Lateral condyle fracture of humerus in children

Upper Limb Trauma in Children - Fracture Lateral Condyle of Humerus

1. Lateral Condyle Fracture of Humerus in Children Dr Aiman Ali Orthopaedic Surgery Resident – Postgraduate year 5 Dept of Orthopaedics & Trauma, Khyber Teaching Hospital Peshawar

2. Anatomy Lateral Condyle of humerus is a large, trabeculated eminence located at the distal part of humerus. It extends medially to form main part of lower articular end of humerus. It gives attachment to: Radial Collateral ligament Supinator Forearm extensors

3. Lateral Condyle Humerus Fracture-Overview Comprises 17 % of distal humerus fractures Peak age is 6 years It is Salter-Harris type IV physeal Injury

4. Mechanism of Injury Pull-Off Theory Pull-off of the common extensor musculature results in avulsion of the lateral condyle. More common than Push-Off injury Push-Off Theory Fall on the outstretch hand causes impaction of the radial head into lateral condyle , causing fracture. Can also result from a direct blow to the olecranon

5. Patho-anatomy Fracture originate proximally in the metaphysis & extends distally & anteriorly across the physis and epiphysis into the elbow joint. Fracture may extend medially into the trochlear groove making the elbow unstable and prone to dislocation

6. Presentation Hx Signs and Symptoms Lateral Elbow Pain & Soft tissue Swelling May be subtle if fracture is minimally displaced Tenderness over the lateral side which may be increased with wrist extension Hematoma and Crepitus if more displaced

7. Imaging Radiographs AP, Lateral & Oblique views of Elbow Internal oblique view most accurately shows fracture displacement because fracture is posterolateral. To determine the importance of internal oblique view in the radiographic eval uation of nondisplaced or minimally displaced lateral condylar fractures, song et al. compared the oblique view to standard AP views and found that the amount of displacement differed between two views in 75% of children. They recommended routine use of an internal oblique view to evaluate the amount of fracture displacement and stability Sometimes Xray of Contralateral elbow is needed for comparison when ossification is not yet complete.

8. Imaging cont.  Arthrogram 。 indicated in minimally displace fracture 。 to assess cartilage surface when there is incomplete/absent epiphyseal ossification.  MRI 。 provides the ability to assess the cartilaginous integrity of trochlea 。 useful for operative planning of delayed or non-union 。 expensive 。 required GA/sedation to perform test Ultrasound evaluation Most recently it has been suggested to identify unstable fractures in acute setting and to aid preoperative planning for late displacement, delayed union and malunion.

9. Radiographic finding in lateral condyle of humerus fracture Figure A: Injury film of a 7 year old with a non displaced fracture of lateral condyle (small arrows).Attention was drawn to the site of fracture because of extensive swelling on lateral aspect(white arrow) Figure B: Because of extensive soft tissue injury, there was little intrinsic stability, allowing the fracture to become displaced at 7 days(arrow)

10. Radiographic finding in lateral condyle of humerus fracture cont . Figure A: a small ossific nucleus in the swollen lateral soft tissue Figure B ： An arthrogram shows the defect left by the displaced lateral condyle(closed arrow). The displaced condyle is outlined in the soft tissues(solid arrow)

11. Radiographic finding in lateral condyle of humerus fracture cont. Figure A: Radiograph of what appears to be stable type II fracture of the lateral condyle in a 10 year old child Figure B: MRI imaging clearly shows that this is a fracture of entire distal humeral physis. In fracture of entire distal humerus physis, the proximal radius and ulna usually are displaced posteromedially. The relationship of lateral condylar ossification center to the proximal radius remains intact. But in true fracture involving only the lateral condylar phyis, the relationship of condylar ossification center to proximal radius is disrupted. In addition, displacement of the proximal radius and ulna is more likely to be lateral.

12. Radiographic finding in lateral condyle of humerus fracture cont . Figure ： Angular deformities. A: capitellar fracture. B: fracture extending into the trochlea

13. p r ognosis  Outcome have historically been worse than supracondylar fractures missed diagnosis higher risk of malunion/nonunion

14. Classification of Lateral Condyle Fracture Lateral condylar physeal fractures can be classified by either the fracture line's anatomic location or by the amount of displacement

15. Milch classification Type I Fracture line lateral to trochlear groove(less common, elbow is stable as fracture does not enter trochlear groove) Type II Fracture line extends medially into trochlear groove (more common, more unstable) This classification is used infrequently because of its poor reliability and predictive value.

16. Jakob’s classification Stage I Fracture relatively nondisplaced ,articular surface intact Stage II Articular surface disrupted; fragment and olecranon displaced Stage III Fragment rotated and displaced

17. Weiss classification Type I <2 mm displacement Type II >2 mm displacement with intact cartilaginous hinge Type III >2 mm displacement with nonintact cartilaginous hinge

18. Song et al. classification on the basis of fracture displacement & Fracture Pattern stage Displacement(mm) Fracture pattern stability 1 ≤2 Limited to metaphysis stable 2 ≤2 Indefinable ； extends to epiphyseal articular cartilage indeterminate 3 ≤2 Medial and lateral displacement of distal fragment Unstable 4 ≥2 No rotation of fragment Unstable 5 ≥2 Rotation of fragment unstable

19. Treatment Non-Operative vs Operative Depending on the degree of displacement & amount of instability

20. Do you need to pin all un-displaced lateral condyle fractures ?

21. When in Doubt, YES , PIN!

22. Treatment ( Cont ) Non-Operative: Long arm cast /posterior splint for 4-6 wks Indications: <2mm displacement in all views medial cartilaginous hinge must remain intact Technique: cast with elbow at approx. 90 degrees with the forearm in neutral rotation weekly follow up radiographs every week for first 3 weeks, including internal oblique view

23. Operative Treatment CRPP+ 4-6 wks in long arm bivalved cast . Indications: Fractures with 2-4 mm of displacement that are found to be stable with intact articular hinge, either by stress maneuvers, arthrography, or other imaging modality. Technique: Closed reduction is best achieved with the elbow extended, forearm supinated , wrist extended and varus elbow stress Instrumentation: divergent pin configuration most stable cannulated screw fixation considered for more rigid fixation, allows early motion and compresses fracture site

24. Treatment ( Cont ) Outcome of CRPP: According to Song et al. All types of lateral condyle fracture can be treated with CRPP They listed three element essential for obtaining good result with CRPP: Accurate interpretation of direction of fracture displacement Routine intraoperative confirmation of the reduction on both AP and internal oblique view. maintenance of reduction with two parallel k wires

25. Operative Treatment- ORIF ORIF + posterior splint/bivalve long arm cast with elbow flexed 90 degrees for 4-6 weeks Indications: displaced, unstable fracture with articular malangulation and malrotation fracture nonunion Technique: approach- anterolateral approach as blood supply comes from posteriorly avoid dissection of the posterior aspect of lateral condyle (source of vascularization) Instrumentation: most fracture can be fixed with 2 percutaneous pins (3 if comminuted) in parallel or divergent fashion single screw for large fragment or nonunion

26. Operative Treatment – ( Cont ) Supracondylar Osteotomy: Deformity Correction in Late Presenting Cubitus Valgus

27. Treatment Algorithm

28. Complications Lateral Spur formation –one of the most common complication Elbow stiffness Cubitus varus Cubitus valgus Physeal arrest Growth disturbance-Fishtail deformity Osteonecrosis Neurological complications :acute nerve injury , tardy ulnar nerve palsy Malunion Delayed union Nonunion

29. Thank You