Epiphyseal Separation Research Articles

Epiphyseal Separation of the Proximal Humerus in a Newborn

Epiphyseal Separation of the Proximal Humerus in a Newborn

Relationship between lumbar disc herniation and Roussouly classification in the sagittal alignment of the spine and pelvis in young people.

The sagittal plane of spine-pelvis morphology of adult patients with lumbar disc herniation (LDH) differs from that of normal people. There is a correlation between abnormal sagittal plane morphology and adult LDH. This study aimed to investigate the relationship between LDH in young people and the Roussouly classification in the sagittal alignment of the spine and pelvis. A total of 126 patients with LDH hospitalized in our tertiary hospital between January 2020 and January 2021 who met the inclusion and exclusion criteria were retrospectively analyzed in a cross-sectional study. Participants were grouped according to the spinal level of disc herniation (L4/5 group, L5/S1 group, L3/4 group). Pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) of all cases were measured using standing lateral spinal radiographs. Facet joint angles (FJA) were measured using lumbar computed tomography (CT) horizontal radiographs, and the height of the anterior, middle, and posterior margins of the herniated disc was measured using sagittal radiographs. The classification of Pfirrmann disc degeneration was determined via magnetic resonance imaging (MRI) film of the lumbar region. Roussouly classification was performed according to sagittal plane morphology, and data were analyzed among each group. In all, 126 patients aged from 18 to 40 years, with an average age of 31.04±5.886 years were included. There were 63 cases of L4/5 disc herniation, 59 cases of L5/S1 herniation, and 4 cases of L3/4 herniation. There were 35 cases of epiphyseal separation. The Roussouly classification included 21 cases of type 1, 56 cases of type 2, 32 cases of type 3, 4 cases of type 4, and 13 cases of type 3 + anteverted pelvis (type 3-AP). The L4/5 disc herniation group had significantly more types 2 and 3 than the other groups, and the L5/S1 disc herniation group had significantly more types 1 and 2 than the other groups. There were no significant differences in the Pfirrmann grade of intervertebral disc degeneration; epiphyseal separation; the height of anterior, middle, and posterior margins of the herniated disc; the difference between left and right facet angle and bilateral facet angle; and the thoracic kyphosis (TK) value among any of the groups (P>0.05). There were significant differences in PI, PT, SS, lumbar lordosis (LL), and height of the anterior and posterior margins of the intervertebral space among all groups (P<0.05). PI values were grouped at 50°; PT, SS, and LL were significantly different (P<0.05), whereas TK values were not significantly different between the 2 groups (P>0.05). SS values were grouped at 35°, and there were significant differences in PI, TK, and LL between the 2 groups (P<0.05). According to the disc herniation segment, the patients were divided into L4/5 and L5/S1 groups. There were significant differences in PI, PT, anterior edge height, anterior to posterior edge height, left facet angle, right facet angle, and bilateral facet angle (P<0.05). LDH is common in L4/5 and L5/S1 segments. The incidence of Roussouly type 1 and 2 LDH is significantly higher than other types, and type 4 is the lowest. Small PI and small SS are more obvious in the L5/S1 segment. L5/S1 disc herniation is more common in patients with Roussouly type 1 and 2 classifications, whereas L4/5 disc herniation is more frequent in patients with Roussouly type 2 and 3 classifications.

Battered baby syndrome

Battered child syndrome, shaken baby syndrome, non accidental injuries of childhood, etc. are all variants of forms of child abuse that has many names but a single outcome – the child is injured at the hands of perpetrators. A four- months old female child was brought to the hospital with multiple bruises, left upper and right lower limb swelling with an open wound over right leg. On detailed examination and investigations, multiple fractures found in radius, ulna & amp; humorous in left hand and fracture of femur with tibia epiphyseal separation in right leg. The etiology was unclear at presentation. History obtained from the mother and father, was of conflicting nature. Inter-caste love marriage of mother and father, poor family support, poverty, presence of multiple bruises over the body, blue black discoloration of skin over right leg with multiple fractures revealed in X - Ray scan lead to the diagnosis of bettered baby syndrome.

