Pediatric Lateral Condyle Fractures

Study Notes

Pediatric Lateral Condyle Fractures Overview

Second most common elbow fractures in children, typically occurring around age 6.
Higher risk of complications, including nonunion, malunion, and avascular necrosis (AVN).
Most often classified as Salter-Harris IV fractures, involving the lateral condyle.
Treatment varies based on degree of articular displacement; may require closed reduction and percutaneous pinning (CRPP) or open reduction.

Pathophysiology

Mechanisms of Injury:
- Pull-off theory: Avulsion fracture due to pull of common extensor muscles.
- Push-off theory: Impact from a fall on an outstretched hand causing fracture.
Fracture Characteristics:
- Extend proximally from the distal humerus metaphysis into the elbow joint.
- May compromise the stability of the elbow if extending into the trochlear groove.

Clinical Presentation

Typical history involves a fall on an outstretched hand.
Symptoms include lateral elbow pain, swelling, and potential subtlety in presentation if minimally displaced.
Physical exam may show limited swelling and tenderness; lateral ecchymosis indicates an unstable fracture.

Imaging Techniques

Radiographs: Essential for diagnosis, with AP, lateral, and oblique views recommended.
- An internal oblique view best visualizes fracture displacement.
Additional Imaging:
- Arthrogram: Useful for minimally displaced fractures to assess cartilage surface.
- CT Scans: Rarely indicated unless fracture type is uncertain.
- MRI: Helpful for evaluating cartilage integrity and planning for non-unions but expensive and requires sedation.

Classification Systems

Milch Classification:
- Type I: Fracture line is lateral to the trochlear groove; stable.
- Type II: Fracture line extends into the trochlear groove; unstable.
Fracture Displacement Classification: Weiss et al.'s classification assesses displacement severity.

Treatment Options

Nonoperative: Long arm casting indicated for <2 mm displacement.
- Immobilization in neutral rotation, weekly follow-ups and radiography to monitor for early displacement.
Operative: Indicated for unstable fractures or those >2 mm displaced.
- Techniques include CRPP or open reduction, especially for significant displacement or joint incongruity.
- Postoperative care typically involves casting for 3-6 weeks.

Complications

Generally worse outcomes compared to supracondylar fractures, with risks for:
- Stiffness: Most common complication, often self-resolving.
- Delayed Union: Fractures healing longer than 6 weeks, management varies based on displacement.
- Nonunion: Higher incidence than other elbow fractures; requires careful monitoring and may need surgical intervention.
- Cubitus Valgus and Tardy Ulnar Nerve Palsy: Due to physeal arrest or nonunion.
- AVN: Can occur 1-3 years post-fracture, risk influenced by surgical techniques.
- Fishtail Deformity: Contour abnormality of the distal humerus from skeletal development issues, potentially leading to functional impairment.

Anatomical Considerations

Blood supply from the brachial artery and posterior anastomotic vessels.
Lateral collateral ligament remains attached to proximal condyle fragment, critical for stability.

Late Presentation Management

Treatment after 2-3 weeks may include reduction and ORIF or bone grafting.
Associated risks include AVN and physeal arrest.

Surgical Techniques

Closed Reduction and Pinning (CRPP): Aids in stabilization; optimal with divergent pin configuration.
Open Reduction: Anterolateral approach preferred to preserve blood supply, ensuring visual confirmation of joint reduction.

Summary of Outcomes

Nonoperative treatment has a notable nonunion rate, particularly for displaced fractures.
Success of interventions and complications must be monitored closely in pediatric patients.

Description

Explore the intricacies of pediatric lateral condyle fractures, a prevalent injury in children aged around 6 years. Understand their classification as Salter-Harris IV fracture patterns and the potential complications such as nonunion and malunion. This quiz will help consolidate your knowledge on the treatment approaches for these fractures.