Lateral condylar fractures of the distal humerus

Lateral condylar fractures of the distal humerus

1. Lateral Condylar Fractures of the distal humerus Dr. Mohammad Mahdi Shater Orthopedic Surgery Resident Baqiyatallah University of Medical Sciences بسم الله الرحمن الرحیم Rockwood and Green's Fractures in Adults 9 th Edition

2. Introduction the most common physeal injuries after distal radius average age around 6 years medial condylar physis are rare and occur most often in children 8 to 12 years of age Fractures involving the total distal humeral physis may occur in neonates or within the first 2 to 3 years of life

3. Introduction less common than supracondylar fractures Dislocation(PL) of the elbow Radial head fractures Fractures of the olecranon , which are often greenstick fractures Diagnosis( Obl view)

4. Introduction Two mechanisms have been suggested: “push-off” and “ pull-off.” Sign and Symptom: soft-tissue swelling and pain Stage I displacement flexing the wrist S tage II or III displacement, there often is a hematoma present laterally, and attempted manipulation may result in some local crepitus with motion of the lateral condylar fragment .

5. Introduction Radiogeraphy In the AP view, the metaphyseal fragment or “ flake ” may be small and seemingly minimally displaced. The degree of displacement may be seen on the true lateral view . Oblique views are especially helpful in patients in whom a stage I displacement is suspected but not evident on AP and lateral views It use to evaluate amount of fracture displacement and to assess stability if a lateral condylar fracture is suspected Arthrography or MRI evaluation and Ultrasonography

6. Classification Anatomic Location: The Milch classification, based on whether or not the fracture extends through (type I) or around (type II) the capitellar ossific nucleus Type I salter IV Type II salter II

7. Stages of Displacement: The amount of fracture displacement has been described by Jakob et al. in three stages: First stage , the fracture is relatively nondisplaced , and the articular surface is intact ,with no lateral shift of the olecranon. Second stage , the fracture extends completely through the articular surface which allow lateral displacement of the olecranon. Third stage , the condylar fragment is rotated and totally displaced laterally and proximally, which allows translocation of both the olecranon and the radial head .

8. Stage II displacement—articular surface disrupted

9. Lateral Condylar Of The Distal Humerus 13 Stage III displacement—fragment rotated

10. Stages of Displacement: Weiss et al. Modified classification based on fracture displacement and disruption of the cartilaginous hinge . Type I fractures are displaced less than 2 mm ; Type II fractures are displaced more than 2 mm but have an intact cartilaginous hinge ; And type III fractures are displaced more than 2 mm and do not have an intact cartilaginous hinge. This classification was found to be predictive of both the major and minor complications .

11. Figure 19-7 classification of lateral humeral condylar fractures. Type I , less than 2 mm of displacement; Type II , 2 mm or more of displacement and congruity of the articular surface; Type III , more than 2 mm of displacement and lack of articular congruity.

12. Treatment Options for Lateral Condylar Fractures Fractures involving the lateral condylar physis can be treated with immobilization alone, closed reduction and percutaneous pinning , or open surgical reduction depending on the degree of displacement and amount of instability.

13. Immobilization Minimally displaced fractures ( <2 mm ) are stable and have intact soft-tissue attachments that prevent displacement of the distal fragment. Immobilization of nondisplaced or minimally displaced (less than 2 mm) fractures in a posterior splint or cast is adequate. Radiographs are obtained during the first 3 weeks after injury to ensure that rare late displacement does not occur. Nonoperative Treatment of Lateral Condylar Fractures

14. Radiographs are taken within the first week after the fracture with the cast removed and the elbow extended . If there is no displacement, the radiographs are repeated once again during the next 1 to 2 weeks . Immobilization is continued until fracture union is apparent, usually between 4 and 6 weeks after injury

15. Closed Reduction and Percutaneous Pinning Displaced more than 2 mm is required to restore anatomic alignment of the joint and physis . Closed reduction is best achieved with the forearm supinated and the elbow extended . Placing a varus stress on the extended elbow allows easier manipulation of the fragment. Standard closed reduction with thumb pressure on the fracture fragment, elbow flexion, forearm supination, and wrist dorsiflexion usually results in an aligned fracture. The smooth pins are then advanced across the fracture site to the opposite cortex to obtain stability. Anatomic alignment of the joint and fracture stability are confirmed by stress testing and arthrography. If a satisfactory reduction cannot be obtained, then reduction can be achieved and maintained by open reduction and internal fixation .

16. ORIF If the fracture is completely displaced, malrotated , and/or grossly unstable ( stage III ), open reduction and internal fixation are indicated. We prefer open reduction and internal fixation of all fractures with stage III displacement. It is important that open reduction is performed within a few days after the injury. The standard lateral Kocher approach provides sufficient exposure of the fragment. Extensive posterolateral soft-tissue dissection risks osteonecrosis of the condyle and so dissection is performed anteriorly with minimal soft-tissue stripping

17. ORIF A long arm cast is applied with the elbow flexed 90 degrees and the forearm in neutral or slight pronation . The cast and pins are removed in 4 weeks if there is adequate healing on radiographs. Early active motion is started at that time. If necessary, pin removal can be delayed 1 to 2 weeks to allow further healing in older children .

18. Complications Lateral Spur Formation Is one of the most common sequelae after a fracture involving the lateral condylar physis . After both nonoperative and operative treatment More frequent after displaced fractures ( Jakob types II and III) and those treated with PCP or ORIF than in those treated with cast immobilization Mild cubitus varus ( pseudovarus )

19. Cubitus Varus The incidence of cubitus varus is as high as 40% Due to an inadequate reduction , growth stimulation of the lateral condylar physis from the fracture insult, or a combination of both. - Rarely is severe enough to cause concern or require further treatment

20. Cubitus Valgus Is much less common after united lateral condylar fractures than cubitus varus . If cubitus valgus is symptomatic , it can be treated with: Medial closing wedge osteotomy Dome osteotomy and internal fixation Osteotomy and gradual distraction through an external fixator

21. Delayed Union Most common in patients treated nonoperatively Various reasons have been suggested for delayed union of lateral condylar fractures, including: Poor circulation to the metaphyseal fragment Bathing of the fracture site by articular fluid, which inhibits fibrin formation and subsequent callus formation. Tension forces exerted by the extensor musculature arising from the condylar fragment * Lateral spur formation or cubitus varus is relatively common with these late healing fractures

22. Delayed open reduction( more than 3 weeks after injury ) has a risk of osteonecrosis and further loss of elbow motion. The need for further treatment depends on: The presence of significant symptoms Limited motion Risk of further displacement

23. Nonunion True nonunion occurs in patients with progressive displacement of the fragment or late of initial treatment of a displaced fracture. If the fracture is displaced and is not united by 12 weeks , it is considered a nonunion Weakness or symptoms can occur when the arm is used for high-performance activities. The fragment migrates both proximally and laterally Nonunion can lead to a cubitus valgus deformity, Tardy ulnar nerve palsy Lateral translocation of the proximal radius and ulna

24. Surgical treatment for established nonunion if: • A large metaphyseal fragment • Displacement of less than 1 cm from the joint surface • An open , viable lateral condylar physis

25. Fish tail deformity

26. Neurologic Complications Acute Nerve Injuries - Is Rare Transient radial nerve paralysis Posterior interosseous nerve injury Tardy Ulnar Nerve Palsy A late complication of fractures After the development of cubitus valgus from malunion or nonunion Motor loss occurs first , with sensory changes developing somewhat later Anterior transposition of the nerve