Lateral condyle of humerus fracture in children

1. LATERAL CONDYLE FRACTURE
OF THE DISTAL HUMERUS IN
CHILDREN
PRESENTER: Dr. ANIL KC
ORTHOPEDIC RESIDENT
GUANGXI MEDICAL UNIVERSITY

2. OVERVIEW
 Pediatric lateral condyle fracture is second most common
fracture in pediatric elbow and are characterized by higher risk
of malunion, nonunion, and AVN then in other elbow fracture.
 Treatment is dictated by degree of articular displacement and
may need CRPP or ORIF.

3. EPIDEMIOLOGY
INCIDENCE:
。17% of all distal humerus fractures in the pediatric population
。2nd most common elbow fracture after supracondylar
DEMOGRAPHICS:
。Typically occurs in patient with the average age of 6 years.
LOCATION:
。Most commonly are salter-harris IV fracture pattern of the
lateral condyle

4. 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 outstretched hand causes impaction of the radial head into the lateral
condyle causing fracture.
Pathoanatomy:
。 fracture originate proximally in the metaphysis and extend distally and anteriorly
across the physis and epiphysis into elbow joint.
。 fracture may extend medially into the trochlear groove, making the elbow
unstable and prone to dislocation

5. Presentation
 History
。 fall onto outstretched hand
Symptoms
。 lateral elbow pain and swelling
。 may be subtle if fracture is minimally displaced
Physical exam
Inspection
。 little distortion of elbow, lack of 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

6. Presentation cont.
 Motion
。 local tenderness over the condylar fracture site, which may be increased with
resisted wrist extension/flexion.
。 with more displaced fracture may feel local crepitus at the fracture site

7. Imaging
 Radiograph
recommended views ：
。 AP, lateral, and oblique of elbow
。 Internal oblique view most accurately shows fracture displacement because
fracture is posterolateral.
。 To determine the importance of internal oblique view in the radiographic
evaluation of nondisplaced or minimally displaced lateral condylar fractures, song et al.
compared the oblique view to standard AP views and found that the amount of
displacement differed between two views in 75% of children. They recommended routine
use of an internal oblique view to evaluate the amount of fracture displacement and
stability.
。 sometime x-ray of contralateral elbow is needed for comparison when
ossification is not yet complete.

8. Imaging cont.
 Arthrogram
。 indicated in minimally displace fracture
。 to assess cartilage surface when there is incomplete/absent epiphyseal
ossification.
 MRI
。 provides the ability to assess the cartilaginous integrity of trochlea
。 useful for operative planning of delayed or non-union
。 expensive
。 required GA/sedation to perform test
Ultrasound evaluation
Most recently it has been suggested to identify unstable fractures in acute setting and
to aid preoperative planning for late displacement, delayed union and malunion.

9. Radiographic finding in lateral condyle of humerus fracture
Figure A: Injury film of a 7 year old with a non
displaced fracture of lateral condyle (small
arrows).Attention was drawn to the site of fracture
because of extensive swelling on lateral
aspect(white arrow)
Figure B: Because of extensive soft tissue injury,
there was little intrinsic stability, allowing the
fracture to become displaced at 7 days(arrow)

10. Radiographic finding in lateral condyle of humerus fracture cont.
Figure A: a small ossific nucleus in the
swollen lateral soft tissue
Figure B：An arthrogram shows the
defect left by the displaced lateral
condyle(closed arrow). The displaced
condyle is outlined in the soft
tissues(solid arrow)

11. Radiographic finding in lateral condyle of humerus fracture cont.
Figure A: Radiograph of what appears to be stable
type II fracture of the lateral condyle in a 10 year
old child
Figure B: MRI imaging clearly shows that this is a
fracture of entire distal humeral physis.
In fracture of entire distal humerus physis, the
proximal radius and ulna usually are displaced
posteromedially. The relationship of lateral
condylar ossification center to the proximal radius
remains intact. But in true fracture involving only
the lateral condylar phyis, the relationship of
condylar ossification center to proximal radius is
disrupted. In addition, displacement of the
proximal radius and ulna is more likely to be
lateral.

