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Updated: Jan 21 2023

Lateral Condyle Fracture - Pediatric

4.3

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Images
https://upload.orthobullets.com/topic/4009/images/2_moved.jpg
https://upload.orthobullets.com/topic/4009/images/milch2.jpg
https://upload.orthobullets.com/topic/4009/images/figure_4c_0953789_lateral_condyle_delayed_union_3.jpg
https://upload.orthobullets.com/topic/4009/images/milch1.jpg
https://upload.orthobullets.com/topic/4009/images/elbow-radiograph-age-two.jpg
  • 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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