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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 51-56

Nonunion of the Lateral Condyle of Humerus


Department of Paediatric Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission05-May-2021
Date of Decision10-Sep-2021
Date of Acceptance30-Sep-2021
Date of Web Publication25-May-2022

Correspondence Address:
Hitesh Shah
Department of Paediatric Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-3665.346019

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  Abstract 


Lateral condyle humerus fracture in children is known to have union complications. Delay in diagnosis, pull at the common extensor origin, precarious blood supply and lack of appropriate treatment may result in non-union. Non-union of lateral condyle can lead to progressive cubitus valgus. Progressive cubitus valgus may be associated with pain, instability and stiffness of the elbow and ulnar nerve paresis. Plain radiographs of the elbow are required for the assessment of the joint congruity, size of the lateral condyle fragment, extent of the elbow deformity and physis status. Corrective osteotomy with anterior transposition of the ulnar nerve gives good cosmetic and functional results.

Keywords: Cubitus valgus, Lateral condyle humerus, Non-union, Tardy ulnar nerve palsy


How to cite this article:
Singh KA, Shah H. Nonunion of the Lateral Condyle of Humerus. J Orthop Assoc South Indian States 2022;19, Suppl S1:51-6

How to cite this URL:
Singh KA, Shah H. Nonunion of the Lateral Condyle of Humerus. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:51-6. Available from: https://www.joasis.org/text.asp?2022/19/3/51/346019




  Introduction Top


Fracture of the lateral condyle of the humerus in children that does not unite after 12 weeks following injury, is considered as nonunion of the lateral condyle. Non-union may occur following non-displaced lateral condyle fracture. It might be due to delay in diagnosis and inappropriate treatment [Figure 1]. It can also happen even despite treatment.[1] In a developing country, it is common due to financial constraints and poor quality/inadequate radiographs. Occasionally, it is a result of the inability to assess the extent of displacement, inadequate reduction, and loss of reduction in the plaster cast.[1] Innocent nondisplaced lateral condyle fracture may get displaced in due course of time; a frequent follow-up is necessary.[1] Apart from anteroposterior and lateral radiographs, an internal oblique view is important in the diagnosis and planning for the treatment of acute lateral condyle fractures.
Figure 1: Initial radiographs of a 4-year-old child following elbow trauma. The child was not treated for the un-displaced lateral condyle fracture. Radiographs of the same child after 4 months following trauma show nonunion lateral condyle

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  Causes for the Nonunion Top


The displacement primarily occurs due to the pull of the supinator, long extensors of the wrist and fingers, and radial collateral ligaments. Displaced rotated intra-articular fracture with torn articular cartilage and bathing of fracture site by synovial fluid may further worsen the situation, leading to delay in union or nonunion.[1] Precarious blood supply of the lateral condyle may contribute to premature physeal arrest and avascular necrosis if the surrounding soft tissue is poorly handled.[2] The lateral epicondylar artery and a branch of the middle collateral artery supply the lateral condyle mass from the posterolateral aspect. These arteries do not anastomose with the interosseous metaphyseal or epiphyseal arteries [Figure 2].
Figure 2: Blood supply to the lateral condyle comes from terminal branches from the radial artery (1). Synovial fluid bathes the fracture site of the displaced lateral condyle (2). The pull of the extensors displaces the lateral condyle fracture (3)

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  Natural History of Nonunion of the Lateral Condyle Fracture Top


Nonunion of the lateral condyle may lead to cosmetic deformity (cubitus valgus) and functional limitations.[3] Rotational deformities are rare since most of the articular components of the elbow are maintained. Restriction of movements in the sagittal plane is secondary to avascular necrosis, growth arrest, or fish-tail deformity. Gap nonunion of the lateral condyle may cause weakness at the elbow due to instability of the elbow.[4] Progressive cubitus valgus may result in tardy ulnar nerve palsy.[4],[5]


  Clinical Evaluation Top


Presenting symptoms must be evaluated in detail. The common presenting symptoms are pain, instability, deformity, stiffness of the elbow, and ulnar nerve paresis.[6] Frequently, it may be asymptomatic.[6]

