Fracture line is lateral to trochlear groove (less common, elbow is stable as fracture does NOT enter trochlear groove)
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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?
Avascular necrosis of the lateral fragment
Fishtail deformity of the distal humerus
Fracture nonunion and a normal carrying angle
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Figure B represents an acute lateral condyle fracture. Cubitus valgus deformity may occur due to a nonunion, malunion, or premature physeal closure. Acute neurologic injuries are rare with these injuries, however tardy ulnar nerve palsy (as demonstrated by the claw-hand deformity in Figure A) occurs late in the treatment and follow-up of lateral condyle fractures and usually is due to cubitus valgus. In addition to claw-hand deformity, other classical examination findings consistent with ulnar nerve palsy include Froment sign (compensatory thump IPJ flexion due to weak adductor pollicis) and Wartenberg's sign (persistent abduction and extension of the small digit during active adduction due to weak interosseous and lumbrical musculature). Interosseous and/or first web space atrophy is another common finding.
Storm et al reviewed elbow deformities after fracture. With regards to lateral condyle fractures, they state that the most common sequela in the setting of nonunion with displacement is the development of progressive cubitus valgus deformity. Valgus deformity can place an individual at risk for the developement of tardy unlar nerve palsy. This is a well-known late complication, occuring on average 22 years after initial injury in one series.
Illustration A is a radiograph demonstrating severe cubitus valgus deformity after lateral condyle nonunion.
Answer 2 - Avascular necrosis is typically the result of excessive posterior dissection during open reduction, and most often occurs following treatment of nonunions or delayed unions.
Answer 3 - A fishtail deformity of the distal humerus occurs as a result of a loss of ossific contact between the capitellum and trochlea. This deformity usually does not result in any significant dysfunction and is treated nonoperatively.
Answer 4 - Fracture nonunion with an associated normal carrying angle is unlikely to cause ulnar nerve irritation or damage.
Answer 5-Myositis ossificans is a rare finding after lateral condyle injuries and typically would not lead to ulnar nerve irritation.
Storm SW, Williams DP, Khoury J, Lubahn JD.
Hand Clin. 2006 Feb;22(1):121-9. PMID: 16504784 (Link to Abstract)
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Nonunion following a pediatric lateral condyle fracture has been associated with which of the following?
Ulnar nerve palsy
Radial nerve palsy
Parsonage Turner syndrome
Displaced pediatric lateral condyle fractures should be treated with surgical reduction and fixation to avoid nonunion. Nonunion has been associated with cubitus valgus, pain, loss of motion, and tardy ulnar nerve palsy. The ulnar nerve palsy develops as the nerve becomes stretched from cubitus valgus deformity. A radiographic example of a lateral condyle nonunion is provided in Illustration A. In the presence of a painless non-union, in situ screw fixation and bone grafting is the recommended treatment option. Shimada et al reviews 16 patients who were treated with surgical osteosynthesis for lateral condyle nonunion an average of 5 years following fracture. Thirteen achieved union following the index operation. Fifteen reported good to excellent clinical results. One patient reported a poor outcome complicated by osteonecrosis.
Shimada K, Masada K, Tada K, Yamamoto T.
J Bone Joint Surg Am. 1997 Feb;79(2):234-40. PMID: 9052545 (Link to Abstract)
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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?
External oblique radiograph
Internal oblique radiograph
Anteroposterior in maximum flexion
Anteroposterior in maximum extension
Lateral in maximum extension
Pediatric patients suspected of having a lateral condyle fracture should receive 3 view radiographs of the involved elbow: AP, lateral and internal oblique. Maximum displacement of the lateral condyle fracture can be best evaluated on an internal oblique radiograph. Classically, >2mm of displacement on any of the three views should be considered unstable and surgical fixation of the fracture warranted.
Bast et al reviewed 95 patients with lateral condyle fractures and found 2 non-unions, both of which retrospectively had >2mm displacement seen only on the internal oblique x-ray.
Song et al found the internal oblique view most accurate at demonstrating the fracture gap and pattern in lateral condyle fractures. They suggested that all pediatric patients suspected of having a lateral condyle fracture should receive 3 views of the involved elbow: AP, lateral and internal oblique.
