[Fractures around the knee in children : Epiphysiolysis and physeal fractures of the distal femur and proximal tibia]

Epiphysiolysis and epiphyseal fractures of the distal femur and proximal tibia are an extremely rare entity, but due to their far-reaching consequences with associated functional restrictions of the knee joint, they must be recognized and treated thoroughly. Complete and correct diagnosis is essential and, diagnostically speaking and in addition to standard x‑rays in two planes, the threshold for cross-sectional imaging examination techniques should be low. A conservative treatment attempt is possible for undisplaced fractures, but surgical retention and stabilization using wires and screws is usually indicated. Growth disorders often and inevitably occur after such injuries. Clinical monitoring of complications only ends once growth is complete.

Overuse Injury of the Epiphyseal Primary Physis

Year-round participation in youth sport that involves high levels of repetitive movement fosters an environment in which overuse injuries are likely to occur. Epiphyseal primary physeal stress injuries (PSIs), unique to skeletally immature athletes, are a particular concern, given their potential for growth disturbance. Initially observed in Little League baseball players, these injuries are now known to affect the long bones around the shoulder, elbow, wrist, hand, knee, ankle, and foot of skeletally immature athletes involved in a variety of sport activities.This article offers an epidemiological and radiologic perspective on the extent and distribution of epiphyseal PSIs in youth sport. We also review a novel framework for understanding the pathophysiologic mechanisms causing these injuries. This information is essential for the early identification of epiphyseal PSIs and devising preventive measures that can reduce a delayed diagnosis and long-term morbidity. Preventing and reducing injury to the epiphyseal growth plates is essential because impairment and dysfunction can result in lifelong morbidity and a risk of premature osteoarthritis.

Operative treatment of isolated epiphyseal fracture of the distal fibula: 1 case report and literature review

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

Management of Pediatric Supination-inversion Ankle Injuries Involving Distal Tibia and Intraepiphyseal Distal Fibula Fractures

Pediatric ankle fractures are prevalent injuries that make up a notable portion of all periphyseal injuries. The Salter-Harris classification is the most popular classification about physeal and periepiphyseal injuries. Ogden expanded on this and described type 7 fractures which are completely intraepiphyseal and include propagation of the fracture from the articular surface through the epiphyseal cartilage and do not involve the physis. These injuries are common about the distal fibula in pediatric patients with supination-inversion type injuries. There are no specific guidelines or recommendations on treatment of these injuries in the literature. We present three cases of this injury pattern and describe our chosen management that leads each patient to full, painless ankle range of motion and return to all prior activities and sports without complication. Supination-inversion type pediatric ankle fractures are common injuries that all orthopaedic surgeons will encounter at some point throughout their practice or training. Recognizing fracture variants and understanding treatment options of pediatric ankle fractures are important for the orthopaedic community as a whole.

Stabilisation of femoral capital physeal fractures using transcervical pinning in cats: 19 cases (2014-2022)

OBJECTIVES

To report the short-term clinical and radiographic outcomes in cats with femoral capital physeal fractures stabilised with transcervical pinning.

MATERIALS AND METHODS

Medical records of cats diagnosed with femoral capital physeal fractures and treated with transcervical pinning were reviewed. The collected data included signalment, weight, time from lameness to surgery, reported trauma, affected side, concomitant orthopaedic injuries, radiographs, osteoarthritis, femoral neck osteolysis, proximal femoral epiphysis to femoral neck ratio, fracture reduction, implants, complications and clinical evaluation results. An owner questionnaire was used for long-term follow-up.

RESULTS

Nineteen cats with a total of 21 fractures met the inclusion criteria. Fifteen of the 19 cats showed no signs of lameness at the 1-month follow-up. Major and catastrophic complications occurred in 9.5% and 23.8% of the fractures, respectively. All catastrophic complications occurred in fractures with a high preoperative osteolysis grade (2 or 3).

CLINICAL SIGNIFICANCE

In our study, transcervical pinning was found to be a reliable fixation method for the treatment of femoral capital physeal fractures in cats with minimal preoperative femoral neck osteolysis. High rates of implant failure with loss of fracture reduction were observed in cats with high-grade preoperative osteolysis.

