LATERAL CONDYLEFRACTURES IN CHILDREN Dr.MADHUSUDAN Assistant professor Dept. of orthopaedics Osmania General Hospital
LATERAL CONDYLE FRACTURE IN CHILDRENcommon frx in children(20% of pediatric elbow frx);- occurs most often between 6-10 yrs of age;Fracture of necessity
Mechanism of injury:->When a varus force is applied to the extended elbow.->They tend to be unstable and become displaced because of pull of the forearm extensors.->Since these fractures are intra-articular they are prone to nonunion because the fracture is bathedin synovial fluid.- associated injuries: elbow dislocation;
ANATOMY OF ELBOW JOINT- ossification center of lateral condyle appears between 18 mo & two yrs- it extends medially to form main part of lower articular end of humerus;- lateral epicondyle ossifies at age 13 & fuses w/ capitellum at age 16;- radial collateral ligament, supinator, & forearm extensors are attached;
Ossification CentresMnemonic CRITOE C - capitellum R - radial head I - Internal Epicondyle T - Trochlea O - Olecranon E - External Epicondyle
Ossification Centres Age at appearance Age at Closure Capitellum 1-2 14 Radius 3 16 Internal 5 15 Epicondyle Trochlea 7 14 Olecranon 9 14 External 11 16 epicondyle
Milch Classification Type I fracture,: The fracture line courses medially to thetrochlea through andinto the capitellar-trochlear groove.Type II fracture: The fracture line extends into the area of the trochleaandproduces inherent instability of the elbow.
Figure 2Illustrations of the Milch classification of lateral condylar fracture.A, In type I, the fracture line courses lateral to the trochlea and exits into thecapitulotrochlear groove.B, In type II, the fracture line extends into the apex of the trochlea.(Reproduced from Sullivan JA: Fractures of the lateral condyle of the humerus.J Am Acad Orthop Surg 2006;14:58-62.)
Lateral condylar fractures also havebeen classified according to the amount ofdisplacement.(JACOB)Classification based on fracture displacementType 1 displacement <2mm, indicating intact cartilaginous hingeType 2 displacement 2-4mm, displaced joint surfaceType 3 displacement >4mm, joint displaced and rotated
Finnbogason et al.Type AFracture through the lateral humeral condyle with minimal lateral gap .A stable fractureType BFracture through the lateral humeral condyle to theepiphyseal cartilagewith a lateral gap.A fracture with undefinable risk.Type CFracture throughthe lateral humeral condyle with the fracture gap aswide laterally as medially.A fracture with high risk of lateral displacement.
RADIOGRAPHYnot ossified then•Radiographs if the lateral condyle and capitellum have•radiographic findings can be subtle•contra-lateral radiographs are very important•internal oblique view most accurately shows maximum displacement andfracture pattern, - with the arm internally rotated will best demonstrate amount ofdisplacement & rotation of lateral condyle fragment; - often multiple oblique radiographs will be needed to accuratelydetermine whether frx is displaced or non displaced; - references: - Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. - Twenty-degree-tilt radiography for evaluation of lateral humeralcondylar fracture in children. - stress views: - varus stress views (with appropriate anesthesia) may be required to helpasses frx stability;
Lateral Condyle fractures x rays .The diagnosis of a lateral condyle fracture can be challenging.Fracture lines are sometimes barely visible .Remembering the fact that the lateral condyle fracture is the second most commonelbow-fracture in children and because you know where to look for will help youlateral condyle fracture. On the x-ray only a small metaphyseal fragment isvisible. The detatched fragment however is larger than it appears on theradiograph. The fracture extents into the lateral ridge of the trochlea. Elbow isprobably unstable.
ARTHROGRAPHY- arthrogram: - may be indicated when the diagnosis isstrongly suspected but cannot be confirmed;
CT SCAN Sometimes the fracture runs through the ossified part of the capitellum. In those cases it is easy.The case shows a lateral condyle fracture extending through the ossified part of the capitellum.This is a Milch I fracture. The elbow is stable. There is too much displacement so osteosynthesis has to be performed.CT reconstruction of displaced lateral condyle fracture. Humeroulnar joint isstable.
MRIcan be helpfull in depicting the full extent of the cartilaginous component of thefracture.The case on the left shows a fracture extending into the unossifiedtrochlear ridge. The fracture through the trochlear cartilage is so far medial thatthe ulna is only supported on the medial side.This means that the elbowjoint isunstableMR of lateral condyle fracture. Milch II and unstable elbow. T2 image with fatsaturation on the right shows cartilaginous fracture. Fracture-fragmentsurrounded by synovial fluid
TREATMENTDo we need to pin all undisplaced lateralcondyle fractures?
THE MESSAGE: -WHEN IN DOUBT PIN -FOLLOW UNTIL FULLY HEALEDCLINICALLY AND RADIOGRAPHICALLY
STAGE II CLOSED REDUCTION AND INTERNAL FIXATION
COMPLICATIONS- ULNAR NERVE PALSY - over several years, ulnar nerve is repeatedly stretched by motion ofelbow over apex of deformity, & becomes inflamed behind medial condyle; - typically symptoms are not seen until second decade; - at earliest signs of neuritis, ulnar nerve should undergo transposition;
AVN of capitellum: - will cause growth distrubance & deformity of capitellum & radialhead; - during exposure, posterior aspect of frx fragment is leftundisturbed because it is source of blood supply to the capitellum; - in children, vascular supply of trochlea is vulnerable to injury; - risk of AVN with late open reduction of LCF at >3 weeks isreduced if no tissue is stripped off the fracture fragmentposteriorly; - cubitus varus: - a more common complication than cubitus valgus; - may be due to over-stimulation of the lateral condylar condylarphysis;