Acute Lateral condyle fractures in Children

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

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

Post op radiographs

• Keep watch on ‘funny looking’ post surgery radiographs

When in Doubt

• Oblique, varus stress films
• Contralateral radiographs
• Arthrogram