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Lateral humeral condyle fracture

Lateral humeral condyle fracture


 Introduction

 Due to the potential bad outcomes, all lateral condyle fractures need immediate orthopedic consultation. Prompt recognition and treatment are necessary to avoid complications and limit functional impairment. The fracture lateral condyle accounts for about 15% of the fracture around the elbow and it's the second most common after supracondylar fracture and the age is about six years and why it's important because as we said it's intra-articular fracture.


Classification

Milch

 two types and this is based about the mechanism of fracture: 

Type 1 

is rare and it's considered as Salter Harris fracture type 4. The fracture line is lateral to the trochlear groove. The fracture line goes through the capitellar ossification center. 

Type 2

 is more common and it's due to avulsion from the lateral collateral ligament and the common extensor origin of the forearm and it's considered to be Salter-Harris type 2. The fracture line extends medially into the trochlear groove. The fracture line runs medial to the capitellar ossification center.

 

Jakob Classification (1975): 

There are three degrees of lateral condyle fractures according to the Jakob Classification.

 Type 1

 is a non-displaced fracture less than two mm. 

Type 2

 is a minimally displaced fracture more than two mm with an intact cartilaginous hinge. 

Type 3 

fractures are displaced and the capitellum is rotated from the joint. So the first and the second types of Jakob classification are considered to be minimally displaced and more stable than type 3 which is the displaced type.

IN type 2 there is an incidence of later displacement so we have

to be aware of this in treatment.


Clinically


It is  present with pain, limited elbow range of motion and swelling. Lateral condyle fractures can frequently look with minimal swelling and deformity, which can lead to a delay in presentation and diagnosis of the fracture. 

 

Plain radiograph

The fracture can be underestimated on AP films and may be seen as a small sliver of bone adjacent to the proximal border of the capitellum. The fracture through the lateral condyle will have a large cartilaginous component as well as a small osseous portion. 


The best view to see the lateral condyle fracture is an internal oblique and this should always be performed when a lateral condyle fracture has been diagnosed. The displacement of the distal fracture component is best demonstrated on the internal oblique view. 


 stress views:

 varus stress views (with appropriate anesthesia) may be required to help assess fracture stability.


an undisplaced fracture of the lateral condyle. An undisplaced lateral condyle fracture may be difficult to see on plain x-ray. The presence of anterior and posterior fat pad signs may be the only clue. 


Stress view of the same patient


sometimes it's hard to tell if the fracture extends to the the articular surface so we have other investigations as the ultrasound and MRI. MRI is a better way to evaluate the

fracture but it needs sedation for the children and it's more expensive.  



Treatment 

 if we have a gap less than 2-millimeter can do a cast and we need to follow up with this patient every week by an x-ray and until healing. If we have more than two millimeter

gap, we think about surgery either close percutaneous pinning or open reduction

internal fixation. In the non-displaced if you are concerned about the ability for follow-up and the

compliance of the parents to come every week to do an x-ray. We'll put the elbow in hyperflexion and pronation and then we go percutaneously with 2 k wires. 


Open reduction is indicated for the rotated fractures because they are unstable. We Use a lateral approach to open and reduce the fracture. We can put more than two wires to be sure that we have stabilized this rotated fragment. We can use  a tourniquet we should always be away from the blood supply to avoid avascular necrosis. We have to see the articular surface to be sure that we have reduced the intra-articular fracture and then we go on and fix it with the pins.


complication 


 fracture delayed Union is less than 12 weeks and more than 12 weeks is considered non-union. physis growth arrest, the fishtail deformity, new bone formation, lateral spurt, angular deformities could be

through the valgus and then affect the ulnar nerve, lateral condylar overgrowth myositis ossificans and

stiffness.


So complications are much more

than the supracondylar fractures.


 so the lateral humeral condyle fracture has a significant risk of problems if maltreated and we have we should be aware about how to treat it 


Frequently asked questions

Do I need to refer to an orthopaedic doctor now?

Yes,  all lateral condyle fractures require immediate orthopaedic consultation.


What advice should you give to the child parents?

The slab and sling should be worn under clothing  and not through the sleeve of the shirt.

Close follow-up is required to ensure that the fracture remains in the correct position.

What is incidence of fracture lateral condyle of humerus and what is its mechanism of injury?

Lateral condyle fractures of elbow are the 2nd most common paediatric elbow fracture after supracondylar fractures. The peak age of incidence is 6 years.

They usually occur as a result of following a fall on an outstretched hand.


Is it better to do X ray after splintting this fracture?

No.These fractures do not require splinting prior to imaging as there is usually less pain and swelling. This allows subtle fracture lines to be more visible on x-ray.


What is the ED management ?

lateral condyle fractures require an orthopaedic consult. Undisplaced fractures can be immobilised in an above elbow back-slab with the elbow flexed to 90 degrees and a sling. X ray should be done without a slab. Patients should be kept nil orally until a decision about surgery is made. Tetanus immunisation status should be assessed, for open fractures.

What are the common complications associated with this fracture?

see above






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