Lateral Condyle Fracture ORIF

Authors:

Planning

B

Preoperative Plan

1

Evaluate fracture displacement

  • <2mm treat nonoperatively
  • 2-4mm treat with closed reduction percutaneous pinning and arthrogram to evaluate articular surface (open treatment if articular surface not aligned)
  • >4mm treat with open reduction and pin fixation

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
C

Room Preparation

P

1

Surgical instrumentation

  • smooth k-wires (usually 0.062" K-wires)
  • can use 0.08" K-wire or small cannulated screw (3.5mm) in larger children
Pitfalls
  • We recommend using at least 0.062 K-wires even in very small children (smaller k-wires do not provide as stable of fixation)

2

Room setup and equipment

  • setup OR with standard operating table and radiolucent arm board
  • c-arm in from foot of bed

3

Patient positioning

  • supine with shoulder at edge of bed
  • place sterile tourniquet
  • abduct 90 degrees and internally rotate the arm

Technique

D

Lateral Approach

1

Mark out the anatomy

  • identify and mark out the lateral condyle. identifies fracture fragment as origin of common extensor tendon.

2

Mark out the incision

  • draw an approximately 5 cm incision with two thirds of the incision proximal to the elbow joint and one third distal to the elbow joint
  • this incision should be directly over lateral condyle (if arm is very swollen confirm with c-arm)

3

Make the incision

E

Deep Dissection

1

Expose the lateral condyle

  • incise fascia on anterior aspect of lateral condyle at level of fracture.
  • There will often be a large egress of fracture hematoma. Bulb irrigation at this point can help with visualizing the anatomy and fracture

2

Expose the articular surface

  • expose the anterior articular surface of the elbow by developing the tear in the brachioradialis and elevating soft tissue off of the anterior aspect of the fracture fragment
  • keep the dissection anterior because the blood supply of the lateral condyle is posterior
  • A chandler retractor can be slid across the anterior aspect of the distal humerus to aid in visualization
  • elevate the soft tissue (brachioradialis and joint capsule) from proximal to distal until the fracture is well visualized
  • continue exposure until the trochlea or the medial extent of the fracture can be identified anteriorly
F

Fracture Reduction

P

1

Inspect the articular surface

  • lift the anterior soft tissues with a retractor (usually chandler or army-navy) to visualize the articular surface
  • remove any blocks to reduction in the fracture site

2

Reduce the fracture

  • can place a kirschner wire into the distal fragment to use as a joystick to control the reduction
  • reduce the fracture
  • the fracture can in many cases be maintained in a reduced position with a pointed towel clip on the lateral aspect of the fracture fragment and metaphysis of the distal humerus
Pearls
  • can use K-wire joystick or pointed dental tool to align fracture fragment
G

Fracture Fixation

P
P

1

Confirm the reduction

  • visually evaluate the reduction (intraarticular surface, metaphysis anteriorly, metaphysis laterally)
  • It is also often possible (and beneficial) to feel the articular surface and have tactile confirmation that this is smooth without any stepoff
Pitfalls
  • In cases of severe displacement the fragment may have plastic deformation so it won't completely key in at lateral metaphysis
  • This is alright as long as the articular surface is anatomically reduced

2

Stabilize with K wires

  • 0.062 " K- wires are then placed in either a parallel or divergent fashion
  • If placing divergently: one K- wire is placed up the lateral column, and one parallel to the joint but this pin should be in bone and not cartilage to maximize stability
  • all pins should engage the medial cortex
  • In older/larger children one can use either 0.08" K-wires or a small cannulated screw (3.5mm) up the lateral column
  • If using a screw this is placed in the metaphysical spike (avoiding the physis), across the fracture site and up the lateral column
  • Care should be taken to avoid the olecranon fossa if using a screw
  • The advantage of screw is that it may allow earlier mobilization; disadvantage is the need for later screw removal
  • the authors prefer smooth guide wires if using cannulated screws as we are aware of cases of ulnar nerve injury from threaded guide wires advanced too far medially in this location
Pitfalls
  • Care should be taken to avoid the olecranon fossa if using a screw

3

Check K wire placement with fluoroscopy

  • 2 or more pins crossing the fracture site
  • placed in a parallel or divergent manner
  • all pins engage cortex medially
Pearls
  • Confirm pins are in bone not cartilage for better stability

4

Cut K wires

  • bend the K wires 90 degrees outside of the skin and cut
  • cover cut K wire tips or use felt to cover the whole area
H

Wound Closure

1

If possible, try to close the lateral periosteum with 0-vicryl

  • this may reduce spur formation and help speed healing

2

Close deep fascia with 0-vicryl

3

Close superficial fascia with 3- vicryl

4

Close skin with running monocryl

5

Immobilization

  • Immobilize with a long arm cast with the elbow flexed to 90-120 degrees (depending on swelling) and the forearm in neutral

Patient Care

K

Preoperative H & P

P

1

Obtains history and performs basic physical exam

  • injury mechanism
  • radial and ulnar pulse assessment
  • identify medical co-morbidities that might impact surgical treatment

2

Order basic imaging studies

  • AP, lateral and oblique views

3

Prescribe nonoperative treatments

  • long arm cast in 90-120 degrees of flexion and the forearm in neutral
  • done for nondisplaced or minimally displaced fractures (<2 mm displacement)

4

List potential surgical complications

  • pin site infection
  • avascular necrosis
  • damage to surrounding nerves (especially ulnar if using threaded guide wire for cannulated screws
  • posterior or posterolateral metaphyseal bone spurs ( generally asymptomatic but should warn parents of this up front)
  • delayed union
  • nonunion
Pearls
  • Warn parents of posterior or posterolateral metaphyseal bone spur formation which is generally asymptomatic
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • cast care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow-up in 1-2 weeks
M

Intermediate Evaluation and Management

P

1

Recognize vascular,nerve or other associated injuries

  • document neurovascular status
  • document radial and ulnar pulses along with median, radial, and ulnar nerve sensation
  • AIN neuropraxia (test A-OK sign); radial nerve (thumb/wrist extension) palsy and ulnar nerve (hand intrinsics) depending on fracture pattern

2

Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret AP, lateral, and internal oblique radiographs

3

Splints or casts fracture appropriately

  • place cast in 90-120 degrees of flexion with hand in neutral

4

Provides post-operative management and rehabilitation

  • postop: 1-2 week postoperative visit
  • wound check if any suspicion for wound infection
  • change splint/cast if indicated and continue non-weight bearing
  • check radiographs (AP, lateral and internal oblique)
  • diagnose and manage early complications
  • postop: 4 week postoperative visit
  • check xrays for callus formation out of splint/cast (AP/lateral and internal oblique)
  • Remove K wires with heavy needle driver in clinic
  • If there is a persistent fracture line without bridging callus in all views then recast
  • If adequate callus formation then begin range of motion exercises to wrist, hand, and elbow
  • return to activity once ROM is improved at approximately ~8 wks

5

Capable of diagnosis and early management of complications

  • compartment syndrome
  • pin tract infection
  • cast problems
  • nonunion
Pearls
  • Supracondylar fractures tend to have more acute complications (neurovascular, compartment syndrome )
  • Lateral condyle fractures have delayed issues (nonunion, avascular necrosis)
 

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