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Fracture-separation of the distal humeral epiphysis
Injury, Int. J. Care Injured (2006) 37, 843—848
www.elsevier.com/locate/injury
Fracture-separation of the distal humeral epiphysis Long-term follow-up of five cases Cosimo Tudisco, Federico Mancini, Fernando De Maio *, Ernesto Ippolito Department of Orthopedic Surgery, Policlinico Tor Vergata, University of Rome, ‘‘Tor Vergata’’, Viale Oxford, 81-00133 Roma, Italy Accepted 13 February 2006
KEYWORDS Fracture-separation; Distal humeral epiphysis; Cubitus varus; Deformity
Summary Fracture-separation of the distal humeral epiphysis is a rare injury described in young children. The diagnosis is often difficult because most of the ossification centre are not visible. We report a long-term follow-up study of five cases, evaluated after an average of 38 years. At the time of fracture, all the patients were more than 3 years old. Three patients had been treated with overhead traction, closed reduction and immobilisation in a long-arm plaster cast, one patient with closed reduction and immobilisation and another one, initially not diagnosed, had been treated after 2 weeks with only immobilisation in a long-arm plaster cast. Cubitus varus deformity was observed in one of the five patients. In the remaining four cases the cubitus was less valgus than the opposite side. No patient complained of any functional disability even though in two of them, one treated late and another one who had an inadequate reduction, radiographic signs of degenerative arthritis were present. We believe that the amount of displacement of the fragments, the quality of the reduction and the age at the time of fracture are important factors influencing the development of cubitus varus deformity. # 2006 Elsevier Ltd. All rights reserved.
Introduction Fracture-separation of the distal humeral epiphysis is a transcondylar injury of the entire distal humeral physis and epiphysis.14 It is a rare injury, which * Correspondence to: Via di San Crescenziano 48, 00199 Rome, Italy. Tel.: +39 06 86399565. E-mail address: [email protected] (F. De Maio).
may be mistaken roentgenographically either for a fracture of the lateral condyle or for a traumatic dislocation of the elbow or for supracondylar humeral fracture1,11 (Fig. 1). This injury has been described more frequently in children younger than 3 years of age, and the diagnosis is often difficult because most of the ossification centres are not visible. Few cases have been reported, most of them with a short-term
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.02.018
844
C. Tudisco et al.
Figure 1 Radiologic differential diagnosis of fracture-separation in elbow trauma: normal elbow (A), dislocation of the elbow (B), fracture of lateral humeral condyle (C), supracondylar humeral fracture (D), and fracture-separation of distal humeral epiphysis (E). De Lee et al.4
follow-up and with a high rate of residual deformities.2,11 We report a long-term follow-up of five cases, all of them were older than 3 years at the time of the fracture, evaluated after an average of 38 years.
Materials and methods Five patients with fracture-separation of the distal humeral physis were evaluated from 31 to 43 years after the fracture (Table 1). All of their original Xrays were available for review. Four were males and one was a female. The left side was affected in three cases and the right in two. All the fractures were closed and the cause of the injury was always a fall; from a bicycle in two cases, from a horse in one case, and for miscellaneous causes in the remaining two cases. According to the De Lee et al. classification (1980)4 based on the patient’s age at fracture, we observed five group C fractures. The mean age at the time of fracture was 7.6 years (from 6 to 9 years), while at follow-up it was 45 years (from 37 to 51 years). Three of the five patients had been treated with traction for an average of 48 h, followed by closed reduction under general anaesthesia and immobilisation for a period of 30 days in a long-arm plaster cast with the elbow flexed at 908 and the forearm pronated; in one patient, the fracture was reduced closed and immobilised without traction. In another case the fracture, initially not recognised, had been subsequently treated after 2 weeks by immobilisation without reduction for 30 days (Table 1). At follow-up we performed a physical and roentgenographic examination evaluating the symptoms, and range of motion (flexion—
extension and pronation—supination) and measuring the carrying angle of both elbows on full-length radiographs of both arms in extension. We evaluated the displacement between the fragments at the time of the fracture, measuring on the X-rays the percentage of displacement of the capitellum ossification centre compared with the normal one (Fig. 2). We considered it mild if the displacement that was less than 30%, and severe if it was more than that. The reduction was also evaluated, and was considered good if the alignment was satisfactory, fair when it was acceptable and inadeguate when the fragments were not aligned. In accordance with Hardacre et al.6 the results were evaluated as excellent when there were no symptoms, no deformity, full range of motion of the elbow and only slight radiographic changes were present. A result was considered good when there was 108 of impairment of the range of motion of the elbow and/or 58 of change in the carrying angle with some radiographic abnormalities. A fair result corresponded to a loss of movement between 10 and 208 for each elbow movement and/or a change of more than 58 in the carrying angle, with initial signs of degenerative arthritis. A result was considered poor when the range of motion of the elbow was limited by more than 208 for each movement and the carrying angle was changed by more than 58 with the presence also of pain, neurological deficit, nonunion, avascular necrosis or severe radiographic signs of degenerative arthritis. We also measured the carrying angle at the time of consolidation of the fracture and then at follow-up to evaluate its possible variation from the time of fracture to the end of skeletal growth.
