Paediatric Lateral Condyle Fracture of the Humerus
Lateral condyle fractures of the elbow are the second most common paediatric elbow fracture after supracondylar fractures.
They account for 12-20% of elbow fractures in children.
The peak age of incidence is six years.
Lateral condyle fractures involve a fracture line entering into the elbow joint.
The Milch classification system classifies the fracture according to the location of the fracture line in relation to the capitellar ossification center.
Milch type I – it is a rare type, the fracture line goes through the capitellar ossification center and it is equivalent to a Salter-Harris type IV fracture.
Milch type II – it is the most common type, where the fracture line runs medial to capitellar ossification center. And it is equivalent to a Salter-Harris type II fracture.
They usually occur as a result of indirect forces being applied to the elbow following a fall on an outstretched hand.
Angular and rotational forces are thought to contribute.
The child will present with pain, swelling, and limited elbow range of motion.
Lateral condyle fractures can frequently look benign with minimal swelling and minimal deformity, which can lead to delays in presentation and recognition of the fracture.
On examination, the elbow joint is swollen and tender; the range of movement is painfully restricted.
All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.
Anteroposterior (AP) and lateral x-rays of the elbow should be obtained without splinting.
If a lateral condyle fracture is suspected or minimally displaced on x-rays, then oblique views are often useful.
If there is any clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered.
In the x-ray, look for the displacement of the fracture (Undisplaced, <2 mm of displacement, and > 2 mm of displacement).
Undisplaced fractures can be immobilized in an above-elbow back slab with the elbow flexed to 90 degrees. No reduction is required.
Minimally displaced (<2 mm gap) can either be managed with immobilization alone or with closed reduction and percutaneous pinning.
All displaced fractures (>2 mm gap and/or angulation of the lateral condyle) will need to go to theatre either for closed reduction and percutaneous pinning or open reduction.
Emphasis should be placed on the elevation of the limb (elbow above the heart) for the first 48 hours and active finger mobilization.
Back slab and sling should be worn under clothing and not through the sleeve.
Close follow-up is required to ensure that the fracture remains in the correct position.
In the majority of minimally displaced fractures, the union will occur. Fractures managed with operative intervention have a high union rate.
Non-union – This is a common outcome for non-operative treatment of displaced lateral condyle fractures. The risks of non-union increase with an increased degree of displacement or angulation of the fragment.
Overgrowth at the lateral condyle can cause an unsightly bump on the outside of the elbow.
Elbow deformity: growth disturbance can occur resulting in angular growth of the elbow. Typically this results in the valgus shape to the elbow. This can become progressively worse causing a late injury to the ulnar nerve (tardy ulnar nerve palsy).
Neurological injuries can result from the fracture itself or the treatment. The great majority of the neurological injuries resolve with time.