Pediatr Radiol

DOI 10.1007/s00247-014-3249-9

ORIGINAL ARTICLE

Fishtail deformity — a delayed complication of distal humeral

fractures in children
Srikala Narayanan & Randheer Shailam &
Brian E. Grottkau & Katherine Nimkin

Received: 12 June 2014 / Revised: 16 October 2014 / Accepted: 19 November 2014

# Springer-Verlag Berlin Heidelberg 2014

Abstract Conclusion Fishtail deformity of the distal humerus is a rare

Background Concavity in the central portion of the distal
humerus is referred to as fishtail deformity. This entity is a
rare complication of distal humeral fractures in children.
Objective The purpose of this study is to describe imaging
features of post-traumatic fishtail deformity and discuss the
pathophysiology.
Materials and methods We conducted a retrospective analysis
of seven cases of fishtail deformity after distal humeral fractures.
Results Seven children ages 7–14 years (five boys, two girls)
presented with elbow pain and history of distal humeral fracture.
Four of the seven children had limited range of motion. Five
children had prior grade 3 supracondylar fracture treated with
closed reduction and percutaneous pinning. One child had a
medial condylar fracture and another had a lateral condylar
fracture; both had been treated with conservative casting. All
children had radiographs, five had CT and three had MRI. All
children had a concave central defect in the distal humerus.
Other imaging features included joint space narrowing with
osteophytes and subchondral cystic changes in four children,
synovitis in one, hypertrophy or subluxation of the radial head in
three and proximal migration of the ulna in two.
S. Narayanan : R. Shailam : K. Nimkin (*)
Department of Radiology, Division of Pediatric Imaging,
Massachusetts General Hospital,
55 Fruit St., Boston, MA 02114, USA
e-mail: knimkin@partners.org
complication of distal humeral fractures in children. This
entity is infrequently reported in the radiology literature.
Awareness of the classic imaging features can result in earlier
diagnosis and appropriate treatment.
Keywords Fishtaildeformity . Trochlea . Avascularnecrosis .
Magnetic resonance imaging . Distal humeral fracture .
Radiography . Children
Introduction
Fishtail deformity of the distal humerus is a rare delayed
complication of distal humeral fractures in children. The term
fishtail deformity was coined by J.N. Wilson [1] in 1955 and
describes a configuration of the distal humerus that resembles
the tail fins of a fish. The deformity results from a non-
developing or underdeveloped lateral trochlea. It has been
described after a variety of distal humeral fractures in early
childhood, most commonly after supracondylar fractures
[2–5]. Children typically present several years after the initial
injury with elbow pain and cracking. Precarious blood supply
to the lateral trochlea likely predisposes to this condition
[6–9].
Our objective is to draw attention to this uncommon entity,
describe the imaging features of post-traumatic fishtail defor-
mity and discuss the pathophysiology.

B. E. Grottkau
Department of Orthopaedics, Pediatric Orthopaedics,
Massachusetts General Hospital, Materials and methods
Boston, MA, USA
This retrospective study was approved by our institutional
Present Address:
S. Narayanan
review board and complies with the Health Insurance Porta-
Department of Radiology, University of Pittsburgh Medical Center, bility and Accountability Act. We analyzed seven cases of
Pittsburgh, PA, USA fishtail deformity obtained with a keyword search of final