Open anatomical reduction by anterior transverse mini approach for the treatment of distal humeral epiphyseal separation in young children.

The treatment of distal humeral epiphyseal separation (DHES) in young children includes closed reduction and cast immobilization or fixation by Kirschner (K) wire with the assistance of an elbow joint arthrogram. In this study, we aimed to introduce and evaluate open reduction using an anterior transverse mini approach in the treatment of DHES in young children. We retrospectively analyzed the clinical data of patients diagnosed with DHES at our hospital between January 2015 and December 2019. After applying the inclusion and exclusion criteria, 70 patients were included in this study. The fracture type was classified using DeLee's classification. The conservative group (14 patients; group A) underwent closed reduction and cast immobilization. Open surgery was performed using an anterior mini-transverse approach, and K-wires were used for fixation in group B (56 patients). After 3-5 weeks, the K-wires were removed following radiographic confirmation of callus formation. All elbow functions were evaluated using Flynn's criteria. Complications such as cubitus varus, nerve palsies, incision infection, and K-wire skin irritation were analyzed. According to DeLee's classification, in group A, five, four, and five patients were of types A, B, and C, respectively. In group B, 11, 10, and 35 patients were of types A, B, and C, respectively. There was a significant difference in Flynn's criteria ( P = 0.0007). In groups A and B, five and four patients developed cubitus varus, respectively, with a significant difference observed in the complication rate ( P = 0.0127). Five patients developed K-wire skin irritation. Nerve injury was not observed in either group. One patient in group B had avascular necrosis of the trochlea. Open anatomic reduction via the anterior mini-transverse approach can be a choice of treatment for DHES in young children. Level of evidence: IV.

An Unusual Presentation of a Child with Scurvy: A Case Report

Nutritional deficiency is very common in pediatric patients, especially in developing countries. A 4-year-old Maldivian boy presented with pain in major joints of lower limbs since two months and was unable to stand and walk since one month. There was no history of fever or fall. The growth was average with mild pallor. There was no joint swelling. Xray knee joint showed epiphyseal separation, cortical thinning suggesting a radiological diagnosis of Scurvy and after Vit C supplementation the child showed clinical and radiological improvement in two weeks. So, a high index of suspicion is required for early diagnosis and treatment.

Do bisphosphonates alter the clinico-radiological profile of children with Perthes disease? A systematic review and meta-analysis.

This meta-analysis is aimed to analyze the efficacy of bisphosphonates in the management of Perthes disease. A total of 8 animal and 7 human studies have been shortlisted for this analysis. In human studies, common variables for pain, Harris Hip Score (HHS), propensity for femoral head collapse, and total hip arthroplasty (THA), were assessed. In contrast, in animal studies, the data was recorded for epiphyseal quotient, trabecular volume, trabecular separation, trabecular thickness, and trabecular number. Meta-analysis of human studies on ONFH (Osteo-Necrosis of Femoral Head) revealed a statistically significant outcome in HHS [p<0.001; (95% CI: 4.79 - 8.87)], collapse of the femoral head [p=0.079; (95% CI: -0.16 - 0.01)], and THA [p=0.002; (95% CI: -0.19 - -0.04)] whereas the pain score showed an insignificant outcome [p=0.067; (95% CI: -0.62 - 0.04)]. The meta-analysis of selected variables in animal studies revealed a noteworthy outcome in bone volume (p<0.001, 95% Cl), trabecular number (p<0.001, 95% Cl), trabecular thickness (p<0.013, 95% Cl) and trabecular separation (p<0.026, 95% Cl) but not in epiphyseal quotient. Further, analysis of stratified datasets in animal studies revealed a contradictory outcome with significant observations described later in the paper. The use of bisphosphonates holds a promising treatment option in Perthes disease. Although, good quality RCTs are needed to validate it further.

