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Lateral Condyle Fracture - Pediatric

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Topic updated on 10/10/14 4:50pm
Introduction
  • Fractures involving the lateral condyle of the humerus 
  • Epidemiology
    • incidence
      • 17% of all distal humerus fractures in the pediatric population
    • demographics
      • typically occurs in patients aged 5-10 years old
    • location
      • most commonly are Salter-Harris II or IV fracture patterns of the lateral condyle 
  • Pathophysiology
    • mechanism of injury
      • pull-off theory
        • avulsion fracture of the lateral condyle that results from the pull of the common extensor musculature
      • push-off theory
        • fall onto an outstretched hand causes impaction of the radial head into the lateral condyle causing fracture
  • Prognosis
    • outcomes have historically been worse than supracondylar fractures
      • articular naturemissed diagnosis, and higher risk of malunion/nonunion
Classification
 
Milch Classification
Type I

Fracture line is lateral to trochlear groove (considered a SH IV fracture)

 
Type II Fracture line into trochlear groove (considered a SH II fracture)
 
 
Fracture Displacement Classification
Type 1 <2mm, indicating intact cartilaginous hinge

Type 2 2-4mm, displaced joint surface
Type 3 >4mm, joint displaced and rotated
 
Presentation
  • History
    • fall onto an outstetched hand
  • Symptoms
    • lateral elbow pain
    • mild swelling
  • Physical exam
    • inspection
      • exam may lack the obvious deformity often seen with supracondylar fractures
      • swelling and tenderness are usually limited to the lateral side
    • motion
      • may have increased pain with resisted wrist extension/flexion
      • may feel crepitus at the fracture site
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, and oblique views of elbow
        • internal oblique view most accurately shows maximum displacement and fracture pattern 
    • optional views
      • contralateral elbow for comparison when ossification is not yet complete
      • routine elbow stress views are not recommended due to risk of fracture displacement
    • findings
      • fracture fragment most often lies posterolateral which is best seen on internal oblique views
  • CT scan
    • indication
      • improved ability to assess the fracture pattern in all planes
    • findings
      • CT has limited ability to evaluate the integrity of articular cartilage
      • may require sedation to perform the test
  • MRI
    • indication
      • provides the ability to assess the cartilaginous integrity of the trochlea
    • findings
      • increased expense
      • may require sedation to perform the test
Differential

Pediatric Elbow Injury Frequency
Fracture Type
% elbow injuries
Peak Age
Requires OR
Supracondylar fractures
41%
7
majority
Radial Head subluxation
28%
3
rare
Lateral condylar physeal fractures
11%
6
majority
Medial epicondylar apophyseal fracture
8%
11
minority
Radial Head and Neck fractures
5%
10
minority
Elbow dislocations
5%
13
rare
Medial condylar physeal fractures
1%
10
rare

Treatment
  • Nonoperative
    • long arm casting
      • indications
        • only indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most likely intact
        • sub-acute presentation (>4 weeks)
      • technique
        • cast with elbow at 90 degrees and forearm supination
        • weekly follow up
        • radiographs out of cast may be useful
        • total length of casting is 3-7 weeks
  • Operative
    • CRPP
      • indications
        • some authors suggest CRPP for all lateral condylar fractures with < 2 mm of displacement
        • ability to maintain fracture fragment in a position to prevent late displacement
      • technique
        • closed reduction performed by providing a varus elbow force and pushing the fragment anteromedial
        • divergent pin configuration most stable
        • third pin may be used in transverse plan to prevent fragment derotation
        • arthrogram can confirm joint congruity
    • open reduction and fixation
      • indications
        • if > 2mm of displacement
        • any joint incongruity
        • fracture non-union
      • technique
        • direct lateral approach
        • avoid dissection of posterior aspect of lateral condyle (source of vascularization)
        • percutaneous or subcutaneous pins may be used for fixation
        • singe screw may also be used with non-unions +/- bone grafting 
Complications
  • AVN
    • posterior dissection can result in lateral condyle osteonecrosis
    • may also occur in the trochlea
  • Nonunion/malunion
    • caused from delay in diagnosis and improper treatment
    • may result in cubitus valgus and tardy ulnar nerve palsy   
  • Tardy ulnar nerve palsy
    • slow, progressive paralysis of the ulnar nerve
    • caused by stretching of the nerve, as is seen with cubitus valgus
    • usually late finding, presenting many years after initial fracture
  • Lateral overgrowth/prominence (spurring)   
    • in up to 50% of cases regardless of treatment, families should be counseled in advance
    • lateral periosteal alignment will prevent this from occurring
    • presence of spurring is correlated with greater initial fracture displacement
  • Growth arrest with or without angular deformity
  • Unsatisfactory appearance of surgical scar
  • Late elbow presentation or deformity
    • cubitus varus deformity is most common in nondisplaced and minimally displaced fractures
    • cubital valgus less common, but more likely with significant deformities that cause physeal arrest 
    • controversy whether to treat subacute fractures (week 3-12) nonoperatively or surgically
    • most deformities can be corrected after skeletal maturation with a supracondylar osteotomy

