitation is that our results were not compared with findings in children examined only with radiography, CT or ultrasound. To reduce radiography utilization musculoskeletal sonographic evaluation can be useful to find soft tissue swelling, adjacent and subperiostal hematomas and bone fragments or distal humeral epiphyseal separation [11, 12]. …”

Diagnosing neonatal transphyseal fractures of the distal humerus

“…Distal humerus transphyseal fractures can be separated into two sub‐groups according to the aetiology – birth related or non‐birth related. The non‐birth related fractures, usually present from the community and for this sub‐group there should be a high index of suspicion for non‐accidental injury …”