Elbow Ulnar Collateral Ligament Shoelace Repair with Internal Bracing for Treating Throwing Athletes Who Have Ulnar Collateral Ligament Instability

This Technical Note aimed to present a surgical technique of ulnar collateral ligament (UCL) shoelace repair using suture anchors and double suture tapes in combination with internal bracing to correct UCL instability along with epiphyseal avulsion of the medial epicondyle in throwing athletes Skeletally immature throwing athletes playing baseball and softball are at a risk of sustaining medial epicondyle epiphyseal separation that can result in UCL instability, predisposing to elbow UCL disruption later. There are several surgical techniques that can restore elbow UCL function and stability. In cases where large fragments of the medial epicondyle are present in skeletally immature athletes, the residual bony fragment and the shortened, chronically injured UCL make surgical treatment quite challenging. Recent studies have shown that UCL repair with internal bracing can effectively treat acute UCL injury. However, this procedure is not ideal for restoring large disruption of the UCL such as fragmentation. Here, we present a surgical technique of UCL shoelace repair using suture anchors with double suture tapes in combination with internal bracing for correcting UCL instability concurrent with epiphyseal fragmentation of medial epicondyle in throwing athletes.

Incarcération du périoste dans le cartilage de croissance dans une fracture-décollement épiphysaire: à propos d'un cas

L´incarcération de corps étranger dans le cartilage de croissance est une pathologie rare. Elle survient souvent lors d´un décollement épiphysaire. Son diagnostic est radiologique, reposant sur l'imagerie par résonnance magnétique (IRM) cérébrale. Nous rapportons ici, le cas d´une fille de 13 ans qui s´est présenté pour un genou douloureux post traumatique gauche. L´examen clinique et les radiographies standards réalisées était en faveur d´un décollement épiphysaire type 1 de Salter-Harris. Le traitement de première intention qui avait consisté en une immobilisation plâtrée pendant trois semaines était non satisfaisante. Devant cet échec thérapeutique, une IRM a été réalisée et mise en évidence une incarcération de corps étranger dans le cartilage de conjugaison. La prise en charge secondaire a été chirurgicale avec des suites opératoires simples.

A case of epiphyseal separation of the distal ulna without distal radial fracture

A case of epiphyseal separation of the distal ulna without distal radial fracture

New System for the Classification of Epiphyseal Separation of the Coracoid Process: Evaluation of Nine Cases and Review of the Literature.

Objectives and Design. Epiphyseal separation of the coracoid process (CP) rarely occurs in adolescents. In this retrospective case series, we reviewed the data of nine patients treated at our center and those of 28 patients reported in the literature. This injury can be classified into three types according to the injured area: Type I, base including the area above the glenoid; Type II, center including the coracoclavicular ligament (CCL); and Type III, tip with the short head of the biceps and coracobrachialis, as well as the pectoralis minor. Patients/Participants. A total of 37 patients were included in the analysis. Data on sex, age, cause and mechanism of injury, separation type, concomitant injury around the shoulder girdle, treatment, and functional outcomes were obtained. Main Outcome Measurements and Results. Type I is the most common type. The cause of injury and associated injury around the shoulder girdle were significantly different between Type I, II, and III fractures. The associated acromioclavicular (AC) dislocation and treatment were significantly different between Type I and III fractures. Our new classification system reflects the clinical features, imaging findings, and surgical management of epiphyseal separation of the CP. Type I and II fractures are mostly associated with AC dislocation and have an associated injury around the shoulder girdle. Type III fractures are typically caused by forceful resisted flexion of the arm and elbow. Although the latter are best managed surgically, whether conservative or surgical management is optimal for Type I and II fractures remains controversial. Conclusions. We noted some differences in the clinical characteristics depending on the location of injury; therefore, we aimed to examine these differences to develop a new system for classifying epiphyseal separation of the CP. This would increase the clinicians' awareness regarding this injury and lead to the development of an appropriate treatment.

