Bilateral Distal Humeral Physeal Separation-From Birth Trauma to Family Trauma

Chondro-epiphyseal separation of the distal humerus is a rare injury, which can occur as a consequence of excessive traction on the upper extremity accompanying a dystocic birth or one complicated by cephalopelvic disproportion. Such fracture patterns can also result from a combination of rotatory and shear forces, also typically seen following child abuse. It can be easily mistaken for a posterior elbow dislocation, creating a delay in diagnosis. Since unossified cartilage cannot be seen radiographically, these injuries are better appreciated by ultrasound or magnetic resonance imaging.

We present a case of an 8-day-old neonate who presented with pseudoparesis of the left arm following birth. Posterior displacement of the elbow joint was identified on the radiograph. On ultrasound, a trans-physical supracondylar distal humerus fracture was identified. This was presumed as trauma secondary to a difficult delivery. At the 11th week of follow-up, the patient presented with a fracture of the right proximal tibia, followed by a fracture shaft left femur at 5 months of follow-up. Chest X-ray at this time revealed uniting rib fractures with callus formation. After ruling out any congenital collagen disorder (osteogenesis imperfecta), the patient was diagnosed with a case of battered baby syndrome. The case was reported to child protection services and parents were questioned and counseled for the same.

This case report highlights the importance of a high degree of suspicion of child abuse in any child with a rare fracture pattern, uncommon serial fracture occurrence, and unconventional clinic-radiological presentation.