Lateral Condyle Fracture - Pediatric

Introduction
Fractures involving the lateral condyle of the humerus that have higher risk of nonunion,
malunion, AVN than other pediatric elbow fractures
A. Epidemiology
1. incidence
17% of all distal humerus fractures in the pediatric population, 2nd most common
elbow fracture (after supracondylar)
2. demographics
typically occurs in patients aged 6 years
3. location
most commonly are Salter-Harris IV fracture patterns of the lateral condyle

B. Pathophysiology
mechanism of injury
1. pull-off theory
avulsion fracture of the lateral condyle that results from the pull of the common
extensor musculature
2. push-off theory
fall onto an outstretched hand causes impaction of the radial head into the lateral
condyle causing fracture
C. Prognosis
outcomes have historically been worse than supracondylar fractures articular
nature, missed diagnosis, and higher risk of malunion/nonunion

Classification

Milch Classification-controversial
Type I Fracture line is lateral to trochlear groove (less common, elbow is stable as
fracture does NOT enter trochlear groove)
Type II Fracture line into trochlear groove (more common, more unstable)

Fracture Displacement Classification-Jakob et al.

Type 1 <2mm, indicating intact cartilaginous hinge Casting
Type 2 >2 mm < 4 displacement, intact articular cartilage on arthrogram Open/closed
reduction and
fixation
Type 3 >2-4 mm, articular surface disrupted on arthrogram Open
reduction and
fixation

Presentation
A. History
fall onto an outstetched hand
B. Symptoms
lateral elbow pain and mild swelling
C. Physical exam
1. inspection
Exam may lack the obvious deformity often seen with supracondylar
fractures
Swelling and tenderness are usually limited to the lateral side
2. motion
May have increased pain with resisted wrist extension/flexion may feel
crepitus at the fracture site

Imaging
A. Radiographs
1. recommended views
AP, lateral, and oblique views of elbow. Internal oblique view most accurately
shows fracture displacement because fracture is posterolateral
2. optional views
Contralateral elbow for comparison when ossification is not yet complete.
Routine elbow stress views are not recommended due to risk of fracture
displacement
3. findings
Fracture fragment most often lies posterolateral which is best seen on
internal oblique views
B. Arthrogram
Indications
To assess cartilage surface when there is incomplete/absent epiphyseal
ossification. Allows dynamic assessment.
C. CT scan
1. indication
Improved ability to assess the fracture pattern in all planes
2. findings
CT has limited ability to evaluate the integrity of articular cartilage may
require sedation to perform the test
D. MRI
1. indication
provides the ability to assess the cartilaginous integrity of the trochlea
2. expensive
require GA/sedation to perform the test, arthrograms preferred to MRI

Differential
Pediatric Elbow Injury Frequency
Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7 majority
Radial Head subluxation 28% 3 rare
Lateral condylar physeal fractures 11% 6 majority
Medial epicondylar apophyseal
8% 11 minority
fracture
Radial Head and Neck fractures 5% 10 minority
Elbow dislocations 5% 13 rare
Medial condylar physeal fractures 1% 10 rare
Treatment
A. Nonoperative
1. long arm casting x 6wks
a. indications
only if < 2 mm displacement (cartilaginous hinge most likely intact)
(30-70% are nondisplaced)
sub-acute presentation (>4 weeks)
b. technique
cast with elbow at 90 degrees and forearm supination
weekly follow up and radiographs every 3-7 days x first 3 weeks
total length of casting 6 weeks
B. Operative
1. CRPP + 3-6 wks in above elbow cast
a. indications
somewhat controversial, but Weiss et al suggest fractures with < 4
mm of displacement have intact articular cartilage and can be
treated with CRPP
b. technique
closed reduction performed by providing a varus elbow force and
pushing the fragment anteromedial
divergent pin configuration most stable
third pin may be used in transverse plane to prevent fragment
derotation
arthrogram used to confirm joint congruity
2. open reduction and fixation + 3-6 wks in above elbow cast
a. open reduction (rather than closed) necessary to align joint surface
b. indications
if > 2-4mm of displacement
any joint incongruity
fracture non-union
c. technique
interval between the triceps and brachioradialis
avoid dissection of posterior aspect of lateral condyle
(source of vascularization)
implants
o most fractures can be fixed with 2 percutaneous
pins (3 if comminuted) in parallel or divergent
fashion
o single screw for large fragments or non-union
bone grafting
3. supracondylar osteotomy
Indications : deformity correction in late presenting cubitus valgus

Complications

A. Stiffness (most common complication)

B. Nonunion
1. higher rate of nonunion than other elbow fractures
2. normal radiographic union of lateral condyle fracture is 6wks
 3. risk
nonsurgical management
4. mechanism
constant pull by extensors
intra-articular (synovial fluid impede fracture healing)
poor metaphyseal circulation to distal fragment
5. prevent nonunion by
preserving soft tissue attachments to lateral condyle
stable internal fixation
6. treatment
ORIF + bone grafting
C. AVN
1. occurs 1-3 years after fracture
2. posterior dissection can result in lateral condyle osteonecrosis (may also
occur in the trochlea)
D. Malunion
1. caused from delay in diagnosis and improper treatment
2. 20% cubitus varus in nondisplaced/minimally displaced fractures
traumatic inflammation leads to lateral overgrowth (see spurring below)

3. 10% cubitus valgus tardy ulnar nerve palsy

because of lateral physeal arrest as fracture is Salter Harris IV
4. fishtail deformity
area between medial ossification center and lateral condyle ossification
center resorbs or fails to develop
does NOT predispose to arthritis
may predispose to further fracture
5. treatment
supracondylar osteotomy
E. Tardy ulnar nerve palsy
1. slow, progressive ulnar nerve palsy caused by stretch in cubitus valgus
2. usually late finding, presenting many years after initial fracture

F. Lateral overgrowth/prominence (spurring)

1. up to 50% regardless of treatment, families should be counseled in
advance
2. lateral periosteal alignment will prevent this from occurring
3. spurring is correlated with greater initial fracture displacement
G. Growth arrest with or without angular deformity
H. Unsatisfactory appearance of surgical scar
I. Late elbow presentation or deformity
1. cubitus varus most common in nondisplaced and minimally displaced
fractures
2. cubital valgus less common, but more likely with significant deformities that
cause physeal arrest
3. controversy whether to treat subacute fractures (week 3-12) nonoperatively
or surgically
J. most deformities can be corrected after skeletal maturation with