[Epiphyseal fracture of the second metatarsal in adolescents: report of two cases]

Epiphyseal fractures of the metatarsal head are a rare entity specially as an isolated injury and is rarely seen in patients with skeletal immaturity. Due lack of documentation for this type of fracture, the treatment of choice is uncertain. The purpose of the present study is to present two cases and treatment of epiphyseal fracture of the second metatarsal head, to our knowledge there are no publications for this injury.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation

BACKGROUND

The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW.

MATERIALS AND METHODS

This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014).

RESULTS

A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27).

DISCUSSION AND CONCLUSION

Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Proximal femoral physeal fractures in children: a rare abusive injury

BACKGROUND

Proximal femoral physeal fractures are rare in abused children. Recognition may be hampered due to their rarity and lack of an ossified femoral head. Prompt diagnosis and treatment are essential to preventing coxa vara.

OBJECTIVE

To demonstrate the radiographic features of proximal femoral physeal fractures both with unossified and ossified femoral heads.

MATERIALS AND METHODS

We reviewed our Institutional Review Board-approved 21-year radiology database of 2,206 children who had a skeletal survey as part of their medical evaluation for possible abuse. Cases of proximal femoral physeal fractures were identified.

RESULTS

Eight patients, ages 2.5 to 26 months, with 10 fractures were found, yielding a prevalence of 0.4% (8/2,206). In all fractures, there was lateral displacement of the proximal femur. In three fractures, the femoral head was not ossified, simulating a hip dislocation. The intra-articular location of the femoral head was verified by ultrasound or abdomen computed tomography. Subperiosteal new bone formation was present in six fractures, all non-weight-bearing patients. The femoral head was ossified in seven cases, all with medial rotation of the femoral head. Metaphyseal irregularity was present in three of four fractures of the weight-bearing patients; two of three also had metaphyseal scalloping resembling osteomyelitis. The three with metaphyseal irregularity developed coxa vara.

CONCLUSION

Proximal femoral physeal fractures are rare in abuse cases. All present with lateral displacement of the proximal femur. With an unossified femoral head, it can simulate hip dislocation, which can be clarified with hip sonogram. Metaphyseal irregularity appears to be a feature in weight-bearing patients.

Percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fractures in children

PURPOSE

To describe clinical and radiographic outcomes after surgical management of angulated radial neck fracture in children.

METHODS

Twenty children (aged 2-11 years) with angulated radial neck fracture with more than 30° angulations (Judet type III and IV fractures) were retrospectively reviewed. All the enrolled patients were surgically treated with percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation. Clinical outcomes were evaluated using Tibone and Stoltz score and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes were evaluated with Métaizeau score. Complications were also evaluated.

RESULTS

At a mean follow-up of 20 months, no patients showed axial deformity of the upper limb or instability of the elbow. The mean value of the MEPS was 99.2, and excellent clinical results were achieved in 14 patients (73.7%) at Tibone and Stoltz score. The final X-rays showed fracture healing in all patients; furthermore, 75% of patients showed excellent reduction at Métaizeau score. No patient developed complication. There were no iatrogenic nerve injuries or pin infections.

CONCLUSIONS

The results demonstrate that percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fracture treatment is a simple, effective, rapid and inexpensive procedure.

LEVEL OF EVIDENCE

IV (case series and systematic review of level IV studies).

Management of neglected distal femur epiphyseal fracture-separation

INTRODUCTION

Neglected epiphyseal fracture-separations of the distal femur are rare. Still reported in developing countries, they lead to therapeutic issues. The objective of the study is to describe their characteristics and to propose treatment options.

MATERIALS AND METHODS

Ten years of ongoing study was held in our orthopedics department. All patients with a neglected epiphyseal fracture-separations of the distal femur after a knee trauma were included in the study. Pre-operative and post-operative data were collected and analyzed.

RESULTS

A total of 13 cases of neglected traumatic epiphyseal fracture-separations of the distal femur were found among 8616 in-patients of the department. It was mainly boys (9M/4F) around 16 years that were received 14 weeks after knee trauma. Most of the injuries were an AO-type 33-E/2.1 (Simple Salter-Harris' type II) (n=12) distal femur malunion (n=10). Associated complications were cutaneous opening (n=7), superficial infection (n=4), deep infection (n=4). Fractures were management surgically (n=12) by an open osteoclasis procedure (n=9), debridement (n=7) and a thigh amputation (n=1). The outcome was better if an open osteoclasis procedure was early performed in closed distal femur mal-union with a complementary rehabilitation program.

