summary Lateral Condyle Fractures are the second most common fracture in the pediatric elbow and are characterized by a higher risk of nonunion, malunion, and AVN than other pediatric elbow fractures. Diagnosis is made with plain elbow radiographs. Treatment may be nonoperative or operative depending on the degree of articular displacement. 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 Anatomic location most commonly are Salter-Harris IV fracture patterns of the lateral condyle Etiology 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 pathoanatomy fractures originate proximally at the posterior aspect of the distal humerus metaphysis and extend distally and anteriorly across the physis and epiphysis into the elbow joint fracture may extend medially into the trochlear groove, making the elbow unstable and prone to dislocation posteromedial elbow dislocation result of FOOSH with slight elbow flexion and adduction force rare concomitant injury pattern Anatomy Ossification centers of elbow lateral (external) epicondyle ossifies/appears at age 11 years fuses at age 12-14 years age of ossification/appearance and age of fusion are two independent events that must be differentiated Ossification center of the Elbow Years at ossification (appear on xray) Years at fusion (appear on xray) Capitellum 1 12-14 Radial head 3 14-16 Internal (medial) epicondyle 5 16-18 Trochlea 7 12-14 Olecranon 9 15-17 External (lateral) epicondyle 11 12-14 Blood Supply the brachial artery lies anteriorly in the antecubital fossa most of the blood supply of the distal humerus comes from the anastomotic vessels that course posteriorly Lateral collateral ligament remains intact and attached to lateral condyle fragment proximally and radial neck distally Classification Milch Classification 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 extends medially into trochlear groove (more common, more unstable) Fracture Displacement Classification- Weiss et al Characteristics Treatment 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 outstretched hand Symptoms location lateral elbow pain and swelling severity may be subtle if fracture is minimally displaced Physical exam inspection exam lacks the obvious deformity often seen with supracondylar fractures swelling and tenderness are usually limited to the lateral side lateral ecchymosis implies a tear in the aponeurosis of the brachioradialis and signals an unstable fracture 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 in displaced fractures, the capitellum is laterally displaced in relation to radial head posteriorly based Thurston-Holland fragment on the lateral view Arthrogram indications minimally displaced fractures 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 medial cartilaginous hinge must remain intact technique cast with elbow at approx 90 degrees as long as swelling is mild weekly follow up and radiographs every week x first 3 weeks, including internal oblique view occasionally > 6 weeks of casting is needed Operative CRPP + 3-6 wks in above elbow cast indications fractures with 2 - 4 mm of displacement have intact articular cartilage and can be treated with CRPP open reduction and fixation + 3-6 wks in above elbow cast indications > 4mm of displacement open reduction (rather than closed) necessary to align the joint surface joint incongruity fracture non-union supracondylar osteotomy indications deformity correction in late-presenting cubitus valgus - rarely needed Techniques CRPP approach closed reduction perhaps aided by pushing the fragment anteromedially to close the gap instrumentation divergent pin configuration most stable screw considered for more rigid fixation allows early motion compresses fracture site complications pins are less stiff screw may need to be removed if crossing the physis ORIF approach anterolateral approach as blood supply comes from posteriorly soft tissue below the skin, dissection to the joint is most often already accomplished by injury avoid dissection of the posterior aspect of lateral condyle (source of vascularization) bone work directly visualize the joint reduction, at times the metaphyseal reduction may not be perfect, as fracture fragment may have plastic deformation instrumentation 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 complications pins are less stiff screw may need to be removed if crossing the physis Complications Stiffness incidence most common complication risk factors stiffness may be an early sign of a non-union or delayed union treatment usually self-resolving by 24 weeks 90% of motion returns and full motion is present by 48 weeks Delayed Union fracture that does not heal with 6 weeks of immobilization risk factors fracture that is seen more than 2 weeks after injury treatment may be treated with immobilization if minimally displaced surgical treatment if displaced must be followed until radiographic union as nonunion is common in this scenario Nonunion incidence higher rate of nonunion than other elbow fractures risk factors nonsurgical management mechanism - theoretical constant motion at fracture site from pull of the wrist 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 goal is to obtain union of metaphyseal fragment, not restore joint surface may require bone graft ORIF with screw Cubitus Valgus ± tardy ulnar nerve palsy due to lateral physeal arrest or more commonly a nonunion slow, progressive ulnar nerve palsy caused by stretch incidence 10% less common than cubitus varus risk factors significant deformities that cause physeal arrest treatment supracondylar osteotomy after skeletal maturity and ulnar nerve transposition AVN incidence occurs 1-3 years after fracture risk factors posterior dissection can result in lateral condyle osteonecrosis (may also occur in the trochlea) 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 Lateral overgrowth/prominence (spurring) incidence up to 50% regardless of treatment, families should be counseled in advance risk factors result of displacement of the metaphyseal fragment in addition to disruption of the periosteal envelope lateral periosteal realignment will prevent this from occurring spurring is correlated with greater initial fracture displacement Growth arrest incidence rare complication risk factors varus or valgus deformity treatment young patients may be treated with bar resection or osteotomy older patients best treated with completion of the epiphysiodesis and osteotomy Unsatisfactory appearance of surgical scar Prognosis Outcomes have historically been worse than supracondylar fractures articular nature, missed diagnosis, and higher risk of malunion/nonunion Associated posteromedial elbow dislocations prolonged return of ROM final ROM similar to isolated lateral condyle fracture