Poor 158
Good 58
Fair 88
Fair 108
148
108— 08 20—1258 38 45
128— 48 0—1408 34 42
—158 108 5—1258 42 51
108— 58 0—1408 31
08 10—1308 43 51
Not done 40% M 7 5
L
Good 15% M 8 4
L
Fair 100% M 9 3
R
Good 35% F 6 2
L
8
R
M
40%
Inadequate
CR, plaster cast 30 days o-h tract, CR, plaster cast 30 days o-h tract, CR, plaster cast 30 days o-h tract, CR, plaster cast 30 d Treated late, plaster cast 30 days
37
—148
L R
845
Results
1
Reduction Displacement Sex Side Age
Table 1
Long-term follow-up of five patients
Treatment
Age at follow-up
Length of follow-up
Elbow range of motion
Carrying angle at fracture healing
Carrying angle at follow-up
Carrying angle variation
Fair
Result
Fracture-separation of the distal humeral epiphysis
In the four patients treated immediately, one showed a good result consisting of a very mild deformity (78 valgus in the affected elbow and 128 in the controlateral one) with a complete range of motion. In the other three cases the results were fair. Compared to the controlateral side, the carrying angle was decreased by 88 in one case, 108 in another case, and by 148 in the third case. The range of motion of the elbow was limited in two patients: in one case by 58 of extension and 158 of flexion, and in the other one by 108 of extension and 108 of flexion (Fig. 3). A limitation of pronation or supination was never observed (supination 908 and pronation 908). In the late diagnosed case, the result was poor, with 158 loss of flexion and 208 loss of extension and a 158 decrease in the carrying angle. In this last case a paraesthesia over the ulnar nerve territory was reported initially, this resolved completely after 3 months. No patient had any vascular damage. Mild radiographic irregularities of the distal humeral profile were present in three patients, while initial signs of degenerative arthritis were observed in the other two patients, one of whom had an inadequate reduction and the other was treated late (Fig. 3). Of the four patients with a recent injury, the displacement was mild in one case and severe in three cases. In the late treated case, the displacement was considered severe. According to these measurements, the final results was good in one case with mild displacement, while they were fair in three cases and poor in one case, all of them with severe displacement. Four patients underwent reduction, this was considered good in two patients, fair in one and inadequate in one. At the final follow-up, of the two patients with good reduction, one was considered good and one fair, while the case with fair reduction and the other case with inadequate reduction were considered fair. As concerns a possible change in the carrying angle at the time of consolidation of the fracture and then at the end of skeletal growth, we observed a positive variation in two cases, a negative variation in two other cases and no variation in the last case. At the final follow-up, the case with no variation showed a fair result, while the cases where the carrying angle was changed were considered good in one case, fair in two cases and poor in one case. No patient complained of any functional disability, even though in two of them, both manual workers, the result was fair.
846
C. Tudisco et al.
Figure 2 Fracture-separation of the distal humeral epiphysis: evaluation of the displacement of the fragments measured on the X-rays. (a) Distance from the center of the humeral condyle to the lateral border of the distal humeral epiphysis in the fractured elbow; (b) same measurement in the normal elbow; and (c) width of the distal humeral epiphysis.