CONCLUSION

Specialized trauma care facilities must be increased, and trauma education programs must be undertaken to avoid neglected epiphyseal fracture-separations of the distal femur in developing countries.

Diagnostic accuracy of the shaft-condylar angle for an incomplete supracondylar fracture of elbow in children

OBJECTIVE

The incomplete supracondylar fracture of distal humerus poses difficulty for diagnosis. A shaft-condylar angle and a lateral capitellohumeral angle, which can be measured from a routine lateral view of plain film of the injured elbow, may be a clue to assist in the diagnosis. Nevertheless, no literature explains about the accuracy of these angles for diagnosis. Our goal is to investigate the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the shaft-condylar angle and the lateral capitellohumeral angle for diagnosis of the incomplete supracondylar fracture.

METHODS

The retrospective study in tertiary care hospital was performed from January, 2014, to January, 2018. The patients aged below 15 years with elbow injury were recruited. The patients with complete fracture were excluded. The rest of the patients were divided into four groups which consisted of incomplete fracture and non-fracture group. With the shaft-condylar angle at 40° and the lateral capitellohumeral angle at 50°, the diagnostic accuracy of both angles were calculated.

RESULTS

A total number of patients were 53. For the SCA, the accuracy was 92%, the sensitivity was 76%, the specificity was 93%, the positive predictive value was 92% and the negative predictive value was 93%. For the LCHA, the accuracy was 70%, the sensitivity was 55%, the specificity was 72%, the positive predictive value was 67% and a negative predictive value was 72%.

CONCLUSION

The shaft-condylar angle less than 40° in lateral elbow film might be a useful tool for diagnosis of the incomplete supracondylar fracture in pediatric patients with elbow injury.

The effect of stem fit on the radiocapitellar contact mechanics of a metallic axisymmetric radial head hemiarthroplasty: is loose fit better than rigidly fixed?

BACKGROUND

Radial head hemiarthroplasty is commonly used to manage comminuted displaced fractures. Regarding implant fixation, current designs vary, with some prostheses aiming to achieve a tight "fixed" fit and others using a smooth stem with an over-reamed "loose" fit. The purpose of this study was to evaluate the effect of radial head hemiarthroplasty stem fit on radiocapitellar contact using a finite element model that simulated both fixed (size-for-size) and loose (1-, 2-, and 3-mm over-reamed) stem fits. It was hypothesized that a loose stem fit would improve radiocapitellar contact mechanics, with an increased contact area and decreased contact stress, by allowing the implant to find its "optimal" position with respect to the capitellum.

METHODS

Finite element models of the elbow were produced to compare the effects of stem fit on radiocapitellar contact of a metallic axisymmetric radial head implant. Radiocapitellar contact mechanics (contact area and maximum contact stress) were computed for 0°, 45°, 90°, and 135° of elbow flexion with the forearm in neutral rotation, pronation, and supination.

RESULTS

The data suggest that the loose smooth stem radial head implant may be functioning like a bipolar implant in optimizing radiocapitellar contact. Over-reaming of 3 mm produced a larger amount of stress concentration on the capitellum, suggesting there may be a limit to how loose a smooth stem implant should be implanted.

CONCLUSIONS

The loose 1 to 2 mm over-reamed stem provided optimal contact mechanics of the metallic axisymmetric radial head implant compared with the fixed stem.

Experimental Induction of Physeal Injuries by Fracture, Drill, and Ablation Techniques: Analyses of Immunohistochemical Findings

BACKGROUND

Although physeal fractures and physeal bars can result in significant clinical consequences to growth and development of the injured physis, little orthopaedic research has focused upon this topic. Our objective was to extend a previously developed rat model to examine the immunohistochemical features following surgical application of techniques disrupting the physis.

METHODS

Physes were surgically disrupted using fracture (control), epiphyseal scrape (ES), or epiphyseal drill (ED). After 1, 3, 6, 10, or 21 days, animals were euthanized, sites processed for histology and immunohistochemical localization of vascular endothelial growth factor (VEGF), Factor VIII, Sox-9, PTHrP (parathyroid hormone-related protein) and PTHrP-R (parathyroid hormone-related protein receptor) in resting, proliferative, and hypertrophic physeal zones. Incidence of physeal bars, vertical septa and islands within the metaphysis was quantified. Semiquantitative analysis of immunohistochemistry was performed.

