Lateral Condyle Fractures

Epidemiology

 

Average age 6 years (4 - 10)

 

20% distal humeral fracture

- second most common elbow fracture

- after supracondylar

 

Mechanism

 

Pull offLateral condyle

Pull off                                     

 

Pull Off 

- more common

- fall on outstretched arm

- lateral condyle is pulled off by the common extensor origin

- varus stress

 

Push offLat condyle

Push off

 

Push off

- radial head pushes off the lateral condyle

- valgus stress

 

Classification

 

Anatomical

 

Milch I

Milch I

 

Milch I 

- SH IV

- fracture line lateral to trochlear groove

- elbow stable

 

 

Milch IIMilch II xray

Milch II

 

Milch II

- SH II

- fracture line goes more medially into trochlear notch

- lateral wall of trochlear part of fracture fragment

- more common

- elbow can be unstable

 

Latera condyle elbow dislocationLat condyle

Lateral condyle fracture with elbow dislocation

 

Displacement ~ Weiss Classification

 

Type I:     < 2 mm displaced with articular surface intact

Type II:     2 - 4 mm displaced with articular surface intact

Type III:   < 4 mm displaced, articular surface disrupted

 

Clinical

 

Age 6 

History fall

Lateral pain

Swelling

 

X-ray

 

Undisplaced

- typically metaphyseal flake

- looks minimally displaced on AP and lateral

- perform an internal oblique x-ray to exclude displacement

 

Lateral Condyle Paeds UndisplacedLateral condyle paeds undisplaced 2

 

Displaced

 

Lateral condyleDisplaced lat condyle

 

CT 

 

MRI

 

Not typically used due to need for sedation

 

Management

 

Non operative

 

Indication

 

Lateral Condyle Paeds Undisplaced

 

Undisplaced 

Displaced < 2 mm

 

Technique

 

Confirm fracture is truly undisplaced

- internal oblique xray

- xray other arm

 

Serial xrays for first 3 weeks

 

Remove case 4 - 6 weeks

 

Mildly displaced lateral condyleOther elbow for comparison

Injured left elbow v injury right elbow

 

Results

 

Knapik et al J Paediatr Orthop 2017

- systematic review of 6 studies

- nonoperative management of lateral condyle fractures < 2 mm displaced

- risk of subsequent displacement 15%, usually within first week

- associated with non union and malunion

 

Internal oblique xray

 

Edmonds et al J Paediatr Orthop 2021

- 140 cases lateral condyle fracture treated non operatively

- displacement < 1.2 mm on internal oblique had failure rate of 58%

- displacement > 1.2 mm on internal oblique had failure rate of 1%

 

Kurtulmus et al Eur J Orthop Surg Traumatol 2014

- 27 patients with < 2 mm displacement on AP view

- 16 found to have > 2 mm displacement on subsequent internal oblique view

 

Operative

 

Surgical indications

 

1.  Unstable / Milch II

 

2.  Displaced > 2 mm

 

Options

 

1. Closed reduction and percutaneous K wires

2. Open reduction and K wire or screw

 

Closed reduction and percutaneous K wires

 

K wires LC 1K wires lateral condyle 2

 

Indications

- residual displacement < 2 mm

- no rotation

- confirm joint surface anatomically reduced (arthrogram)

 

Technique

- reduce by extension and varus

- pronation uses flexor mass to pull lateral condyle forward

- percutaneous K wire

 

Open reduction and K wires / screw fixation

 

AO surgery reference lateral approach distal humerus

 

Vumedi video open lateral condyle fracture

 

Lateral approach to distal humerus

- curved incision over lateral supracondylar ridge of humerus, and over proximal radius

- proximally intermuscular interval between brachioradialis & triceps

- proximally elevate brachioradialis and ECRL off the distal humerus

- distally split common extensor origin between ECRB and EDC and elevate anteriorly

 

Don't dissect posteriorly to protect blood supply

Don't need to dissect distal fragment

 

Use anterior homan retractor across distal humerus to elevate anterior capsule

- visualize distal joint line and perform anatomical reduction under vision

- one K wire parallel to joint surface across fracture into trochlea

- one K wire at 45 degrees to first engaging medial metaphysis

- bury K wires as need to be in for 6 weeks

 

