1. INJURY TO LOWER MEDIAL EPIPHYSIS OF THE HUMERUS BEFORE DEVELOPMENT OF OSSIFIC CENTRE WITH IPSILATERAL FRACTURE PROXIMAL SHAFT HUMERUS – A RARE CASE REPORT
AUTHORS DR. RAJESH DULANI
DR.SANDEEP SHRIVASTAV
DR. SUDHANSHU KOTHADIA
DATTA MEGHE INSTITUTE OF MEDICAL SCIENCES UNIVERSITY,SAWANGI(M),WARDHA

2. INTRODUCTION
Injury to lower medial epiphysis in children before the age of 12 is rare. Generally it is neglected in children below the age of 10 yrs because epiphysis of trochlea get fused at 9-10 yrs. Fracture of medial condyle is one of this and it is very rare in children. Very few cases are reported in literature. Incidence of such type of injury is 1-2%. Commonest age group for such type of injury is between 8-12 yrs. This is an intra-articular type IV injury according to Salter- Harris.

3. CASE REPORT
Here I m presenting case report of 3 yrs old female child who came to us with an history of fall on outstretched hand from 15 feet of height sustained injury to her right elbow and right arm followed by swelling and pain in right elbow and right arm.
clinical examination revealed swelling on proximal aspect of right elbow and right arm, tenderness was present along sswith crepitus, deformity was there, abnormal mobility was present ,movements at elbow joint were painful and restricted.
On radiological examination there was fracture of proxiamal shaft of humerus with fracture of medial epicondyle of humerus. On further investigation we done Ultrasonography of elbow and we found fracture of medial condyle also alongwith fracture of medial epicondyle.

5. As this being an intra-articular injury we decided to operate on this child. Open reduction and internal fixation done with 1.5mm sized 2 k-wires by medial approach.

6. Post-operatively this child was given an above elbow cast for one month as this child was also having fracture of shaft of humerus. The plaster was removed at the end of one month when there was clinical and radiological signs of union noted and then physiotherapy started.

7. This child is now having full range of motion in flexion, extension, pronation and supination at elbow joint without disability and deformity.

11. DISCUSSION
Fractures of medial condyle of humerus in children per se is a rare and cases are often missed in children due to too many epiphyseal centres.
Lower End of humerus ossifies from four centres. Each for trochlea , capitulum , medial condyle , lateral condyle . Ossification begins in the medial epicondyle in 4th year in female and 6th year in male and fuses around the age of 9 years. Capitulum is the first to start ossify during first year of life. Centre of medial region of throchlea appears in 9ht year in female and 10th year in male. Centre for lateral condyle , capitulum and trochlea fuses around puberty and composite epiphysis unites with the shaft in the 14th year in female and 16th year in male. Fracture medial condyle consists of medial epicondyle and medial end of throchlea and attached fragment of metaphysis. This is a type IV injury according to Salter-Harris.
Mechanism of injury of this fracture is due to fall on apex of flexed elbow , outstretched hand where elbow can get valgus stress.
Two types of fracture medial condyle are decribed depending upon the direction of fracture line , size and position of fractured fragement in children above 8 yrs when ossification centre for medial condyle has appered.

12. TYPE I – Fracture line extends from capitulo-trochlear groove to medial supracondylar ridge just above the medial epicondyle, the resulting fragment displaced medially but not rotated.
These type of fractures can be treated conservatively but with word of caution , regular radiological assessment should be done to know that this fragment is not getting displaced.

14. TYPE II – Fracture line is similar to in type-I but resulting fragment is rotated medio-laterally in frontal plane so that the fracture surface lye underneath the skin on medial side of elbow while the medial epicondyle displaced distally.
These type of fractures always need open reduction and internal fixation as the fractured fragment is displaced and rotated due to origin of common flexors attached to this fragment.. Open reduction is done by taking a medial approach to the elbow, isolation of ulnar nerve,opening the joint and getting a anatomical reduction of an intra-articular portion of a fracture and fixation of this fragment by two k-wires.

16. CONCLUSION
I have presented this case for its rare occurance and it always needs proper reduction and internal fixation to get stability and mobility at the elbow joint. An ultrasonography of elbow joint should be done in each and every case of fracture lower end humerus before 8 yrs of age to avoid missing of fracture medial condyle in diagnosis.

17. REFERENCES
COTHAY. D. M.: Injury to the Lower Medial Epiphysis ofthe Humerus Before Development ofthe OssifIc Centre. Report ofa Case. J. Bone and
Joint Surg B: Nov
Fracture of the medial condyle of the humerus - MH Ghawabi J Bone Joint Surg Am. 1975;57:
CFIAHA. P. B. : Fracture of the Medial Condyle of the Humerus with Rotational Displacement. Report of Two Cases. J. Bone and Joint Surg..
52-A: , Oct. 1970
FAHEY. J. J. . and OBRIEN. E. T.: Fracture-Separation ofthe Medial Humeral Condyle in a Child Confused with Fracture ofthe Medial Epicondvle.
J. Bone and Joint Surg.. 53-A: I 102-I 104. Sept
KI1.E0YI.F. R. NI.: Fracture of the Medial Condyle and Epicondyle of the Elbow in Children. Clin. Orthop.. 41:
FowlesJV, Kassab MT. Displaced fractures ofthe medial humeral condyle in children. JBoneJoint Surg[AmJ 1980:62 A: I
Medial Condyle Fractures of the Humerus in Children
Arabella I. Leet, M.D., †Colby Young, M.D., and †M. Mark Hoffer, M.D.
Bensahel H, Csukonyi Z, Badelon O, Badaoui S. Fractures of the
medial condyle of the humerus in children. J Pediatr Orthop 1986;
6:430–3.
Ingersoll RE. Fractures of the humeral condyles in children. Clin
Orthop 1965;41:32–42.
Kilfoyle RM. Fractures of the medial condyle and epicondyle of
the elbow in children. Clin Orthop 1965;41:43–50.
Papavasiliou V, Nenopoulos S, Venturis T. Fractures of the medial
condyle of the humerus in childhood. J Pediatr Orthop 1987;7:
421–3.