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Case of the Month - July 2014

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OIC Medical Director

on 30 July 2014

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Transcript of Case of the Month - July 2014

2+1 y/o boy - UCC Clinical Exam
Tenderness on right elbow
Significant swelling on right upper extremity
Mild deformity
Soft compartments on right arm and forearm
Normal neurovascular distal examination right upper extremity
Swelling and tenderness to palpation left ankle
Afebril
Case of the Month - July 2014

2+1 y/o boy
Presented to UCC with mother
Mother indicated that patient fell from a bed, landing on the right elbow
Since then, crying inconsolably
Swelling on the right elbow
Diagnosis
1. Elbow dislocations are very rare at this age. Unlike this case, the capitellum remains in its place in a patient with an elbow dislocation.
2. While the lateral view suggests a lateral condyle fracture, the AP view suggests medial displacement of the ulna-radius-capitellum unit, which would not be the case in a lateral condyle fracture.
3. No fracture lines are appreciated in the metaphyseal region of the distal humerus, ruling-out a SCHF.
4. Patients with nursemaid elbows usually have normal elbow radiographs. There is a clear radiographic abnormality in this patient.
5. Unlike patients with Monteggia fractures, the radio-capitellar joint in this patient appears to be well reduced.
Diagnosis
In this particular case, you should have suspected a transphyseal fracture of the right elbow
Diagnosis
Did you noticed the medial displacement of the elbow, with preservation of the radio-capitellar relationship?
X-rays
What is your diagnosis?
1. Elbow dislocation
2. Lateral condyle fracture
3. Supracondylar humerus fracture (SCHF)
4. Nursemaid elbow
5. Monteggia fracture-dislocation
6. Transphyseal fracture
The entire radius-ulna-capitellum complex is shifted medially
This is a different patient with a similar injury; he presented to clinic late. Notice the callus formation and the varus deformity, which is typical with this injury
Diagnosis
The cartilaginous portion of the distal humerus is displaced medially
Transphyseal Fracture
Does not involve the articular surface
Blood supply to the trochlea is at risk
Often associated with non-accidental trauma
Distal humerus usually displaced posteriorly and medially
Must be differentiated from a lateral condyle fracture
Contra-lateral elbow radiographs can be useful
Skeletal survey to rule-out other injuries
Social services consult
Back to our patient
He underwent CRPP
Anatomic reduction
No evidence of residual cubitus varus
Transphyseal Fracture - Management
The goal is early recognition, with avoidance of cubitus varus deformity. It is critical to rule-out non-accidental trauma as the etiology
Recommended Reading
Questions?
msilva@mednet.ucla.edu
Pediatric Supracondylar Fractures and Pediatric Physeal Elbow Injuries
Ortho Clin North Am, 2008 Apr;39(2):163-71
Shrader MW.
Thanks!!
Full transcript