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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 38-50

Acute lateral condyle fractures of the humerus


Department of Orthopaedics, Vasudev Hospital, Bellary, Karnataka, India

Date of Submission29-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication25-May-2022

Correspondence Address:
Petnikota Harish
Vasudev Hospital, Bellary, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-3665.346026

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  Abstract 


A good outcome in Acute Lateral condyle fractures can be achieved by proper assessment and protocol based treatment. Clinical assessment of fracture stability can be indirectly assessed by associated soft tissue swelling, fracture crepitus elbow joint stability. Radiographs will help in determining the displacement and thereby the fracture stability and classify the fracture. It should essentially include all three views, the Anteroposterior, 15 degrees Internal Oblique and Lateral views, during initial as well as during follow-up. If stability and pattern of fracture cannot be determined on radiographs, especially in very young children, MRI and Ultrasonography will aid in determining the stability of undisplaced fractures by looking at intact cartilage hinge. Stable fractures (Song's Grade 1 and 2) can be managed non-operatively. Weekly followup radiographs out of the cast for the first 2 weeks is essential as majority of undisplaced fractures get displaced within first 2 weeks. Displaced fractures are treated by closed or open reduction. Intra operative arthrogram can aid assessment of fracture fragment and its reduction. Two K-wires, one placed transversely and other obliquely at an approximate angle of 45-60 degrees, will be sufficient to provide good stability. A screw can be placed in older children with a large capitellum or a metaphyseal fragment. A low threshold for open reduction should be considered with an aim to achieve good articular reduction. The commonest concern is lateral prominence causing Pseudovarus deformity. It usually resolves over sometime.

Keywords: Lateral Condyle Fractures of the humerus, Internal oblique view, Song's Classification, Non-operative treatment, Closed Reduction, Arthrogram, Open Reduction, K-wire fixation, Non-union.


How to cite this article:
Harish P. Acute lateral condyle fractures of the humerus. J Orthop Assoc South Indian States 2022;19, Suppl S1:38-50

How to cite this URL:
Harish P. Acute lateral condyle fractures of the humerus. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:38-50. Available from: https://www.joasis.org/text.asp?2022/19/3/38/346026




  Background Check of Lateral Condyle Humerus Fractures in Children Top


Lateral condyle humerus (LCH) fractures in children are associated with a high rate of complications is a myth! Complications of malunion, nonunion, avascular necrosis of capitellum, and elbow stiffness and deformity can be minimized with proper assessment and management.

Fractures of the lateral condyle are the second-most frequent elbow fractures in children, occurring frequently in the 5–10 years age group, with a peak age of 6 years. The overall incidence is about 16.9% (12%–20%) of pediatric elbow injuries, next only to supracondylar fractures.[1],[2],[3],[4],[5] The most difficult part in managing these fractures is identifying the extension of fracture into the articular surface on radiographs, as trochlea is not ossified completely until early adolescence.

Categorization based on timeline of injury

In those who present early after the injury, there will be no morphological changes. In contrast, the late presenting ones often have varying degrees of displacement, morphological changes, pseudarthrosis, and soft-tissue contractures including the common extensors arising from the lateral epicondyle. Elbows can be stiff due to arthrofibrosis and capsular contractures. These suggest a wide spectrum of presentations, and it is imperative that the management has to be customized.

Considering the anatomical changes with the progress of time, categorization is based on the timeline of presentation after the injury.

  1. Early presenting fractures are those which present within 4 weeks after the injury.
  2. Late presenting are those which present later than 4 weeks but within 12 weeks (3 months) after the initial injury.
  3. Chronic fractures are those which present more than 3 months after the injury.


Such a categorization will help us in determining the prognosis and discussing with the parents what to expect after treatment. It will also aid in a better comparison of the treatment outcomes for future studies. This chapter will deal with acute early presenting fractures of the lateral condyle.

[TAG:2]Understanding the Applied Anatomy of the Fracture[2],[3][/TAG:2]

LCH fracture is a complex intraarticular fracture, associated with disruption of a major portion of the distal humerus, including the physeal growth mechanism.[3] It involves nearly half of the distal end of the humerus [Figure 1]. Yet, it appears innocuously small on a radiograph. This is because the fragment contains a small ossification center of the lateral condyle surrounded by a large chunk of epiphyseal and articular cartilage of the capitellum and varying degrees of the lateral part of the trochlea. Lateral one-third to half of the distal humerus physis and a thin layer of adjoining metaphysis (Thurston-Holland fragment) are a part of the fracture fragment. These are Type 4 Salter–Harris physeal injuries [Figure 2].
Figure 1: Pictorial depiction of Milch Type 2 lateral condyle fracture. Often more than half of the distal humerus cartilaginous surface is part of the fracture fragment

