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C OPYRIGHT Ó 2021 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Ipsilateral Displaced Physeal Fractures of the

Proximal and Distal Humerus with Subperiosteal
Extrusion in a 6-Year-Old Child
A Case Report
Aditya Kaushal, MS, Sanya Vermani, MD, Jessica Kaushal, MBBS, and Lalit Kaushal, MS
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Investigation performed at Magnus Hospital, Panchkula, India

Abstract
Case: We present a case of a 6-year-old male child with ipsilateral proximal and distal physeal separation of humerus with
subperiosteal extrusion after manipulation by a bonesetter. Treatment included open reduction and internal fixation with
Kirschner wire proximally and distally. At 1.5-year follow-up, the child had a shortening of 0.5 cm, no pain, and/or no
instability.
Conclusion: Manipulation by bonesetters, a commonplace in developing countries, can produce unpredictable com-
plications and compromise outcomes. Although accepted in certain settings, the regional orthopaedic surgeons should be
mindful of the unique clinical challenges imposed by such a practice.

T
he proximal humerus physeal injury accounts for 0.5%
of all pediatric fractures, whereas the distal humeral
transphyseal fractures are less common1,2.
We present a case of ipsilateral severely displaced physeal
injury of the proximal and distal humerus after manipulation
by a traditional bonesetter (TDS) in a 6-year-old child. The
mechanism of injury, radiology, management, and complica-
tions of this injury are discussed here.
The patient and his parents were informed that data
concerning their cases would be submitted for publication, and
they provided consent.
Case Report
There was no active range of motion in shoulder and elbow,
and passive movements were painful. Neurovascular status was
normal. Radiological findings included a severely displaced
proximal and distal humerus physeal separation with subper-
iosteal extrusion (Fig. 2).
After informed consent for open reduction internal fixa-
tion, the patient was taken to the operating room, and after
induction of general anesthesia, gentle closed reduction (directed
opposite to deformity) was attempted, without success. Any forced
manipulation was deferred to avoid neurovascular complications,
and the surgeons progressed to open reduction. The proximal
humerus site was opened first through the deltopectoral approach,
and the displaced proximal end was identified to be stripped off

A 6-year-old male child reported to our emergency outpa-

tient department with 3-day-old injury on nondominant
extremity with pain, swelling, and loss of function. According
from the periosteum and pierced through the pectoralis major
muscle. The proximal diaphysis was freed from soft tissue, held
with small bone holding forceps, and longitudinal traction was
to the parents/guardians, the patient sustained the injury by fall applied, which was not successful. We then proceeded to open the
on outstretched arm, and the pain and deformity were further distal fracture site using anterolateral (slightly posterior incision)
worsened by manipulation performed by a TDS, and subse- approach. The elbow joint capsule was found to be intact, and
quently, the child was referred to our institution. Any history of there was no associated elbow dislocation. The injury was identi-
child abuse was also ruled out. On examination, there was fied as purely physeal injury (transphyseal fracture). Distal end
tenderness, palpable swelling, bruising, and visible deformity of the displaced shaft was identified and held with bone hold-
in the axillary and elbow region (Fig. 1). The injury was also ing forceps. Simultaneous longitudinal and lateral pressure with
associated with bony prominence in the subcoracoid region. thumb was applied on the proximal end, and longitudinal pulling
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B743).
Keywords: Physeal injury; pediatric; case report; proximal humerus physeal; distal humerus transphyseal; manipulation; traditional bonesetter; K-wire
fixation; subperiosteal extrusion; Shortening; angular deformity

