Lateral condylar fractures of the distal humerus

1. Lateral Condylar Fractures of the distal
humerus
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
‫الرحیم‬ ‫الرحمن‬ ‫اهلل‬ ‫بسم‬
Rockwood and Green's Fractures in Adults 9th Edition

2. Introduction
• the most common physeal injuries after distal radius
• average age around 6 years
• medial condylar physis are rare and occur most often in children 8 to 12
years of age
• Fractures involving the total distal humeral physis may occur in neonates or
within the first 2 to 3 years of life

3. Introduction
• less common than supracondylar fractures
– Dislocation(PL) of the elbow
– Radial head fractures
• Fractures of the olecranon, which are often greenstick fractures
• Diagnosis(Obl view)

4. Introduction
• Two mechanisms have been suggested: “push-off” and “pull-off.”
• Sign and Symptom: soft-tissue swelling and pain
• Stage I displacement flexing the wrist
• Stage II or III displacement, there often is a hematoma present laterally, and
attempted manipulation may result in some local crepitus with motion of the
lateral condylar fragment.

5. Introduction
• Radiogeraphy
• In the AP view, the metaphyseal fragment or “flake” may be small and
seemingly minimally displaced.
• The degree of displacement may be seen on the true lateral view.
• Oblique views are especially helpful in patients in whom a stage I
displacement is suspected but not evident on AP and lateral views
• It use to evaluate amount of fracture displacement and to assess stability if a
lateral condylar fracture is suspected
• Arthrography or MRI evaluation and Ultrasonography

9. Classification
• Anatomic Location: The Milch classification, based on whether or not the
fracture extends through (type I) or around (type II) the capitellar ossific
nucleus
• Type I salter IV
• Type II salter II

10. Stages of Displacement:
• The amount of fracture displacement has been described by
Jakob et al. in three stages:
• First stage, the fracture is relatively nondisplaced, and the
articular surface is intact ,with no lateral shift of the olecranon.
• Second stage, the fracture extends completely through the
articular surface which allow lateral displacement of the
olecranon.
• Third stage, the condylar fragment is rotated and totally displaced
laterally and proximally, which allows translocation of both the
olecranon and the radial head.

12. Stage II displacement—articular surface
disrupted

13. Lateral Condylar Of The Distal Humerus
1
Stage III displacement—fragment rotated

14. Stages of Displacement:
• Weiss et al. Modified classification based on fracture
displacement and disruption of the cartilaginous hinge.
– Type I fractures are displaced less than 2 mm;
– Type II fractures are displaced more than 2 mm but have
an intact cartilaginous hinge;
– And type III fractures are displaced more than 2 mm and
do not have an intact cartilaginous hinge.
• This classification was found to be predictive of both the
major and minor complications.

15. Figure 19-7 classification of lateral humeral condylar fractures.
Type I, less than 2 mm of displacement;
Type II, 2 mm or more of displacement and congruity of the articular surface;
Type III, more than 2 mm of displacement and lack of articular congruity.

19. Treatment Options for Lateral Condylar Fractures
• Fractures involving the lateral condylar physis can be
treated with immobilization alone, closed reduction and
percutaneous pinning, or open surgical reduction
depending on the degree of displacement and amount of
instability.

20. Immobilization
• Minimally displaced fractures (<2 mm) are stable and have intact soft-tissue
attachments that prevent displacement of the distal fragment.
• Immobilization of nondisplaced or minimally displaced (less than 2 mm)
fractures in a posterior splint or cast is adequate.
• Radiographs are obtained during the first 3 weeks after injury to ensure that
rare late displacement does not occur.
Nonoperative Treatment of Lateral Condylar Fractures

21. • Radiographs are taken within the first week after the fracture with the cast
removed and the elbow extended.
• If there is no displacement, the radiographs are repeated once again
during the next 1 to 2 weeks.
• Immobilization is continued until fracture union is apparent, usually
between 4 and 6 weeks after injury

