SUDANESE JOURNAL OF PAEDIATRICS

2020; Vol 20, Issue No. 2

IMAGE

Transphyseal separation of distal humerus in an infant diagnosed with the help of radiography and ultrasonography

Sonal Saran (1), Mohit Singh (1)

(1) Department of Radiology, All India Institute of Medical Science (AIIMS) Rishikesh, Uttarakhand, India

Correspondence to:

Sonal Saran

Department of Radiology, All India Institute of Medical Science (AIIMS) Rishikesh, Uttarakhand, India

Email: sonalsaranmalik [at] gmail.com

Received: 06 January 2020 | Accepted: 26 April 2020

How to cite this article:

Saran S, Singh M. Transphyseal separation of distal humerus in an infant diagnosed with the help of radiography and ultrasonography. 2020;20(2):186–188.

https://doi.org//10.24911/SJP.106-1578123593

---

A 3-day-old male neonate presented to the Orthopedic Outpatient Clinic with grossly swollen left elbow and motionless upper limb with palpable crepitus. There was history of normal vaginal delivery at home with immediate cry at birth. The birth weight was 2,300 g. Antenatal course was uneventful. Conventional radiograph of the child’s elbow was performed which showed posteromedial dislocation of upper end of radius and ulna with respect to humerus and extensive soft tissue swelling in the lower arm and complete forearm region (Figure 1). Clinical and radiographic diagnosis of transphyseal separation of the distal humerus (TPSDH) was made and ultrasound was advised to confirm the diagnosis. High frequency ultrasound examination of the elbow showed separation of the base of distal humeral epiphysis from the humeral metaphysis and bare surface of metaphysis without epiphyseal coverage (Figure 2). Associated joint effusion and soft tissue swelling were also present. Ultrasound of the normal contra lateral elbow was performed to show normal appearance of humeral, radial and ulnar epiphysis and their alignment (Figure 3). The infant underwent closed reduction and cast application under anesthesia. The above elbow cast was applied with 90° flexion. Adequate callus formation was seen after 15 days, subsequent to which cast was removed and active elbow motion was allowed.

Figure 1. Conventional radiograph of the child’s elbow showing posteromedial dislocation of upper end of radius and ulna with respect to humerus and extensive soft tissue swelling in the lower arm and complete forearm region.

Figure 2. High frequency ultrasound examination of the affected elbow showing separation of the base of distal humeral epiphysis from the humeral metaphysis and bare surface of metaphysis without epiphyseal coverage.

Figure 3. Ultrasound of the normal contra lateral elbow showed normal appearance and alignment of humeral epiphysis (HEp) and radial epiphysis (REp).

TPSDH is very rare entity, mainly seen in young children and the causes include traction and rotatory forces (often birth trauma) and falling on outstretched hand. Typical presentation includes swelling around the elbow joint and decrease movement of affected upper extremity which is noticed after few days of birth [1,2]. Important differential diagnosis includes traumatic elbow dislocation, inflammatory/infective arthritis and child abuse [3]. The delay in diagnosis of TPSDH can lead to serious elbow deformities.

Imaging modalities for evaluation include conventional radiography, ultrasonography and magnetic resonance imaging (MRI). At birth, the entire distal humeral epiphysis is cartilaginous and not visualized on radiography, whereas it is easily seen on ultrasound as hypoechoic structure with internal specks of hyper-echogenicity. The diagnosis of TPSDH is therefore challenging on radiography. The only sign of TPSDH is posteromedial displacement of the radius and ulna in relation to the distal humerus along with swelling around the elbow joint. Ultrasound is very cost effective, non invasive and easily available tool in differentiating physical separation from elbow dislocation, inflammatory and infective arthritis of elbow joint. MRI is the most accurate modality which gives multiplanar view of cartilage, bone and soft tissue of the elbow joint; however, the examination requires long waiting time and sedation which leads to delay in treatment [4,5]. MRI was not needed in our case. Diagnosis of TPSDH requires high index of suspicion. Prompt closed reduction and immobilization gives excellent results.

---

DECLARATION OF CONFLICTING INTERESTS

None.

---

FUNDING

None.

---

ETHICAL APPROVAL

Ethical approval obtained from the ethical committee of our institute.

---

CONSENT FOR PUBLICATION

Signed informed consent for participation and publication of medical details was also obtained from the parents of the patient. Confidentiality was ensured at all stages.

---

REFERNCES

1. Jacobsen S, Hansson G, Nathorst-Westfelt J. Traumatic separation of the distal epiphysis of the humerus sustained at birth. J Bone Jt Surg Br. 2009;91:797-802.
2. Oh CW, Park BC, Ihn JC, Kyung HS. Fracture separation of the distal humeral epiphysis in children younger than three years old. J Pediatr Orthop 2000; 20:173–176.
3. Hansen M, Weltzien A, Blum J, Botterill NJ, Rommens PM. Complete distal humeral epiphyseal separation indicating a battered child syndrome: a case report. Arch Orthop Trauma Surg 2008; 128:967–972.
4. Nimkin K, Kleinman PK, Teeger S, Spevak MR. Distal humeral physeal injuries in child abuse: MR imaging and ultrasonography findings. Pediatr Radiol 1995; 25:562–565.
5. Ziv N, Litwin A, Katz K, Merlob P, Grunebaum M. Definitive diagnosis of fracture-separation of the distal humeral epiphysis in neonates by ultrasonography. Pediatr Radiol 1996; 26:493–496.