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