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Figure 2: (a) Pictorial representation of actual fracture and the large chunk of distal humerus cartilage not visualized on the radiograph. (b) Radiograph appearance of a similar fracture

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The Milch Classification of Fracture Types (fracture line-based classification)

Less often, the fracture line traverses through the ossification center of the lateral condyle and exits through the capitellar–trochlear groove, disrupting the articular surface of the capitellum. These are termed Milch Type 1 injuries of the lateral condyle. More often, the fracture propagates medial to the ossification center and extends into the trochlea to disrupt the trochlear articular surface. The capitellar articular surface is intact. These are called the Milch Type 2 fractures [Figure 3]. The significance of this classification lies in understanding the elbow stability and the ensuing deformity in the case of nonunion. In Type 1 Milch injuries, the elbow can only be angulated, but the elbow is stable. In completely displaced Type 2 Milch fractures, there may be posterolateral subluxation or instability of the elbow. This is due to the loss of support of the capitellum and the major portion of the trochlea to the radial head and the olecranon [Figure 4]. The medial collateral ligaments of the elbow are often intact.
Figure 3: Milch classification of lateral condyle fracture types. (a) Type 1 fractures line passes through secondary ossification center and exits through capitello trochlear groove. (b) Type 2 passes medical to ossification center and exits through trochlea articular surface

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Figure 4: In severely displaced Type 2 Milch fractures, there can be angulation and subluxation of the elbow. Instability is due to a lack of support from the displaced distal humerus fragment

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Healing potential

Metaphysis at the supracondylar level has a very small cross-sectional area and only a small portion is attached to the avulsed fragment. Hence, the area available for bone-to-bone healing is very small, compared to large cartilage surfaces.[3] The cartilage-to-bone volume ratio of the fragment is also high [Figure 5]. This explains the high propensity for delayed union and nonunion. Suturing of soft tissue and periosteum around the metaphyseal area will help hasten the process of healing and enhance fracture stability.
Figure 5: In lateral condyle fractures cartilage: Bone ratio of the distal humerus is high. At fracture surface, the area available for bone-to-bone healing is small compared to a large cartilaginous surface

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Blood supply and significance of associated soft-tissue injury

The avulsion forces exerted by the attached radial collateral ligament and common extensor origin cause varying degrees of displacement and rotation of the fracture fragment [Figure 5] and [Figure 6]. In severe injuries, there is associated extensive periosteal and capsular tear which will further add to the instability of the lateral condyle. This internal soft-tissue injury is clinically evident by ecchymosis, and excess soft-tissue swelling on the lateral and posterior sides of the elbow and in the proximal forearm. It is important to look and consider these clinical findings when predicting fracture stability and the risk of subsequent displacement.
Figure 6: Progression of fracture from nondisplaced to nondisplaced type. (a) Initial radiograph with a faint fracture line, treated by a cast (b) radiograph of the same child done after 2 weeks showing displacement

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The lateral condyle can be considered as an end organ, with regard to the blood supply. The main vascular channels entering the lateral condyle are from the lateral epicondylar artery entering posterolaterally near the anconeus attachment and from the posteromedial aspect. In complete fractures, the attached soft tissue is the only source of vascular supply to the fracture fragment, as the main blood supply is disrupted by the fracture. Preservation of these soft-tissue attachments is paramount while performing an operative intervention.

Why do some nondisplaced fractures get displaced subsequently?

Nondisplaced fractures are held only by the epiphyseal cartilage hinge of the distal humerus. If the fracture stops at or proximal to the physis (Song's Stage 1 and 2 or Jackob's Stage 1), the cartilage hinge is thick and these are relatively stable injuries. If the fracture propagates further distal across the physis into the cartilage of the trochlea (Song's Stage 3 or Jacob's Stage 2 fractures), the cartilaginous hinge gets smaller and may not be able to counter the avulsion forces of the common extensors. Sometimes, even movements of the wrist and fingers are enough to transfer the traction force of the cartilage hinge which can break and fracture can get displaced. This is the reason why some of these fractures get displaced even when immobilized in a slab or cast [Figure 6].

