Metaphyseo-diaphyseal junction fracture of distal humerus in children Ramesh Kumar Sen, Sujit Kumar Tripathy, Amit Kumar, Amit Agarwal, Sameer Aggarwal and Sarvdeep Dhatt Six metaphyseo-diaphyseal junction fractures of distal humerus and 182 supracondylar fractures of humerus treated in our institute over a period of 5 years were retrospectively analyzed. Clinical data regarding child’s age, neurovascular status, mechanism of injury, mode of treatment, and ultimate clinical outcome were collected for both these fractures and a comparison was made. Oblique (n = 2), comminuted (n = 3), and transverse types (n = 1) of fracture patterns were identified at distal humeral metaphyseo-diaphyseal junction. The oblique and comminuted fractures were managed by closed reduction and plaster of Paris cast, whereas the only transverse fracture was treated by closed reduction and Kirschner wire fixation. In contrast, 125 patients of supracondylar fractures were treated by closed reduction and plaster of Paris cast and the remaining 57 fractures needed Kirschner wire fixation after closed reduction. Assessment by Flynn criteria after 1 year after of injury revealed better functional outcome in metaphyseo-diaphyseal junction fractures. Although transverse fractures are unstable and may require surgical fixation; oblique and comminuted fractures at the metaphyseo-diaphyseal junction of distal humerus can be managed conservatively. J Pediatr Orthop B 21:109–114  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2012, 21:109–114 Keywords: children elbow fracture, metaphyseo-diaphyseal junction fracture of humerus, pediatric fracture, supracondylar fracture humerus Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India Correspondence to Dr Ramesh Kumar Sen, MS, DNB, PhD, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India Tel: +91 9914209744; fax: +91 172 2744401; e-mail: senrameshpgi@yahoo.in Introduction Supracondylar fractures of humerus are the most common injury around the elbow joint in the pediatric age group (more than 50% of all elbow fractures and 17% of all childhood fractures). The fracture typically remains extra- articular and involves thin bone between coronoid fossa and olecranon fossa of distal humerus [1–5]. However, the area proximal to the olecranon fossa, involving the metaphyseo-diaphyseal junction of the distal humerus remains as a ‘grey zone’ in children. Fractures at this region had been treated like supracondylar fractures or distal humeral fractures till Fayssoux et al. [6] described these injuries as a separate entity. We report six children with this uncommon injury, treated in our institute over a period of 5 years. The fracture lines showed a typical level and pattern, unusual enough to demand special narration. Materials and methods A review of medical records was conducted to identify all pediatric elbow fractures treated at our institution from 2000 to 2005. We could identify 182 supracondylar fractures and six metaphyseo-diaphyseal junction frac- tures after exclusion of open injuries. As per definition, the ‘metaphyseo-diaphyseal area’ (we named it as supra- supracondylar area) is the region between horizontal lines drawn proximally on the anteroposterior radiograph of the distal humerus where the transverse anteroposterior width of the humerus changed from a consistent value in the shaft to an increasing width in the metaphyseal area. Distally, the border is a horizontal line drawn tangential to the top of the olecranon fossa (Fig. 1). All data were collected in relation to the patient’s age, neurovascular status of the affected limb, mechanism of injury, fracture pattern, mode of treatment, and the ultimate clinical outcome. The fracture pattern in this supra-supracondylar region (n = 6) was further categor- ized into three patterns as per radiographs: oblique (n 1= 2), comminuted (n 2 = 3), and transverse type (n 3 = 1). The oblique and comminuted fractures were relatively undisplaced. Even in comminuted fractures with butterfly fragments, alignment was not much disturbed. All patients with oblique (Fig. 2a) and comminuted (Fig. 3a) fractures (except one neglected case) were treated early (within 48 h of injury) by closed reduction under sedation. Postoperatively, the limb was kept immobilized for a period of 3 weeks in above-elbow plaster of Paris (POP) cast. Then gradual mobilization of elbow joint was started. The neglected patient with a long oblique fracture presented late (after 4 weeks of injury) with complaint of swelling and stiffness. The radiograph showed good amount of callus formation at the fracture site. Therefore, without any further immobilization, physiotherapy was started. The only case of transverse fracture was stabilized surgically with Kirschner wires (K wire, two lateral and one medial) after closed reduction (Fig. 4a–c). Postoperatively, the extremity was immobilized Original article 109 1060-152X  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/BPB.0b013e32834ba9d6 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.