Fracture-separation of the distal humeral epiphysis.

Sixteen patients were seen with fracture-separation of the distal humeral epiphysis. The difficulty that may be encountered in making the diagnosis is thought to be partly responsible for the relative paucity of previous reports of this condition. All sixteen patients revealed posteromedial displacement of the distal humeral epiphysis on the initial roentgenogram. Child-abuse was documented or suspected as a cause in six of the sixteen fractures. Treatment consisted of closed reduction and immobilization with the elbow in 90 degrees of flexion and the forearm pronated, for three weeks. Post-injury cubitus varus, which developed in three patients and was thought to be due to inadequate reduction, did not progress. Fracture-separation of the distal humeral epiphysis has been considered to be a very rare injury; only thirteen cases have been reported in the orthopaedic literature since 19507.9-II.Ifi. 17.21. 2:t One of the reasons for this, however, is that the injury is often misdiagnosed. Macafee reported three cases of infantile supracondylar fracture. Close examination of his study, however, indicates that the injuries were indeed of the distal humeral epiphyses rather than supracondylar fractures. Stimson credited Gurlt with the first description of a fracture-separation of the distal humeral epiphysis in 1818. However, the first complete description of this injury which differentiated it from supracondylar fracture and dislocation of the elbow is in the S Division of Orthopaedic Surgery. University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, Texas 78284. t Department of Radiology, Northwestern University Medical School, 303 East Chicago Avenue, Chicago, Illinois 6061 1. classic article by R. W. Smith, published in 1850. Poland described six previously reported cases in 1898, and Ashhurst reported an additional six cases in 1910. The fracture was not described again until F. M. Smith published his excellent monograph on the elbow in 1954. Authors of current pediatric orthopaedic texts made little or no mention of separation of the entire distal humeral epiphysis3”3’22. This injury has been reported as occurring after a traumatic delivery, and in the newborn iO.16 This report deals with sixteen patients with fractureseparation of the distal humeral epiphysis. Five of them had been previously reported on by two of us (L. F. R. and C. A. R.)’4. Materials and Methods From June 1969 to October 1977, sixteen patients with fracture-separation of the distal humeral epiphysis were treated at our institution. Although many of the injuries were managed by the resident staff, treatment of each patient was carefully supervised and documented by one of us. Adequate follow-up evaluation, consisting of a physical and roentgenographic examination, was available for twelve of the sixteen patients. Although the other four children were located, their parents refused to bring them in for follow-up. In these four patients child-abuse was either suspected or documented, possibly explaining the parents’ reluctance to comply with follow-up care. The ages of the patients ranged from six months to seven years. There was a peak incidence of this fracture in patients from newborn to 2.5 years old (eleven patients). Ten fractures involved the left elbow and six involved the right. Nine of the patients were boys and seven were girls. The length of follow-up ranged from twelve to sixty-six FIG. 1-A FIG. 1-B FIG. 1-C Fig. 1-A: Roentgenogram of a posteromedially displaced fracture in a patient in Group A (newborn to nine months old). Note that the ossification center has not yet developed in the capitellum and no Thurston-Holland fragment is present. Fig. 1-B: In a patient in Group B (seven months to three years old), the ossification center has developed in the capitellum and a very small or no Thurston-Holland fragment is present. Fig. I-C: In a patient in Group C (three to seven years old), the ossification center has developed in the capitellum and a large Thurston-Holland fragment is present (arrow). FRACTURE-SEPARATION OF THE DISTAL HUMERAL EPIPHYSIS 47 VOL. 62.A, NO. 1, JANUARY 1980 months, with an average of thirty-nine months. In all patients, initial roentgenograms revealed posteromedial displacement of the distal humeral epiphysis.