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