Transphyseal elbow fracture in newborn: review of literature

Abstract

Transphyseal elbow fracture is a rare entity in newborns, and in the last century, only case reports or small case series have been published; however, precise epidemiological data lack. Such fractures occur more often in emergency Caesarian section or vaginal delivery. The differential diagnosis with elbow dislocation can be challenging. Radiography, arthrography, magnetic resonance, ultrasound or a combination of these have already been described to make diagnosis, but guidelines for the management of this injury in the neonate are not well established. A review of the literature of the last century about distal transphyseal fracture of the humerus in newborns was performed. A bibliographic search was conducted accessing usual medical databases. The work-up methods, treatments, results at follow-up and the rate of complications were collected. Twenty case reports or small retrospective case series reporting a total of 33 cases were included. A posteromedial displacement of the radioulnar complex was found in 21 elbows (64 %). Four patients (12 %) underwent surgical treatment, whilst 29 (88 %) were managed without surgery. An attempt of reduction was reported in 23 cases (69 %). At follow-up, 88 % recovered completely the carrying angle and 80 % range of motion. A relationship between the type of treatment (conservative or surgical, with attempt of reduction or not) and results at follow-up could not be demonstrated. The most common complication was cubitus varus. Transphyseal elbow fractures are rare among newborns. Regardless of the treatment choice, such lesions are in most cases associated with a good prognosis.

Diagnosing neonatal transphyseal fractures of the distal humerus

“…The anteroposterior radiograph may also demonstrate medial displacement of the proximal ulna and radius. 5 There may also be a small distal humerus bone fragment, present in two of our cases, consistent with an associated displaced humeral metaphyseal fracture fragment indicating a Salter-Harris type II injury ( Fig. 2a,b).…”

“…The initial investigation is plain radiography, as for our four cases, consisting of anteroposterior and lateral radiographs. Although radiography is often diagnostic the unossified nature of the epiphyses in this age group may lead to misinterpretation as elbow dislocations, lateral humeral condyle fractures or radial head dislocations . Obtaining adequate projections can be technically difficult in this age group and this may also contribute to a delayed or missed diagnosis .…”

“…There is no uniformly accepted treatment for transphyseal fractures of the distal humerus, with treatment studies limited by the rarity of this injury. Treatment options include conservative management with immobilisation (casting with 90 O of elbow flexion and a pronated forearm) only, closed reduction with or without (percutaneous) fixation, traction with or without (percutaneous) fixation or immobilisation and open reduction with or without (internal) fixation . Management for three of our cases was immobilisation, and the remaining one was reduced prior to percutaneous placement of a single K‐wire for immobilisation (Fig.…”

“…Although radiography is often diagnostic the unossified nature of the epiphyses in this age group may lead to misinterpretation as elbow dislocations, lateral humeral condyle fractures or radial head dislocations. [5][6][7] Obtaining adequate projections can be technically difficult in this age group and this may also contribute to a delayed or missed diagnosis. 3 The absence of an elbow effusion, for the exclusion of a fracture, is also unreliable as the fracture is often extra-capsular.…”

“…6). The most common side effects are cubitus varus deformity and reduced range of motion 6 with the occurrence ranging in the literature between 5% and 71%, 3,5,6,15,16 but the most probable best estimate is one in ten cases. Rarer adverse outcomes include cubitus valgus, 6 non-union, 8 avascular necrosis 7,16 and physis injury.…”