The answer is not always in black and white: a frequently missed diagnosis in a child presenting with elbow pain

Clinical introduction

A 1-month-old baby was referred to a tertiary paediatric centre from a local hospital with a 2-day history of reduced movement and swelling of the left elbow. There was no history of preceding trauma or relevant obstetric history.

On examination, tenderness and swelling of the left elbow with restriction of movement was noted. There was no evidence of systemic illness or infection.

Left elbow radiographs were performed (figure 1):

Question

What is the diagnosis?

Elbow dislocation

Distal humeral supracondylar fracture

Septic arthritis

Distal humeral transphyseal fracture

Answer: D

Transphyseal fractures of the distal humerus are rare, typically occurring in children under the age of 2 years, and are frequently misinterpreted on plain radiographs as elbow dislocation (figure 2).1

Clinical findings include elbow swelling, crepitus and restricted movement. Associated mechanisms of injury include birth trauma...

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