Distal Humerus Physeal Separation

Clinical History

A three-year-old child presented to the emergency department following an unwitnessed fall down a slide at an indoor playpark, sustaining a closed injury to the left elbow. Examination revealed a deformed, tender elbow in extension, with diffuse swelling. Further assessment of the circumstances ruled out non-accidental injury.

Imaging Findings

Radial axis in line with the ossified capitellum. The epiphysis, radius and ulna are displaced posteromedially.

Discussion

Distal humerus physeal separation (DHPS) is an injury that occurs in young children due to blunt trauma to the elbow joint. This injury is frequently associated with non-accidental injury (up to 50% [1]). It is therefore essential that the clinician assessing the injured child keep this diagnosis in mind. The injury may also be sustained following a fall from a height or from rotating forces through the elbow joint.

This injury is frequently mistaken for elbow dislocation which accounts for only 3-6% [2] of elbow injuries in all children. DHPS presents radiographically with subtle features, however close inspection reveals that the radial axis is inline with the capitellum ruling out a dislocation of the olecranon-trochlear articulation. The epiphysis, radius and ulna are displaced posteromedially which may be the only feature in the very young child with a non-ossified capitellum.

Anteroposterior, lateral and oblique view gives an assessment of the nature of the injury. It may prove challenging to obtain optimal views on plain imaging, especially in the young child. If the diagnosis is in doubt static or dynamic imaging may be required, under anaesthesia if necessary.

The treatment of this injury is closed reduction and internal fixation, ideally within four hours of presentation to the emergency department. This fracture healed clinically and radiologically with a satisfactory return of elbow function.

Detection of this injury is important due its significant association with non-accidental injury. Early recognition may lead to improved outcomes for the child, as growth abnormalities may be a complication of this physeal injury.

Differential Diagnosis List

Final Diagnosis

Distal Humerus Physeal Separation

URL:	https://eurorad.org/case/13155
DOI:	10.1594/EURORAD/CASE.13155
ISSN:	1563-4086