Displacement and rotation

In incomplete fractures which are held by the intact cartilage hinge, the fragment can only tilt in the coronal plane. In complete fractures, varying degrees of displacement can occur depending on the force of the muscle pull and initial momentum. In addition to tilt in the coronal plane, the fragment can rotate in sagittal plane resulting in the lateral portion lying posterior and the medial end lying anterior. Furthermore, the fragment can rotate in the horizontal plane, sometimes up to 180o resulting in the articular surface lying against the denuded metaphysis of the proximal fragment.[2]


  Mechanism of Injury Top


From a treatment point of view, understanding the mechanism of injury will aid in fracture reduction and in preventing displacement. The fracture can result from the valgus force where there is impaction of the radial head against the lateral condyle or the most commonly accepted mechanism is avulsion of lateral condyle caused by a varus force.

More often than not, Milch Type 1 fractures are from direct impaction. The olecranon edge acts as a lever at the trochlea–capitellar groove and the radial head impacts the capitellum (“push-off theory”) to cause a fracture which passes through the ossification center of the lateral condyle. Some of these fractures can also result from a fall on the elbow.

Varus moment with the forearm in pronation exerts avulsion force on the lateral epicondyle (“pull-off theory”). The muscles of the mobile wad of the forearm, along with the lateral collateral ligament of the elbow, avulse the lateral condyle. The fracture starts at the site of a weak spot in an area located in the posterolateral corner of the metaphysis. The fracture then propagates anteromedially for varying degrees, resulting in the displacement of varying grades.


  Clinical Presentations, Assessment, and Findings Top


In subtle nondisplaced fractures, a child is often brought a couple of days after the injury due to the persistence of pain and swelling, whereas those with complete fractures are often brought immediately with symptoms of severe pain and swelling around the elbow and forearm. It is not so uncommon to see children who have been subjected to traditional treatment and massage by a quack. They can present with an extensively swollen elbow and forearm and sometimes even with blisters and impending or established compartment syndrome, resulting from a tight bandage. In these patients, a proper assessment of the neurovascular status should be done. Another presentation is that of late referral for the displacement of an initially barely visible or nondisplaced fracture. This would have happened despite immobilization in a slab or a cast.

In children who present early after the injury, assessment should be directed at looking for swelling or ecchymosis which suggests significant underlying soft-tissue injury and a potentially severe and unstable fracture pattern[2] [Figure 7]. Another important clinical finding is the presence of fracture crepitus. It suggests that the fracture is complete and if it is nondisplaced to start with, it has a high risk of subsequent displacement.[2] Clinicians should also look for any other injuries around the elbow, especially proximal ulna and radius. For those presenting several days after the injury, assessment should be directed at checking elbow instability and range of movements.
Figure 7: Severe soft-tissue swelling in an undisplaced fracture indicates an unstable fracture pattern. (a) Swollen elbow and forearm (b) radiograph of the same child showing tilt and displacement more in lateral view. (c) Intraoperative finding confirms the soft-tissue disruption (arrow)

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  Radiological Assessment and Classification Top


Radiological assessment plays a vital role in the treatment of LCH fractures, as the entire decision-making depends on the staging of the fracture displacement.

In very young children, especially those below 5 years of age, the ossification center of capitellum is small. Capitellum being the only ossification centre of distal humerus which can be seen on a radiograph, it makes the fracture assessment difficult, specially to an untrained eye. Accurate assessment of fracture and its displacement becomes important. In a standard AP view, the lateral column of the distal humerus will be oblique to the radiograph cassette. For most of the nondisplaced fractures and minimally displaced fractures, fracture displacement is not well appreciated in the AP view. With 15°–20° of internal rotation (internal oblique view), the true profile of the lateral column will be placed parallel to the radiograph cassette. This view gives a better assessment of the fracture pattern and displacement [Figure 8] and [Figure 9].[6],[7],[8] Imada et al.[9] have consistently found the fracture to be in 21° ± 2° in sagittal plane, which is another reason for better visibility of fracture in the internal oblique view. Song et al.[6] and Kurtulmuş et al.[7] have found that compared to the AP view of the elbow, the internal oblique view was more sensitive in assessing the fracture displacement and stage and will guide in proper decision-making. Song et al.[6] found that in 70% of the fractures, the amount of lateral condylar fracture displacement was higher, whereas the fracture stage was higher in 75% of fractures. It is now considered mandatory to get an internal oblique view in addition to anteroposterior and lateral view of the elbow in all children with suspected LCH fracture of the humerus.
Figure 8: (a) Position of limbs for AP and internal oblique views. (b) Demonstration of subtle fracture in internal oblique view in a 7-year-old boy with suspected lateral condyle fracture. In AP view, distal humerus and elbow joint are apparently normal. In the internal oblique view, entire point of the lateral column (circle) is visible. Undisplaced fracture (arrow) is seen as a faint crack in the metaphysis

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Figure 9: (a) AP view showing Stage 2 fracture, along with proximal ulna fracture. (b) Internal oblique view showing Stage 4 fracture

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Fracture staging

Staging is based on the extent and displacement of fracture patterns visible on radiographs. This staging guides in the assessment of fracture severity, whether it is a complete or an incomplete fracture and whether it is a stable or unstable fracture pattern. Fracture staging has been described by Jakob et al.,[9] Finnbogason et al.,[10] Song et al.,[11] and others. The most comprehensive of all these is the Song's staging of fracture displacement, which has evolved from the latter two.