The character and site of pain should be evaluated thoroughly. The pain might be present due to stiffness, instability, or the paresis of the ulnar nerve. The most common presentation is cubitus valgus deformity. This deformity may progress as the child grows. Occasionally, weakness of the elbow and hand is the complaint. Some children may present with an ulnar claw hand and decreased sensation on the volar aspect of ulnar fingers.[7]

The clinical examination must include the site of the tenderness, prominence of the lateral condyle, severity of the coronal plane deformity of the elbow, the status of the ulnar nerve, and active and passive range of the elbow movements.[8]

The prominence of the lateral condyle is a frequent finding. The prominence would be hard in consistency and nontender. It is not easy to demonstrate the mobility of the fracture fragment. The three-point bony relationship will be altered. There may be an increase in distance between the lateral condyle and medial condyle, lateral condyle and olecranon, but the distance between the olecranon and medial condyle is comparable to the normal side. It is a good practice to determine the extent of prominence to differentiate it from myositis ossificans.[9]

Carrying angle measurement and its comparison with the normal elbow helps to quantify the coronal plane deformity. Active and passive range of elbow movements must be checked,[8] as they are vital for the optimum function of the child. Medio-lateral elbow instability is assessed in children complaining of elbow weakness.[4] Radial head position and forearm pronation and supination must be assessed to rule out associated forearm injury.

Hypothenar wasting and clawing of the ring and little fingers would be present in tardy ulnar nerve palsy. Children with clawing should be assessed for ulnar nerve motor and sensory function [Figure 3]. There may be minimal restriction of terminal flexion and extension.[10]
Figure 3: Tardy ulnar nerve palsy following nonunion of lateral condyle fracture

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  Radiological Evaluation Top


The plain radiograph of the elbow in both views is enough for the assessment of the fracture site and deformity. The alignment of the humerus-ulnar joint, joint congruity, and joint orientation must be assessed. The size of the fracture fragment, level, and orientation of the fracture, the severity of the fracture fragment displacement, including distance and rotation of the fragment, must be assessed in the plain X-rays [Figure 4]. The plane of the fracture is not transverse but oblique in orientation; the fracture line starts superolaterally and extends inferomedially. In doubtful cases, the oblique view adds information regarding the fracture orientation, fragment size, and displacement.[11] A special attention is required in younger children for physis health and growth arrest.[12]
Figure 4: The anteroposterior and lateral radiographs of the left elbow of a 10-year boy showing lateral condyle fracture. The alignment of the humerus-ulnar joint is in the valgum. A large fracture fragment is seen with irregularities of the joint-line, fracture fragment <1 cm displaced and rotated

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Computed tomography of the elbow is required in patients with elbow stiffness and progressive deformity to rule out associated articular cartilage injuries and TRASH injuries. The elbow joint congruity and status of the physis are better evaluated in advanced imaging.[6],[13]

Magnetic resonance images (MRI) are not indicated. In very rare instances, MRI is useful in a case of persistent instability of the elbow to evaluate TRASH lesions and to diagnose collateral ligament injury and AVN.[14]

Nerve conduction study: ulnar sensory and motor nerve conduction studies are required in patients with ulnar nerve palsy. An absolute conduction velocity of <50 m/s or a relative drop in conduction velocity of >10 m/s is diagnostic of ulnar nerve dysfunction.[10]

Aims of the treatment

  • To prevent functional disability (by preventing progressive deformity and ulnar nerve damage, and by improving joint stability)
  • To improve the cosmetic appearance of the limb.


