Lateral Condyle fractures
Don't be deceived by small visible bony fragment, most of fragment is cartilage. This is a significant injury and prone to problems if not actively managed or closely watched!
Asses displacement and soft tissue integrity to guide treatment.
12% of childrens elbow fractures.
Classification
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Stimson was one of the first to
describe two separate fracture lines Milch attributed clinical significance to the anatomic location of the fracture. Milch I - fracture exits lateral to trochlea through capitulotrochlear groove. In this type, elbow stability is retained. Milch type II, fracture line extends into the apex of the trochlea, which produces elbow instability. Displacement occurs 3 stages. First stage - fracture relatively undisplaced and the articular surface is intact. Because the trochlea is intact, there is no lateral shift of the olecranon. Second stage - fracture extends through articular surface. This allows the proximal fragment to become more displaced and can allow lateral displacement of the olecranon. Third stage - condylar fragment is rotated and totally displaced laterally and proximally, allowing translocation of both olecranon and radial head. Badelon modified the description of stage I displacement to include fractures with less than 2 mm of displacement seen on the anteroposterior or lateral x-ray only or seen on both views. |
Radiology
AP Lateral Elbow - dont be deceived by small fragment, take note of displcement on lat.
Arthrogram/ MRI - can be useful to asses grade of injury and demonstrate if any joint surface displacement
Management
Undisplaced fracture (less than 2 mm) - Conservative splint 2-3/52 then mobilise (Keep close eye! at 3- 5days remove splint and re x-ray, repeat 3-5 days later.)
About 40% of lateral condylar physeal fractures are sufficiently undisplaced that they can be treated by simple immobilization. If fracture line is barely perceptible on the original x-ray, the degree of displacement usually is minimal and the chance for subsequent displacement is low. Only fractures with type I displacement (ie, the fracture line is seen on only one x-ray view) can be safely treated nonoperatively. Any undisplaced fracture, even if it is less than 2 mm, can displace later (8% stage I displace late).
The potential to displace depends more on degree of soft-tissue injury and whether the articular cartilage of the trochlea is intact, rather than on the amount of initial displacement. Soft tissue swelling on the lateral aspect of the distal humerus, can be appreciated both clinically and on x-rays. If crepitus between the fragments is detected with motion of the forearm or elbow, significant loss of soft-tissue attachments and a potentially unstable fracture should be suspected.
Displaced - EUA and percutaneous K wires or ORIF (ensure joint congruity)
Fractures with stage II displacement (2 to 4 mm), varus stress views should be obtained and arthrography performed. If the fracture is stable, percutaneous pinning is possible
ORIF - If the fractures is grossly unstable (stage III displacement). avoid damage to blood supply of distal fragment. Pins out 3 weeks if there is adequate healing on x-rays. Pin removal can be delayed 1 to 2 weeks in older children.
Complications
Late or neglected cases, treat the symptoms not the x ray or the clinical deformity.
See animation