radiology reports in a radiology information system database
and teaching file.
We reviewed orthopedic outpatient medical records,
documenting patient age at presentation with distal humeral
fracture, fracture type and grade, side, arm dominance, treat-
ment, age at presentation with post-traumatic symptoms, char-
acter of symptoms, and interventions, if any. Two pediatric
radiologists with eight and 23 years of post-fellowship expe-
rience reviewed radiographs, CT and MRI studies. CT scans
were performed on a GE LightSpeed VCT 64-slice helical
scanner (GE Healthcare, Waukesha, WI). MRI scans were
performed on a 1.5-T or 3-T Siemens Magnetom (Siemens
Healthcare, Malvern, PA) or a GE Signa (GE Healthcare,
Waukesha, WI) clinical scanner.
Results
Seven children age 7–14 years (mean age 10.6 years; five
boys, two girls), had fishtail deformity and a history of distal
humeral fracture. Age at the time of initial fracture was 2–
6 years and the children presented 4–8 years later with delayed
complications including elbow pain, limited movement and
stiffness. Five children had prior grade 3 supracondylar frac-
ture treated with closed reduction and percutaneous pinning.
One child had a lateral condylar fracture and another had a
medial condylar fracture, both treated with conservative cast-
ing. Six of seven fractures were on the left side. Five of seven
initial fractures involved the side of the non-dominant hand
(Table 1).
All children had radiographs, five had CT and three had
MRI. Characteristic radiographic abnormality of a concave
defect secondary to underdeveloped lateral trochlear ossifica-
tion center was noted in all cases. Concave defect extended to
the growth plate in all cases and no normal growth plate was
seen at the fishtail deformity (Figs. 1, 2, 3, 4 and 5). Additional
findings included joint space narrowing (Fig. 3), cartilage loss,
subchondral cystic change and osteophytes in four children
(Figs. 3 and 5), volar subluxation and hypertrophy of the
radial head in three (Fig. 3), proximal migration of the ulna
in two and post-traumatic synovitis in one.
Discussion
Trochlear avascular necrosis following elbow trauma was
initially described in 1948 by McDonnell and Wilson [10].
Since then, several series have described cases of fish-
tail deformity in children [2, 5, 11, 12]. Age range of
the initial humeral injury is from 13 months to 13 years.
This complication can occur after displaced and non-
displaced fractures and with or without internal fixation.
Bronfen et al. [2] reported six cases of fishtail deformity
Pediatr Radiol
after grade 3 supracondylar fractures. Glotzbecker et al.
[12] reported 15 cases of fishtail deformity in a
recent article, with similar imaging findings to ours,
including several cases with subluxation of the radial
head and proximal migration of the ulna. There has
been a recent report of a 10-year-old presenting with bilateral
cubitus varus deformity who was found to have bilateral
fishtail deformity, 7 years after bilateral supracondylar frac-
tures [13].
Pathophysiology
Proposed mechanisms for fishtail deformity include post-
traumatic avascular necrosis as well as premature fusion of
the physeal plate. Most recent reviews favor avascular necro-
sis over premature fusion of the growth plate as the mecha-
nism of growth disturbance in most cases; this is based on
classic MRI findings of avascular necrosis and on surgical
observation [2]. In addition, studies have shown that the
trochlear ossification center has a precarious blood supply that
is vulnerable to injury. Haraldsson [6, 7] described an end
vessel extending into the ulnar part of the epiphysis that
terminates at the future site of formation of the trochlear
ossification nucleus. Wadsworth [9] found longitudinal vas-
cularity in the epiphyseal cartilage between the capitellum and
the trochlea. Yang et al. [8] confirmed the importance of these
findings; sparse longitudinal vascularity in the epiphyseal
cartilage between the capitellum and the trochlea is likely
more susceptible to fractures. Kimball et al. [14] performed
cadaver studies and documented the sparse vascularity in the
lateral trochlea (Fig. 6). Based on these studies, blood supply
to the lateral aspect of the medial crista, trochlear groove or
apex is particularly vulnerable to injury. Beaty and Kasser [15]
described two types of trochlear osteonecrosis depending on
the vascular supply involved. These include type A trochlear
avascular necrosis resulting from injury to the posterior ves-
sels supplying the lateral aspect of the trochlea, which leads to
fishtail deformity, and type B trochlear avascular necrosis,
resulting from insult to both the medial and lateral vascular
supplies of the trochlea and leading to osteonecrosis of the
entire trochlea, often with consequent cubitus varus deformity
and occasional late-onset ulnar neuropathy [15].
Imaging considerations
Trochlear ossification usually appears at 7–10 years of age and
ossifies by multiple foci, which fuse with the metaphysis at
age 12–17 years. Trochlear avascular necrosis would not be
evident on radiographs in younger children. This likely partly
explains the long delay between initial elbow injury and
subsequent diagnosis of fishtail deformity.
Fishtail deformity is typically first detected on radiographs.
CT is useful for delineation of bony anatomy and assessment
 Pediatr Radiol

Table 1 Summary of seven cases with fishtail deformity post distal humeral fracture

