LATERAL CONDYLE FRACTURES IN CHILDREN

Dr.MADHUSUDANAssistant professor Dept. of orthopaedicsOsmania General Hospital

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

->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; 

Mechanism of injury:

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; 

Ossification CentresMnemonic CRITOEC - capitellumR - radial headI - Internal EpicondyleT - TrochleaO - OlecranonE - External Epicondyle

Ossification Centres

Age at appearance Age at Closure

Capitellum 1-2 14

Radius 3 16

Internal Epicondyle

5 15

Trochlea 7 14

Olecranon 9 14

External epicondyle

11 16

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.

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.)

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 hingeType 2

displacement 2-4mm, displaced joint surfaceType 3

displacement >4mm, joint displaced and rotated

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 CFracture throughthe lateral humeral condyle with the fracture gap as wide laterally as medially.A fracture with high risk of lateral displacement.

•Radiographs if the lateral condyle and capitellum have not ossified then •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;

RADIOGRAPHY

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.

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

ARTHROGRAPHY

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.

CT SCAN

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

MRI

TREATMENTDo we need to pin all undisplaced lateral condyle fractures?

THE MESSAGE:

-WHEN IN DOUBT PIN-FOLLOW UNTIL FULLY HEALED

CLINICALLY AND RADIOGRAPHICALLY

STAGE II CLOSED REDUCTION AND INTERNAL FIXATION

STAGE III LATERAL CONDYLE

PERFECT ARTICULAR AND PHYSEAL REDUCTION

LATE PRESENTATION LATERAL CONDYLE FRACTURES IN CHILDREN

What do late presenters present with?

COMPLICATIONSPhyseal arrest – cubitus valgusPhyseal stimulation – cubitus varusOsteonecrosis.Nonunion with resultant cubitus valgus @ tardy ulnar nerve palsy

If you can not fix the non unionWhat do we treat?

Problem oriented solutions

Situation 1 Rom Deformity Instability palsy

Good Acceptable Absent Absent

Situation 1 Rom Deformity Instability palsy

Good Acceptable Absent Absent

solution

observation

Rom Deformity Instability palsy

Situation 2

Good Acceptable Absent present

Rom Deformity Instability palsy

Situation 2

Good Acceptable Absent present

solution

Transposition of ulnar nerve

Situation 3

Rom Deformity Instability palsy

Good unacceptable Absent present

Situation 3

Rom Deformity Instability palsy

Good unacceptable Absent present

solution

Osteotomy with or without ulnar transposition

Good Acceptable presentAbsent

Rom Deformity Instability palsy

Situation 4

Good Acceptable presentAbsent

Rom Deformity Instability palsy

Situation 4 solution

Osteosynthesis insitu

-           - 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; 

ULNAR NERVE PALSY

COMPLICATIONS

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;