An unusual case of neonatal elbow septic arthritis mimicking a distal humerus physeal injury/elbow dislocation

Neonatal septic arthritis is a rare entity and an important differential diagnosis of distal humeral epiphyseal separation (DHES). DHES is yet again an infrequent phenomenon seen in less than 3.9% of physeal injuries which often masquerades as elbow dislocation. We report on a 20-day old term neonate referred with a suspected diagnosis of elbow dislocation following trauma. Subsequent to evaluation in a tertiary care hospital this was found to be a rare case of septic arthritis of elbow in a neonate mimicking DHES. The diagnosis of septic arthritis in neonates is often delayed because the characteristic symptoms and signs seen in older children are absent or subtle. DHES is a rare injury, which to an untrained eye, may be misdiagnosed as an elbow dislocation. Septic arthritis and acute osteomyelitis are differential diagnoses of DHES, however, the history of incidental trauma hoodwinked us to provisionally diagnose it as the latter.

Closed Reduction of Pediatric Distal Radial Fractures and Epiphyseal Separations.

Sedated, closed reduction of a displaced distal radial fracture followed by cast immobilization is indicated in cases of unacceptable alignment on post-splint imaging. The aim of this procedure is to obtain acceptable reduction and cast immobilization for fracture-healing. The patient is positioned supine with the injured arm on the image intensifier. Adequate sedation is achieved with conscious sedation, general anesthesia, or regional anesthesia (hematoma block). The radial or ulnar translation is corrected with in-line traction. The wrist is typically hyperdorsiflexed, and traction is applied to the distal fragment. The distal fragment is then walked up and over as axial traction is applied and the wrist is brought from extension to flexion. The reduced wrist is held in a position of gentle flexion and slight ulnar deviation, and post-reduction fluoroscopy in anteroposterior and lateral views is obtained. A long-arm cast is applied by first applying a short-arm cast and a 3-point mold. Minimal cast padding is utilized to obtain the optimal "cast index." The wrist is re-imaged on the fluoroscopy device to obtain anteroposterior and lateral views. Alternative treatments include cast immobilization in situ, closed reduction and percutaneous pinning, and open reduction and internal fixation. Closed reduction and cast immobilization is a low-risk procedure that has a high rate of union with acceptable alignment without the risk of an additional surgical procedure. The long-arm cast is maintained for 6 weeks, and radiographs are obtained at 1 and at 2 weeks postoperatively to confirm maintained alignment. It is advisable to instruct the patient not to put anything down the cast because this can result in skin breakdown. Additionally, care must be taken on removal of the cast. Cast saws should be kept sharp and be replaced frequently. There are commercially available "zip sticks" and other such devices to prevent cast-saw burns that should be utilized if cast technicians or residents are assisting in the removal. Following removal of the cast, we recommend wrist-motion exercises be performed 3 times daily. If the fracture line is clearly visible on radiographs, a removable wrist splint is utilized for another 2 to 4 weeks. A full return to activity is expected at 3 months. Some residual deformity is acceptable if the remodeling capacity is excellent at the distal aspect of the radius. However, the tolerance for malreduction decreases as the patient ages, if the deformity worsens, or if there is a deformity further from the physis. Particular attention should be given to the median nerve sensory component. The thumb, index, and long fingers are assessed for sensation and compared with the 2 ulnar digits. Acute carpal tunnel syndrome is possible in children who have distal radial fractures.Waterproof cast padding is not recommended in cases in which a closed reduction is performed because such padding does not provide good protection to the skin with adequate cast molding.After reduction is obtained, no additional traction should be applied. If an assistant applies traction with the wrist in extension, reduction can be lost, so it is preferred to maintain the wrist in slight flexion while placing the cast.Although it is beneficial to hold the fracture in the cotton-loader position, this position should not be exaggerated because this position can cause excessive pressure on the carpal tunnel.The median nerve passes through the carpal tunnel and is often at risk because of hematoma formation as a result of a distal radial fracture.A cast index of 0.8 or more has been found to have an increased risk of failure of closed treatment. The cast index is the ratio of sagittal (measured on a lateral view) to coronal (measured on an anteroposterior view) width from the inside edges of the cast at the fracture site.Keeping cast saw blades sharp, using saws attached to vacuum devices, and cooling the blade while in use can prevent cast-saw burns.Zip sticks can be utilized to protect the skin but can sometimes be difficult to get under the cast.It is important to remember that swelling will occur following fracture reduction. The cast should not be wrapped tightly. Consideration should be given to bivalving the cast at the time of reduction and overwrapping after a few days when acute swelling has improved.Vigilance for growth arrest is necessary in patients with fractures of the distal aspect of the radius. This can occur in up to 4% to 5% of cases and is more common with reduction, particularly late reduction. Radiographic screening 6 to 12 months after the injury can help identify an early arrest.

