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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 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-controversial
Type I

Fracture line is lateral to trochlear groove

 
Type II Fracture line into trochlear groove
 
 
Fracture Displacement Classification-Weiss et al.
Type 1 <2mm, indicating intact cartilaginous hinge

Type 2 >2 mm < 4 displacement, intact articular cartilage on arthrogram
Type 3 >2-4 mm,  articular surface disrupted on arthrogram
 
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
        • somewhat controversial, but Weiss et al suggest fractures with < 4 mm of displacement have intact articular cartilage and can be treated with CRPP
      • 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 plane to prevent fragment derotation
        • arthrogram used to confirm joint congruity
    • open reduction and fixation
      • indications
        • if > 2-4mm 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
        • single screw may also be used with non-unions +/- bone grafting 
Complications
  • Nonunion
    • higher rate of nonunion than other elbow fractures
  • AVN
    • posterior dissection can result in lateral condyle osteonecrosis
    • may also occur in the trochlea
  • 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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Questions (5)

(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? Review Topic

QID:3615
FIGURES:
1

Cubitus valgus

89%

(2474/2790)

2

Avascular necrosis of the lateral fragment

2%

(62/2790)

3

Fishtail deformity of the distal humerus

6%

(174/2790)

4

Fracture nonunion and a normal carrying angle

2%

(62/2790)

5

Myositis ossificans

1%

(16/2790)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

Incorrect Answers:
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.


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Question COMMENTS (10)

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

QID:3302
1

Ulnar nerve palsy

73%

(1481/2042)

2

Radial nerve palsy

5%

(95/2042)

3

Heterotopic ossification

2%

(49/2042)

4

Parsonage Turner syndrome

1%

(20/2042)

5

Cubitus varus

19%

(390/2042)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

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(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? Review Topic

QID:2999
FIGURES:
1

External oblique radiograph

23%

(336/1447)

2

Internal oblique radiograph

68%

(990/1447)

3

Anteroposterior in maximum flexion

2%

(33/1447)

4

Anteroposterior in maximum extension

2%

(27/1447)

5

Lateral in maximum extension

4%

(56/1447)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.


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(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? Review Topic

QID:421
1

medial

3%

(29/864)

2

lateral

3%

(24/864)

3

superior

4%

(31/864)

4

anterior

6%

(53/864)

5

posterior

83%

(720/864)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.


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Question COMMENTS (2)

(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? Review Topic

QID:830
FIGURES:
1

Observation with treatment in a sling

0%

(1/908)

2

Closed reduction and long arm casting

3%

(27/908)

3

Closed reduction percutaneous pinning with k-wires

23%

(211/908)

4

Open reduction internal fixation with k-wires

73%

(662/908)

5

Open reduction with plate fixation

0%

(3/908)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.

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