22. Closed Reduction and Percutaneous Pinning
• Displaced more than 2 mm is required to restore anatomic alignment of the
joint and physis.
• Closed reduction is best achieved with the forearm supinated and the
elbow extended.
• Placing a varus stress on the extended elbow allows easier manipulation of
the fragment.
• Standard closed reduction with thumb pressure on the fracture fragment,
elbow flexion, forearm supination, and wrist dorsiflexion usually results in
an aligned fracture.
• The smooth pins are then advanced across the fracture site to the opposite
cortex to obtain stability.
• Anatomic alignment of the joint and fracture stability are confirmed by
stress testing and arthrography.
• If a satisfactory reduction cannot be obtained, then reduction can be
achieved and maintained by open reduction and internal fixation.

24. ORIF
• If the fracture is completely displaced, malrotated, and/or grossly unstable
(stage III), open reduction and internal fixation are indicated.
• We prefer open reduction and internal fixation of all fractures with stage III
displacement.
• It is important that open reduction is performed within a few days after the
injury.
• The standard lateral Kocher approach provides sufficient exposure of the
fragment.
• Extensive posterolateral soft-tissue dissection risks osteonecrosis of the
condyle and so dissection is performed anteriorly with minimal soft-tissue
stripping

25. ORIF
• A long arm cast is applied with the elbow flexed 90 degrees and the
forearm in neutral or slight pronation.
• The cast and pins are removed in 4 weeks if there is adequate healing on
radiographs.
• Early active motion is started at that time.
• If necessary, pin removal can be delayed 1 to 2 weeks to allow further
healing in older children.

27. Complications
Lateral Spur Formation
- Is one of the most common sequelae after a fracture involving the lateral condylar physis.
- After both nonoperative and operative treatment
- More frequent after displaced fractures (Jakob types II and III) and those treated with PCP or
ORIF than in those treated with cast immobilization
- Mild cubitus varus (pseudovarus)

29. Cubitus Varus
• The incidence of cubitus varus is as high as 40%
• Due to an inadequate reduction, growth
stimulation of the lateral condylar physis from the
fracture insult, or a combination
of both.
- Rarely is severe enough to cause concern or
require further treatment

31. Cubitus Valgus
• Is much less common after united lateral condylar fractures than cubitus
varus .
• If cubitus valgus is symptomatic, it can be treated with:
- Medial closing wedge osteotomy
- Dome osteotomy and internal fixation
- Osteotomy and gradual distraction through an external fixator

32. Delayed Union
• Most common in patients treated nonoperatively
• Various reasons have been suggested for delayed union of lateral condylar
fractures, including:
- Poor circulation to the metaphyseal fragment
- Bathing of the fracture site by articular fluid, which inhibits fibrin formation
and subsequent callus formation.
- Tension forces exerted by the extensor musculature arising from the
condylar fragment
*Lateral spur formation or cubitus varus is relatively common with these late
healing fractures

33. • Delayed open reduction(more than 3 weeks after injury) has a risk of
osteonecrosis and further loss of elbow motion.
• The need for further treatment depends on:
- The presence of significant symptoms
- Limited motion
- Risk of further displacement

36. Nonunion
• True nonunion occurs in patients with progressive displacement
of the fragment or late of initial treatment of a displaced fracture.
- If the fracture is displaced and is not united by 12 weeks, it is considered
a nonunion
- Weakness or symptoms can occur when the arm is used for high-
performance activities.
- The fragment migrates both proximally and laterally
- Nonunion can lead to a cubitus valgus deformity,
- Tardy ulnar nerve palsy
- Lateral translocation of the proximal radius and ulna

39. • Surgical treatment for established nonunion if:
• A large metaphyseal fragment
• Displacement of less than 1 cm from the joint surface
• An open, viable lateral condylar physis

41. Fish tail deformity

42. Neurologic Complications
• Acute Nerve Injuries
- Is Rare
- Transient radial nerve paralysis
- Posterior interosseous nerve injury
• Tardy Ulnar Nerve Palsy
- A late complication of fractures
- After the development of cubitus valgus from malunion or nonunion
- Motor loss occurs first, with sensory changes developing somewhat later
- Anterior transposition of the nerve