Lateral condyle fractures of the elbow are common in children between ages 6-10 years. They occur when a varus force is applied to an extended elbow. These fractures are prone to displacement and nonunion due to pull from forearm extensors and being bathed in synovial fluid. Treatment depends on the amount of displacement, with undisplaced fractures often treated non-operatively and displaced fractures requiring closed or open reduction and internal fixation. Complications can include ulnar nerve palsy, osteonecrosis, nonunion, and cubitus deformities.

1. LATERAL CONDYLE
FRACTURES IN CHILDREN
Dr.MADHUSUDAN
Assistant professor
Dept. of orthopaedics
Osmania General Hospital

2. LATERAL CONDYLE FRACTURE IN CHILDREN
common frx in children
(20% of pediatric elbow frx);
- occurs most often between 6-10 yrs of age;
Fracture of necessity

3. 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 bathed
in synovial fluid.
- associated injuries: elbow dislocation;

4. 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;

5. Ossification Centres
Mnemonic CRITOE
 C - capitellum
 R - radial head
 I - Internal Epicondyle
 T - Trochlea
 O - Olecranon
 E - External Epicondyle

6. 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

8. Milch Classification
Type I fracture,:
The fracture line courses medially to thetrochlea through and
into the capitellar-trochlear groove.
Type II fracture:
The fracture line extends into the area of the trochlea
andproduces inherent instability of the elbow.

9. 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 the
capitulotrochlear 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[1]:58-62.)

10. Lateral condylar fractures also havebeen classified according to the amount of
displacement.(JACOB)
Classification based on fracture displacement
Type 1
displacement <2mm, indicating intact cartilaginous hinge
Type 2
displacement 2-4mm, displaced joint surface
Type 3
displacement >4mm, joint displaced and rotated

11. Finnbogason et al.
Type A
Fracture through the lateral humeral condyle with minimal lateral gap .
A stable fracture
Type B
Fracture through the lateral humeral condyle to theepiphyseal cartilage
with a lateral gap.A fracture with undefinable risk.
Type C
Fracture throughthe lateral humeral condyle with the fracture gap as
wide laterally as medially.
A fracture with high risk of lateral displacement.

13. 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 and
fracture pattern,
- with the arm internally rotated will best demonstrate amount of
displacement & rotation of lateral condyle fragment;
- often multiple oblique radiographs will be needed to accurately
determine 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 humeral
condylar fracture in children.
- stress views:
- varus stress views (with appropriate anesthesia) may be required to help
asses frx stability;

14. 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 common
elbow-fracture in children and because you know where to look for will help you
lateral condyle fracture. On the x-ray only a small metaphyseal fragment is
visible. The detatched fragment however is larger than it appears on the
radiograph. The fracture extents into the lateral ridge of the trochlea. Elbow is
probably unstable.

15. ARTHROGRAPHY
- arthrogram:
- may be indicated when the diagnosis is
strongly suspected but cannot be confirmed;

16. 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 is
stable.

17. MRI
can be helpfull in depicting the full extent of the cartilaginous component of the
fracture.The case on the left shows a fracture extending into the unossified
trochlear ridge. The fracture through the trochlear cartilage is so far medial that
the ulna is only supported on the medial side.This means that the elbowjoint is
unstable
MR of lateral condyle fracture. Milch II and unstable elbow. T2 image with fat
saturation on the right shows cartilaginous fracture. Fracture-fragment
surrounded by synovial fluid

18. TREATMENT
Do we need to pin all undisplaced lateral
condyle fractures?

19. THE MESSAGE:
-WHEN IN DOUBT PIN
-FOLLOW UNTIL FULLY HEALED
CLINICALLY AND RADIOGRAPHICALLY

20. STAGE II CLOSED REDUCTION AND
INTERNAL FIXATION

21. STAGE III LATERAL CONDYLE

22. PERFECT ARTICULAR AND PHYSEAL
REDUCTION

24. LATE
PRESENTATION
LATERAL
CONDYLE
FRACTURES IN
CHILDREN

25. What do
late
presenters
present with?

26. COMPLICATIONS
Physeal arrest – cubitus valgus
Physeal stimulation – cubitus varus
Osteonecrosis.
Nonunion with resultant cubitus valgus
@ tardy ulnar nerve palsy

27. If you can not fix the non union
What do we treat?
Problem oriented solutions

28. Situation 1
Rom Good
Deformity Acceptable
Instability Absent
palsyAbsent

29. Situation 1 solution
Rom Good
Deformity Acceptable observation
Instability Absent
palsyAbsent

30. Situation 2
Rom Good
Deformity Acceptable
Instability Absent
palsy present

31. Situation 2 solution
Rom Good Transposition of
Deformity Acceptable ulnar nerve
Instability Absent
palsy present

32. Situation 3
Rom Good
Deformity unacceptable
Instability Absent
palsy present

33. Situation 3 solution
Rom Good
Deformity unacceptable
Osteotomy with or
Instability Absent without ulnar transposition
palsy present

34. Situation 4
Rom Good
Deformity Acceptable
Instability present
palsy Absent

35. Situation 4 solution
Rom Good
Deformity Acceptable
Osteosynthesis insitu
Instability present
palsy Absent

36. COMPLICATIONS
-
ULNAR NERVE PALSY
- over several years, ulnar nerve is repeatedly stretched by motion of
elbow 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;

37. AVN of capitellum:
- will cause growth distrubance & deformity of capitellum & radial
head;
- during exposure, posterior aspect of frx fragment is left
undisturbed 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 is
reduced if no tissue is stripped off the fracture fragment
posteriorly; - cubitus varus:
- a more common complication than cubitus valgus;
- may be due to over-stimulation of the lateral condylar condylar
physis;