No: Age (y) Sex Clinical exam Initial fracture Imaging Treatment and follow-up

Age (years) Type Treatment

1 7 F Pain 3 Left supracondylar Closed reduction and XR-fishtail deformity Lateral epiphysiodesis to prevent
Grade 3 percutaneous pinning overgrowth of lateral column.
Persistent elbow clicking post-
operatively
2 14 F Pain, limited extension, 6 Right supracondylar Closed reduction and XR, CT, MRI-fishtail deformity, joint space Contracture release, debridement
increased carrying angle Grade 3 percutaneous pinning narrowing with osteophytes and with resection of osteophytes
subchondral cystic changes in the and loose bodies. No recent
capitellum, radial head and medial trochlea. follow-up
Enlargement of radial head
3 12 M Pain, mild flexion 6 Left supracondylar Closed reduction and XR, CT, MRI -fishtail deformity with mildly Arthroscopy and debridement.
deformity Grade 3 percutaneous pinning increased T2 signal in trochlea, suchondral Ablation of radial-capitellar
cyst in capitellum and medial trochlea, and physis. Occasional locking
proximal migration of ulna post-operatively
4 11 M Mild pain 6 Left supracondylar Closed reduction and XR, CT-fishtail deformity No follow-up
Grade 3 percutaneous pinning
5 8 M Limited range of movement, 2 Left medial condylar Casting XR, CT-fishtail deformity, volar subluxation Persistent pain and synovitis
varus deformity fracture and hypertrophy of the radial head, requiring steroid injections and
subchondral cysts in capitellum. Proximal ulnar nerve decompression
migration of the ulna, joint space narrowing
and osteophytes
6 11 M Intermittent pain 3 Left lateral condylar Casting XR, CT-Non-united lateral condylar fracture Conservative management, no
fracture and wedge- shaped fishtail deformity recent follow-up
7 11 M Pain, stiffness, limited range 5 Left supracondylar Closed reduction and XR, MRI-fishtail deformity, volar subluxation Conservative management,
of motion Grade 3 percutaneous pinning of the radial head, subchondral cystic persistent flexion contracture
changes in the capitellum. Synovitis and with limited range of motion
joint space narrowing