Variables influence the decision-making

  • Range of motion: Stiffness of the elbow may be related to intra-articular injury, associated injuries of the coronoid process, morphological changes of the joint, shallow olecranon fossa or fibrosis, and adhesion due to previous treatment. Range of motion should be improved or maintained while attempting the correction of the deformity or union of the fracture site. All necessary steps must be done to maintain a functional range of motion.
  • Age of the child: Angular deformity may increase as the child grows. Younger children with nonunion must be treated to get metaphyseal union compared to the child near maturity. Osteosynthesis in younger children prevents progressive deformity and ulnar nerve stretching
  • Duration after injury: The duration after the injury plays a crucial role in the decision of osteosynthesis. In long-standing nonunion, it is difficult to differentiate the occurrence of a range of motion at the elbow compared to the fracture site. The surgeon must be careful to make a decision of osteosynthesis in long-standing nonunion (more than 3 years).[15] Nonunion within 3 years of the injury can be treated with metaphyseal osteosynthesis.
  • Deformity of the elbow: The prime aim of the treatment of nonunion lateral condyle is to prevent functional disability. Corrective osteotomy may be considered for moderate to severe deformity. A severe progressive cubitus valgus can lead to the stretching of the ulnar nerve. This stretching of the nerve can be prevented by the corrective osteotomy.
  • The stability of the elbow is compromised because of pseudoarthrosis at the fracture site. For a child with stability issues, osteosynthesis can be considered to improve the stability and function of the elbow.
  • Ulnar nerve palsy: Functional ulnar nerve is crucial in the decision-making process. The slow stretch of the ulnar nerve might be permanent. Many times, it might not be corrected with corrective surgery. The severity of involvement must be evaluated in every case of lateral condyle nonunion. In the presence of mild symptoms of the ulnar nerve, paresis must be treated by anterior transposition of the nerve and warrants early correction of the deformity.[10]


Treatment options

  • Observation – Mild deformity in a child near skeletal maturity with small lateral condyle fragment and normal functioning ulnar nerve should be observed. The child should be followed up at regular intervals.
  • Open reduction and internal fixation/in situ fixation with bone grafting – Large metaphyseal fragments with displacement <1 cm in a child with open physis may be treated with open reduction and internal fixation. Other patients may benefit from in situ fixation [Figure 5]. The range of motion may reduce with anatomical reduction of the lateral condyle nonunion, in situ osteosynthesis with the metaphysis without anatomical reduction of intra-articular fracture is the key for treatment of nonunion lateral condyle.[6],[16] Lengthening of the common extensors at the origin can help in the reduction of the lateral condyle.[17]
  • Fixation with bone grafting improves the stability at the nonunion site and preoperative elbow range of movement is preserved to a greater extent. However, isolated osteosynthesis may not correct progressive deformity and stretching of the ulnar nerve.
Figure 5: An 8-year-old girl presented with left cubitus valgus treated 3 years back conservatively for left lateral condyle fracture. The sagittal plane movement was 10°–110°. No instability or ulnar nerve paresis. In situ fixation of the large metaphyseal fragment gave a good outcome

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Surgical exposure

Fracture of the lateral condyle, its displacement, and rotation are reassessed under the image intensifier. Identify and mark the lateral supracondylar ridge of the humerus and radial head. The incision begins 5 cm proximal to the joint over the supracondylar ridge and extends downward to the radial head and then continues medially and posteriorly toward the ulna. A plane is created between the triceps muscle posteriorly and the brachioradialis anteriorly. The lateral humeral condyle and anterior surface of the distal humerus are dissected. Care is taken to avoid stripping soft tissue from the posterior surface of the lateral condyle mass. The entire length of the fracture line is exposed anteriorly.

Nonunion site preparation

Mobility of the fracture fragment is assessed. Depending on the duration of the injury, callous or fibrous tissue is encountered at the fracture site. Fibrous tissue is excised to freshen the fracture margins. The raw surface is created at the ununited site. Gently mobilize the lateral condyle mass and reduce it to the proximal fragment till there is no restriction of movement of the elbow joint. A k-wire in the distal fragment can be used as a joystick. Once the desired position is achieved, the k-wire is advanced to the metaphysis of the proximal fragment. A second k-wire is passed from the metaphysis of the distal fragment to the metaphysis of the proximal fragment or from the epiphysis of the lateral condyle to the medial condyle. The k-wire is replaced by screws or plates and screws if the physis is closed. The freshened site is filled with cancellous grafts harvested from the ilium. The elbow range of movements is reassessed, and the wound is closed in layers over a draining tube. The above elbow slab is applied with the elbow in 90° flexion and the forearm in the neutral position.