Jakob's staging[9] [Figure 10] has three stages, where Stage I is an Incomplete Fracture: Non-displaced with an intact articular surface. Stage II is a Complete Fracture: Fracture extends through the articular surface. There is partial displacement/rotation. These are potentially unstable fracture. Stage III – Complete displacement and Capitellar rotation with elbow instability.
Figure 10: Jakob's tagging of lateral condyle fracture of humerus in children

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Song et al.[11] [Figure 11] and [Chart 1] described five stages of LCH fractures. In stages 1-3, the displacement is less than 2mm in all the three views. If the fracture is limited to metaphysis, they are graded as Stage 1 fractures. The cartilage hinge is intact and hence it is considered a stable pattern. Further extension of fracture beyond the physis into the epiphyseal cartilage makes the assessment of stability of these fractures undefinable. It depends on the thickness of the cartilage hinge, which cannot be visualised on a standard radiograph. These are termed Stage 2 and are seen as a gap in the lateral metaphysis in a radiograph. This is due to opening up the fracture fragment caused by pull of the attached muscles. If the cartilage hinge gives away, the fracture opens up both on the medial and lateral side of the metaphysis. These are categorised as Stage 3 fractures and are unstable fractures to start with.
Figure 11: Song's staging of lateral condyle fracture in children. Radiograph views to be used: Anteroposterior, 15° internal oblique, and lateral

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If the fracture displacement is more than 2 mm in any of the three radiographic views, they are categorized as Stage 4 or 5 depending on the displacement and rotation. If the fracture is only tilted and partially displaced, they are categorized as Stage 4. In Stage 5, the fragment is completely displaced, rotated, and tilted. In these severe injuries, the elbow joint can be unstable and can be subluxed posterolaterally [Figure 5].

Song classification's inter- and intra-observer reliability, successful treatment guidance, and prognosis have been validated.[12] In the subsequent sections of this article, when the word Staging is used, it means Song's staging.

When to get additional radiological investigations?

Both magnetic resonance imaging (MRI) and ultrasonography (USG) have been advocated for further evaluation of fractures when stability or extent cannot be determined with radiographs in Stage 1–3 fractures.

It is advisable to get an MRI/USG after about 7–10 days post injury because most of the incomplete fractures transform into a complete fracture by 1 week. By delaying them for a week, the chances of picking up a complete fracture are higher. Surgical intervention if at all is needed based on MRI findings is still not difficult and results are similar compared to when intervention was even before. Furthermore, by 1 week, they can be performed without much discomfort as acute pain and swelling would have somewhat settled.

Ultrasound

Ultrasound is low cost and often does not require sedation or general anesthesia for elbow examination. The reliability has increased with newer imaging techniques like transverse plane methods. About 30%–35% of the nondisplaced/<4 mm displacement have been diagnosed to have interrupted cartilage hinge on USG.[13],[14],[15] It is limited by the expertise required to properly assess the fracture and sometimes by the difficulty to get the child to cooperate, who has an acutely painful and swollen elbow.

Magnetic resonance imaging

Similar to USG, studies have found that nearly one-third (21%–42%) of the fractures which appear nondisplaced on radiographs are found to be complete on MRI.[16],[17],[18] It has the advantage of providing comprehensive information and better anatomic detailing. The main concern is the need for anesthesia or sedation to keep the child immobile till the imaging is complete. Thévenin LC et al.[16] suggested that MRI time can be reduced by using injury-specific sequences. They used T2-weighted (T2) and proton density fat-saturated (PD FatSat) sequences. By reducing the time, they were able to avoid general anesthesia and get MRI done using only oral sedation. This can be adopted in most of the settings, more so in smaller towns and cities where the facility to get an MRI under anesthesia will not be available and Triclofos oral sedation (most commonly used in India) method can be used to get MRI in children.

The amount of initial displacement on a radiograph gives an indirect clue as to whether the articular surface (the cartilage hinge) is intact or not. Weiss et al.,[19] while describing their arthrogram based fracture staging found that all type II fractures (≥ 2mm displacement with intact articular surface) had < 4 mm of maximum displacement on initial radiographs. While in all type III fractures (≥2mm displacement and articular surface not intact) had ≥ 4mm displacement on initial radiographs.