JBJS Case Connect 2021;11:e20.00881 d http://dx.doi.org/10.2106/JBJS.CC.20.00881

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Fig. 1
Fig. 1 Clinical examination depicting subcoracoid swelling and bruising. Fig. 2 Radiograph depicting bipolar physeal separation (severely displaced
proximal and distal humerus physeal injury). Note: Separation from periosteum (*).
force with small bone holding forceps on the distal end was
applied, after which, the humerus was observed to “fall into place.”
After maintaining length, angular and rotational alignment was
confirmed clinically and image intensifier. Single 2.0-mm smooth
Kirschner wire (K-wire) was used for fixation first at proximal site
and then at distal site between fracture ends under image guidance
(Fig. 3). Stability of elbow and shoulder was assessed and found to
be adequate. Wound closure was performed in layers, Kirschner
wires were left outside the skin, and plaster splint was applied.
Postoperatively, the neurovascular status was reassessed,
and careful monitoring for swelling was performed. Staples
were removed by second week postoperatively, and Kirschner
wires were removed by fourth week after radiographic signs of
union. The splint was removed at 6th week and replaced by arm
sling. Intermittent shoulder and elbow range of motion exer-
cises were started. Patient was able to return to daily activities
after 8 weeks. The radiographs at 1-year (Fig. 4) and 1.5-year
(Fig. 5) follow-up, as well as the elbow range of motion at 1.5-
year follow-up, are shown (Fig. 6).
Discussion
M ost proximal humeral physeal injuries (PHPI) can be
managed nonoperatively primarily because of the immense
growth and remodeling potential3. However, injuries that are either
severely displaced, irreducible, and causing severe skin compromise
warrant a surgical intervention. Single or multiple K-wires can be
I P S I L AT E R A L D I S P L A C E D P H Y S E A L F R A C T U R E S
Fig. 2
used4,5. In concurrence with our approach, Dobbs et al.6 outlined
treatment guidelines in patients with severely displaced proximal
humerus physeal injury based on age and angulation.
Transphyseal distal humerus fracture (TDHF) dislocation
is a relatively rare injury, and its presence coupled with subperi-
osteal diaphyseal separation and severe displacement both prox-
imally and distally because of manipulation make this case unique.
TDHF dislocation has also been previously documented to occur
as a result of nonaccidental trauma, frequently child abuse in
children younger than 2 years and secondary accidental trauma in
older children7-9. In contrast to the PHPI, a thorough clinical and
radiological evaluation is important in the management of elbow
injuries. Supracondylar fracture humerus, being more common,
needs to be excluded. Another differential is elbow dislocation,
albeit, rare7 (See Supplemental Digital Content 1, http://links.lww.
com/JBJSCC/B743). However, management of these injuries can
be performed through percutaneous or open pinning (single
or multiple pins)7,10-13.
The mechanism of injury in our case is truly unknown;
however, we suspect that the frequently seen proximal physeal
injury (however, initially undisplaced/minimally displaced) could
have resulted from the primary trauma of fall and the manipulation
performed by TDS played a key role in severe displacement as well
as subperiosteal extrusion of the diaphysis. The unusual type of
distal physeal injury resulted either at the time of primary trauma
or secondary insult by manipulation. Moreover, the distracting
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Fig. 4
Anterior posterior and lateral radiographs performed at 1-year follow-up.

maintenance of reduction20. Fracture healing in our patient can

Fig. 3
Immediate postoperative radiographs.
forces generated by manipulation displaced the distal humerus
proximally and the proximal humerus anteriorly because of the
thin and weak periosteum in this region, although the thick
posterior periosteum remained intact. Subsequently, the humeral
diaphysis displaced proximally and adducted because of the pull of
the deltoid and pectoralis major muscles, respectively. In con-
currence with our hypothesis, injuries around the elbow have
been most associated with previous manipulation and similar
complications such as aggravation of deformity, among others
such as elbow stiffness, malunion, nonunion, nerve entrapment,
Volkmann ischemia, and even gangrene in some cases14-19.
In our patient, although the displacement was severe in
both proximal and distal physis, the child had attained a con-
siderable part of the skeletal growth before the time of injury
(See Supplemental Digital Content 1, http://links.lww.com/
JBJSCC/B743). Regarding the distal humerus, which contrib-
utes only 20% of the growth of the bone and 10% to the growth
of the upper extremity, growth disturbances rarely cause any
significant limb shortening. Age of child and proximity to the
metabolically active metaphysis favor a rapid bone healing and
remodeling; however, premature physeal closure and growth
arrest proximally at the shoulder joint (contributing 80% of
bone growth) is a concern and should be observed with sequential
monitoring. However, it should also be taken into consideration
that bone and growth disturbances in the upper extremity rarely
cause functional disability. The presence of growth plate and thick
periosteum in a pediatric skeleton is not only responsible for rapid
fracture healing and remodeling but also aid in reduction and
be appreciated by observing the extensive involucrum in 1- and
1.5-year follow-up radiographs (Figs. 4 and 5). There is evidence
of subperiosteal new bone formation or involucrum over the
entire length of the bone, suggesting an extensive periosteal stripping
from humerus at the time of injury and a good remodeling despite
such an injury. However, formation of a bony bar can be appreciated
proximally, and the possibility of residual shortening by the end of
maturity should not be ruled out.
Evaluation of the functional status at 1.5 years shows that
there is loss of external rotation at shoulder and at elbow and
there is flexion deformity of 35° at affected side. Other
movements at shoulder and elbow are comparable. There is
shortening of 0.5 cm and can be expected to increase with
growth. Angular deformity is not appreciated. There is no
neurological or muscular deficit. Currently, the child can
perform activities of daily living comfortably and, however,
has difficulty in lifting heavy objects on the affected side.
Moreover, the possibility of development of future difficul-
ties in intense physical activities such as sports related can-
not be ruled out. The authors keep the patient on follow-up
for several more years, to monitor for complications such as
limb shortening and/or angular deformity.
Fig. 5
Anterior posterior and lateral radiographs performed at 1.5-year follow-up.
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Fig. 6
Elbow and shoulder range of motion at 1.5-year follow-up.
Conclusion
M anipulation by bonesetters, although accepted in some
developing countries, can produce adverse outcomes
and unpredictable complications. Orthopaedic surgeons in
these regions should be cognizant of the unique clinical problems
that may be created by this practice. n
Aditya Kaushal, MS1
Sanya Vermani, MD2
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I P S I L AT E R A L D I S P L A C E D P H Y S E A L F R A C T U R E S
Jessica Kaushal, MBBS3
Lalit Kaushal, MS4
1Department of Orthopaedics, PGIMER, Chandigarh, India
2Department of Radiodiagnosis, PGIMER, Chandigarh, India
3Government Medical College, Amritsar, Punjab, India
4Magnus Hospital, Panchkula, Haryana, India
E-mail address for S. Vermani: drsanyavermani@gmail.com
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