Tips

The elbow should be properly visualized in the image intensifier. Skin incision should be centered over the lateral condyle. Avoid stripping of the soft tissues from the dorsal surface of the lateral humeral condyle. Alignment of the elbow and range of movements should be checked before definite fixation. Cancellous grafts help in the union of the ununited site and should be used. After immobilization, an active range of motion exercises is started.

Contraindication

Osteosynthesis must not be performed when the range of motion of the elbow happens at the fracture site rather than the joint itself.

  • Osteotomy – The majority of these children are brought with unsightly deformity of the elbow. Closing wedge osteotomy through the medial approach for cubitus valgus can be done. Closing wedge osteotomy produces unsightly protuberance on the opposite side. This can be prevented by displacing the distal fragment to compensate for the protuberance. Modifications in the form of dome osteotomy through the posterior approach[18] and step-cut osteotomy help in compensating for the protuberance [Figure 6].[19] The strong fixation should be used to stabilize the fragments after the osteotomy.
  • Osteotomy with ulnar nerve transposition corrects the deformity and helps in the recovery of tardy ulnar nerve palsy. If osteotomy is done in a younger child with severe deformity, ulnar nerve transposition prevents stretching of the nerve if deformity progresses [Figure 7].
Figure 6: A 12-year-old girl presented with left cubitus valgus treated 6 years back conservatively for left lateral condyle fracture. No instability or ulnar nerve paresis. Corrective supracondylar osteotomy improved the appearance and maintained preoperative range of movement

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Figure 7: A 28-year-old patient with right cubitus valgus and ulnar claw hand. He sustained an injury 19 years back which was not treated. The sagittal plane movement was 10°–140°. He was treated with corrective osteotomy and anterior transposition of the ulnar nerve

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Complications

  • Cubitus varus and lateral bar formation – It occurs after the healing of the fracture due to growth stimulation. Mild asymptomatic deformities do not produce symptoms and may not require intervention.[2] Regular follow-up is advised for these patients
  • Cubitus valgus – Progression of the deformity even after osteotomy might be related to growth disturbances of distal humerus physis or unaddressed nonunion.[20],[21] It is a mild deformity due to the nongrowing end of the humerus. Deformity correction done during skeletal maturity has a better outcome in terms of progression[22]
  • Nonunion – Persistent nonunion after the intervention may be possible.[2] The management depends on the functional status, growth left, amount of deformity, elbow range of motion, and ulnar nerve status. Unacceptable cosmesis, elbow weakness, and tardy ulnar nerve palsy warrants surgical intervention.
  • Avascular necrosis – It is rare with conservative management. This common complication occurs after the posterior approach to the nonunion lateral condyle or attempted open reduction and internal fixation after 12 weeks of lateral condyle fracture.[11] Surgical intervention may insult the blood supply to the lateral condyle mass and result in AVN.[23] The function of the patients depends on the severity of AVN. Occasionally, it is associated with restriction of range of motion. Most of these children have normal elbow function and do not require intervention.[24]
  • Premature physeal closure and fish-tail deformity rarely produce functional limitations. The range of movement of the elbow is maintained. Since most of these patients will not have symptoms, intervention is not required.[2]



  Conclusion Top


Decision-making for the treatment of the nonunion of the lateral condyle is not easy. The authors follow this algorithm for the management of the nonunion of the lateral condyle [Figure 8]. The optimum decision should be taken to prevent functional disability and long-term complications without compromising the range of motion and complications such as avascular necrosis and growth arrest.
Figure 8: Algorithm to treat nonunion of the lateral condyle of the humerus

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Flynn JC. Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-6.  Back to cited text no. 1
    
2.
Stevenson RA, Perry DC. Paediatric lateral condyle fractures of the distal humerus. Orthop Trauma 2018;32:352-9.  Back to cited text no. 2
    
3.
Bernthal NM, Hoshino CM, Dichter D, Wong M, Silva M. Recovery of elbow motion following pediatric lateral condylar fractures of the humerus. J Bone Joint Surg Am 2011;93:871-7.  Back to cited text no. 3
    