Figure 3 (a and b) Eight-year-old boy with a fracture-separation of the right distal humeral epiphysis. The entire humeral epiphysis is severely displaced posteromedially, but the head of the radius maintains its relationship with the humeral condyle. (c) After reduction, the fracture was immobilised in a long-arm cast for 30 days. The reduction was considered inadequate. (d and e) Two years after the fracture, the elbow showed a varus alignment in the anteroposterior X-ray and a good alignment in the lateral view. (f—i) X-rays of both elbows taken 43 years after the fracture showed a 148 decrease of the carrying angle and signs of degenerative arthritis in the right elbow. (l and m) At the clinical examination, a right cubitus varus was present and the range of motion showed a 108 lack of both extension and flexion.
Fracture-separation of the distal humeral epiphysis
Discussion Fracture-separation of the distal humeral epiphysis is a very rare injury, most frequently affecting children younger than 3 years of age. The patients we have reported were older than most of the other cases previously described: all our patients were in De Lee age group C (more then 3 years old). Cubitus varus deformity is a very common complication after fracture-separation of the distal humeral epiphysis. The reported incidence is variable, according to several authors, from 25 to 70% of the cases.2,4,7 Some authors believe that this deformity is a consequence of an inadequate reduction3 or of an avascular necrosis.2 Different observations have been reported on the development of cubitus varus and the age at the time of fracture. Some authors observed a minimum loss of the carrying angle at follow-up in patients who had the fracture before 2 years of age,4 and also in patients of the same age with persistent displacement of the fragments.12 Others authors, however, noticed that cubitus varus is more common in patients who had the fracture before the age of 2 years,2,3 regardless of the type of treatment.7 On the other hand, no cubitus varus was observed by Peiro et al.15 in their series of patients all in De Lee’s group C, who were treated with closed reduction and pin fixation. Mizuno et al.13 also reported excellent results in patients whose age at the fracture was from 2 to 8 years, treated by open reduction and wire fixation. In our series, four of the five patients had a cubitus with a decrease of the carrying angle from 8 to 158 and all of them were more than 3 years old at the time of the fracture. No sign of avascular necrosis was observed in any of these patients.2 All of them had a severe displacement (from 35 to 100%); after reduction, one of them showed a good alignment, one a fair alignment, one an inadequate alignment, and another one had been immobilised without reduction. These last two patients had also been treated with immobilisation in a plaster cast without a period of overhead traction. At follow-up, they presented a severe decrease of the carrying angle ( 14 and 158) and a limited range of motion. Two patients had fair results. One of them had severe displacement (35%) with good alignment and the other one had a worse displacement (100%) with fair alignment. At follow-up both cases showed a decrease of the valgus angle and one of them had also a decrease of range of motion of the elbow. We think that a displacement over 30%, although with good reduction, is responsible for unsatisfactory results. Other authors, who have described fracture-separation of the distal humeral epiphysis in
847 older patients, have reported good results after a treatment by closed or open reduction and pin fixation of the fragments.13,15 In agreement with these authors, we believe that in cases of severe displacement, good reduction and pin fixation can lead to better results. In the patient, that we considered a good result, the displacement was mild and the reduction good; in these cases, in our opinion, pin fixation can be avoided. In one of our patients, the fracture was initially not recognised and the treatment was started after 2 weeks. The problem of a correct diagnosis is confirmed by the fact that misdiagnosed cases have been reported in almost all the previous papers.4,7,12,13,15 For this reason, some authors advise the use of arthrography5,13 or ultrasonography8 as a useful adjunct for the diagnosis of this type of fracture especially in very young patients, whose cartilaginous distal aspect of the humerus is not completely visible on the radiographs. De Lee et al.4 described three patients younger than 3 years, who had a delay in diagnosis and were treated with a cast without reduction, who had a good result. Satisfactory results have also been reported by McIntre et al.12 in a younger group of patients, even with persistent displacement of the fragments. These authors concluded that late diagnosed fractures should not be manipulated because they often show normal alignment even if they have healed in a translocated position. The results we obtained on our one late diagnosed case are not as good as those reported by previous authors. We think that, besides the lack of reduction of the fracture, the older age of our patient was responsible for a poor remodeling of the elbow, with a consequent poor clinical and radiographic result. We also observed two positive and two negative variations in the value of the carrying angle of the elbow from the end of treatment to the end of skeletal growth. Similar observations have been reported by Ippolito et al.9 in a long-term followup study of humeral supracondylar fractures in children, but have not been described in previous studies on fracture-separation of the distal humeral epiphysis whose follow-up was shorter than ours.3,4 We agree with other authors7,9,10 that different types of possible damage caused by the trauma to the growing cells of the physis or a malreduction of the fracture may be responsible for this unpredictable evolution. Although three of our five patients had a fair result and one had a poor result, no patient complained of any functional disability, including the two who were engaged in heavy manual labour. No signs of degenerative arthritis were observed on the
848 X-rays of three of our patients, while initial radiographic signs were present in two patients, one of whom had an inadequate reduction and the other was treated late, who had a severe displacement and no reduction of the fragments. From the study of the various parameters analysed, we believe that not only the quality of reduction but also the amount of displacement and the age at the time of fracture are important factors which influence the functional and cosmetic results in patients treated for a fracture-separation of the distal humeral epiphysis.
