You are in: eMedicine Specialties > Orthopedic Surgery > ELBOW Lateral Humeral Condyle FractureArticle Last Updated: Mar 26, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital Janos P Ertl is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society Editors: Mark D Lazarus, MD, Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas R Hunt III, MD, John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: avascular necrosis, distal humerus fracture, lateral condylar physeal fracture, Milch I fracture, Milch II fracture INTRODUCTIONSection 2 of 11
  In 1883, Stimson first described the fracture patterns in lateral condyle fractures in his book Treatise on Fractures.1 He described the fracture as beginning in the lateral metaphysis proximal to the condyle, coursing distally, and exiting through the articular surface through the medial trochlear notch or through the capitellotrochlear groove. In 1955, Milch recognized the significance of these fracture patterns as they related to elbow stability.2 Thus, the fracture patterns of the lateral condyle bear his name and are classified as either Milch I or Milch II fractures.3, 4 ProblemThe distal humerus is primarily cartilage at the age when these injuries typically occur, and knowledge of the secondary centers of ossification is necessary to understand the possible fracture patterns. Due to incomplete ossification, the fracture may appear subtle on radiographs as it courses through the cartilage anlage (see Image 1 and Image 2). The physis of the lateral condyle extends into the trochlear notch of the distal humerus (see Image 8). Therefore, in some fractures, the lateral crista of the trochlea may be part of the fracture fragment, leading to an unstable humeral ulnar articulation. The difficulties related to treatment of this fracture are both biologic and technical. Biologic problems are a result of the healing process and may occur with appropriate treatment and anatomic reduction. These problems include lateral spur formation with pseudo cubitus varus and true cubitus varus. Technical difficulties are the result of errors in management and may result in nonunion, malunion, valgus angulation, avascular necrosis, or a combination of these conditions. FrequencyLateral condyle fractures account for 17% of all distal humerus fractures and 54% of distal humeral physeal fractures (see Image 3). The frequency of lateral condyle fractures peaks in children aged 6 years. Most fractures occur in children aged 5-10 years. Cases have been reported in patients as young as 2 years and as old as 14 years. EtiologyTwo theories of the mechanism of injury for this fracture exist. The first is the pull-off theory, in which avulsion of the lateral condyle occurs at the origin of the extensor/supinator musculature. This may occur as a varus stress is applied to the extended elbow with the forearm supinated. This is thought to be the most common mechanism of injury. The second is the push-off theory, in which a fall onto the extended hand leads to impaction of the radial head into the lateral condyle, causing the fracture.5 PathophysiologyThe lateral condyle fracture is a Salter-Harris IV fracture pattern and follows physeal injury principles. For more information about injuries of the growth plate, see Salter-Harris Fractures. The fracture fragments in these patients are primarily cartilaginous as a result of the young age of the patients. The radiographic interpretation may be misleading because the visible fragment appears smaller than the actual size and, in addition, the amount of displacement is not appreciated. ClinicalChildren usually present with a history of a fall onto an extended arm. Patients present with pain and associated elbow swelling. Physical examination demonstrates a swollen elbow, pain greatest over the lateral condyle, and refusal of the patient to actively move the elbow. Occasionally, crepitus is present in an unstable fracture pattern. Significant deformity may indicate an elbow dislocation. INDICATIONSSection 3 of 11
Operative management is essential for all displaced fractures and in those demonstrating joint instability or the potential for delayed joint instability. Stage I, or type I, lateral condyle fractures with less than 2 mm of displacement may be treated with immobilization. If there is a question of stability or the possibility of delayed displacement in these type I fractures, percutaneous pinning is recommended. If the degree of fracture displacement is questioned, anatomic reduction and surgical stabilization is needed. Open reduction is indicated for all displaced type II and type III fractures. CONTRAINDICATIONSSection 4 of 11
Fractures that are not greatly displaced and are identified on a delayed basis greater than 3 weeks should not undergo surgical intervention. Healing has progressed to a point that extensive dissection would be required to achieve reduction leading to a high incidence of avascular necrosis of the lateral condyle. WORKUPSection 5 of 11
Imaging Studies
Staging
TREATMENTSection 6 of 11
Medical therapyStage I fractures with less than 2 mm of displacement may be treated with immobilization. Maintain cast immobilization for 3-4 weeks at 90° of flexion and forearm supination. Close follow-up is necessary because of the high incidence of late displacement and subsequent malunion. Obtain follow-up radiographs with the arm out of plaster for better fracture evaluation and assessment of possible displacement. If any question remains regarding joint stability or the possibility of delayed displacement, perform closed pinning. If fracture identification is delayed by 6 weeks or longer, continue closed treatment regardless of displacement. A high incidence of avascular necrosis occurs with delayed open reduction and fixation. Surgical therapyOperative management is required in type I fractures that demonstrate delayed displacement or instability. Fragment stabilization is most frequently performed using 2 percutaneously placed smooth Kirschner wires (K-wires). All type II and III fracture patterns require open reduction and fragment stabilization. Preoperative detailsMake a preoperative plan prior to performing an open reduction.