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Lateral Condyle Fracture ORIF Lindsay Andras James Pace Pediatrics - Lateral Condyle Fracture - Pediatric
QUESTIONS 1 of 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Previous Next (OBQ18.53) A 3-year-old patient presents with left arm pain after a fall. The patient noticed immediate pain and deformity with the inability to flex or extend at the elbow. Radiographs are demonstrated in figures A-C. What is the optimal definitive treatment for this injury? QID: 212949 FIGURES: A B C Type & Select Correct Answer 1 Closed reduction of elbow and immobilization in cast for 6 weeks 2% (38/1584) 2 ORIF with repair of the LCL to the lateral condyle 9% (139/1584) 3 ORIF with repair of the LCL to the supinator crest 2% (39/1584) 4 Open reduction with percutaneous fixation or internal fixation 54% (852/1584) 5 Closed reduction and percutaneous pinning of the lateral condyle 32% (503/1584) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.187) A 9-year-old child is on follow-up for a lateral condyle fracture of the distal humerus. AP radiographs are taken on the date of injury and at 6 weeks postoperatively, shown in Figures A and B respectively. Which of the following statements is true? QID: 4822 FIGURES: A B Type & Select Correct Answer 1 The final range of motion of the elbow is not influenced by the size of the lateral spur. 45% (1669/3723) 2 Lateral spurring is common in patients treated surgically because of surgical disruption of the overlying periosteum. 22% (804/3723) 3 Younger patients are more likely to develop larger spurs compared with older patients because of greater growth potential. 19% (696/3723) 4 The size of the lateral spur is independent of the amount of initial fracture displacement. 12% (444/3723) 5 Arthroscopic or open trimming of the lateral spur is recommended to prevent late cubitus varus tarda. 2% (87/3723) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ13PE.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? QID: 4923 FIGURES: A Type & Select Correct Answer 1 Observation alone 5% (384/7003) 2 Observation with splinting 2% (111/7003) 3 Osseous fragment excision 10% (682/7003) 4 Internal fixation of the nonunion 82% (5731/7003) 5 Ulnar nerve decompression 1% (38/7003) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3615 FIGURES: A B Type & Select Correct Answer 1 Cubitus valgus 85% (4069/4783) 2 Avascular necrosis of the lateral fragment 3% (146/4783) 3 Fishtail deformity of the distal humerus 8% (368/4783) 4 Fracture nonunion and a normal carrying angle 3% (129/4783) 5 Myositis ossificans 1% (42/4783) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.209) Nonunion following a pediatric lateral condyle fracture has been associated with which of the following? QID: 3302 Type & Select Correct Answer 1 Ulnar nerve palsy 69% (2124/3072) 2 Radial nerve palsy 5% (146/3072) 3 Heterotopic ossification 4% (110/3072) 4 Parsonage Turner syndrome 1% (36/3072) 5 Cubitus varus 21% (643/3072) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ09TR.11.1) A 6-year-old boy presents to the emergency room after a fall from his bicycle with an isolated left elbow injury. A radiographic series is obtained and the fracture line is only appreciated on the internal oblique view. The greatest distance between the humerus and the fracture fragment is measured to be 2 mm. The patient's mother is strongly opposed to operative intervention and he is placed in a cast. However, the resident explains to her that this injury has the highest rate of nonunion about the elbow and that close follow-up will be necessary. Which of the following injuries is described in this scenario? QID: 210709 Type & Select Correct Answer 1 Medial condyle fracture 23% (464/2049) 2 Lateral condyle fracture 69% (1416/2049) 3 Radial neck fracture 1% (28/2049) 4 Transphyseal separation 3% (67/2049) 5 Supracondylar humerus fracture 3% (54/2049) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 2999 FIGURES: A B Type & Select Correct Answer 1 External oblique radiograph 20% (504/2462) 2 Internal oblique radiograph 71% (1749/2462) 3 Anteroposterior in maximum flexion 2% (56/2462) 4 Anteroposterior in maximum extension 2% (52/2462) 5 Lateral in maximum extension 4% (90/2462) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 421 Type & Select Correct Answer 1 medial 4% (65/1659) 2 lateral 3% (48/1659) 3 superior 3% (58/1659) 4 anterior 8% (136/1659) 5 posterior 81% (1337/1659) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 830 FIGURES: A Type & Select Correct Answer 1 Observation with treatment in a sling 1% (12/1948) 2 Closed reduction and long arm casting 3% (60/1948) 3 Closed reduction percutaneous pinning with k-wires 27% (520/1948) 4 Open reduction internal fixation with k-wires 68% (1328/1948) 5 Open reduction with plate fixation 0% (6/1948) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.6) A 6-year-old girl is referred for the elbow injury seen in Figure 2. What is the most appropriate treatment? QID: 6066 FIGURES: A Type & Select Correct Answer 1 Immobilization in a long arm cast for 3 weeks 5% (27/585) 2 Immobilization in a long arm cast for 8 weeks 3% (15/585) 3 Open reduction and immobilization in a long-arm cast for 3 weeks 3% (18/585) 4 Open reduction and internal fixation with smooth pins or cannulated screw 88% (512/585) 5 Open reduction and internal fixation with plate and screw construct 1% (5/585) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
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