Limited role of computed tomography scan

Computed tomography (CT) scan has been proposed with a view of its easy and fast utility, and with the advantage of reformatted images facilitating detailed evaluation. It has limited ability to evaluate the cartilaginous hinge. Hence, it has a limited role in older age groups.


  Treatment Simplified Top


For this “fracture of necessity,” there is clear evidence and there is no disagreement or a dilemma to treat displaced acute fractures by operative treatment (closed or open reduction and fixation). However, the crux of decision-making lies in the management of a nondisplaced fracture. It involves assessment of the risk for subsequent displacement and appropriate management.

Song et al.[6] mentioned that the most common cause of nonunion of fractures of the lateral condyle of the humerus in children is inadequate treatment of fresh fractures and not only the anatomic cause of instability of the distal fragment. Moreover, that cause of inadequate treatment is because the primary health-care provider, and sometimes, the orthopedist, may not diagnose the fracture accurately. The reason is some of these nondisplaced fractures which appear innocuous on initial radiographs can displace subsequently [Figure 6]. Adopting well-documented protocols in the literature helps in an optimal outcome.

Treatment can be summarized in four points

  1. Proper clinical assessment of soft-tissue injury
  2. Proper radiographic assessment of fracture displacement and its stability
  3. Planning appropriate treatment based on the fracture stage and stability – either nonoperative treatment with a long-arm cast or an operative treatment – in situ Fixation with K-wires or fixation following a closed or open reduction of the fracture
  4. Immobilization till the fracture healing is evident (4–12 weeks).


Nondisplaced (≤2 mm) incomplete fractures – Song's Stages 1 and 2/Jackob Stage 1

Assessment of fracture stability is an essential and important part of managing these fractures [Chart 2]. Nondisplaced fractures are best treated nonoperatively with vigilant follow-up radiographs to assess late displacement [Chart 3].



An above elbow posterior splint covering 2/3rd circumference of the limb (with the forearm in neutral or supination) is preferred for an initial 1 week. It is then switched over to a cast after the weekly follow-up assessment. The child is followed up at regular intervals of 5–7 days, for the first 2–3 weeks from the injury to diagnose subsequent fracture displacement if any. During weekly follow-up visits, it is important to do the assessment out of the cast. Bony prominence and fracture crepitus indicate a displaced and complete fracture, respectively. Radiographs in all three views have to be obtained to assess displacement. If the radiographic findings are inconclusive, the clinician should help the parents understand the need to get a USG or MRI for further decision-making.

Minimally displaced fractures can displace by a few more millimeters by continued motion but do not rotate or displace significantly as to the degree of displaced fractures. The risk of subsequent displacement of a nondisplaced fracture is about 15%–20% and it would happen in the first 2 weeks in the majority of the fractures.

Greenhill et al.,[20] in a retrospective review of 139 children with Song's Stage 2, found that 82% of them would not need surgery. They reported excellent clinical and anatomical results in those who had successful nonoperative treatment. Knapik et al.[21] also found that 85% of minimally displaced fractures would not displace further and they heal well. Close observation and follow-up would need only a couple of extra clinic visits and radiographs of the elbow but can prevent unnecessary surgery. Prophylactic pinning of these fractures is unwarranted, as it exposes the child to the risk of surgery and anesthesia.

If there is no further displacement of fracture during the follow-up visits, plaster cast immobilization is continued for 4–8 weeks [Figure 12]. Fracture healing will be evident by bridging callus in the metaphyseal region, usually in the posterior aspect as seen in the lateral view. Post immobilization, stiffness is dealt by assisted active and passive mobilization exercises. If a fracture is not progressing to the union even after 8 weeks, they can be considered for percutaneous pinning.
Figure 12: Radiographs of an 8-year-old boy with Song's Stage 1 lateral condyle fracture visible only in internal oblique views (arrow). The child was treated conservatively with weekly follow-up. Fracture heled well by 5 weeks. (a) Injury film, (b) 2 weeks, and (c) 5 weeks

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If there is an increase in fracture gap or change in the alignment of the lateral condyle fragment as seen on radiograph, or cartilage hinge is found to be fractured in USG/MRI, then operative intervention is indicated. These fractures can be managed by fixation with 1.5–2 mm-thick smooth pins [Figures 13]. Fracture reduction and fixation is aided by intraoperative arthrogram.
Figure 13: (a) Eight years boy sustained a posterior dislocation of the elbow with Type 1 Milch lateral condyle fracture, (b) closed reduction of the fracture into anatomical position, (c) increase in fracture gap and subtle lateral at 2 weeks, and (d) treated with closed reduction and fixation with K-wires