Song KS, Kang CH, Min BW, Bae KC, Cho CH
J Bone Joint Surg Am. 2007 Jan;89(1):58-63. PMID: 17200311 (Link to Abstract)
Bast SC, Hoffer MM, Aval S.
J Pediatr Orthop. 1998 Jul-Aug;18(4):448-50. PMID: 9661850 (Link to Abstract)
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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?
The predominant blood supply to the lateral condyle of the distal humerus comes posteriorly. Nonunions occur because of these fractures are intra-articular and bathed in synovial fluid. When nonunions occur, the characteristic deformity is a cubitus valgus and subsequent ulnar nerve symptoms. Skak et al found that trochlear growth may become impaired after this fracture. DIsplaced lateral condyle fractures require (typically open) reduction and internal fixation to obtain anatomic articular alignment. Jakob et al noted that dissection during ORIF can lead to osteonecrosis of the condylar fragment, so care should be taken.
J Am Acad Orthop Surg. 2006 Jan;14(1):58-62. PMID: 16394169 (Link to Abstract)
Jakob R, Fowles JV, Rang M, Kassab MT.
J Bone Joint Surg Br. 1975 Nov;57(4):430-6. PMID: 1104630 (Link to Abstract)
Skak SV, Olsen SD, Smaabrekke A.
J Pediatr Orthop B. 2001 Apr;10(2):142-52. PMID: 11360781 (Link to Abstract)
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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?
Observation with treatment in a sling
Closed reduction and long arm casting
Closed reduction percutaneous pinning with k-wires
Open reduction internal fixation with k-wires
Open reduction with plate fixation
The radiograph demonstrates a laterally displaced and rotated intra-articular lateral condylar fracture, a Type III fracture. Type I fractures are non-displaced, stable fractures that may be treated with a long arm cast, but must be followed closely for possible displacement. Type II fractures are minimally displaced and may undergo attempted closed reduction with percutaneous pinning if the fracture is able to be anatomically reduced and found to be stable with stress arthrography. If anatomic reduction is not obtained, open reduction with internal fixation must be performed. Type III fractures are displaced, unstable fractures that require open reduction and fixation. Although there have been recent articles published recommending attempted closed reduction on all fractures, Rockwood & Wilkin's still recommends against closed reduction for Type III fractures because of the difficulty maintaining reduction of these fractures.
Launay et al found that immobilization alone resulted in additional displacement and more nonunions than did operative treatment and concluded that displaced fractures should be fixed surgically.
The Sullivan article is an overview of lateral condyle fractures.
Illustration A displays the classification system of I, II, & III from left to right.
Launay F, Leet AI, Jacopin S, Jouve JL, Bollini G, Sponseller PD
J Pediatr Orthop. 2004 Jul-Aug;24(4):385-91.PMID: 15205620 (Link to Abstract)
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HPI - This patient had a fall and sustained a lateral condyle fracture which was treated in a peripheral hospital with cast immobilization.
She is now 14 months post injury.
No ulnar nerve symptoms at the moment.
Her primary complaint is a significant elbow deformity.
How would address this problem surgically?
HPI - h/o fall in the park a week before presentation.was treated in a slab in another hospital.
How would you treat this fx now that it is seven days old?
HPI - The patient had a history of a fall in childhood that was treated nonoperatively by the village bone setter. Patient went about his life with deformity but no limitation to his work.
Then 7 months ago the patient fell again and developed acute pain in his right elbow. Patient did not seek immediate treatment.
Three months after the fall, he returned to his native country and surgery was performed. (see Postop Procedure 1 films).
He now presents with persistent pain and hardware prominence.
Do you think the large lateral condyle fragment represents an acute nonunion (from fall 7 months ago) or a chronic nonunion from his pediatric lateral condyle fx?
HPI - Patient fell from height 3 months ago. Underwent ORIF at an outside institution. K-wires removed at 4 weeks
How would you treat this condition?
HPI - child had a fall 4 weeks ago was treated after initial xray in a slab with advise weekly check xray.patient however followed up 2 weeks later xray was done another surgeon saw her and continued slab after taking xray.
child seenagain after another 2 weeks (total 4 weeks in slab) . now she has restricted motion 20 degrees to 90 degrees flexion passively.
How would you treat this patient now that 4 weeks have passed since the injury?