RESULTS

Physeal bars, vertical septa, and displaced cartilage islands were present each of the surgical treatments. Fisher's exact test showed a statistically significant increase in the presence of physeal bars (P=0.002) and vertical septa (P=0.012) in the ED group at 10 and 21 days. Analysis of VEGF showed significant differences among the surgical treatments involving the resting zone, and the proliferative zone for days 1, 6, and 21 (P≤0.02) with greater mean scores present in the fracture (control) group, followed by the ED group; the lowest scores were present in the ES group. PTHrP-R immunolocalization showed significant differences among treatments in the hypertrophic zone at days 6 and 21 (P=0.022 and 0.044, respectively).

CONCLUSIONS

On the basis of the type of surgical treatment, results show significant differences in the presence of VEGF (reflecting the vascular bed) in the resting and proliferating zones at days 1, 6, and 21. VEGF localization was less abundant in the ED group (which had more physeal bars), suggesting that lack of vascular ingrowth plays a role in physeal bar formation.

CLINICAL RELEVANCE

Basic science data presented here provide insight into the importance of the various regions of the physis and its repair and continued growth after physeal fracture. We suggest that a better understanding of the cellular basis of physeal arrest following physeal fracture may have future relevance for the development of treatments to prevent or correct arrest.

The shape match of the olecranon tip for reconstruction of the coronoid process: influence of side and osteotomy angle

BACKGROUND

The integrity of the coronoid process is critical to maintaining elbow stability. Unreconstructible fractures and chronic coronoid deficiency are challenging clinical problems with no clear solution. The purposes of this study were to investigate the shape match of the ipsilateral and contralateral olecranon tips as graft options and to determine the influence of the osteotomy angle on fitment.

METHODS

Nineteen paired cadaveric elbow joints were investigated by 3-dimensional digital analysis of computed tomography DICOM (Digital Imaging and Communications in Medicine) data. After construction of an ulnar coordinate system, the ipsilateral and contralateral olecranon tips were digitally harvested at 10°, 20°, 30°, 40°, 50°, and 60° osteotomy angles. In an overlay analysis, we compared the shape match of the ipsilateral and contralateral grafts and the different angles.

RESULTS

The ipsilateral grafts showed an average mismatch of 1.8 mm (standard deviation, 1.38 mm), whereas the contralateral grafts had a significantly lower (P < .001) mean mismatch of 1.3 mm (standard deviation, 0.95 mm). The 50° osteotomy plane showed the best shape match in comparison with the native coronoid-in both the ipsilateral and contralateral grafts. Evaluation of the intraclass correlation coefficient was calculated at r = 0.944, showing high repeatability of the measurements.

CONCLUSIONS

The contralateral olecranon tip graft showed significantly better shape matching to the native coronoid than the ipsilateral olecranon graft. Specifically, the contralateral graft more closely matched the biomechanically critical anteromedial coronoid facet. Finally, both the contralateral and ipsilateral olecranon grafts had better shape matching with the native coronoid when osteotomy was performed at higher angles, specifically 50°.

Capitellar erosion after radial head arthroplasty: A comparative biomechanical study of operated radial head fractures on cadaveric specimens

BACKGROUND

We asked whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA), common techniques used for the confrontation of displaced or comminuted radial head fractures, are correlated with cartilage wear of the capitulum.

HYPOTHESIS

We hypothesized that neither ORIF nor RHA are correlated with capitellar cartilage wear.

MATERIAL AND METHODS

On 5 cadaveric elbow specimens, osteotomies were employed to simulate radial head comminuted fractures followed with ORIF by Herbert screws. Radial heads were also excised from other 5 cadaveric elbow specimens and were replaced by metallic monopolar implants. Finally, 2 elbows were not operated and used as a control group. Custom-made rotary machines, working unstoppably, generated 700,000 pronation and supination forearm movements at a 110° arc of motion. The elbow joints were examined with pre- and postoperative magnetic resonance imaging (MRI) scans and the articular surfaces of the capitula were resected and sent for histopathology study.

RESULTS

In the 2 cadaveric elbows of the control group and the 4 elbows treated with ORIF, no cartilage damage was found. The fifth one displayed cartilage fissures, which were, classified according to International Cartilage Repair Society (ICRS) grading system as grade I cartilage damage. On the contrary, all 5 elbows treated with RHA sustained complete cartilage loss, exposure of the subchondral bone and were classified as ICRS grade IV cartilage damage.

