Current Concepts in the Treatment of Lateral Condyle Fractures in Children

Joshua M. Abzug, MD; Karan Dua, MD; Scott H. Kozin, MD; Martin J. Herman, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(1):e9-e19. 

In This Article

Complications

Malunion

Malunion occurs when the fragmented lateral condyle heals in a nonanatomical position, resulting in either a cubitus valgus deformity, or more frequently, a cubitus varus deformity.[32] Malunion can also occur secondary to lateral condyle overgrowth or partial premature physeal closure.[32] However, the distal humeral physis only accounts for 20% of humeral growth and therefore physeal disturbances rarely result in deformity. Early posttraumatic arthritis can occur if the articular surface is malreduced.

Delayed Presentation and Nonunion

Delayed presentation of a lateral condyle fracture is considered to be present 3 to 12 weeks after the initial injury. A nonunion can present either as a pseudarthrosis between the distal humerus and fractured fragment or no bony union >3 months after the injury.[33,34] Nonunions occur because of a missed fracture, displacement of a nonsurgically treated fracture, or after surgical fixation.[34,35] Patients may present with clinical deformity, typically with valgus, lateral condyle tenderness, and occasionally painful and/or restricted elbow ROM[33] (Figure 6). Osteosynthesis of displaced fractures >3 weeks after the initial injury is challenging. The best results are seen when excessive soft-tissue and muscle stripping is not required to achieve reduction because osteonecrosis of the distal humerus may occur with extensive fragment and posterior humeral subperiosteal exposure.[2,33] An open reduction can be beneficial for delayed presenting fractures if the soft tissues overlying the lateral condyle are preserved or the fracture gap is <1 cm. The fragmented piece should be fixed in an anatomic position. If this cannot be achieved, achievement of metaphyseal healing and gross realignment of the distal humeral surface allows for the greatest amount of elbow motion and addresses the valgus instability that results from the nonunion. Liu et al[34] performed ORIF with Kirschner wires for delayed presentation of displaced lateral condyle fractures in 16 children, which resulted in improved postoperative Dhillon scores. Seven children had a fishtail deformity and eight had partial premature physeal closure.[34]

Figure 6.

Clinical photographs and AP radiograph of a 10 year-old boy with left elbow deformity: (A) elbow extension with valgus deformity of the left elbow, (B) left elbow flexion contracture, and (C) AP radiograph with an established lateral condyle nonunion and valgus deformity.

Nonunions can be treated by several techniques including bone-grafting with pins or cannulated screws, osteosynthesis in situ, and closed reduction percutaneous fixation with a cannulated lag screw. Agarwal et al[35] performed an ORIF with bone graft and Kirschner wires on 22 children with lateral condyle nonunions, which resulted in a high rate of bony union and satisfactory elbow function according to the Liverpool Elbow Score Assessment. Park et al[33] performed in situ osteosynthesis with cannulated screw fixation on 16 patients who presented at an average of 4.8 months after their initial injury with nonunion of the fragmented lateral condyle. The authors reported all fractures achieved bony union with improvement in the patients' elbow function. Some had residual deformity because the in situ technique does not focus on concentrically reducing the articular surface.

For those with valgus deformity associated with the nonunion, a corrective osteotomy can be used to correct the angular deformity[33] (Figures 7–9). Untreated nonunions with cubitus valgus deformity often also have valgus elbow instability, which may eventually lead to a tardy ulnar nerve palsy. Ulnar nerve transposition may be needed in conjunction with nonunion surgery.

Figure 7.

Intraoperative photograph of a supracondylar dome osteotomy performed to restore alignment.

Figure 8.

Intraoperative photograph of a supracondylar dome osteotomy being secured with plate and screw fixation.

Figure 9.

AP radiograph of a patient with a healed supracondylar dome osteotomy for a lateral condyle nonunion.

Fishtail Deformity

Narayanan et al[36] described the fishtail deformity as a concavity visible on radiographs where the lateral trochlear ossification center fails to develop because of disrupted blood supply to the trochlea (Figure 10). A fishtail deformity occurs when only the lateral tributaries are disrupted, whereas frank osteonecrosis occurs when both the medial and lateral blood supplies are injured. This is a late manifestation, usually occurring 4 to 8 years after the initial injury resulting in limited ROM, stiffness, pain, loose bodies, and a cubitus valgus deformity.

Figure 10.

AP radiograph with a fishtail deformity characterized by deepening of the trochlear groove.

Early evaluation of the trochlea for fishtail deformity can be difficult and often requires an MRI to help delineate the epiphyseal plate and cartilage. Treatment options include longitudinal observation if no pain is present, removal of loose bodies, epiphysiodesis, osteotomy, and/or ulnar nerve transposition.[36] Many are asymptomatic.

Growth Arrest

Trochlear ossification center growth arrest results in a varus deformity and growth arrest of the capitellum ossification center results in a valgus deformity. Cates and Mehlman[37] reported the average time until capitellum ossification center growth arrest was 2.6 years after injury. Symptoms can include progressive pain, catching and locking, and limited elbow extension or flexion. Deformities can be corrected by resection and interposition or an osteotomy performed later in the disease process.[37]

Lateral Spurring. Lateral humeral condyle overgrowth is identifiable on plain radiographs. Skak et al[32] reported that all patients had evidence of radiographic overgrowth of the injured distal humerus at the lateral and/or medial condyles after treatment. Pribaz et al[38] reported 73% of patients had evidence of lateral spurring, with 91% (87/96) of the patients treated with surgery and 59% treated conservatively. The occurrence of lateral spurring has been correlated with increased initial fracture displacement and treatment with ORIF using Kirschner wire fixation because it may be related to greater soft-tissue injury;[29] cannulated screw fixation potentially decreases the risk of lateral condyle overgrowth.[18,30] Lateral bony overgrowth can result in pseudocubitus varus deformity, which typically does not have any long-term sequelae[29] and requires no treatment.

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