References 1. Barrett WP, Almquist EA, Staheli LT. Fracture-separation of the distal humeral physis in the newborn. J Pediatr Orthop 1984;4:617—9. 2. Chang-Wug O, Byung-Chul P, Joo-Chul I, Hee-Soo K. Fracture separation of the distal humeral epiphysis in children younger than three years old. J Pediatr Orthop 2000;20:173—6. 3. De Jager LT, Hoffman EB. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Br 1991;73-B:143—6. 4. De Lee JC, Wilkins KE, Rogers LF, Rockwood CA. Fractureseparation of the distal humeral epiphysis. J Bone Joint Surg Am 1980;62-A:46—51.
C. Tudisco et al. 5. Hansen PE, Barnes DA, Tullos HS. Arthrographic diagnosis of an injury pattern in the distal humerus of an infant. J Pediatr Orthop 1982;2:569—72. 6. Hardacre JA, Nahigian SH, Froimson AI, Bronn JE. Fractures of the lateral condyle of the humerus in children. J Bone Joint Surg Am 1971;53-A:1083—95. 7. Holda ME, Manoli A, LaMont RL. Epiphyseal separation of the distal end of the humerus with medial displacement. J Bone Joint Surg Am 1980;62-A:52—7. 8. Howard CB, Shinwell E, Nyska M, Meller I. Ultrasound diagnosis of neonatal fracture separation of the upper humeral epiphysis. J Bone Joint Surg Br 1992;74-B:471—2. 9. Ippolito E, Caterini R, Scola E. Supracondylar fractures of the humerus in children. Analysis at maturity of fifty-three patients treated conservatively. J Bone Joint Surg Am 1986;68-A:333—44. 10. Kaplan SS, Reckling FW. Fracture separation of the lower humeral epiphysis with medial displacement. Review of the literature and report of a case. J Bone Joint Surg Am 1971;53A:1105—8. 11. Marmor L, Bechtol CO. Fracture-separation of the lower humeral epiphysis. J Bone Joint Surg Am 1960;42-A:333—6. 12. McIntre WM, Wiley JJ, Charette RJ. Fracture-separation of the distal humeral epiphysis. Clin Orthop 1984;188:98—102. 13. Mizuno K, Hirohata K, Kashiwagi D. Fracture-separation of the distal humeral epiphysis in young children. J Bone Joint Surg Am 1979;61-A:570—3. 14. Ogden JA. Skeletal injury in the child Saunders; 1990. 15. Peiro A, Mut T, Aracil J, Martos F. Fracture-separation of the lower humeral epiphysis in young children. Acta Ortop Scand 1981;52:295—8.
www.elsevier.com/locate/injury
Fracture-separation of the distal humeral epiphysis Long-term follow-up of five cases Cosimo Tudisco, Federico Mancini, Fernando De Maio *, Ernesto Ippolito Department of Orthopedic Surgery, Policlinico Tor Vergata, University of Rome, ‘‘Tor Vergata’’, Viale Oxford, 81-00133 Roma, Italy Accepted 13 February 2006
KEYWORDS Fracture-separation; Distal humeral epiphysis; Cubitus varus; Deformity
Summary Fracture-separation of the distal humeral epiphysis is a rare injury described in young children. The diagnosis is often difficult because most of the ossification centre are not visible. We report a long-term follow-up study of five cases, evaluated after an average of 38 years. At the time of fracture, all the patients were more than 3 years old. Three patients had been treated with overhead traction, closed reduction and immobilisation in a long-arm plaster cast, one patient with closed reduction and immobilisation and another one, initially not diagnosed, had been treated after 2 weeks with only immobilisation in a long-arm plaster cast. Cubitus varus deformity was observed in one of the five patients. In the remaining four cases the cubitus was less valgus than the opposite side. No patient complained of any functional disability even though in two of them, one treated late and another one who had an inadequate reduction, radiographic signs of degenerative arthritis were present. We believe that the amount of displacement of the fragments, the quality of the reduction and the age at the time of fracture are important factors influencing the development of cubitus varus deformity. # 2006 Elsevier Ltd. All rights reserved.