DISCUSSION

Our study suggests that metallic monopolar RHA after a displaced or comminuted radial head fracture carries a high risk of rapidly evolving cartilage loss of the capitulum.

What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?

BACKGROUND

Isolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear.

QUESTIONS/PURPOSES

The objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms.

METHODS

Between June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images.

RESULTS

Patients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2-46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8-333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2-168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%).

CONCLUSIONS

Isolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field.

LEVEL OF EVIDENCE

Level III, prognostic study.

Physeal Fractures in Foals

Physeal fractures are common musculoskeletal injuries in foals and should be included as a differential diagnosis for the lame or nonweightbearing foal. Careful evaluation of the patient, including precise radiographic assessment, is paramount in determining the options for treatment. Prognosis mostly depends on the patient's age, weight, and fracture location and configuration.

Type-I monteggia with ipsilateral fracture of distal radius epiphyseal injury: A rare case report

Simultaneous Monteggia injuries of the elbow and ipsilateral fracture distal radius with epiphyseal injury both bone are a unique case. A unique case of a Type I Monteggia fracture equivalent with ipsilateral fracture distal radius with epiphyseal injury (Salter-Harris Type II) in a child is reported. We describe the management of this unique fracture and discuss the possible mechanism of injury. We have highlighted a rare combination of injuries. Early recognition and prompt surgical intervention can lead to a satisfactory outcome even in these complex injuries. Résumé Les traumatismes de Monteggia simultanés du coude et le rayon distal de fracture ipsilatérale avec lésion épiphysaire des deux os sont un cas unique. Un cas unique d'une fracture de Monteggia de type I avec un rayon distal de fracture ipsilatérale avec lésion épiphysaire (Salter-Harris Type II) chez un enfant est rapporté. Nous décrivons la gestion de cette fracture unique et discuter du mécanisme possible de la blessure. Nous avons mis en évidence une combinaison rare de blessures. Une reconnaissance précoce et une intervention chirurgicale rapide peuvent conduire à un résultat satisfaisant même dans ces blessures complexes.

Distal Humeral Epiphyseal Separation in a Newborn

Distal humeral epiphyseal separations are rare and treatment strategies are not well defined. The case of a full-term male newborn with a distal humeral epiphyseal separation as the result of a birth trauma was reviewed. A literature review of this topic was undertaken to better understand its occurrence, diagnosis, and treatment options. The patient sustained a distal humeral epiphyseal separation during a vaginal delivery. Deformity and decreased movement in the elbow were observed. Radiographs and subsequent ultrasound were used to make the diagnosis of distal humeral epiphyseal separation. Given the displaced and acute nature of the fracture, a closed reduction and percutaneous pinning was performed. Intraoperatively, this was greatly facilitated by an elbow arthrogram. Immobilization consisted of a posterior plaster splint and swathe. Postoperative follow-up with clinical and radiographic examination showed abundant bony healing and early restoration of function. Ultrasound is useful to confirm the diagnosis of a distal humeral epiphyseal separation for elbow injuries in very young patients. However, once the diagnosis is confirmed, an intraoperative elbow arthrogram helps highlight the fracture fragments and ensures proper reduction and fixation of the fracture. [Orthopedics. 2016; 39(4):e764-e767.].

[Growth behavior after epiphyseal plate injury: importance of "watertight" osteosynthesis]

BACKGROUND

The frequency figures for epiphyseal plate injuries of long bones given in the literature are inexact and they probably occur with a frequency of 15% of all fractures of the growing skeleton. In order to be able to give correct figures in the future a classification system, such as the LiLa classification should be used, which does not attempt to be oriented to an assumed growth prognosis but is oriented to therapy and makes a strict differentiation between shaft and joint fractures. For epiphyseal joint fractures a differentiation must be made between those where the epiphysis is still open and those where the epiphysis has begun to close, in order to be able to incorporate all epiphyseal joint fractures and differentiate them from epiphyseal shaft fractures (epiphysiolysis).