Disp ORIF 1Disp ORIF 2

Open reduction of displaced lateral condyle in left elbow

 

Lat condyle screw 2Lat condyle screw 1

 

Lat cond ORIF 1Lateral condyle ORIF 2

 

Screw fixation 3Screw fixation 4

 

Post op

- very real risk of non union

- elbow in POP for 6 weeks

- don't remove K wires until obvious union at 6 weeks

 

Results

 

Closed v open reduction

 

Pennock et al J Paediatr Orthop 2016

- lateral condyle fractures displaced 2 - 5 mm

- 51 open reduction and pinning, 23 closed reduction and pinning

- all healed by 12 weeks

- no major complications in closed reduction and percutaneous pinning

- open reduction had 1 AVN, 1 osteomyelitis, 1 refracture requiring repeat surgery

 

K wires v screws

 

Screw

- compression of fragment

- potentially less non union

- more difficult to remove

 

Li et al Int Orthop 2012

- 60 patients treated with lag screws or K wires

- no difference in outcome

- less stiffness in screw fixation due to earlier mobilisation

 

Screw fixation 1Screw fixation 2

 

 

 

Delayed Presentation

 

Definition

 

Presentation after 3 weeks

 

Option 1. Reduction and ORIF

 

Risk of AVN and growth arrest due to excessive soft tissue stripping

- exact incidence / risk is unknown

- best option if fragment is displaced and mobile

- may do up to 6 weeks to 6 months

- controversial

 

Option 2.  Bone graft and screw in situ

 

Will have valgus deformity

- delayed osteotomy

 

Complications

 

Issues

 

Higher rate of complications in comparison to supracondylar fractures

- intra-articular fracture

- transphyseal fracture

- inherently unstable

- tenuous blood supply (AVN)

- synovial fluid in fracture site (non union)

- often need open reduction and thus more scarring

 

Tan et al Arch Orthop Trauma Surg 2018

- systematic review of 2440 cases

- nonunion 1.6%

- flexion loss 10%, extension loss 11%

- valgus deformity 6% / varus deformity 8%

- prominent lateral condyle 27%

- fishtail deformity 14%

- growth plate closure 5%

- AVN 2%

- neurological deficit 11%

 

Non Union

 

Lateral condyle nonunion

 

Incidence

 

1.6%

- higher with increasing displacement

 

Definition

 

Delayed union - 6 weeks

Non union - 12 weeks

 

Causes

 

1.  Non operative treatment / missed displaced fractures of the lateral condyle

 

2.  Surgical malreduction

 

Salgueiro et al J Paediatr Orthop 2017

- 210 surgical cases

- delayed union and nonunion associated with > 1mm residual fracture gap after surgery

 

Presentation

 

Pain

Loss of ROM

Cubitus valgus

Tardy ulna nerve palsy

 

Management non displaced non union

 

Observe for union until 3 months

- then screw fixation +/- graft metaphyseal non-union

 

Management displaced non-union

 

A.  Reduce and ORIF +/- bone graft

- though to be acceptable if < 6 months and fragment mobile

 

B.  ORIF in situ +/- bone graft

- later osteotomy for malunion / valgus instability

 

Lateral condyle nonunionScrew in situ 1Screw in situ 2

In situ screw fixation delayed nonunion

 

Results

 

Park et al J Paediatr Orthop 2015

- in situ fixation of 16 cases of nonunion with screw

- average 5 months post surgery with average 6 mm displacement

- all united

- 3/16 residual deformity

 

Cubitus Varus / Overgrowth lateral condyle

 

Lateral condyle overgrowth

 

Common problem

- little cosmetic or functional problem

 

Cubitus Valgus and Tardy Ulnar Nerve Palsy

 

Causes

- AVN

- nonunion

- malunion

- physeal arrest / malunion

 

Management

- anterior transposition nerve

- +/- osteotomy

 

Fishtail Deformity

 

Trochlea AVN

AVN trochlea and fishtail deformity

 

Causes

- trochlear AVN

- central growth arrest

- often asymptomatic