Updated: 1/21/2023

Lateral Condyle Fracture - Pediatric

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  • 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
      • 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

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Technique Guides (1)
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Questions (14)

(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

Closed reduction of elbow and immobilization in cast for 6 weeks



ORIF with repair of the LCL to the lateral condyle



ORIF with repair of the LCL to the supinator crest



Open reduction with percutaneous fixation or internal fixation



Closed reduction and percutaneous pinning of the lateral condyle



L 4 A

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(SBQ13PE.4.1) Figures A&B are the radiographs of an 8-year-old girl who sustained an elbow injury in a foreign country 2 years ago. She was treated by a local ”healer“ with arm massage. Today she denies pain or functional limitations. On examination, there is obvious cubitus valgus, she is neurovascularly intact, the elbow is not tender, and no instability is appreciated. The decision is made to continue treatment by way of observation. With continued conservative management, what should the family should be counseled about in advance?

QID: 214867

Disuse osteopenia of the trochlea



Lateral ulnar collateral ligament laxity



Numbness in the ring and small fingers



Medial overgrowth/spurring



Triceps insufficiency



L 2 E

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(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

The final range of motion of the elbow is not influenced by the size of the lateral spur.



Lateral spurring is common in patients treated surgically because of surgical disruption of the overlying periosteum.



Younger patients are more likely to develop larger spurs compared with older patients because of greater growth potential.



The size of the lateral spur is independent of the amount of initial fracture displacement.



Arthroscopic or open trimming of the lateral spur is recommended to prevent late cubitus varus tarda.



L 2 B

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(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

Observation alone



Observation with splinting



Osseous fragment excision



Internal fixation of the nonunion



Ulnar nerve decompression



L 2 A

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(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

Cubitus valgus



Avascular necrosis of the lateral fragment



Fishtail deformity of the distal humerus



Fracture nonunion and a normal carrying angle



Myositis ossificans



L 1 B

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

QID: 3302

Ulnar nerve palsy



Radial nerve palsy



Heterotopic ossification



Parsonage Turner syndrome



Cubitus varus



L 2 B

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(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

Medial condyle fracture



Lateral condyle fracture



Radial neck fracture



Transphyseal separation



Supracondylar humerus fracture



L 3 C

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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?

QID: 2999

External oblique radiograph



Internal oblique radiograph



Anteroposterior in maximum flexion



Anteroposterior in maximum extension



Lateral in maximum extension



L 3 C

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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?

QID: 421
















L 1 C

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(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

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



L 2 D

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(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

Immobilization in a long arm cast for 3 weeks



Immobilization in a long arm cast for 8 weeks



Open reduction and immobilization in a long-arm cast for 3 weeks



Open reduction and internal fixation with smooth pins or cannulated screw



Open reduction and internal fixation with plate and screw construct



L 2 E

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