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Displaced (>2 mm)/complete fractures – Song's Stages 3, 4, and 5

Operative intervention is indicated in all complete fractures. The aim is to restore anatomical alignment, without compromising the vascularity of the fracture fragment. Reduction of fracture can be achieved by closed or open means. The assessment of reduction can be done with the use of an intraoperative arthrogram. The fracture is secured with two to three smooth pins (K-wires). In older children, combined fixation with a 4 mm cannulated screw and a K-wire or a screw alone can be considered. The advantage of screw fixation is better compression of fracture, significant reduction in nonunion rates, and reduction in the chances of formation of lateral osteophyte or bony prominence.[22],[23]

Arthrogram

Intraoperative arthrogram will aid in the assessment of the status of cartilage hinge in nondisplaced or minimally displaced fractures and also in the assessment of fracture reduction and anatomical alignment when the fracture is reduced by closed means and sometimes even after open reduction.

Commonly used dye is diatrizoic acid 76%, diluted with an equal volume of distilled water or normal saline. An important technical tip is to inject the dye from the posterior aspect, starting just about the tip of the olecranon. When a lateral side entry is used, leakage of dye into soft tissues can obscure the fragment, thus making the visualization of the fragment very difficult. It can result in suboptimal reduction. Sometimes, a dye can be mistaken for intraarticular vertical fracture when injected into the olecranon fossa; this can be avoided by rotating live fluoroscopy images.

Closed reduction and percutaneous fixation with K-wires (Jackob's 1 and 2/Song's Stages 2 and 3)

Arthrogram has to be an essential part of the closed reduction method and K-wires can be used as a joystick to aid in reduction. It is advisable to first perform an arthrogram and assess the intactness of the cartilage hinge (articular surface). With an intact hinge, it is simple to reduce the fracture by gentle valgus stress with the elbow in extension and by supinating the forearm and extending the wrist to relax the mobile wad muscles. Direct pressure over the fragment is applied with the thumb to reduce the fracture. It is acceptable to have a low threshold for open reduction if there is any difficulty or uncertainty in the reduction. The reduced fracture is fixed percutaneously with at least two K-wires (1.5–2 mm) placed at about 45° [Figure 14]b. Depending on the size of the metaphyseal fragment, the wires can be passed through the metaphysis or through the capitellum. While placing the transverse wire, care should be taken to avoid injury to the ulnar nerve medially.
Figure 14: Four years boy with Type 3 lateral condyle fracture, referred 2 weeks after the injury. Radiographs at (a) initial (b) 2 weeks. (c) Open reduction and fixation with K-wires. Transverse wire placed in metaphysis for better fixation and stability. (d) Eight weeks postoperative. (e) 5 months postoperative. Good union and mild lateral condyle thickening. Clinically child had full elbow movements

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A technical tip here is to pass the wire from posterolateral to anteromedial direction, as the bulk of the metaphyseal fragment is posterior and also it will avoid the ulnar nerve medially. Another technical tip is to pass the transverse wire into the medial metaphysis rather than the medial cartilage of the distal humerus. This will give better fixation because it is in the bone rather than cartilage. The oblique wire can be passed from the anterolateral aspect to the medial cortex.

The wires are bent and cut. They are kept in place till the fracture heals. Burying the wires under the skin increases the chances of deep infection, and for their removal, the procedure will need anesthesia either local or regional with or without sedation. Leaving them outside the skin is a simpler option. Although the chances of superficial pin tract infections are higher, they can be managed with simple dressing and oral antibiotics. Removal is easy and can be done quickly on an outpatient basis.

Conventionally, the closed reduction technique has been used for minimally displaced fractures. To limit additional soft-tissue trauma and prevent avascular necrosis, the closed reduction technique has been successfully extended to even in completely displaced and rotated fractures (Song's Stages 4 and5). This technique has a high learning curve and further reading can be done from the articles described by Song et al. and Prusick et al.[24],[25] Closed reduction can always be used as an initial method in all displaced fractures, failing which open reduction can always be considered.

Open reduction and fixation

Open reduction is indicated in displaced fractures where closed reduction cannot be attempted or achieved and in all displaced fractures presenting later than 2 weeks [Figure 14]a and [Figure 14]b.

Anterolateral (lateral) versus posterolateral, which approach is better for open reduction

Irrespective of the approach, the basic rule which has to be followed strictly is to preserve the soft-tissue attachment of the lateral condyle, as this is the only source of blood supply to the fragment until the healing occurs.

