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| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Elbow Pain and Swelling in a Three-Month-Old Infant After a Fall (continued) | ||
| Answer: This injury should raise the suspicion of child abuse. When appropriate, a series of radiographs of the entire skeleton should be made and the child and family should be evaluated by child protective services. | ||
| For larger view, click on image | ||
 Fig. 1 |
 Fig. 3 |
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| Discussion | ||
| Fracture-separation of the distal humeral physis is a rare injury compared with other elbow injuries seen in children. It has been postulated that one reason for the rarity of this injury is that it is frequently missed or misdiagnosed1. | ||
| Determining the relationship of the olecranon process to the medial and lateral humeral epicondyles during the physical examination may help to differentiate between elbow dislocation and fracture-separation of the distal humeral physis; however, painful examination and swelling in the area may make palpation of these landmarks difficult. A "muffled" crepitus (in contrast to the distinct osseous crepitus heard between two osseous fragments) may be appreciated during movement of the elbow as the cartilaginous ends of the fracture move against one another2. | ||
| Radiographic diagnosis in neonates and young infants can be challenging because of the lack of visible ossification centers. The anatomic alignment of the proximal aspect of the radius and ulna with respect to one another and their posteromedial displacement relative to the humeral metaphysis radiographically are suggestive of fracture-separation of the distal humeral physis. The diagnosis is easier in older children when the ossification center in the capitellum becomes visible (age one to nine months). With ossification of the capitellum, normal radiocapitellar alignment is observed in physeal fracture-separation at the distal humerus. Elbow dislocations are rare in infants due to the strength of the ligaments compared with bone, and when they occur they are most often posterolateral3. Supracondylar fractures of the distal aspect of the humerus are also rare in infants and can be differentiated from distal humeral physeal fracture-separations by observing the entire fracture line in the supracondylar segment proximal to the physis1. | ||
| When the diagnosis is still in doubt despite comparative plain-film imaging of the injured and contralateral elbows, other imaging modalities may be useful. Ultrasound with sedation has been demonstrated to aid in the diagnosis of elbow injuries in children, including fracture-separation of the distal humeral physis, and has the advantages of being noninvasive, available in real-time, and relatively inexpensive4. Arthrography and examination under anesthesia has been shown to be helpful in demonstrating separation and displacement of the physis. Additionally, a more complete physical examination can take place during this procedure, but general anesthesia must be administered5. Magnetic resonance imaging has proven useful in making the diagnosis of a fracture-separation of the distal humeral physis in neonates and young infants. Disadvantages to magnetic resonance imaging include cost and the need for sedation, and possibly general anesthesia, although a recent report of successful magnetic resonance imaging of a sleeping infant held by his mother has been reported6. Radionuclide bone scintigraphy is less useful in evaluating physeal injuries in infants because of the intense uptake and activity seen in this region in normal physes due to the rapid growth at these sites5. | ||
| A current treatment for distal physeal fracture-separation of the humerus is closed reduction with percutaneous pin fixation, which allows for immediate evaluation of the carrying angle7,8. Early recognition and treatment are important because, when treatment is delayed and callus formation has begun, the treatment then should consist solely of immobilization of the elbow. If deformity results, it can be corrected subsequently with osteotomy. Complications following distal humeral physeal fracture-separation include cubitus varus deformity, which is more likely to develop in children who are less than two years of age1,7,8. | ||
| In a series of sixteen patients with fracture-separation of the distal humeral physis, child abuse was documented or suspected in six of sixteen patients, all of whom were less than two years of age1. Unlike older children, who frequently fall on outstretched hands, it is unlikely for infants to sustain an elbow injury in falls typically seen in this age group. Such injuries in infants and children should prompt consideration of a skeletal survey to rule out occult injuries and should also prompt an investigation by child protective services unless the injury was witnessed by other reliable persons. | ||
| In a more recent retrospective review of skull and long-bone fractures in seventy-four children who were less than one year of age at the time of presentation to an emergency department, it was determined that the possibility of abuse is underestimated at the initial presentation for approximately 25% of patients. The authors recommended admitting all of these children to the hospital as well as initiating an evaluation by child protective services9. If there is a high index of suspicion for abuse, imaging of the brain for occult head injury may be considered because a funduscopic examination is not as useful in evaluating retinal hemorrhage10. A recent review article by Kocher and Kasser provides an excellent summary of the orthopaedic aspects of child abuse11. | ||
| *The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. | ||
| References | ||
1. DeLee JC, Wilkins KE, Rogers LF, Rockwood CA. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Am. 1980;62:46-51. |
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