Acute Lateral condyle fractures in Children

https://www.youtube.com/live/qXqz7foVUA4?si=s2ltdgempNzhFs8h

Lateral condyle of humerus fracture
Classification of the Lateral Condyle Fracture

Milch – morphology
Weiss – displacement
Song – displacement and stability

Milch Type 1
• Fracture exits LATERAL to trochlear groove
Stable

Milch Type 2

• Fracture exits MEDIALLY into trochlear groove
• Unstable

Milch – modified
• Uses the capitello-trochlear sulcus as landmark

Milch classification is less reliable. doesn’t say about treatment outcome and what treatment to follow

Weiss
• Built on Jakobs Classification
• Displacement
• Articular integrity

Weiss Classification Type	Displacement	Articular Surface
I	< 2mm	Intact
ll	> 2mm < 4mm	Intact
III	> 4mm	Disrupted

Weiss classification treatment plan

Weiss type l : Casting
Weiss type ll : Closed reduction + fixation
Weiss type lll : Open reduction + fixation

Song Classification Stage	displacement	fracture	stability
1	<2mm	Metaphysis only Minimal gap	stable
2	<2mm	Lateral gap only	Unknown
3	<2mm	Gap complete	Unstable
4	>2mm	Without rotation	Unstable
5	>2mm	With rotation	Unstable

Song stage 1 and 2 : Cast
Song stage 3 : Closed reduction and fixation
Song stage 4& 5 : open reduction and fixation

How to treat Lateral condyle fracture?
Accuracy of radiograph : it underestimates displacement by 1.6 – 6.0mm

Metaphyseal Plastic Deformation
• Fragment has changed shape

1) Articular surface displacement is key
2) Radiographs can’t accurately demonstrate this
3) Metaphyseal displacement is not a surrogate for articular displacement or reduction

All immobilized for 6 weeks regardless of treatment

Non operative management
• Undisplaced fractures’ subsequently ‘displace’ frequently (up to 15%)*
• So give yourself the best chance of picking this up

Active non operative management
• AP, lateral and internal oblique Xrays Out of plaster should be obtained at 1, 2 and 3 weeks post injury
• If acceptable, total 6 weeks in plaster

Open reduction and screw fixation

For large metaphyseal fragment
Stay outside of growth plate
Stable internal fixation
More posterior than posterolateral……
Good approach if there is a reasonable metaphyseal fragment
Small fragment bone clamp in olecranon fossa
2.7mm cortical screws work well – ? Washers
Ensure screw engages far cortex!
If there’s a problem – revise promptly

Late presentations- Non-union lateral condyle humerus

Late presentations are not uncommon in our country
Diagnosis is difficult, functional loss of motion is not so severe, financial constraints, native bone setters
Late presentations or non unions- when there is no attempt of callus or fracture line clearly visible after 2-3 months
There are clear guidelines for late presenting lateral condyle non unions
Fontanette- open reduction should not be done 3-4 weeks after injury’
Wilkins- ” If we believe fracture union can be obtained without loss of motion and avoidance of AVN of lateral condyle, then we recommend surgery for selected patients”
Open reduction- difficulty in distinguishing the metaphyseal and articular region of fragment, overgrowth of condylar fragment, fibrosis, contracted soft tissues
Elbow stiffness and avascular necrosis can ensue
In situ or percutaneous screw fixation- safe and minimally invasive minimal risks of elbow stiffness, blood supply disruption

1) Percutaneous screw fixation promotes Healing of lateral condyle nonunion in children
(J Pediate orthop 2014:34:155 -160)

16 patients in age group 2-10
12/16 (75% united after surgery- mean of 15.7 wks from injury
4/16 (25%) failed to unite- mean of 225 weeks from injury
Technique successful if non union addressed within 16 weeks from injury
Minimally invasive with no risks of complications encountered with open reduction

Treatment modality for late presenting non unions- lack of consensus: In-situ fixation, open reduction and bone grafting; corrective osteotomy with or without ulnar nerve transposition

Moving from era of neglect to era of intervention
Reduce deformity and instability by trying to restore anatomy In situ / open reduction/corrective osteotomy
Discuss pros and cons with patient and parents- informed decision on a case by case basis

Take Home

Lateral condylar fracture of humerus in children have significant long term sequelae
Late presentations challenging . Assess carefully the clinical problems

Post op radiographs