Physeal Separation of the Distal Humerus, a Rare Consequence of Trauma at Birth. Case Report

The patient is a 3.520 kg term girl with a footling breech presentation; delivery of the upper limbs and trunk was difficult. Forceps/vacuum were not used. Absence of active movement of the right shoulder and an undisplaced mid-third fracture of the clavicle were observed before discharge. Finger movements were normal. The first diagnosis was obstetrical Erb’s paralysis and clavicle fracture. At the 14-day follow-up, swelling and point tenderness above the clavicle resumed while right ipsilateral elbow was swollen without direct signs of trauma. Passive elbow movement in a range of 20– 908 was possible if done very gently. Radiographs (Fig. 1 a and b) showed the radius and ulna were not in alignment with the distal humerus. Radiographs of the opposite elbow were normal. Perinatal child abuse was ruled out. An ultrasound (US) of the elbow was obtained with a 7.5 MHz linear transducer. The examination was consistent with physeal separation of the distal humerus with posterior and medial displacement. On longitudinal view one can see the periostal elevation while the subperiostal space in the distal humerus is seen to be hyperechogenic thus being consistent with incipient callus. The transverse view showed posteromedial physeal displacement (Fig. 2 a and b). The standard sonographic examination should include examination of the controlateral elbow.