Epiphyseal separation of distal humerus of congenital insensitivity to pain with anhidrosis : A case report

Epiphyseal separation of distal humerus of congenital insensitivity to pain with anhidrosis : A case report

Birth-related distal humerus epiphyseal separation: Outcome following surgical management

Distal humerus epiphyseal separation is a rare entity that can present as a birth-related injury. It commonly presents in children younger than 2 years of age and can be a result of a fall or forceful manipulation during delivery. It commonly presents with elbow swelling and decreased movement in newborns. It can be misinterpreted as elbow dislocations due to the lack of ossification in the distal part of the humerus on plain radiographs. Several treatment approaches have been reported in the literature including surgical and nonsurgical treatment modalities. We present a 2-day-old girl with a right distal humerus epiphyseal separation following spontaneous vaginal delivery. An anatomical and a stable reduction of the fracture was the aim in the management of this injury and was achieved using an arthrogram-assisted closed reduction and a single percutaneous Kirschner wire fixation. The patient was followed for 12 months and showed a satisfactory outcome.

Simple method of differential diagnosis between lateral condylar fracture and epiphyseal separation of distal humerus in children based on the direction of displacement of distal lateral metaphyseal fragment

Simple method of differential diagnosis between lateral condylar fracture and epiphyseal separation of distal humerus in children based on the direction of displacement of distal lateral metaphyseal fragment

Long-term outcomes of distal humeral epiphyseal separations treated via closed reduction and pinning under arthrogram

BackgroundThe purpose of this study is to report the longterm radiological and clinical outcomes of the distal humeral epiphyseal separations (DHESs) treated by arthrogram-assisted closed pinning, retrospectively. MethodsAmong patients surgically treated from February 2000 to March 2010, 12 patients followed-up for at least 7 years were investigated. After careful inspection of initial simple radiographs, we performed intraoperative arthrogram for all children, confirmed DHES status, and concluded with closed reduction and pinning. At the final follow-up, the radiological and clinical outcomes were evaluated. ResultsThe mean age at injury was 23.5 months, and four patients were male (42%). The mean age at final follow-up of 12 children/adolescents was 11.6 years. The mean follow-up period was 9.7 years (116.2 months). The dominant arm was injured in seven children. Two, seven, and three children were of the modified DeLee classifications A, B, and C, respectively. At the final follow-up, the mean humeral lengths of the injured and contralateral (normal) sides were 24.00 cm and 24.1 cm, thus not significantly different (P = 0.32). The final carrying angles were 10.75°, with significantly different with contralateral side (13.67°, P = 0.011). However, final shaft-condylar angles were not different (P = 0.207). There was no finding of avascular necrosis around trochlear area in all patients. The mean MEPS was satisfactory and the flexion/extension ranges were similar to those of the normal side (P = 0.317, 0.083). ConclusionsK-wire fixation via the arthrogram is useful when treating DHES, as it enhances anatomical reduction and minimizes later risk of cubitus varus. The clinical outcomes in school-age children and adolescents were satisfactory in most cases; however, longer follow-up of adolescents with cubitus varus is required. Level of EvidenceLevel IV, Therapeutic.

