Lateral Condyle Fractures
- Second most common fracture pattern about the elbow in pediatrics
- Most commonly due to fall from height onto outstretched arm
- Can often be missed on radiographs, internal oblique elbow x-rays are critical
- Non-operative treatment must be followed closely to monitor for further displacement
- Articular reduction is the primary goal in surgical intervention of displaced fractures
- Complications can be relatively common and may be significant
Lateral condyle fractures are the second most common elbow fracture after the supracondylar humerus fracture in children. This fracture pattern is typically through the lateral metaphysis extending into the epiphysis and often extends into the articular surface. They are associated with higher complications than other elbow fractures, thus it is critical to appropriately diagnose and treat. Generally, the majority of these patients have excellent outcomes. Milch was the first to describe lateral condyle fracture patterns. Milch type 1 fractures extend through the ossification center of the trochlea, while Milch type 2 fractures extend medial to the ossification center. Unfortunately, this classification system does not provide treatment or prognostic guidance. Jakob et al categorized fractures based on fracture displacement. Type I is nondisplaced with an intact articular surface. Type II fracture extends through the articular surface, and type III involves complete displacement (Jakob, 1975). Weiss et al. further categorized based on displacement and integrity of the articular surface (Weiss, 2009).
Fracture Displacement Classification - Weiss et al
Lateral condyle fractures account for 12-20% of all pediatric distal humerus fractures. These fractures have been associated with higher energy injuries compared to other elbow fractures. The average age is 6 years (Landin, 1986).
Patients present with swelling, ecchymosis and tenderness to palpation to the lateral aspect of the elbow. The arm frequently does not appear significantly deformed beyond swelling. Neurovascular compromise is uncommon with these injuries, though this status should still be assessed.
AP, lateral, and internal oblique radiographs should be obtained when a lateral condyle fracture is suspected. Internal oblique views are paramount in identification of this injury as the fracture fragment often displaces posterolateral, so the displacement can be most appreciated with this view. Fractures of < 2mm displacement may only be visualized on the internal oblique view (Tejwani, 2011).
Rarely utilized, CT can be obtained to help better understand the fracture pattern preoperatively as one study showed that its use altered treatment in 2 of 10 patients (Chapman, 2005). Other alternative imaging such as MRI and ultrasound have been shown to adequately identify the fracture and articular surface, however their clinical use is limited across the nation. MRI can be beneficial to assess the integrity of the articular surface, however, it is costly and often requires sedation of the patient. Ultrasound on the other hand is relatively inexpensive but requires a skilled technician to obtain quality images.
Arthrogram is a useful adjunt to assess the articular surface intraoperatively.
This injury can result from many mechanisms. The most commonly reported cause is a fall from a height onto an outstretched arm. There are 2 theories suggested for the forces acting to displace the fracture: “push-off” and “pull-off.” Milch described the push-off theory as a result of the radial head impacting the distal humerus causing a displacement of the lateral condyle that is up and outward (Tejwani, 2011). The pull-off mechanism is believed to occur due to avulsion by extensor carpi radialis longus and brevis as well as brachioradialis. There are more proponents for the latter.
The degree of displacement dictates management. Type I fractures with less than 2 mm of displacement have been successfully managed non-operatively with cast immobilization (Marcheix, 2010). The preferred method of immobilization is a long arm cast or splint with the elbow flexed between 60-90 degrees. It is recommended the patient returns to the clinic within 1 week for follow up radiographs out of the cast/splint to assess for further displacement. While Marcheix et al did not shown any further displacement, another study by Pirker et al showed 5 of 51 to have increased displacement requiring surgery (Pirker, 2005). Casting for 4 weeks is frequently sufficient for this injury but radiographs need to be obtained to confirm healing before discontinuation of cast treatment.
Variation in management occurs with increased displacement. Type II factures, with intact articular hinge, have been successfully treated with closed reduction and pinning. Surgeons have the option of using 2 versus 3 pins and percutaneous versus subcutaneous with pros and cons related to each. Surgeons should have a low threshold for open reduction as an anatomic articular reduction is important for obtaining a good clinical outcome. Arthrography is valuable in assessing the reduction intraoperatively.
Type III fractures are managed with open reduction and pinning. The lateral approach is utilized and dissection of the fracture should be anterior to the joint. Avoidance of soft tissue dissection of the posterior aspect of the fragment is important to prevent avascular necrosis (Sawyer, 2015). Articular congruence is the primary goal of the reduction.
Post operatively for Type II and III fractures the patient is placed in a long arm cast or splint with the elbow at 90 degrees of flexion and the forearm in neutral position. The cast and pins are generally removed at 4 weeks if healing is evident on radiographs. Early active range of motion is then started (Sawyer, 2015).
Lateral condyle fractures are associated with higher rates of complications compared to other pediatric elbow fractures. The most common are lateral overgrowth and cubitus varus (Kyoung, 2010). Although the incidence is 75% and 25% respectively there is little clinical sequelae. Lateral condyle fractures more commonly result in some limitation of range of motion. They also have a higher risk of nonunion than other elbow fractures (Sinikumpu, 2017). Higher rates of nonunion are shown to be related to non-operative treatment. Tardy ulnar nerve palsy is a slow progressive paralysis of the ulnar nerve that presents on average at 22 years of age and can surgically be addressed with an anterior ulnar nerve transposition (Tejwani, 2011). Growth disturbance is of lower incidence as the fracture rarely involves the ossific nucleus in addition to the fact that the majority of longitudinal growth occurs at the proximal humeral physis (Badelon, 1988).
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Fig 1 A,B,C: AP, Lat, and IR oblique x-rays reveal a Type II lateral condyle fracture sustained after a 4 year old male fell while playing.
Fig 2 A,B: Intra-operative fluoroscopy images following arthrogram reveal articular cartilage is intact and fracture is well reduced.
Fig 3 A, B, C: AP, Lat, and IR oblique x-rays reveal Type III lateral condyle fracture in 3 year old male who fell off a slide.
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Mark Plumby MD
Daniel Gran MD