Introduction Fracture-separation of the distal humeral epiphysis is a transcondylar injury of the entire distal humeral physis and epiphysis.14 It is a rare injury, which * Correspondence to: Via di San Crescenziano 48, 00199 Rome, Italy. Tel.: +39 06 86399565. E-mail address: [email protected] (F. De Maio).
may be mistaken roentgenographically either for a fracture of the lateral condyle or for a traumatic dislocation of the elbow or for supracondylar humeral fracture1,11 (Fig. 1). This injury has been described more frequently in children younger than 3 years of age, and the diagnosis is often difficult because most of the ossification centres are not visible. Few cases have been reported, most of them with a short-term
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.02.018
844
C. Tudisco et al.
Figure 1 Radiologic differential diagnosis of fracture-separation in elbow trauma: normal elbow (A), dislocation of the elbow (B), fracture of lateral humeral condyle (C), supracondylar humeral fracture (D), and fracture-separation of distal humeral epiphysis (E). De Lee et al.4
follow-up and with a high rate of residual deformities.2,11 We report a long-term follow-up of five cases, all of them were older than 3 years at the time of the fracture, evaluated after an average of 38 years.
Materials and methods Five patients with fracture-separation of the distal humeral physis were evaluated from 31 to 43 years after the fracture (Table 1). All of their original Xrays were available for review. Four were males and one was a female. The left side was affected in three cases and the right in two. All the fractures were closed and the cause of the injury was always a fall; from a bicycle in two cases, from a horse in one case, and for miscellaneous causes in the remaining two cases. According to the De Lee et al. classification (1980)4 based on the patient’s age at fracture, we observed five group C fractures. The mean age at the time of fracture was 7.6 years (from 6 to 9 years), while at follow-up it was 45 years (from 37 to 51 years). Three of the five patients had been treated with traction for an average of 48 h, followed by closed reduction under general anaesthesia and immobilisation for a period of 30 days in a long-arm plaster cast with the elbow flexed at 908 and the forearm pronated; in one patient, the fracture was reduced closed and immobilised without traction. In another case the fracture, initially not recognised, had been subsequently treated after 2 weeks by immobilisation without reduction for 30 days (Table 1). At follow-up we performed a physical and roentgenographic examination evaluating the symptoms, and range of motion (flexion—
extension and pronation—supination) and measuring the carrying angle of both elbows on full-length radiographs of both arms in extension. We evaluated the displacement between the fragments at the time of the fracture, measuring on the X-rays the percentage of displacement of the capitellum ossification centre compared with the normal one (Fig. 2). We considered it mild if the displacement that was less than 30%, and severe if it was more than that. The reduction was also evaluated, and was considered good if the alignment was satisfactory, fair when it was acceptable and inadeguate when the fragments were not aligned. In accordance with Hardacre et al.6 the results were evaluated as excellent when there were no symptoms, no deformity, full range of motion of the elbow and only slight radiographic changes were present. A result was considered good when there was 108 of impairment of the range of motion of the elbow and/or 58 of change in the carrying angle with some radiographic abnormalities. A fair result corresponded to a loss of movement between 10 and 208 for each elbow movement and/or a change of more than 58 in the carrying angle, with initial signs of degenerative arthritis. A result was considered poor when the range of motion of the elbow was limited by more than 208 for each movement and the carrying angle was changed by more than 58 with the presence also of pain, neurological deficit, nonunion, avascular necrosis or severe radiographic signs of degenerative arthritis. We also measured the carrying angle at the time of consolidation of the fracture and then at follow-up to evaluate its possible variation from the time of fracture to the end of skeletal growth.
