Mohammad Ali Tahririan MDDepartment of OrthopedicsKashani Hospital
Distal Humeral Physeal Fractures
total distal
humeral physis:
First 2-3 Y
Lat. Conylar physis: 6
Y
Med. Condylar physis: 8-
12 Y
Medial epicondyl
ar apophysis: 11-12 Y
Next to those of the distal radius, injuries to the distal humeral physes are the most
common physeal injuries.
16.9% of distal humeral fractures
only occasionally
associated with injuries outside
the elbow region
Fractures Involving the Lateral Condylar Physis
Classification
Two mechanisms have been suggested:
"push-off" and "pull-off"
The pull-off or avulsion theory has
more advocates than the push-off
mechanism
Mechanism of Injury
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.
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.
Signs and symptoms
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
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.
Treatment
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.
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
Percutaneous Pins
Open Reduction
If the fracture is grossly unstable, or satge III
ORIF
Complications
Treating is a difficult dilemma.
Patients are usually asymptomatic except for those with high-demand athletic or labor activities. A mild flexion contracture of the elbow is present, but the cubitus valgus deformity is more cosmetic than functional.
No treatment progressive cubitus valgus deformity
Non union
If surgery is performed, the potential risks of osteonecrosis and loss of elbow motion must be considered.
An open, viable lateral
condylar physis
· Displacemen
t of less than 1 cm from the
joint surface
A large metaphyseal fragment
Indication of surgery:
in patients with a nonunion who have cosmetic concerns but no
functional complaints, treatment is:
supracondylar osteotomy osteosynthesis
√√√ √
patients with asymptomatic nonunion, cubitus valgus
deformity, and symptomatic tardy ulnar nerve palsy should be treated with:
Anterior transposition of the ulnar
nerve.
note
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.
Lateral condylar spur formation is one of the most common deformities.
Lateral Spur Formation
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
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
So
Incidence is as high as 40%
after operative treatment and nonoperative
treatment.
Cubitus Varus
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.
Dilemma ???
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.
Cubitus valgus
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.
Neurologic Complications
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
Osteonecrosis
If the fracture unites,
osteonecrosis of the lateral
condyle reossifies over many
years
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.
Fractures of the Capitellum
Two types:
The first is the more common Hahn-Steinthal
type,I which usually contains a rather large
portion of cancellous bone of the lateral condyle.
The second, or Kocher-Lorenz, type is more of a pure articular. This type of fracture is rare in children.
Classification
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.
Mechanism of Injury
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
treatment
rare in skeletally immature children
less than 1% of fractures involving the distal humerus.
Occur later than lateral condylar fractures
Fractures Involving the Medial Condylar Physis
Mechanism of Injury
Mechanism of Injury
Classification
More common
Clinically and on radiographs, a fracture of the medial condylar physis is most often confused with a fracture of the medial epicondyle.
Diagnosis
Med. Swelling
Valgus instability
Elbow Disloctio
n/ Subluxati
on
Ulnar paresthesia
Med. Condlye
phsis√√√ √√√ Post.
Med. Sx√√√
Med. Epicnodyle apophysis
√√√ √√√ Post.Lat. Dx
√√√
Fat pad sign
√√√
――――
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
Type I posterior splint( Follow-up radiographs at weekly intervals are taken to ensure
there is no late displacement.)
Types II and III ORIF
Treatment
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 Valgusdecreased growth of the trochlea, possibly caused by a vascular insult Cubitus varus
Complication
if the fracture is untreated
nonunion
Cubitus varus
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
Fractures Involving the Entire Distal Humeral Physis
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.
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.
Mechanism of lnjury
Group A fracturesoccur 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 fracturesoccur 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.
Classification
These fractures are almost always extension-type injuries with the distal epiphyseal fragment posterior to the metaphysis
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
note
Group A CR + SplintThe elbow is initially manipulated into extension to correct the medial displacement.
Group B/C CRIFwe perform the manipulation with the patient under general anesthesia and secure the fragment with two lateral pins
Treatment
Simple splint or cast
If treatment is delayed more than 3 to 5 days
If the epiphysis is not freely movable .
note
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
Complication