- Email: [email protected]
Fracture separation of the lower humeral epiphysis due to birth injury: a case report
168
Inpry,14,168-l 69
Printedin GreatBritain
Fracture separation of the lower humeral epiphysis due to birth injury: a case report T. J. Menon Centre for Hip Surgery, Wrightington Hospital, Wigan, Lancashire
Summary
A case of traumatic separation of the lower humeral epiphysis due to birth injury is reported. In the past 20 years, only 3 similar cases have been reported in the English literature. Following a manipulative reduction and immobilization of the arm in a collar and cuff for 3 weeks the baby made an uneventful recovery. When seen IO months after injury, the baby had regained full movements of the elbow except for the last 10’ of extension. INTRODUCTION TRACTIONlesions
of the brachial plexus and fractures involving the long bones like the clavicle, humerus and the femur are common injuries seen in orthopaedic practice. It has been stated that epiphyseal injuries and dislocations rarely result from birth injury (Vaughan and Mckay, 1975). As an obstetric injury, epiphyseal separation of the upper femoral epiphysis has been well documented in the literature (Mortnes and Christensen, 1964). Although traumatic separation of the lower humeral epiphysis was first described by Ashurst as early as 19 IO as an obstetric injury, only Siffert (1963) has reported 3 babies with this injury. A fourth case is reported here, showing how easily it can be mistaken for dislocation of the elbow. CASE REPORT Before the delivery of the second of 2 twins, a difficult manual version of a transverse lie to a breech presentation was performed. It was noted shortly after birth that the baby was not moving the right arm freely. On examination, the right elbow was swollen and had a 30’ flexion deformity. Attempts at moving the elbow were obviously painful. The relationship of the epicondyles to the olecranon was not altered when
Fig. I. Radiograph ofthe right elbow showingdisplacement of the radius and ulna from the lower end ofthe humerus. compared with the opposite side. X-ray examination confirmed the clinical impression of a bony injury, showing a posttromedial displacement of the radius and ulna from the lower end of the humerus (Fig. I). Following manipulation under anaesthesia, the arm was placed in a collar and cufffor 3 weeks. X-ray films
169
Menon: Fracture Separation due to Birth Injury
metaphyseal region (Ferguson, 1975). This is particularly true in the region of the elbow as the lower humeral ossific centres are not present at birth and hence not shown by X-rays. In the case reported here, the initial radiological diagnosis was in fact that of a dislocation of the dbow. Clinical examination of the eIbow helps ‘:o distinguish the two lesions, as the alignment of the epicondyles to the olecranon is altered in a dislocation while it is maintained in an epiphyseal separation. Massive callus around the metaphyseal region, as shown in this case, suggests an epiphyseal injury rather than a dislocation. Further, it is interesting to note that dislocation of the elbow due to birth injury has not yet been described in the literature.
Acknowledgement
I wish to thank Mr C. Faux, Consultant Orthopaedic Surgeon at the Preston Royal Infirmary, for allowing me to report this case.
Fig.
2. Radiograph of the right elbow metaphyseal callus4 weeks after the injury.
showing
Ashurst A. P. C. (I 9 IO) Fractures o/~Ae Elhmt~. ,4n
made 4 weeks after the injury showed a large amount of callus around the distal metaphysis of the humerus (Fig. 2). Ten months later the baby had regained a full range of active and passive movements of the elbow, except for the last 10 ’ of extension. The carrying angle was normal and there was some bony thickening at the lower end of the humerus. DISCUSSION It has been suggested that an epiphyseal
injury in infancy can often be mistaken for a dislocation when seen earlv or for a bone tumour when seen late with iassive callus around the
Requesrs./k reprinrsshould hr addressed to: Mr T. J. Menon,
REFERENCES Anatomical and Surgical Study qf Fractures r?f the Lower end yfthe Humerus. Philadelphia, L~zaand
Febiger. Ferguson A. B.
jun.
Infbncy
and
*ilkins,
p. 17.
(1975) Orthopaedic Surg’erl, in Baltimore, Williams and
Childhood.
Mortnes and Christensen P. (1964) Traumatic separration of the upper femoral epiphysis in tht: newborn infant. Acra. Orrhop. Stand. 34, 239. Siffert R. S. (1963) Displacement of the distal humeral epiphysis in the newborn infant. J. BoneJoinf 45A, 165.
Vaughan and Mckay (1975) NelsonPaediatrics.
I Pickering Close,
Saunders, Philadelphia,
Bury. Lancashire. BL8
I UE.