Poor 158
Good 58
Fair 88
Fair 108
148
108— 08 20—1258 38 45
128— 48 0—1408 34 42
—158 108 5—1258 42 51
108— 58 0—1408 31
08 10—1308 43 51
Not done 40% M 7 5
L
Good 15% M 8 4
L
Fair 100% M 9 3
R
Good 35% F 6 2
L
8
R
M
40%
Inadequate
CR, plaster cast 30 days o-h tract, CR, plaster cast 30 days o-h tract, CR, plaster cast 30 days o-h tract, CR, plaster cast 30 d Treated late, plaster cast 30 days
37
—148
L R
845
Results
1
Reduction Displacement Sex Side Age
Table 1
Long-term follow-up of five patients
Treatment
Age at follow-up
Length of follow-up
Elbow range of motion
Carrying angle at fracture healing
Carrying angle at follow-up
Carrying angle variation
Fair
Result
Fracture-separation of the distal humeral epiphysis
In the four patients treated immediately, one showed a good result consisting of a very mild deformity (78 valgus in the affected elbow and 128 in the controlateral one) with a complete range of motion. In the other three cases the results were fair. Compared to the controlateral side, the carrying angle was decreased by 88 in one case, 108 in another case, and by 148 in the third case. The range of motion of the elbow was limited in two patients: in one case by 58 of extension and 158 of flexion, and in the other one by 108 of extension and 108 of flexion (Fig. 3). A limitation of pronation or supination was never observed (supination 908 and pronation 908). In the late diagnosed case, the result was poor, with 158 loss of flexion and 208 loss of extension and a 158 decrease in the carrying angle. In this last case a paraesthesia over the ulnar nerve territory was reported initially, this resolved completely after 3 months. No patient had any vascular damage. Mild radiographic irregularities of the distal humeral profile were present in three patients, while initial signs of degenerative arthritis were observed in the other two patients, one of whom had an inadequate reduction and the other was treated late (Fig. 3). Of the four patients with a recent injury, the displacement was mild in one case and severe in three cases. In the late treated case, the displacement was considered severe. According to these measurements, the final results was good in one case with mild displacement, while they were fair in three cases and poor in one case, all of them with severe displacement. Four patients underwent reduction, this was considered good in two patients, fair in one and inadequate in one. At the final follow-up, of the two patients with good reduction, one was considered good and one fair, while the case with fair reduction and the other case with inadequate reduction were considered fair. As concerns a possible change in the carrying angle at the time of consolidation of the fracture and then at the end of skeletal growth, we observed a positive variation in two cases, a negative variation in two other cases and no variation in the last case. At the final follow-up, the case with no variation showed a fair result, while the cases where the carrying angle was changed were considered good in one case, fair in two cases and poor in one case. No patient complained of any functional disability, even though in two of them, both manual workers, the result was fair.
846
C. Tudisco et al.
Figure 2 Fracture-separation of the distal humeral epiphysis: evaluation of the displacement of the fragments measured on the X-rays. (a) Distance from the center of the humeral condyle to the lateral border of the distal humeral epiphysis in the fractured elbow; (b) same measurement in the normal elbow; and (c) width of the distal humeral epiphysis.
Figure 3 (a and b) Eight-year-old boy with a fracture-separation of the right distal humeral epiphysis. The entire humeral epiphysis is severely displaced posteromedially, but the head of the radius maintains its relationship with the humeral condyle. (c) After reduction, the fracture was immobilised in a long-arm cast for 30 days. The reduction was considered inadequate. (d and e) Two years after the fracture, the elbow showed a varus alignment in the anteroposterior X-ray and a good alignment in the lateral view. (f—i) X-rays of both elbows taken 43 years after the fracture showed a 148 decrease of the carrying angle and signs of degenerative arthritis in the right elbow. (l and m) At the clinical examination, a right cubitus varus was present and the range of motion showed a 108 lack of both extension and flexion.
