Lateral condylar fracture in

children
Dr A Qadir
 Elbow Fractures in Children
Very common injuries (approximately 65% of
pediatric trauma)
Radiographic assessment - difficult for non-
orthopaedists, because of the complexity and
variability of the physeal anatomy and development
A thorough physical examination is essential,
because neurovascular injuries can occur before and
after reduction
Compartment syndromes are rare with elbow
trauma, but can occur
 Elbow Fractures
Physical Examination
Children will usually not move the elbow if a fracture is
present, although this may not be the case for non-displaced
fractures
Swelling about the elbow is a constant feature, except for
non-displaced fracture
Complete vascular exam is necessary, especially in
supracondylar fractures
Doppler may be helpful to document vascular status
Neurologic exam is essential, as nerve injuries are common
In most cases, full recovery can be expected
 Elbow Fractures
Physical Examination
Neurological exam may be limited by the
childs ability to cooperate because of age,
pain, or fear.
Thumb extension EPL
Radial PIN branch
Thumb flexion FPL
Median AIN branch
Cross fingers/scissors - Ad/Abductors
Ulnar
 Elbow Fractures
Physical Examination
Always palpate the arm and forearm for signs of
compartment syndrome

Thorough documentation of all findings is important

A simple record of neurovascular status is intact is
unacceptable (and doesnt hold up in court)
Individual assessment and recording of motor, sensory,
and vascular function is essential
 Elbow Fractures
Radiographs
AP and Lateral views are important initial views
In trauma these views may be less than ideal, because it
can be difficult to position the injured extremity
Oblique views may be necessary
Especially for the evaluation of suspected lateral condyle
fractures
Comparison views frequently obtained by primary
care or ER physicians
Although these are rarely used by orthopaedists
 Elbow Fractures
Radiograph Anatomy/Landmarks
Baumanns angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes
through the physis of the capitellum
There is a wide range of normal for
this value
Can vary with rotation of the radiograph
In this case, the medial impaction
and varus position reduces Baumans
angle
-Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk:
Unter besonderer Berucksichtigung der Spatfolgen. I. Allgemeines
und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.
-Mohammad. The Baumann angle in supracondylar fractures of the
distal humerus in children. J Pediatr Orthop. 1999;19:6569.
 Elbow Fractures
Radiograph Anatomy/Landmarks

Anterior Humeral Line

Drawn along the
anterior humeral
cortex
Should pass through
the middle of the
capitellum
Variable in very young
children

-Rogers. Plastic bowing, torus and greenstick supracondylar fractures

of the humerus: radiographic clues to obscure fractures of the elbow
in children. Radiology. 1978;128:145.
-Herman. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.
 Elbow Fractures
Radiograph Anatomy/Landmarks

The capitellum is
angulated
anteriorly about
30 degrees.
The appearance
of the distal
humerus is
similar to a
30
hockey stick.
 Elbow Fractures
Radiograph Anatomy/Landmarks

The physis of the

capitellum is
usually wider
posteriorly,
compared to the
anterior portion
of the physis
Wider
 Elbow Fractures
Radiograph Anatomy/Landmarks

Radiocapitellar
line should
intersect the
capitellum in all
views
Make it a habit to
evaluate this line
on every pediatric
elbow film
 Lateral Condyle Fractures
Common fracture,
representing
approximately 15% of
elbow trauma in
children
Usually occurs from a
fall on an outstretched
arm

Landin. Elbow fractures in children. An epidemiological

analysis of 589 cases. Acta Orthop Scand. 1986;57:309.
 Lateral Condyle Fractures
Jakob Classification
Type 1
Non-displaced fracture
Fracture line does not cross through the articular
surface
Type 2
Minimally displaced
Fracture extends to the articular surface, but the
capitellum is not rotated or significantly displaced
Type 3
Completely displaced
Fracture extends to the articular surface, and the
capitellum is rotated and significantly displaced

Jakob. Observations concerning fractures of the lateral

humeral condyle in children. J Bone Joint Surg Br. 1975;57:430.
 Lateral Condyle Fractures
Jakob Type 1
Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to
ensure that the
fracture does not
displace in the cast.
 Lateral Condyle Fractures
Jakob Type 2

Displaced more than 2 mm

On any radiograph
(AP/Lateral/Oblique views)
Reduction and pinning
Closed reduction can be
attempted, but articular reduction
must be anatomic
If residual displacement and the
articular surface is not
congruous
Open reduction is necessary
Fracture line exiting posterior metaphysis
(arrow) typical for lateral condyle fractures

Flynn. Prevention and treatment of non-union of slightly displaced fractures of the lateral
humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087.
 Lateral Condyle Fractures
Jakob Type 3
ORIF is almost always
necessary
A lateral Kocher approach is
used for reduction, and pins or
a screw are placed to maintain
the reduction
Careful dissection needed to
preserve soft tissue
attachments (and thus blood
supply) to the lateral condylar
fragment, especially avoiding
posterior dissection
-Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.
-Song. Closed reduction and internal fixation of completely displaced and rotated
lateral condyle fractures of the humerus in children. J Orthop Trauma.
Lateral Condyle ORIF
 Lateral Condyle Fractures
Complications

Non-union
This usually occurs if the
patient is not treated, or the
fracture displaces despite
casting
Well-described in fractures
which were displaced more
than 2 mm and not treated
with pin fixation
Late complication of
progressive valgus and ulnar
neuropathy reported

Skak. Deformity after fracture of the lateral humeral

condyle in children. J Pediatr Orthop B. 2001;10:142.
 Lateral Condyle Fractures
Complications

AVN can occur after

excessive surgical
dissection
Cubitus varus can
occur, may be because
of malreduction or a
result of lateral
column overgrowth

Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop.