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Introduction
  • Fractures involving the lateral condyle of the humerus that have higher risk of nonunion, malunion, AVN than other pediatric elbow fractures
  • Epidemiology
    • incidence
      • 17% of all distal humerus fractures in the pediatric population
      • 2nd most common elbow fracture (after supracondylar)
    • demographics
      • typically occurs in patients aged 6 years
    • 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 (less common, elbow is stable as fracture does NOT enter trochlear groove)

 
Type II Fracture line into trochlear groove (more common, more unstable)
 
 
Fracture Displacement Classification-Weiss, et al
Type 1 <2mm, indicating intact cartilaginous hinge

Casting
Type 2 >2 mm < 4 displacement, intact articular cartilage on arthrogram
Closed reduction and fixation
Type 3 >4 mm,  articular surface disrupted on arthrogram
Open reduction and fixation
 
Presentation
  • History
    • fall onto an outstetched hand
  • Symptoms
    • lateral elbow pain
    • localized swelling
  • Physical exam
    • inspection
      • exam lacks 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 fracture displacement because fracture is posterolateral 
    • optional views
      • contralateral elbow for comparison when ossification is not yet complete
      • routine elbow stress views are not recommended due to pain and lack of useful information
    • findings
      • fracture fragment most often lies posterolateral which is best seen on internal oblique views
  • Arthrogram
    • indications
      • to assess cartilage surface when there is incomplete/absent epiphyseal ossification 
      • allows dynamic assessment
  • CT scan
    • indication
      • rarely indicated, only if there is uncertainty as to the type of fracture
  • MRI
    • indication
      • provides the ability to assess the cartilaginous integrity of the trochlea
      • useful for operative planning of delayed or non-unions
    • expensive
    • require GA/sedation to perform the test
    • arthrograms generally preferred to MRI 
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 x 4-6wks
      • indications
        • only if < 2 mm displacement in all views
      • technique
        • cast with elbow at 90 degrees
        • weekly follow up and radiographs every week x first 3 weeks, including internal oblue view.  OOP if needed to best visualize
        • occaisionally > 6 weeks of casting is needed
  • Operative
    • CRPP + 3-6 wks in above elbow cast
      • indications
        • Weiss et al suggest fractures with < 4 mm of displacement have intact articular cartilage and can be treated with CRPP
      • technique
        • closed reduction perhaps aided by aided by pushing the fragment anteromedial to close the gap
        • divergent pin configuration most stable
        • arthrogram used to confirm joint congruity
        • consider a screw for most rigid fixation
          • allows early motion
          • compresses fracture site
          • AVOID the olecranon fossa
          • Most screws need to be removed at some point, but a purely metaphyseal screw avoiding the physis may not need to be removed.
    • open reduction and fixation + 3-6 wks in above elbow cast
      • open reduction (rather than closed) necessary to align joint surface
      • indications
        • > 4mm of displacement
        • joint incongruity
        • fracture non-union
      • technique
        • below the skin, disection to joint is most often already accomplished by injury
        • directly visualize the joint reduction, at times the metaphyseal reduction may not be perfect, as fracture fragment may have plastic deformation.
        • avoid dissection of posterior aspect of lateral condyle (source of vascularization)
        • implants
          • most fractures can be fixed with 2 percutaneous pins (3 if comminuted) in parallel or divergent fashion
          • single screw for large fragments or non-union. bone grafting rarely needed 
    • supracondylar osteotomy
      • indications
        • deformity correction in late presenting cubitus valgus - rarely needed
Complications
  • Stiffness
    • most common complication
    • stiffness may be an early sign of a non-union or delayed union
  • Nonunion
    • higher rate of nonunion than other elbow fractures
    • normal radiographic union of lateral condyle fracture is 6wks
    • risk
      • nonsurgical management
    • mechanism - theoretical
      • constant pull by extensors
      • intra-articular (synovial fluid impede fracture healing)
      • poor metaphyseal circulation to distal fragment
    • prevent nonunion by
      • preserving soft tissue attachments to lateral condyle
      • stable internal fixation
    • treatment
      • ORIF with screw
  • AVN
    • occurs 1-3 years after fracture
    • posterior dissection can result in lateral condyle osteonecrosis (may also occur in the trochlea)

  • Malunion
    • caused from delay in diagnosis or loss of reduction
    • 20% cubitus varus in nondisplaced/minimally displaced fractures
      • traumatic inflammation leads to lateral overgrowth (see spurring below)
    • 10% cubitus valgus ± tardy ulnar nerve palsy   
      • because of lateral physeal arrest as fracture is Salter Harris IV
    • fishtail deformity
      • area between medial ossification center and lateral condyle ossification center resorbs or fails to develop
      • does NOT predispose to arthritis
    • treatment
      • supracondylar osteotomy
  • Tardy ulnar nerve palsy
    • slow, progressive ulnar nerve palsy caused by stretch in cubitus valgus
    • usually late finding, presenting many years after initial fracture
  • Lateral overgrowth/prominence (spurring)   
    • up to 50% regardless of treatment, families should be counseled in advance
    • lateral periosteal alignment will prevent this from occurring
    • 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 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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