12. Radiographic finding in lateral condyle of humerus fracture cont.
Figure ：Angular deformities. A: capitellar fracture. B: fracture extending into the trochlea

13. prognosis
 Outcome have historically been worse than supracondylar fractures
missed diagnosis
higher risk of malunion/nonunion

14. Milch classification
Type I Fracture line 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)
This classification is used infrequently because of its poor reliability and predictive
value.

15. Jakob’s classification
Stage I Fracture relatively nondisplaced ,articular surface
intact
Stage II Articular surface disrupted; fragment and olecranon
displaced
Stage III Fragment rotated and displaced

16. Weiss classification
Type I <2 mm displacement
Type II >2 mm displacement with intact cartilaginous hinge
Type III >2 mm displacement with nonintact cartilaginous hinge

17. Song et al. classification on the basis of fracture
displacement and fracture pattern
stage Displacement(mm) Fracture pattern stability
1 ≤2 Limited to metaphysis stable
2 ≤2 Indefinable； extends to
epiphyseal articular cartilage
indeterminate
3 ≤2 Medial and lateral
displacement of distal
fragment
Unstable
4 ≥2 No rotation of fragment Unstable
5 ≥2 Rotation of fragment unstable

19. Treatment
 Non operative
。Long arm cast /posterior splint for 4-6 wks
indication
。 only if <2 mm displacement in all views
。 medial cartilaginous hinge must remain intact
 technique
。 cast with elbow at approx. 90 degrees with the forearm in neutral rotation
。 weekly follow up radiographs every week for first 3 weeks, including internal
oblique view

20. Treatment cont.
 Operative
CRPP+ 4-6 wks in long arm bivalved cast.
Indications
。 Fractures with 2-4 mm of displacement that are found to be stable with intact
articular hinge, either by stress maneuvers, arthrography, or other imaging modality.
Technique
。 Closed reduction is best achieved with the elbow extended, forearm supinated,
wrist extended and varus elbow stress.
Instrumentation
。 divergent pin configuration most stable
。 cannulated screw fixation considered for more rigid fixation, allows early
motion and compresses fracture site

21. Treatment cont.
 Outcomes of CRPP:
According to song et al. all type of lateral condyle fracture can be treated with CRPP.
They reported good results in 46 (76%) of 63 unstable fracture ,53 of which were treated
with CRPP and remaining cases were treated with ORIF after closed reduction failed to
achieve <2mm of displacement.
More recently, Song et al. described close manipulation of 24 completely displaced
and rotated fracture (Jackob type III),followed by pinning. In this series, closed reduction
was successful in 18 (75%).But this technique is technically difficult and has a difficult
learning curve.
They listed three element essential for obtaining good result with CRPP:
1)Accurate interpretation of direction of fracture displacement
2)routine intraoperative confirmation of the reduction on both AP and internal
oblique radiograph
3)maintenance of reduction with two parallel k wire

22. Treatment contd.
 ORIF +POSTERIOR SPLINT/BIVALVE LONG ARM CAST WITH ELBOW FLEXED 90
DEGREES FOR 4-6 WKS
indication
。displaced, unstable fracture with articular malangulation and malrotation
。 fracture nonunion
 technique
。 approach- anterolateral approach as blood supply comes from posteriorly
。 avoid dissection of the posterior aspect of lateral condyle (source of vascularization)
Instrumentation
。 most fracture can be fixed with 2 percutaneous pins (3 if comminuted) in parallel
or divergent fashion
。 single screw for large fragment or nonunion

23. Treatment cont.
 Outcomes of ORIF:
Several large series have reported generally good results with ORIF of lateral condylar
fractures, with complication such as delayed union or nonunion(1%) and osteonecrosis(1%)
being infrequent.
Elbow stiffness is more common after open reduction than after close reduction, but
resolves in most patient by 24 to 28 months after injury.

24. Treatment contd.
 Supracondylar osteotomy
indication
。 deformity correction in late presenting cubital valgus –rarely needed

25. Complications
 Lateral spur formation –one of the most common complication
 Elbow stiffness
 Cubital varus
 Cubital valgus
 Physeal arrest
 Growth disturbance :fishtail deformity
 Osteonecrosis
 Neurological complication :acute nerve injury , tardy ulnar nerve palsy
 Malunion
 Delayed union
 nonunion

26. Thank you