Lateral approach is more commonly used because of the ease of approach, quick dissection, easy positioning, and importantly, reduced rate of complications like elbow stiffness. It also has the advantage of better visualization of the articular surface and fracture line in more lateral fractures such as Milch Type 1 and in some Type 2 fractures which are near the lateral edge of trochlea as the articular surface in this area is present only on the anterior side of the distal part of the humerus.[26]

However, the posterior approach definitely has the advantage of better visualization of the fracture and the joint surfaces in Milch Type 2 injuries where the fracture is extending way medial.[26] It can be considered especially for severely displaced and old untreated injuries. In adult elbow injuries, though the posterior approach is preferred, it is discouraged in children because of “theoretical” risk of jeopardizing the vascularity of the lateral condyle. The risk is only theoretical as the vessels traversing from posteromedial and posterolateral aspect to lateral condyle are already disrupted in displaced fractures.

In an anterolateral approach, the plane is between the ECRL and ECRB anteriorly and the brachioradialis and triceps posteriorly. In the posterolateral approach, it is between the ECRB and anconeus anteriorly and triceps posteriorly.

K-wires versus screw

There is no conclusive evidence in the literature. K-wires are found to have a higher rate of pin tract infection, scarring, and nonunion. This higher rate is only relative to complications with screw fixation but not absolute. The absolute numbers are in the range of 5%–8%. The advantage of screw fixation is better compression of fracture, significant reduction in nonunion rates, and reduction in the chances of formation of lateral osteophyte or bony prominence.[22],[23] The main disadvantage with the use of screw is the need for repeat surgery and anesthesia to remove the implant. Sometimes, a combination of both is used, as there is no adequate place for a second screw to prevent rotation of the fragment. An additional k-wire will suffice [Figure 15].
Figure 15: (a) Four years boy with Stage 4 lateral concyle fracture. Presented 3 months after injury (b) after open reduction, combo fixation ith screw and K-wires done (c) fracture healed by 3 months. Lateral condyle hypertrophy and premature physical closure can be seen

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  Outcomes: What to Expect and What Should the Parents be Counseled About? Top


The described complications following LCH fracture are lateral condyle overgrowth, lateral prominence, delayed union, stiffness, nonunion, growth disturbance causing coronal plane deformities – cubitus varus and cubitus valgus, malunion, avascular necrosis, and late manifestations such as fish-tail deformity of the distal humerus and tardy ulnar nerve palsy.


  Union and functional result Top


Flynn and Richards described that in fractures with < 4 mm displacement treated conservatively, three patterns of healing can be seen. In nearly half of them, it heals by 4–6 weeks by good bridging callus and subperiosteal ossification. In about 38% of them, a union may take 8–12 weeks as it heals by endosteal healing without any bridging callus. The third pattern can be seen in 13%, where there is the gradual displacement of fragments and surgical intervention is needed to prevent nonunion.[27]

Parents should be explained that the time taken for fracture healing would range from 4 to 8 weeks, and very rarely up to 12 weeks even with appropriate treatment. They can be assured that with appropriate treatment, over 90% of children can achieve excellent to good functional outcomes.[28]

Late displacement and need for surgical intervention

Right from the start of conservated treatment of a child with undisplaced fractures, parents should be counseled that even with adequate care and splinting, in 15%–20% of children the fracture can get displaced. They should be counseled about three important aspects of treatment protocol: (1) the importance of weekly follow-up and radiographs out of the cast for 2–3 weeks, (2) the need to USG/MRI for the assessment of fracture, and (3) the possible need for surgical intervention if there is any such displacement.

Stiffness

Stiffness and restriction of movements is temporary in majority of the children. Most of the initial stiffness resulting from immobilization will resolve in 2–4 weeks' time with proper physiotherapy.

Prolonged periods of immobilization can result in arthrofibrosis of the elbow, contractures of muscles, and elbow stiffness. In children whose fracture healing is delayed beyond 4 and 6 weeks, early mobilization can be started out of the slab. After the session is done, the splint is put back.

The presence of K-wires, left outside the skin or buried under, is not a concern for early mobilization. This actually gives an opportunity to clean the pin tracts (of K-wire) and also the limb. Pin tract care can be taught to parents, similar to what is done when a ring fixator is used.

The possibility of stiffness and restriction of movement can be expected to be high in children who present late (after 4 weeks), in those who have a history of massage and application of tight bandages, and in severely displaced fractures with extensive soft-tissue injury requiring open reduction. It can be iatrogenic in cases where anatomical reduction is not achieved. The possibility is also high in children treated with a posterior approach with extensive dissection of the triceps.

