Pediatric Lateral Condyle Fracture - Types, Treatment, and Complications

What Is a Pediatric Lateral Condyle Fracture?

A type of elbow fracture known as pediatric lateral condyle fracture affects children between the ages of 5 and 10. They are the second most common fracture developing in the pediatric elbow. It accounts for 12 percent to 20 percent of pediatric distal humerus fractures. The fracture involves bony prominence on the outer side of the lower end of the humerus bone that forms a part of the elbow joint. The fracture is caused by falling on an outstretched hand or a blow to the lateral aspect of the elbow. As these fractures are associated with higher complications than other elbow fractures, early diagnosis and treatment of the fracture are necessary.

How Are Pediatric Lateral Condyle Fractures Classified?

Based on Milch Classification

1. Type I: Extends through the ossification center of the trochlea.

2. Type II: Fracture extends medial to the ossification center.

Milch classification does not provide treatment or prognostic guidance.

Weiss Classification Based on Fracture Displacement

1. Type I: Less than 2 mm (millimeter) displacement of fractured bones suggesting intact cartilaginous hinge. Casting can be used to treat such fractures.

2. Type II: More than 2mm but less than 4mm fractured bone displacement with intact articular cartilage in arthrogram. The fracture requires closed reduction and fixation.

3. Type III: The fractured parts are more than 4 mm displaced with a disrupted articular surface on the arthrogram. Treatment for the fracture involves open reduction and fixation.

What Are the Signs and Symptoms of Lateral Condyle Fractures?

Children with fractures develop lateral elbow pain, swelling, and tenderness to palpation. The symptoms can be mild if fractures are minimally displaced. A lateral ecchymosis (bruise) suggests a tear in aponeurosis brachioradialis that indicates an unstable fracture. When the wrist is extended or flexed against resistance, discomfort may occur, and the fracture site may exhibit crepitus (grating sound). Neurovascular compromise are rare in this type of fracture.

How Is Pediatric Lateral Condyle Fracture Diagnosed?

A plain elbow radiograph with an internal oblique view demonstrating displacement of the fracture segment is used to diagnose pediatric lateral condyle fracture. The capitellum is laterally displaced in fractures in comparison to the radial head. Other imaging studies like CT (computed tomography), MRI (magnetic resonance imaging), and ultrasound can help better visualize fracture patterns and articular surfaces. Arthrogram is performed in minimally displaced fractures to assess cartilage surface when there is incomplete or absent epiphyseal ossification. To evaluate the articular surface intraoperatively, this image is helpful. The imaging study allows for dynamic assessment. CT scans are usually recommended when there is doubt about the type of fracture. MRI is useful in assessing the cartilaginous integrity of the trochlea and planning operative procedures for delayed or non-unions.

How Is Pediatric Lateral Condyle Fracture Treated?

The fracture is treated through operative or nonoperative methods based on the severity of fractures and the risk of complications.

Non-Operative Procedure:

The casting of the long arms continues for four to six weeks. When the medial cartilaginous hinge is still intact and there is less than a 2 mm displacement in all views, this approach should be used. If the swelling is minimal, a cast is applied to the elbow at a 90-degree angle. After the cast placement, the patients are advised weekly follow-up and radiographs every week for the first three weeks in internal oblique view to monitor for further displacement. Rarely more than six weeks of casting are required.

Operative Procedures:

Articular reduction is the primary goal of surgical intervention in displaced fractures.

• Closed Reduction and Percutaneous Pinning With Three to Six Weeks or More Elbow Cast: The operation is recommended for fractures with intact articular cartilage and more than 2 to 4 mm displacement. Surgeons can use two or three pins and a percutaneous or subcutaneous approach.

• Open Reduction and Fixation With Three to Six Weeks or More Elbow Cast: The procedure is indicated for fractures with more than 4 mm displacement, joint incongruity, and non-union fracture. The fracture anterior to the joint is dissected using a lateral technique. Soft tissue dissection posterior to the fragment must be avoided to prevent avascular necrosis.

• Supracondylar Osteotomy: In rare instances, deformity correction in late-presenting cubitus valgus is performed through supracondylar osteotomy.

What Are the Complications of Pediatric Lateral Condyle Fracture?

Complications are common in pediatric lateral condyle fractures and are significant. Compared to other elbow fractures, these fractures are more likely to result in nonunion, malunion, and avascular necrosis.

• Stiffness is a common complication that is an early sign of non-union or delayed union. The symptom goes away on its own; 90 percent of motion returns after 24 weeks, and 100 percent of motion recovers after 48 weeks.

• Delayed union is a complication where the fracture does not heal even after six weeks of immobilization. This consequence manifests in fractures that are discovered two weeks after the accident. Immobilization treats delayed unions when they are just moderately displaced, while surgery is used when dislocated.

• Due to non-operative therapy, nonunion in this type of fracture is frequent. The problem may result from synovial fluid that prevents fracture healing, continual motion at the fracture site brought on by pulling from the wrist extensors, or poor metaphyseal circulation to the distal fragment. Bone grafting or ORIF (open reduction and internal fixation) with a screw are two treatments for nonunion.

• Cubitus valgus with or without tardy ulnar nerve palsy is a complication that develops due to lateral physeal arrest or nonunion. 10 percent of patients develop the condition, which causes slow and progressive nerve palsy. Supracondylar osteotomy and ulnar nerve transposition are used to treat the problem.

• Avascular necrosis occurs 1 to 3 years following a fracture.

• Fishtail deformity forms when the area between the medial ossification center and lateral condyle ossification resorbs or fails to develop. Treatment involves supracondylar osteotomy.

• Lateral overgrowth or prominence develops in 50 percent of cases regardless of treatment.

• Growth arrest is a rare complication. Treatment options for young children include osteotomy or bar resection. Treatment for older patients includes epiphysiodesis and osteotomy completion.

• The surgical scar's undesirable appearance.

Conclusion

Pediatric lateral condyle fractures are common elbow injuries in children. Early diagnosis, proper classification, and timely treatment are required for optimal healing and complete recovery. As these fractures commonly develop complications, timely intervention is necessary.