Distal Humeral Physeal Fractures Mohammad Ali Tahririan MD Department of Orthopedics Kashani Hospital Next to those of the distal radius, injuries to the distal humeral physes are the most common physeal injuries. total distal humeral physis: First 2-3 Y Med. Condylar physis: 8-12 Y Lat. Conylar physis: 6 Y Medial epicondylar apophysis: 11-12 Y Fractures Involving the Lateral Condylar Physis 16.9% of distal humeral fractures only occasionally associated with injuries outside the elbow region Classification Mechanism of Injury Two mechanisms have been suggested: "push-off" and "pull-off" The pull-off or avulsion theory has more advocates than the push-off mechanism The more common type of fracture, which extends to the apex of the trochlea, is probably a result of avulsion forces on the condyle, with the olecranon's sharp articular surface serving to direct the force along the physeal line into the trochlea. When a child falls forward on his or her palm with the elbow flexed, the radial head is forced against the capitellum and may cause the less common Milch type I physeal fracture that courses through the ossific nucleus of the capitellum. Signs and symptoms Key: location of soft tissue swelling concentrated over the lateral aspect of the distal humerus. Stage I: only local tenderness at the condylar fracture site, which may be increased by forcibly flexing the wrist. Stage II or III: local crepitus with motion of the lateral condylar fragment. A major diagnostic difficulty lies in differentiating this fracture from a fracture of the entire distal humeral physis. In a young child in whom the condyle is unossified, an arthrogram or MRI may be helpful Treatment If the fracture is minimally displaced on radiograph ( less than 2 mm) and the clinical signs also indicate there is reasonable soft tissue integrity, we simply immobilize the elbow in a long-arm cast with the forearm in neutral rotation and the elbow flexed 60 to 90 degrees. If there is any question about the stability MRI or varus stress test Gentle varus stress views with the forearm supinated and the elbow extended should be taken. Percutaneous Pins For fractures with stage II (2 to 4 mm), varus stress views or arthrography should be obtained. If the fracture is stable, percutaneous pinning is indicated Open Reduction If the fracture is grossly unstable, or satge III ORIF Complications Non union Treating is a difficult dilemma. No treatment progressive cubitus valgus deformity Patients are usually asymptomatic except for those with highdemand athletic or labor activities. A mild flexion contracture of the elbow is present, but the cubitus valgus deformity is more cosmetic than functional. If surgery is performed, the potential risks of osteonecrosis and loss of elbow motion must be considered. · A large metaphyseal fragment Displacement of less than 1 cm from the joint surface An open, viable lateral condylar physis Indication of surgery: in patients with a nonunion who have cosmetic concerns but no functional complaints, treatment is: supracondylar osteotomy osteosynthesis √√√ √ note patients with asymptomatic nonunion, cubitus valgus deformity, and symptomatic tardy ulnar nerve palsy should be treated with: Anterior transposition of the ulnar nerve. Lateral Spur Formation Lateral condylar spur formation is one of the most common deformities. Cotton believed that it is caused by coronal rotation of the distal fragment, which tends to displace the flap of periosteum associated with the distal fragment laterally. This periosteum then produces new bone formation in the form of a spur. The spur occurs after both nonoperative and operative treatment. After nonoperative treatment, a smooth outline mild cubitus varus /pseudovarus. After operative treatment a more irregular outline and is usually the result of hypertrophic bone formation from extensive dissection So Before treatment of lateral condylar fractures, the parents may be told that either: lateral overgrowth with mild cubitus varus Or lateral spur may develop, regardless of the treatment method. They should be told that this mild deformity is usually not of cosmetic or functional significance Cubitus Varus Incidence is as high as 40% after operative treatment and nonoperative treatment. Dilemma ??? The cubitus varus deformity is rarely severe enough to cause concern or require further treatment. Posttraumatic cubitus varus deformity may predispose a child to subsequent lateral condylar fracture and should be viewed as more than just a cosmetic deformity. They recommended valgus supracondylar osteotomy of the distal humerus. Cubitus valgus Cubitus valgus is much less common after united lateral condylar fractures than cubitus varus. As with cubitus varus, it is usually minimal and is rarely of clinical or functional significance. Neurologic Complications Acute Nerve Injuries PIN and radial nerve injury after ORIF Tardy Ulnar Nerve Palsy gradual in onset. Motor loss occurs first, with sensory changes developing somewhat later. Subcutaneous anterior transposition of the nerve. Osteonecrosis Osteonecrosis is most commonly associated with the extensive dissection necessary to effect a late reduction or from loss of the blood supply at the time of injury. Osteonecrosis is rare in fractures of the lateral condylar physis that receive little or no initial treatment and result in nonunion If the fracture