Fracture of the Distal Humeral Physis

Definition

  • Separation of the whole distal humeral epiphysis from the metaphysis
  • Salter-Harris I in infants
  • Salter-Harris II in toddlers, with a Thurston-Holland fragment, often lateral

Epidemiology

  • Infants and young children, mostly under 3 years, including after birth trauma
  • Wide, weak physis separates where an older child would dislocate
  • Strong association with non-accidental injury, especially under 2 years

Clinical Features

  • Swollen elbow and reluctance to move the arm
  • Muffled crepitus, as fracture surfaces are cartilaginous
  • History may be vague or inconsistent with the injury
  • Neurovascular injury uncommon

Investigations

Fracture of the Distal Humeral Physis, lateral radiograph of a supracondylar humerus fracture
Lateral radiograph of a supracondylar humerus fracture. Image by James Heilman, MD, Wikimedia Commons, CC BY-SA 4.0.
  • Cartilaginous distal humerus and unossified capitellum make radiographs confusing
  • Radius and ulna displaced together, almost always posteromedially
  • Proximal radius stays aligned with the capitellum, which moves with the forearm
  • Dislocation loses the radiocapitellar relationship and is rare at this age
  • Lateral condyle fracture loses the relationship between capitellum and radius and ulna
  • Ultrasound is quick, avoids anaesthesia and confirms the diagnosis in infants
  • Arthrography under anaesthesia outlines the epiphysis and confirms reduction
  • MRI when the diagnosis is still unclear
  • Skeletal survey and child protection assessment when non-accidental injury is suspected

Management

  • Undisplaced or minimally displaced fractures in an above elbow cast for about 3 weeks
  • Displaced fractures treated with closed reduction, arthrography and percutaneous lateral or crossed pinning
  • Pinning follows supracondylar fracture technique
  • Late presentations beyond about a week left alone, as manipulation risks physeal damage
  • These fractures remodel well
  • Osteotomy later for residual deformity

Complications

  • Cubitus varus is most common, from medial tilt and malunion of the epiphysis
  • Avascular necrosis of the trochlea
  • Growth disturbance
  • Missed non-accidental injury, with risk of further harm to the child

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.