XR radiograph, CT computed tomography, MRI magnetic resonance imaging


Fig. 1 Patient No. 1, a 7-year-old girl who had a grade three supracondylar
fracture at age 3 that was treated with pinning. She presented with
intermittent elbow pain. Anteroposterior radiograph of left elbow shows
fishtail deformity with concave lateral trochlear bony defect (arrow)
Fig. 2 Patient No. 3, a 12-year-old boy who had a grade 3 supracondylar
fracture at age 6 that was treated with pinning. He presented with pain,
clicking and mild flexion deformity. a Anteroposterior (AP) radiograph at age
6 shows healing supracondylar fracture after pinning. b AP radiograph at age
12 shows central distal humeral defect (arrow) with fragmented trochlear
Fig. 3 Patient No. 5, an 8-year-old boy with a history of medial condylar
fracture treated with casting at age 2. He presented with pain and swelling
of the elbow. a Anteroposterior and (b) lateral radiographs show wedge-
shaped central defect in the distal humerus (arrow) and enlargement and
Pediatr Radiol
for loose bodies and subchondral cysts. MR imaging allows
for better delineation of the growth plate, cartilage and syno-
vial inflammation. MRI is particularly useful for early disease
and for evaluating the unossified trochlear anatomy.
Care should be made to not overcall fishtail deformity.
The normal trochlea can be irregularly ossified but should
not have a concave bony defect extending to the physis;
smaller defects in older children are more likely to be
osteochondral lesions.
Clinical presentation and long-term complications
Children with this deformity often have only minimal symp-
toms initially. Long-term outcomes include limited flexion
and extension, stiffness and pain associated with osteoarthri-
tis, loose bodies, cubitus valgus deformity, and proximal
migration of the ulna and radial subluxation. Osteochondral
lesions might be seen in the capitellum, likely from overload
of the residual lateral column [15].
ossification medially (arrowhead), which is also seen on (c) corresponding
coronal reformatted CT image. d Coronal T1-W MR image shows
underdeveloped lateral trochlea (arrow). e Coronal T2-W fat-saturated MR
image shows mild T2 hyperintensity of the trochlea laterally (thin arrow) and
joint fluid (thick arrow)
volar subluxation of the radial head (arrowheads). c Coronal 2-D
gradient-echo MR image shows joint space narrowing, ulnar osteophyte
(arrowhead) and subchondral cyst in the capitellum (arrow)
Pediatr Radiol
Fig. 4 Patient No. 6, an 11-year-old boy who had lateral condylar
fracture at age 3 that was treated with casting; the boy was lost to
follow-up. a Anteroposterior radiograph shows a lateral condylar
fracture (arrow) with some displacement. b He returned 2 years
after the initial fracture with elbow pain. Anteroposterior radiograph
shows non-union of the lateral condylar fracture and fishtail
deformity (arrow)
Differential diagnosis
The differential diagnosis includes the normal pre-ossification
center mimicking ischemic or inflammatory change on MRI,
idiopathic osteonecrosis, osteochondritis dissecans (OCD)
and epiphyseal dysplasia. These are considered in the absence
of prior distal humeral fracture.
The pre-ossification center is a transitional stage in skeletal
maturation that persists for a limited time before the develop-
ment of a secondary ossification center. It can be T2-
hyperintense and may enhance. In children with a cartilagi-
nous distal humeral epiphysis on radiographs, this could
Fig. 5 Patient No. 7, an 11-year-old boy with pain and stiffness after
supracondylar fracture at age 5. a Oblique radiograph shows fishtail
deformity (arrow). b Coronal MR multiplanar gradient recalled
acquisition in the steady state shows subchondral cysts in the
Fig. 6 Dorsal view of cadaver elbow after dye injection into brachial
artery shows relative watershed area centrally at the site of the lateral
trochlea (arrows). Reprinted with permission [14]
potentially mimic infectious, ischemic or inflammatory
changes on MRI and should not be mistaken for those entities
[16]. The preossification center is usually focal and in the
center of the trochlear cartilage; osteonecrosis would have
more diffuse signal abnormality.
Idiopathic osteonecrosis of the humeral trochlea in the
absence of prior trauma has been given the name Hagemann
disease since it was described by Hagemann in 1951 [17].
This may also have fishtail deformity and is quite rare.
Osteochondritis dissecans of the trochlea is uncommon [4,
18, 19]. It is seen in adolescents who participate in repetitive
sport activity, usually throwing athletes with gradually progres-
sive medial elbow pain. This is secondary to repetitive stress
injury and these children usually do not have a history of
capitellum (thin arrow) and concavity in the lateral trochlea (thick
arrow). c Sagittal T2-W fat-saturated MR image shows hyperintense
synovial inflammation (asterisks) and subluxation of the radial head
(arrow)

humeral fracture. A well-circumscribed defect with narrow
transition zone is usually seen at the posterior inferior aspect
of the lateral trochlea at the watershed zone. A pseudocondylar
notch sign has been described in this setting [19]. In one review
of 18 young athletes with trochlear osteochondral lesions, five
also had avascular necrosis of the trochlea. Interestingly, all five
of these patients had a history of remote elbow fractures that
had been treated with K wire fixation [4].
Epiphyseal dysplasia is usually bilateral and affects multi-
ple other joints in a near-symmetrical manner.
Treatment considerations
Children with minimal symptoms are treated conservatively
with observation. In some instances, debridement with remov-
al of loose bodies, capsulotomy, epiphysiodesis, osteotomy or
ulnar nerve transposition may be required. Proximal migration
of the forearm and radial head subluxation correlate with more
severe symptoms and poorer outcome [12]. Likewise, the
greater the trochlear defect the more disability that results.
Newer techniques may be used in the future to restore joint
congruity, including arthroplasty and grafting. It is advised by
some authors that parents of children with distal humeral
fractures be told to return for follow-up if elbow pain and
stiffness occur years after the initial injury [2].
Conclusion
Fishtail deformity of the distal humerus is a rare delayed
complication of distal humeral fractures in children. A char-
acteristic radiographic abnormality of a concave distal humer-
al defect secondary to underdeveloped lateral trochlear ossifi-
cation center is noted in all cases. This entity is infrequently
reported in the radiology literature. Awareness of the classic
imaging features can result in a more accurate diagnosis and
prompt early surgical planning.
Acknowledgments The authors would like to thank Noemi Chavez
and Eleni Balasalle for their assistance with manuscript preparation.
Conflicts of interest None
Pediatr Radiol
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