 

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Qbank (7 Questions)

TAG
(SBQ13.4) A 7-year-old with a history of an elbow injury treated conservatively presents for evaluation of ongoing elbow pain. The coronal alignment of her elbows in extension is symmetric. On physical examination, she has full, but painful range of motion of her elbow. She has tenderness at the lateral elbow. She is able to cross her fingers without difficulty. A radiograph is shown in Figure A. What is the best definitive treatment plan for this patient? Topic Review Topic
FIGURES: A          

1. Observation alone
2. Observation with splinting
3. Osseous fragment excision
4. Internal fixation of the nonunion
5. Ulnar nerve decompression

PREFERRED RESPONSE ▶
TAG
(OBQ11.192) A 36-year-old male presents for evaluation of left hand weakness. A current clnical photograph of his hand is shown in Figure A. His medical history is significant for the elbow injury shown in Figure B, which was treated non-operatively twenty-eight years previously. Current radiographic evaluation of the patients elbow will most likely reveal what deformity? Topic Review Topic
FIGURES: A   B        

1. Cubitus valgus
2. Avascular necrosis of the lateral fragment
3. Fishtail deformity of the distal humerus
4. Fracture nonunion and a normal carrying angle
5. Myositis ossificans

PREFERRED RESPONSE ▶
TAG
(OBQ10.209) Nonunion following a pediatric lateral condyle fracture has been associated with which of the following? Topic Review Topic

1. Ulnar nerve palsy
2. Radial nerve palsy
3. Heterotopic ossification
4. Parsonage Turner syndrome
5. Cubitus varus

PREFERRED RESPONSE ▶
TAG
(OBQ09.186) An 8-year-old boy falls on his right upper extremity and presents to the emergency room with the radiographs shown in Figures A and B. He has exquisite tenderness to palpation along the lateral aspect of his elbow. What additional radiographic view will likely demonstrate the maximum degree of fracture displacement? Topic Review Topic
FIGURES: A   B        

1. External oblique radiograph
2. Internal oblique radiograph
3. Anteroposterior in maximum flexion
4. Anteroposterior in maximum extension
5. Lateral in maximum extension

PREFERRED RESPONSE ▶
TAG
(OBQ08.35) A 7-year-old girl undergoes open reduction internal fixation of a displaced humeral lateral condyle fracture. Dissection around which portion of the fracture fragment should be avoided to protect its blood supply? Topic Review Topic

1. medial
2. lateral
3. superior
4. anterior
5. posterior

PREFERRED RESPONSE ▶
TAG
(OBQ07.169) Figure A shows the radiograph of a 6-year-old girl after a fall on the playground. What is the most appropriate course of action? Topic Review Topic
FIGURES: A          

1. Observation with treatment in a sling
2. Closed reduction and long arm casting
3. Closed reduction percutaneous pinning with k-wires
4. Open reduction internal fixation with k-wires
5. Open reduction with plate fixation

PREFERRED RESPONSE ▶
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