Slipped Capital Femoral Epiphysis (SCFE) Coxa Vara Adolescentium (CVA)

Slipped fem oral capital epiphysis is considered to be one of the most destructive conditions of hip joint during adolescence. The epiphysolysis of the femoral head was first defined in 1572 by the French surgeon Abrois Paré (1510 - 1590). The first authentic traumati c epiphysesolysis of the femoral head was described by Brousseau in 1867. It was in a 15 - year - old boy with multiple injuries after trauma with heavy carriage. Death occurred in a few hours, and was discovered by post - mortem examination. Complete separation of epiphysis of the femur head was found. The first mention of a non - traumatic form of epiphysolysis occurred in a fourteen years old boy later. In 1881, Fiorani reported fifteen cases of distorted hip joint with impaired adduction in children. He describ ed the deformity as a bend of the proximal part of the femur, which was based on rickets. With a high probability, some individua ls were coxa vara adolescentium . The first complete description of the disease was given by E Müller (1888) in his work “ About the bending of the femoral neck in the growth age ” Coxa vara adolescentium (CVA), epiphysesolysis of femural head or slipped femoral capital epiphysis represents a serious hip disease in the pubescent age at which the femoral proximal growth plate loses it s strength and influence mechanical forces, caused mainly by excessive body weight, the non - traumatic epiphysesolysis will occur. Symptoms like pain and twisting are initially vague, but they tend to escalate over time . The incidence of this disease is 0. 1 per one million, affect male more than female 2:1,4 in the rapid growth period 10 - 16 years old. Childhood obesity is the common cause of Slipped femoral capital epiphysis, then endocrine disorders and Down syndrome. Slipped femoral capital epiphysis has three grades first up to 33 degrees of slippage, second grade from 34 - 50% of slippage and the third degree more than 50%.Slipped femoral capital epiphysis, represents a serious disease of the puberty in the pubescent age at which the femoral proximal growth plate loses its strength and influence mechanical forces, caused mainly by excessive body weight, will occu r non - traumatic epiphysesolysis . Symptoms like pain and limping are initially vague, but they tend to escalate over time .

Severe cubitus varus deformity after repeated fracture of the lateral humeral condyle following distal humeral epiphyseal separation : a case report

Severe cubitus varus deformity after repeated fracture of the lateral humeral condyle following distal humeral epiphyseal separation : a case report

Anteromedial epiphyseal separation of the distal humerus in an 8-year-old girl: A case report and literature review of a rare injury pattern

Fractures involving the entire distal humerus are uncommon injuries and are usually seen in infants and neonates. Their occurrence in older children is uncommon and is mostly limited to children younger than seven years. Epiphyseal separation of the distal humerus usually follows an extension pattern, in which the distal fragment is posteriorly displaced. Anteromedial displacement is extremely rare and is considerably rarer in 8-year-old children. This case report describes this extremely rare injury pattern in an 8-year-old girl and provides relevant details of its management.

Case report rare greater trochanter fracture

Introduction: The Greater Trochanter fracture is a rare injury. It is of two types, True fracture which occurs only in Adults or as Epiphyseal separation which are found in adolescent population. It is caused by direct hit or fall muscular disruption displacement of trochanteric fracture is secondary to short external rotators with forceful abduction with leg in external rotation. Case report: In this case report, 26 year male presented with pain over hip with weakness in abduction and limping. On X ray it was greater trochanter fracture which was fixed with cancellous screw, the outcome was good. The patient reverted to his obvious activities with normal range of movement. Conclusion: The surgical minimally invasive treatment have better outcome with early mobilization, good range of hip movement especially abduction post operative in adult.