**8. Fracture of the distal humerus epiphysis**

An extremely rare injury is the epiphysiolisthesis of the distal humerus epiphysis that is commonly diagnosed with delay. Clinical signs are swelling of the elbow, with increased anxiety of the neonate and reduced mobility of the affected arm. The differential diagnosis includes neonatal septic arthritis and brachial plexus palsy. Appropriate clinical examination is essential for the correct diagnosis. Radiological examination reveals signs of possible elbow dislocation (**Figure 22**). There is malalignment of the humerus with the proximal part of the radius and ulna. The distal humerus epiphysis is not ossified and cannot be found separated from the metaphysic on X-ray. The medical

**Figure 21.** *Fracture left humerus, after a CS delivery, as the first sign of Osteogenesis imperfecta*.

**Figure 22.** *Distal humerus epiphysiolisthesis appears on X-rays as an elbow dislocation.*

history of possible forceful handling of the arm during delivery is of importance. Ultrasound examination is helpful by revealing the diffuse hematoma and the separation of the chondral epiphysis. MRI has been used in order to make the diagnosis. The distal epiphysis appears separated from the metaphysis of the humerus.

Appropriate reduction in the first 2–4 days is essential in order to restore the anatomy and appropriate elbow function. Reduction is easily performed in the first 1–2 days with an impressive resolution of the symptoms. The elbow becomes less swollen and the relief of the neonate appears almost immediately. Proper casting with a brace is important for a period of 2 weeks. Reduction must be performed under anesthesia, using C-arm and possibly with the addition of an arthrogram, in order to

#### *Neonatal Fractures DOI: http://dx.doi.org/10.5772/intechopen.110167*

reassure the accurate reduction. Arthrogram in the neonate elbow is hard to be achieved with accuracy but in cases of a fracture with the hematoma of the joint that is swollen, it can be performed. Callus formation from the periosteal elevation in neonates is apparent early and reduction is not advised later than a period of a week.

K-wire stabilization is reported in cases of instability of the epiphysiolisthesis, but Salter type 1 and 2 are usually stable after appropriate reduction and cast immobilization is adequate. Remodeling of the humerus has been reported even in cases that the epiphysiolisthesis was diagnosed later and without reduction. But this extremely rare injury must be treated with adequate reduction in the initial first days [56–65].
