Fracture-Separation of the Distal Femoral Epiphysis in a Premature Neonate

Abstract

racture-separation of the epiphysis of the distal femur is a relatively rare injury in neonates but has been documented as a complication of difficult deliveries. Most of the cases reported previously were associated with vaginal delivery with the neonate in the breech presentation, 1 often due to highbirth-weight neonates.2 Two cases following cesarean delivery were also reported. 3The suggested mechanism for this type of injury is forced traction of the limb with acute angulation or twisting during delivery. 3According to the Salter-Harris classification, 4 this type 1 injury is a fracture through the physis, which causes separation between the epiphysis and metaphysis. The separation results in an increased width of the physis and frequently in displacement of the epiphysis.Here we describe a case of a premature neonate with a type 1 Salter-Harris fracture of the distal femur following cesarean delivery, with gross posterolateral displacement of the epiphysis that was inapparent on plain radiography but accurately diagnosed with sonography. Case ReportA 27-week-gestation, 1470-g premature female neonate was born by cesarean delivery because of vaginal bleeding and maternal fever. According to the obstetrician's report, no appreciable force was applied during the delivery, and no injury was suspected immediately after delivery. However, the initial examination showed bruises on both legs. On the third day of life, soft tissue swelling and knee stiffness were noticed on the left, along with 30°valgus deformation of the left knee. The differential diagnostic considerations included congenital knee dislocation and fracture-separation of the epiphysis. Plain radiographs showed no abnormalities, and the epiphysis was not yet visible because of prematurity (Figure 1). Further investigation with sonography was performed with an HDI 5000 machine and a high-resolution, 5-to 10-MHz transduc-

Birth-related mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature

“…Fractures of the mandible, epiphyseal fractures and classic metaphyseal corner fractures have also been reported, but are less common [20][21][22].…”

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries

“…In these cases, US is a useful complimentary modality especially where strong clinical suspicion remains (Figure 4). 8,[26][27][28][29] US demonstrates a fracture as a step or break in the bone surface, shows epiphyseal or cartilage injury and highlights secondary signs such as sub-periosteal haematoma, joint effusion and changes in the surrounding soft tissues ( Figure 5). 8,30,31 Radiologists and sonographers should be aware of these findings as sometimes fractures are identified unexpectedly, perhaps in a child with a swollen joint that was thought to represent infection ( Figure 6).…”

“…In these cases, US is a useful complimentary modality especially where strong clinical suspicion remains (Figure 4). 8,26–29

Figure 4.Eleven-month-old child with distal humeral epiphyseal fracture-separation. The child presented refusing to move their left elbow after a reported fall from the sofa to the floor.

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Neonatal distal femoral epiphyseal dislocation: an ultrasound diagnosis

“…Among miscellaneous fractures associated with birth trauma, there is fractureseparation of the lower femur epiphysis, which is relatively uncommon and often missed because of the lack of epiphyseal ossification. In such a case, sonography is a sensitive, specific, and accurate technique to confirm the suspected epiphyseal lesion [3].…”