CLINICAL ASPECTS

The growth prognosis encompasses stimulatory and inhibitory growth disorders as well as spontaneous correction of residual axial deviations. The prognosis is fundamentally dependent on the biological age of the patient by fracture, on the localization in the skeleton and the localization in the segment because the growth components of epiphyses are asymmetrically distributed in the segment. Stimulatory growth disorders in the actual growth phase < 10 years of age are the obligatory growth disorders which lead to overgrowth of the section of the skeleton affected. In an age over 10 years they lead to an also obligatory premature closure of adjacent or affected epiphyses which is expressed as a slight shortening. Asymmetrical stimulations are most common in the upper extremities following intra-articular fractures of the radial condyle as the obligatory growth disorder at this site. Asymmetrical stimulation is rare in the lower extremities after extra-articular metaphyseal valgus fractures of the proximal and distal tibia. Asymmetrical premature closure of the epiphysis in the upper extremities is rare in contrast to partial stimulation with less than 5% after extra-articular fractures of the distal radius and proximal humerus. Conversely, asymmetrical inhibitory growth disorders are found significantly more often in the lower extremities after extra-articular and intra-articular fractures of the distal femur, proximal tibia and distal tibia between 50% and 20%. "Spontaneous corrections" of residual axial deviations and side to side shifts after epiphyseal shaft fractures occur reliably without resulting in growth disorders, provided the patient is young enough.

THERAPEUTIC TARGETS

In cases of displacement the aim of therapy in epiphyseal shaft fractures is to reconstitute age-related and tolerable axes. For displaced epiphyseal joint fractures the aim is to reconstruct the joint surfaces. The basic principles of an efficient and targeted diagnostics and the therapeutic options for diminishing the clinical sequelae of growth disorders are discussed.

CONCLUSION

No growth disorders, which are to be expected as a result of every epiphyseal injury, can primarily be therapeutically avoided; however, better foundations can be achieved to reduce the clinical sequelae of growth disorders. Therapy can only follow the differentiation into shaft and joint (and not an assumed growth prognosis) and should integrate a scientifically proven and reasonable spontaneous correction for the patient. A classification must achieve a therapy-related uncoupling of the epiphyseal injuries into shaft and joint fractures.

Shaft-Condylar Angle for surgical correction in neglected and displaced lateral humeral condyle fracture in children

PURPOSE

To assess the outcome after using the Shaft-Condylar angle (SCA) as intraoperative reference for sagittal plane correction in displaced lateral humeral condyle fractures in children presented 3-weeks after injury.

METHODS

Ten children, with delayed presentation of a displaced lateral humeral condyle fracture and undergoing surgery during 1999-2011, were reviewed. The goal was to obtain a smooth articular surface with an intraoperative SCA of nearly 40° and nearest-anatomical carrying angle. They were allocated into two groups according to the postoperative SCA [Good-reduction group (SCA=30-50°), and Bad-reduction group (SCA<30°, >50°)] and the final outcomes were then compared.

RESULTS

All fractures united without avascular necrosis. The Good-reduction group (n=7) showed a significant improvement in final range of motion and functional outcome compared to the Bad-reduction group (n=3) (p=0.02). However, there was no significant difference in pain, carrying angle and overall outcome between both groups.

CONCLUSION

SCA is a possible intraoperative reference for sagittal alignment correction in late presented displaced lateral humeral condyle fractures.

Fracture-dislocation of the humeral condyles in adults: results of surgical treatment

Fracture-dislocation of the humeral condyle is exceptional in adults. The purpose was to analyze the results of surgical treatment by open reduction and internal fixation without ligamentous repair. There were six men with an average age of 31 years. According to the AO classification, five fractures were classified as AO type B1 and one as B2. Dislocation was reduced in emergency before osteosynthesis. Postoperatively, the joint was held immobile with a brace for 25.40 days. Five patients were reviewed after a mean follow-up of 52.96 months. The median arc of flexion/extension was 104.80° and 157.8° for pronation-supination. All elbows were stable and all fractures were consolidated. Two elbows were painful. The results were satisfactory in five patients. The elbow stability can be ensured only by the synthesis of bone structures. Surgical treatment should restore exact anatomy between the condyle and trochlea. This protocol may provide a joint stability and satisfactory results.

Definitive fixation of tibial plateau fractures

Tibial plateau fractures present in a wide spectrum of injury severity and pattern, each requiring a different approach and strategy to achieve good clinical outcomes. Achieving those outcomes starts with a thorough evaluation and preoperative planning period, which leads to choosing the most appropriate surgical approach and fixation strategy. Through a case-based approach, this article presents the necessary pearls, techniques, and strategies to maximize outcomes and minimize complications for some of the more commonly presenting plateau fracture patterns.