4.
Masada K, Kawai H, Kawabata H, Masatomi T, Tsuyuguchi Y, Yamamoto K. Osteosynthesis for old, established non-union of the lateral condyle of the humerus. J Bone Joint Surg Am 1990;72:32-40.  Back to cited text no. 4
    
5.
Toh S, Tsubo K, Nishikawa S, Inoue S, Nakamura R, Harata S. Long-standing nonunion of fractures of the lateral humeral condyle. J Bone Joint Surg Am 2002;84:593-8.  Back to cited text no. 5
    
6.
Little KJ. Elbow fractures and dislocations. Orthop Clin North Am 2014;45:327-40.  Back to cited text no. 6
    
7.
Ibrahim MA, Ismail MS. Corrective osteotomy and in situ fusion for late-presenting nonunion of lateral condyle fractures of the humerus in adults. J Shoulder Elbow Surg 2019;28:520-4.  Back to cited text no. 7
    
8.
Joseph B. Deformities and limitation of movement of the elbow. In: Paediatric Orthopaedic Diagnosis. New Delhi: Springer; 2015. p. 269-78.  Back to cited text no. 8
    
9.
Gabel GT, Hanson G, Bennett JB, Noble PC, Tullos HS. Intraarticular fractures of the distal humerus in the adult. Clin Orthop Relat Res 1987;(216):99-108.  Back to cited text no. 9
    
10.
Rubin G, Orbach H, Bor N, Rozen N. Tardy ulnar nerve palsy. J Am Acad Orthop Surg 2019;27:717-25.  Back to cited text no. 10
    
11.
Herring JA. Tachdjian's Pediatric Orthopaedics e-Book: From the Texas Scottish Rite Hospital for Children. Dallas, Taxas: Elsevier; 2020.  Back to cited text no. 11
    
12.
Flynn JC, Richards JF Jr., Saltzman RI. 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;57:1087-92.  Back to cited text no. 12
    
13.
Chapman VM, Grottkau BE, Albright M, Salamipour H, Jaramillo D. Multidetector computed tomography of pediatric lateral condylar fractures. J Comput Assist Tomogr 2005;29:842-6.  Back to cited text no. 13
    
14.
Waters PM, Beaty J, Kasser J. Elbow “TRASH” (the radiographic appearance seemed harmless) lesions. J Pediatr Orthop 2010;30 Suppl 2:S77-81.  Back to cited text no. 14
    
15.
Papandrea R, Waters PM. Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop Relat Res 2000;370:115-26.  Back to cited text no. 15
    
16.
Inoue G, Tamura Y. Osteosynthesis for longstanding nonunion of the lateral humeral condyle. Arch Orthop Trauma Surg 1993;112:236-8.  Back to cited text no. 16
    
17.
Gaur SC, Varma AN, Swarup A. A new surgical technique for old ununited lateral condyle fractures of the humerus in children. J Trauma 1993;34:68-9.  Back to cited text no. 17
    
18.
Tien YC, Chen JC, Fu YC, Chih TT, Huang PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. Surgical technique. J Bone Joint Surg Am 2006;88 Suppl 1:191-201.  Back to cited text no. 18
    
19.
Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma 1964;4:592-607.  Back to cited text no. 19
    
20.
Ippolito E, Moneta MR, D'Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am 1990;72:757-65.  Back to cited text no. 20
    
21.
Sharma H, Sibinski M, Sherlock DA. Outcome of lateral humeral condylar mass fractures in children associated with elbow dislocation or olecranon fracture. Int Orthop 2009;33:509-14.  Back to cited text no. 21
    
22.
Hyatt BT, Schmitz MR, Rush JK. Complications of pediatric elbow fractures. Orthop Clin North Am 2016;47:377-85.  Back to cited text no. 22
    
23.
Abzug JM, Dua K, Kozin SH, Herman MJ. Current concepts in the treatment of lateral condyle fractures in children. J Am Acad Orthop Surg 2020;28:e9-19.  Back to cited text no. 23
    
24.
Eamsobhana P, Kaewpornsawan K. Should we repair nonunion of the lateral humeral condyle in children? Int Orthop 2015;39:1579-85.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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