Lateral Condylar Fracture : Case discussion

Case summary: A 6 years old male child was referred from a rural hospital to a higher center with a carton paper splint and roll bandage sling insitu. The patient had a history of left elbow pain of 1 day after sustaining fall injury over the left elbow. There was no history of loss of consciousness, altered body movements, external wounds or pain at other sites. On examination after removal of the splint, there was swelling and deformity of the lateral aspect of the left elbow. There was tenderness over the lateral elbow region and extending upto the volar aspect of forearm region. The active range of movement of the involved elbow was severely limited. The X-ray of the left elbow revealed displaced fracture of the lateral condyle and an unossified epiphyseal plate below the fracture line which may be confused with the fracture line itself. Since, there was no complaint at the time of presentation, no analgesics were given. An above elbow posterior slab was applied with elbow in flexion and forearm in supination. The patient was admitted at the Orthopedic ward and ORIF was planned for the next day. Next day, ORIF with K-wire was performed followed by dressing of the wound and reapplication of the above elbow posterior slab.

lateral condylar fracture

Common Injuries around elbow:

  1. Supracondylar fracture (65%)
  2. Condylar fractures (25%)
  3. Fracture neck of radius (5%)
  4. Monteggia’s fracture (2%)
  5. Olecranon fracture (1.5%)
  6. T-condylar fracture (1%)

Relevant anatomy of elbow:

elbow joint anatomy

  • Elbow is a complex joint comprising of:
    1. Humeroulnar joint: Trochlear notch of ulna – Trochlea of humerus (Hinge joint)
    2. Humeroradial joint: Head of radius – Capitulum of humerus (Hinge joint)
    3. Proximal radioulnar joint: Radial notch – Radial head (Pivot joint)
  • At the end of flexion, the coronoid process tucks into the coronoid fossa.
  • At the end of extension, the olecranon process tucks into the olecranon fossa.
  • Extensors: Normal extension of elbow is aided by the gravity, while the forced extension of the elbow is aided by triceps and anconeus.
  • Primary flexors: Brachioradialis, Biceps, Brachialis
  • Pronators: Pronator teres and quadratus
  • Supiantors: Supinator, Biceps
  • Age of ossification of ossification centers in elbow: Mnemonic – CRITOE
    • Capitulum: 2 years
    • Radial head: 4 years
    • Internal (medial) epicondyle: 6 years
    • Trochlea: 8 years
    • Olecranon: 10years
    • External (lateral) epicondyle: 12 years
  • Triangle sign: In flexion, olecranon, lateral and medial epicondyle forms isosceles triangle which is maintained in supracondylar fracture but disturbed in elbow dislocations.
  • Relations of elbow:
    • Anterior: Median nerve and Brachial artery lie medial to the biceps tendon and superficial to the brachialis muscle
    • Posterior: Triceps bursa
    • Lateral: Radial nerve and its posterior interosseous branch
    • Ulnar nerve lies behind the medial epicondyle
    • Lateral epicondyle is the common extensor origin (supinator and forearm extensors) and also provides attachment for radial collateral ligament
    • Medial epicondyle is the common flexor origin and also provides attachment for ulnar collateral ligament

Lateral Condylar Fractures

A) Epidemiology:

  1. 2nd commonest fracture around elbow after supracondylar fracture
  2. Commonest age of occurence: 5-10 years
  3. Lateral condylar fracture is common than medial condylar fracture due to 2 reasons:
    • Radius articulates with the lateral part of the condyle and therefore the force from sudden impacts is primarily directed laterally.
    • Lateral epicondylar ridge is smaller and weaker than its medial counterpart.
  4. It is the fracture of necessity i.e. needs ORIF
  5. Most fractures are Type IV Salter Harris fractures

B) Mechanism of Injury:

  • Pull-off theory: Forced adduction (varus) of elbow in extension causes avulsion of lateral condyle by lateral ligaments and extensor muscles
  • Push-off theory: Fall on outstretched hand causes impaction of radial head into the lateral condyle causing fracture

C) Milch Classification:

  1. Milch Type I: Fracture line lateral to trochelar groove (Salter harris type IV)
  2. Milch Type II: Fracture line into trochlear groove (Salter harris type II)

D) History and Examination:

  1. Mechanism of injury
  2. Swelling and tenderness over lateral aspect of elbow
  3. Reluctance to use the arm and resistance to passive motion
  4. Can lead to minimal swelling and deformity, leading to delayed presentation
  5. Increased pain with resisted wrist extension/flexion

E) X-ray examination:

  1. AP and lateral views of elbow without splinting if possible as the pain and swelling is usually less
  2. Oblique view of elbow (with arm in internal rotation) if lateral condyle fracture is suspected or minimally displaced on X-rays (accurately shows maximum displacement and fracture pattern)
  3. Stress views (with elbow flexion in 90 degrees) are not recommended due to risk of fracture displacement
  4. X-ray of contralateral elbow may be needed for comparison when ossification is not complete
  5. Fracture line may not be apparent until 7-10 days following injury; look for lateral soft tissue swelling on AP radiographs

Arthrogram may be indicated when diagnosis is strongly suspected but cannot be confirmed

F) Treatment:

  1. Undisplaced fractures: Immobilization in above elbow posterior slab with elbow flexed to 90 degrees for 3-6 weeks
  2. Minimally displaced fractures (<2 mm gap): Immobilization alone or  CRPP (Closed reduction and Percutaneous pinning)
  3. Displaced fractures (>2 mm gap): CRPP or ORIF (Open reduction and internal fixation) with K wire

Closed reduction is performed by providing a varus elbow force and pushing the fragment anteromedial

Open reduction is done via lateral approach on elbow via Kocher incision or via Modified posterior approach – the posterior aspect of the fracture fragment is left undisturbed as it is the source of blood supply.

G) Follow-up:

  1. Undisplaced fractures: Within 7 days with repeat X-rays with backslab removed (even undisplaced fractures have tendency to be displaced)
  2. Operated fractures: As advised by Orthopedician

H) Complications:

  1. Avascular necrosis (AVN): as a result of posterior dissection
  2. Non-union/Malunion: due to wide fracture displacement due to constant extensor pull
    • May lead to cubitus valgus deformity (due to undergrowth of lateral condyle) and tardy ulnar nerve palsy
    • Cubitus valgus deformity is treated with wedge osteotomy if the angle is more than 20 degrees
  3. Tardy ulnar nerve palsy: Ulnar nerve palsy seen after several years resulting from friction neuritis (after stretching) due to valgus deformity. It is treated with anterior interposition of the ulnar nerve.
  4. Lateral overgrowth/prominence: sometimes, overgrowth of lateral condyle may occur due to overstimulation of lateral growth plate and parents should be counselled about this in advance; this may lead to cubitus varus (gunstock deformity)
  5. Recurrent dislocations
  6. Osteoarthritis

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