unites, osteonecrosis of the lateral condyle reossifies over many years Fractures of the Capitellum Fractures of the capitellum involve only the true articular surface of the lateral condyle Generally, this fragment comes from the anterior portion of the distal articular surface. In adults, these fractures are not uncommon, but they are rare in children. Classification Two types: The second, or KocherLorenz, type is more of a pure articular. This type of fracture is rare in children. The first is the more common Hahn-Steinthal type,I which usually contains a rather large portion of cancellous bone of the lateral condyle. Mechanism of Injury The most commonly accepted mechanism is that the anterior articular surface of the lateral condyle is sheared off by the radial head. The presence of cubitus recurvatum or cubitus valgus seems to predispose the elbow to this fracture pattern. Treatment If the fragment is: large acute and if an anatomic reduction can be achieved with a minimum of open manipulation or dissection ORIF with two small cannulated screws from posterior to anterior through a lateral approach. treatment If the fracture is : old comminuted or if there is little bone in which to engage the screw threads simple excision Fractures Involving the Medial Condylar Physis rare in skeletally immature children less than 1% of fractures involving the distal humerus. Occur later than lateral condylar fractures Mechanism of Injury Mechanism of Injury Classification More common Diagnosis Clinically and on radiographs, a fracture of the medial condylar physis is most often confused with a fracture of the medial epicondyle. Med. Swelling Valgus instability Elbow Disloction/ Subluxation Med. Condlye phsis √√√ √√√ Med. Epicnodyle apophysis √√√ √√√ Ulnar paresthesia Fat pad sign Post. Med. Sx √√√ √√√ Post.Lat. Dx √√√ ―――― If the true location of the fracture line is questionable in a child younger than 8 to 10 years of age with significant medial elbow ecchymosis: Arthrography or MRI Treatment Type I posterior splint ( Follow-up radiographs at weekly intervals are taken to ensure there is no late displacement.) Types II and III ORIF Complication Both cubitus varus and valgus deformities have been reported in patients whose fractures united uneventfully. secondary stimulation or overgrowth of the medial condylar fragment Cubitus Valgus decreased growth of the trochlea, possibly caused by a vascular insult Cubitus varus if the fracture is untreated nonunion Cubitus varus Fractures Involving the Entire Distal Humeral Physis Most fractures involving the entire distal humeral physis occur before the age of 6 or 7. The younger the child is, the greater the volume of the distal humerus that is occupied by the distal epiphysis will be The fracture lines do not involve the articular surface, so, loss of elbow motion is unlikely if malunion occurs. A hyperextension injury in this age group is more likely to result in a physeal separation than a bony supracondylar fracture. Mechanism of lnjury The exact mechanism of this injury is unknown and probably varies with the age group involved physis is more likely to fail with rotary shear forces than with pure bending or tension forces. Young infants have some residual flexion contractures of the elbow; this prevents the hyperextension injury that results in supracondylar elbow fractures in older children. Rotary forces on the elbow, which can be caused by child abuse or birth trauma in young infants, are probably more responsible for this injury. Classification Group A fractures occur in infants up to 12 months of age, before the secondary ossification center of the lateral condylar epiphysis appears. They are usually Salter-Harris type I physeal injuries. This injury is often not diagnosed due to the lack of an ossification center in the lateral condylar epiphysis. Classification Group B fractures occur most often in children 12 months to 3 years of age in whom there is definite ossification of the lateral condylar epiphysis. Although there may be a small flake of metaphyseal bone, this is also essentially a type I Salter-Harris physeal injury Classification Group C fractures occur in older children, from 3 to 7 years of age and result in a large metaphyseal fragment that is most commonly lateral but can be medial or posterior. These fractures are almost always extension-type injuries with the distal epiphyseal fragment posterior to the metaphysis note If differentiation of this injury from an intra-articular fracture is uncertain Arthrography or MRI In neonates and infants in whom ossification has not begun Ultrasonography Treatment Group A CR + Splint The elbow is initially manipulated into extension to correct the medial displacement. Group B/C CRIF we perform the manipulation with the patient under general anesthesia and secure the fragment with two lateral pins note If treatment is delayed more than 3 to 5 days Simple splint or cast If the epiphysis is not freely movable . Complication Neurovascular Injuries:Rare probably because the fracture fragments are covered with physeal cartilage and do not have sharp edges as do other fractures in this area. In addition, the fracture fragments are usually not markedly displaced. Nonunion: Rare Malunion: Common Significant cubitus varus deformity is common after this injury( but less than supracondylar fractures). Osteonecrosis: Rare