Fracture-separation of the distal humeral epiphysis
Discussion Fracture-separation of the distal humeral epiphysis is a very rare injury, most frequently affecting children younger than 3 years of age. The patients we have reported were older than most of the other cases previously described: all our patients were in De Lee age group C (more then 3 years old). Cubitus varus deformity is a very common complication after fracture-separation of the distal humeral epiphysis. The reported incidence is variable, according to several authors, from 25 to 70% of the cases.2,4,7 Some authors believe that this deformity is a consequence of an inadequate reduction3 or of an avascular necrosis.2 Different observations have been reported on the development of cubitus varus and the age at the time of fracture. Some authors observed a minimum loss of the carrying angle at follow-up in patients who had the fracture before 2 years of age,4 and also in patients of the same age with persistent displacement of the fragments.12 Others authors, however, noticed that cubitus varus is more common in patients who had the fracture before the age of 2 years,2,3 regardless of the type of treatment.7 On the other hand, no cubitus varus was observed by Peiro et al.15 in their series of patients all in De Lee’s group C, who were treated with closed reduction and pin fixation. Mizuno et al.13 also reported excellent results in patients whose age at the fracture was from 2 to 8 years, treated by open reduction and wire fixation. In our series, four of the five patients had a cubitus with a decrease of the carrying angle from 8 to 158 and all of them were more than 3 years old at the time of the fracture. No sign of avascular necrosis was observed in any of these patients.2 All of them had a severe displacement (from 35 to 100%); after reduction, one of them showed a good alignment, one a fair alignment, one an inadequate alignment, and another one had been immobilised without reduction. These last two patients had also been treated with immobilisation in a plaster cast without a period of overhead traction. At follow-up, they presented a severe decrease of the carrying angle ( 14 and 158) and a limited range of motion. Two patients had fair results. One of them had severe displacement (35%) with good alignment and the other one had a worse displacement (100%) with fair alignment. At follow-up both cases showed a decrease of the valgus angle and one of them had also a decrease of range of motion of the elbow. We think that a displacement over 30%, although with good reduction, is responsible for unsatisfactory results. Other authors, who have described fracture-separation of the distal humeral epiphysis in
847 older patients, have reported good results after a treatment by closed or open reduction and pin fixation of the fragments.13,15 In agreement with these authors, we believe that in cases of severe displacement, good reduction and pin fixation can lead to better results. In the patient, that we considered a good result, the displacement was mild and the reduction good; in these cases, in our opinion, pin fixation can be avoided. In one of our patients, the fracture was initially not recognised and the treatment was started after 2 weeks. The problem of a correct diagnosis is confirmed by the fact that misdiagnosed cases have been reported in almost all the previous papers.4,7,12,13,15 For this reason, some authors advise the use of arthrography5,13 or ultrasonography8 as a useful adjunct for the diagnosis of this type of fracture especially in very young patients, whose cartilaginous distal aspect of the humerus is not completely visible on the radiographs. De Lee et al.4 described three patients younger than 3 years, who had a delay in diagnosis and were treated with a cast without reduction, who had a good result. Satisfactory results have also been reported by McIntre et al.12 in a younger group of patients, even with persistent displacement of the fragments. These authors concluded that late diagnosed fractures should not be manipulated because they often show normal alignment even if they have healed in a translocated position. The results we obtained on our one late diagnosed case are not as good as those reported by previous authors. We think that, besides the lack of reduction of the fracture, the older age of our patient was responsible for a poor remodeling of the elbow, with a consequent poor clinical and radiographic result. We also observed two positive and two negative variations in the value of the carrying angle of the elbow from the end of treatment to the end of skeletal growth. Similar observations have been reported by Ippolito et al.9 in a long-term followup study of humeral supracondylar fractures in children, but have not been described in previous studies on fracture-separation of the distal humeral epiphysis whose follow-up was shorter than ours.3,4 We agree with other authors7,9,10 that different types of possible damage caused by the trauma to the growing cells of the physis or a malreduction of the fracture may be responsible for this unpredictable evolution. Although three of our five patients had a fair result and one had a poor result, no patient complained of any functional disability, including the two who were engaged in heavy manual labour. No signs of degenerative arthritis were observed on the
848 X-rays of three of our patients, while initial radiographic signs were present in two patients, one of whom had an inadequate reduction and the other was treated late, who had a severe displacement and no reduction of the fragments. From the study of the various parameters analysed, we believe that not only the quality of reduction but also the amount of displacement and the age at the time of fracture are important factors which influence the functional and cosmetic results in patients treated for a fracture-separation of the distal humeral epiphysis.
References 1. Barrett WP, Almquist EA, Staheli LT. Fracture-separation of the distal humeral physis in the newborn. J Pediatr Orthop 1984;4:617—9. 2. Chang-Wug O, Byung-Chul P, Joo-Chul I, Hee-Soo K. Fracture separation of the distal humeral epiphysis in children younger than three years old. J Pediatr Orthop 2000;20:173—6. 3. De Jager LT, Hoffman EB. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Br 1991;73-B:143—6. 4. De Lee JC, Wilkins KE, Rogers LF, Rockwood CA. Fractureseparation of the distal humeral epiphysis. J Bone Joint Surg Am 1980;62-A:46—51.
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