Textbook
p. 352.
Surg. of
Inpry,14,168-l 69
Printedin GreatBritain
Fracture separation of the lower humeral epiphysis due to birth injury: a case report T. J. Menon Centre for Hip Surgery, Wrightington Hospital, Wigan, Lancashire
Summary
A case of traumatic separation of the lower humeral epiphysis due to birth injury is reported. In the past 20 years, only 3 similar cases have been reported in the English literature. Following a manipulative reduction and immobilization of the arm in a collar and cuff for 3 weeks the baby made an uneventful recovery. When seen IO months after injury, the baby had regained full movements of the elbow except for the last 10’ of extension. INTRODUCTION TRACTIONlesions
of the brachial plexus and fractures involving the long bones like the clavicle, humerus and the femur are common injuries seen in orthopaedic practice. It has been stated that epiphyseal injuries and dislocations rarely result from birth injury (Vaughan and Mckay, 1975). As an obstetric injury, epiphyseal separation of the upper femoral epiphysis has been well documented in the literature (Mortnes and Christensen, 1964). Although traumatic separation of the lower humeral epiphysis was first described by Ashurst as early as 19 IO as an obstetric injury, only Siffert (1963) has reported 3 babies with this injury. A fourth case is reported here, showing how easily it can be mistaken for dislocation of the elbow. CASE REPORT Before the delivery of the second of 2 twins, a difficult manual version of a transverse lie to a breech presentation was performed. It was noted shortly after birth that the baby was not moving the right arm freely. On examination, the right elbow was swollen and had a 30’ flexion deformity. Attempts at moving the elbow were obviously painful. The relationship of the epicondyles to the olecranon was not altered when
Fig. I. Radiograph ofthe right elbow showingdisplacement of the radius and ulna from the lower end ofthe humerus. compared with the opposite side. X-ray examination confirmed the clinical impression of a bony injury, showing a posttromedial displacement of the radius and ulna from the lower end of the humerus (Fig. I). Following manipulation under anaesthesia, the arm was placed in a collar and cufffor 3 weeks. X-ray films
169
Menon: Fracture Separation due to Birth Injury
metaphyseal region (Ferguson, 1975). This is particularly true in the region of the elbow as the lower humeral ossific centres are not present at birth and hence not shown by X-rays. In the case reported here, the initial radiological diagnosis was in fact that of a dislocation of the dbow. Clinical examination of the eIbow helps ‘:o distinguish the two lesions, as the alignment of the epicondyles to the olecranon is altered in a dislocation while it is maintained in an epiphyseal separation. Massive callus around the metaphyseal region, as shown in this case, suggests an epiphyseal injury rather than a dislocation. Further, it is interesting to note that dislocation of the elbow due to birth injury has not yet been described in the literature.
Acknowledgement
I wish to thank Mr C. Faux, Consultant Orthopaedic Surgeon at the Preston Royal Infirmary, for allowing me to report this case.
Fig.
2. Radiograph of the right elbow metaphyseal callus4 weeks after the injury.
showing
Ashurst A. P. C. (I 9 IO) Fractures o/~Ae Elhmt~. ,4n
made 4 weeks after the injury showed a large amount of callus around the distal metaphysis of the humerus (Fig. 2). Ten months later the baby had regained a full range of active and passive movements of the elbow, except for the last 10 ’ of extension. The carrying angle was normal and there was some bony thickening at the lower end of the humerus. DISCUSSION It has been suggested that an epiphyseal
injury in infancy can often be mistaken for a dislocation when seen earlv or for a bone tumour when seen late with iassive callus around the
Requesrs./k reprinrsshould hr addressed to: Mr T. J. Menon,
REFERENCES Anatomical and Surgical Study qf Fractures r?f the Lower end yfthe Humerus. Philadelphia, L~zaand
Febiger. Ferguson A. B.
jun.
Infbncy
and
*ilkins,
p. 17.
(1975) Orthopaedic Surg’erl, in Baltimore, Williams and
Childhood.
Mortnes and Christensen P. (1964) Traumatic separration of the upper femoral epiphysis in tht: newborn infant. Acra. Orrhop. Stand. 34, 239. Siffert R. S. (1963) Displacement of the distal humeral epiphysis in the newborn infant. J. BoneJoinf 45A, 165.
Vaughan and Mckay (1975) NelsonPaediatrics.
I Pickering Close,
Saunders, Philadelphia,
Bury. Lancashire. BL8
I UE.
Textbook
p. 352.
Surg. of