Distal humerus physeal fractures in children under 3 years: a systematic review and quantitative descriptive analysis
Jie C Nguyen1,2, Carlos Yaya-Quezada3, Samuel S Hailu3
1Department of Radiology, Section of Musculoskeletal Imaging, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. nguyenj6@chop.edu.
Insights
Radiographs often misdiagnose distal humerus physeal fractures in young children. Ultrasound and MRI are more reliable for diagnosing these fractures, which can lead to complications in nearly half of affected elbows.
Area of Science:
- Pediatric Orthopedics
- Medical Imaging
- Radiology
Background:
- Distal humerus physeal fractures are uncommon in children under 3 years.
- Accurate and timely diagnosis is crucial for appropriate management and preventing long-term complications.
Purpose of the Study:
- To systematically review imaging diagnosis and modality-specific characterization of distal humerus physeal fractures in children under 3 years.
- To evaluate the diagnostic accuracy of different imaging modalities for these fractures.
Main Methods:
- A systematic literature search was conducted for peer-reviewed publications on distal humerus physeal fractures in children under 3 years.
- Study quality and risk of bias were assessed.
- Data on demographics, injury mechanisms, imaging findings, diagnosis, treatment, and outcomes were collected and analyzed.
Main Results:
- Radiographs were the most common initial imaging modality but had a high rate of misdiagnosis (e.g., joint subluxation-dislocation).
- Ultrasound and MRI demonstrated high accuracy in identifying physeal fractures (97.9% and 94.1%, respectively).
- Posteromedial forearm malalignment was the most frequent radiographic finding, and nearly half of the elbows had complications like cubitus varus and limited range of motion.
Conclusions:
- Radiographs are frequently used for initial screening but are often inadequate for diagnosing distal humerus physeal fractures in young children.
- Ultrasound and MRI are essential for accurate diagnosis and confirmation of these fractures.
- A significant proportion of these fractures result in complications, highlighting the importance of early and accurate diagnosis.
Objective:
To conduct a systematic review on the imaging diagnosis and modality-specific characterization of distal humerus physeal fractures among children under 3 years of age.
Methods:
A literature search was performed to identify peer-reviewed publications that included imaging descriptions on distal humerus physeal fractures in children < 3 years. Study quality and risk of bias were evaluated. Demographic information, mechanisms of injury, imaging workup and findings, radiographic diagnosis, diagnostic imaging modality, treatment, and outcome were collected and summarized using descriptive statistics.
Results:
Thirty-seven studies (published, 1963-2023) included 24 case reports and 13 case series, yielding 101 children (102 elbows), who underwent 175 imaging examinations (102 initial, 7 repeat radiographs; 48 initial, 1 repeat ultrasounds; and 17 MRI examinations). Excluding 3 elbows that underwent concurrent ultrasound, physeal fracture was suspected on radiographs in 55.6% (55/99) and the most common misdiagnosis was joint subluxation-dislocation (53.8%, 21/39). Physeal fractures were identified on ultrasound and/or MRI in 97.9% (47/48) and 94.1% (16/17) of the examinations, respectively. The most reported radiographic finding was posteromedial forearm malalignment (68.6%, 48/70). Most (63.5%, 61/96) elbows were treated with immobilization and residual findings were reported in 44.8% (43/96) of the elbows with the most common findings including cubitus varus (39.5%, 17/43), residual deformity (27.9%, 12/43), and limited range of motion (25.6%, 11/43).
Conclusion:
Radiographs were the most often used initial imaging to screen for distal humerus physeal fractures in children under 3 years, whereas ultrasound and MRI were reserved for workup and confirmation. Nearly half of these elbows had complications.
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