If there is no significant improvement with adequate physiotherapy, gentle manipulation of the elbow under anesthesia can be considered. This will help release the intraarticular adhesions and stretch the capsular contractures. As a last resort, a formal soft-tissue release procedure can be considered.

Lateral prominence, osteophyte formation, and lateral condyle overgrowth

The most common sequelae following LCH fractures are lateral prominence and causing “Pseudo Cubitus Varus Deformity.” Koh et al.[28] in a large series of 175 patients found that 77% of them had radiological overgrowth, which was apparent clinically in about 22% of them as lateral prominence. Similar observations have been reported by several others. The combination of severely displaced fracture requiring open reduction and fixation with K-wires significantly increases the chances of this sequelae.

Parents should be made to understand that this would happen despite appropriate treatment. It can cause cosmetic concerns, but rarely, there can be any functional disability due to this [Figure 16]. And almost always, it does not need any further surgical intervention. It has been observed that some of these deformities gradually correct with growth.
Figure 16: Lateral prominence following lateral condyle fracture (a) 4 years girl with preexisting cubitus varus sustained undisplaced lateral condyle fracture (b) radiograph at 9 months shows remodeling of cubitus varus. The lateral condyle is prominent. (c) Carrying angles are similar but lateral prominence is evident (d) no functional limitation

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True cubitus varus can also occur. This happens when there is varus malunion and when there is lateral overgrowth. Severe deformities will need corrective osteotomy.

Growth disturbances

Since it is a Type 4 physeal injury, growth disturbance can be unpredictable and undefinable. Microscopic damage of germinal cells of physis or “wrong side” physeal injury can lead to premature arrest and cause subsequent deformity, even with excellent closed or open reduction techniques. Accordingly, the treating surgeon must warn the parents of the risk regardless of whether closed or open treatment is used. Malunion and premature fusion can lead to the gradual development of cubitus valgus which may need corrective osteotomy.

Delayed union and nonunion

Delayed union, nonunion, and growth arrests result from minimally displaced fractures more commonly than from markedly displaced and rotated fractures, probably because the displaced fractures are treated aggressively with surgery.

The presence of tenderness at the fracture site, a distinct fracture gap on radiograph long with lateral shifting and blunting of the fracture edges of the metaphyseal fragment with little or no callus formation, if observed after the fifth week of injury, should be recognised as a delayed union. It can progress to nonunion. Flynn et al.[29] observed that early radiographic evidence of nonunion was seen best in the AP view as a “high collar-like projection” of the posterolateral metaphyseal fragment attached to the epiphysis. If it persists after the 3rd month, nonunion is definite, and appropriate surgical treatment should be carried out.[3]

In a conservatively treated fracture and in those treated by closed reduction and fixation (more frequent with K-wires), the presence of a delayed or nonunion is a strong indication that the fragments have not been adequately stabilized or that they may have rotated 90° or 180° and only seem to be reduced. In such a situation, open reduction and exploration are indicated, though the fracture may be several weeks old.[4] Fixation with a screw has to be considered.

Though Song et al. and Koh et al.[11],[24],[28] reported that none of the patients developed complications of avascular necrosis, nonunion, delayed union, or fishtail deformity and there was no stiffness or restriction of movement, one should counsel parents about these complications occurring in about 5%–7% of them.


  Points to Ponder Top


  1. Define Fracture based on the timeline of injury
  2. 15°–20° internal oblique AP radiograph is a must for the evaluation of LCH fracture and is now a gold standard
  3. Song's classification is best in guiding treatment and differentiating subtle fractures.
  4. Beware of late displacement!

    Weekly assessment for the first 2–3 weeks is a must for nondisplaced fractures. Both clinical and radiographic assessments have to be done and it should be out of the cast.
  5. MRI and USG are helpful in the assessment of cartilage hinge in fractures with ≤2 mm
  6. Intraoperative arthrogram is an essential part of closed reduction. It helps in the assessment of intact cartilage hinge and also the accuracy of reduction
  7. Premature mobilization of conservatively managed fractures leads to nonunion with poor outcome
  8. K-wire is most commonly used for fixation of this fracture
  9. Screw fixation has the least risk of infection and provides better compression
  10. Pseudo varus due to lateral prominence is the most common complication but resolves with time in most cases and there is no functional disability.
  11. Overall, a proper protocol has to be followed for a good outcome [Figure 17]
Figure 17: Protocol for treatment of Acute Lateral Condyle Fractures

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]



 

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