Intraoperative detailsWith operative treatment, an anatomic reduction should be achieved. An anterior approach is utilized to avoid the posterior vascular pedicle to the fracture fragment. This is important to avoid avascular necrosis of the fragment. If delayed (7-10 days), open reduction is performed. Irrigate and evacuate the interposed hematoma to assist in reapproximation. On closure, the periosteal flap must be sutured into place to avoid lateral spur formation and pseudocubitus varus. Postoperative detailsElevate the operated extremity above the heart level, and apply ice to the splint at the fracture site. A sling may be applied for support and comfort. Follow-upFollow-up care is performed at 7 days with AP and lateral radiographs, with arm out of plaster, to assess maintenance of reduction. A long-arm cast is applied in supination. The patient then is seen at 3-4 weeks postoperatively, and the K-wires are removed (see Image 7). Physical therapy is initiated, and gentle active range of motion (ROM) is begun. The patient is next seen at 6 weeks, and AP and lateral radiographs are obtained. Return to full activity is allowed once the fracture is healed radiographically.7, 8, 9 COMPLICATIONSSection 7 of 11
Results of lateral condylar fractures are quite good when treated appropriately and in a timely fashion. Complications of lateral condylar fracture management include lateral condylar overgrowth or spur formation (30%), cubitus varus, nonunion, malunion, valgus angulation, ulnar nerve palsy, and avascular necrosis. These complications are either biologic problems, which arise from the healing process, or technical problems, arising from management errors. 10 Biologic-related problems include lateral condylar overgrowth or spur, which is due to overgrowth of the avulsed periosteal flap from the proximal fragment. This spur may give the appearance of a cubitus varus (pseudovarus) and cause difficulty in patients with a small carrying angle. In general, it should not cause a cosmetic or functional problem. This overgrowth usually undergoes remodeling and disappears over time. Cubitus varus occurs in approximately 42% of patients sustaining a lateral condylar fracture, regardless of treatment. The cause of cubitus varus is not clearly evident. However, it probably is due to lateral condylar physeal stimulation or to slight reduction incongruence. Deformities usually are mild, and surgical correction is not necessary. Technical-related problems of lateral condyle fracture treatment include delayed union, nonunion, and cubitus valgus. Delayed union of lateral condyle fractures usually occurs in patients treated nonsurgically. The elbow usually is not painful. The fragment usually is stable and undergoes uneventful union over time. A nonunion is considered present if no healing is evident at 12 weeks following injury. This may be caused by the pull of the extensor musculature, inadequate fixation or stabilization (immobilization), and failure to recognize the fracture. When the fragment is nondisplaced and is diagnosed relatively early, treatment with a compression screw can be performed. If the nonunion is well established, exploration and removal of the interposed fibrous tissue is recommended, followed by insertion of 1 or 2 compression screws. Perform bone grafting if significant fragment separation exists. Definitive treatment can safely be delayed until the patient becomes symptomatic or reaches skeletal maturity. Occasionally, a fishtail deformity of the distal humerus is seen because of the loss of ossific contact between the capitellum and trochlea. This results in a gap or a deficiency of the lateral trochlear buttress. This deformity usually does not result in any significant dysfunction and is treated nonoperatively. A cubitus valgus deformity may occur if there is nonunion or malunion of a lateral condyle fracture. The deformity rarely is caused by lateral condylar epiphysiodesis. In simple valgus malunion cases, a medial closing wedge osteotomy is performed. In cases of angular deformity and nonunion, treatment is complex and difficult. Address and stabilize the nonunion, and perform a medial closing wedge osteotomy to correct the angular malalignment. This may be performed simultaneously, or it may sequentially be staged. Care must be given to the amount of dissection performed to avoid avascular necrosis of the lateral fragment.11 Avascular necrosis of the lateral fragment in lateral condylar fractures is iatrogenic and most often occurs in cases treated late or in nonunions and delayed unions. This complication is the result of aggressive dissection during open reduction. Acute neurologic injuries are rare. Tardy ulnar nerve palsy occurs late in the treatment and follow-up of lateral condyle fractures and usually is due to cubitus valgus. The average time for presentation of ulnar nerve neuropathy is 22 years following the fracture. This ulnar neuropathy can be treated with ulnar nerve transposition, cubital tunnel release, or medial epicondylectomy. Although rare, myositis ossificans may occur. OUTCOME AND PROGNOSISSection 8 of 11
With prompt and appropriate treatment and a satisfactory reduction, good results may be expected with full elbow ROM. FUTURE AND CONTROVERSIESSection 9 of 11
Arthroscopic-assisted reduction with internal fixation offers direct visualization of the articular fragment, ensuring articular congruity, and percutaneous fixation avoids an extended dissection. This option provides a more biologic approach to treatment of this fracture. Cross-training in arthroscopic techniques and fracture management is necessary.12, 13 MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Lateral Humeral Condyle Fracture excerpt Article Last Updated: Mar 26, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
