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

Diagnostic Imaging

Plain Radiographs

Plain radiographs are primarily used to diagnose lateral condyle fractures. AP, internal oblique, and lateral elbow radiographs should be obtained[4] (Figure 1). The internal oblique view is essential in visualizing the fracture in the plane of the posterolaterally directed fracture line.[4] The greatest distance between the humerus and the fracture fragment on any of the radiographic views should be considered the amount of displacement.[4] Song et al[4] determined that 70% of the measured displacements on AP radiographs differed from internal oblique radiographs, but did report high intraobserver and interobserver reliability when comparing preoperative and postoperative AP and internal oblique radiographs.[4]

Figure 1.

Radiographs of (A) AP, (B) oblique, and (C) lateral views of a displaced lateral condyle fracture.

If displacement at the articular surface cannot be ascertained on radiographs, other imaging modalities can be used to further define displacement, especially in young children.

Arthrography

The distal humerus is cartilaginous in young children and therefore is not well visualized on plain radiographs. An arthrogram can be used to either help delineate characteristics of the fracture for a more accurate diagnosis or aid with fracture reduction of the articular surface intraoperatively[6] (Figure 2). This modality has become an important guide for intraoperative decision-making, especially when treating minimally displaced fractures with closed reduction and percutaneous pinning (CRPP).

Figure 2.

Radiographs of (A) AP and (B) internal oblique views of an arthrogram performed in a 3-year-old child with a lateral condyle fracture. Notice the dark line, the dye tracking along the fracture line that stops before reaching the articular surface, thus maintaining an intact cartilaginous hinge.

An arthrogram is performed by injecting contrast dye into the elbow joint[6] (Figure 3). Placed via a posterior or anterolateral injection site, a solution of equal parts of injectable saline and radiopaque dye is used. After injecting 2 to 3 cc, the elbow is brought through a ROM to disperse the dye. Inadvertent extravasation of dye and injection of a contrast volume greater than 3 to 5 cc may make delineation of the articular surface difficult. Interpretation of even an ideal elbow arthrogram may sometimes be challenging, especially for the inexperienced surgeon.

Figure 3.

Clinical photograph of the posterior entry point through the triceps into the olecranon fossa to perform an elbow arthrogram.

CT, MRI, and Ultrasonography

Conventional CT and multidetector CT, a refinement of the conventional CT scan that allows more rapid acquisition of images, are effective tools for evaluating pediatric lateral condyle fractures that do not require patient sedation and may allow for a more accurate determination of fracture displacement compared with plain radiographs.[7,8] MRI[9] and ultrasonography[10] can be used for minimally displaced lateral condyle fractures to assess the integrity of the cartilage surface when findings on plain radiographs are equivocal (Figure 4). Because MRI requires sedation and incurs an additional cost, this modality is not routinely used for evaluating lateral condyle fractures.[9] Ultrasonography is a noninvasive imaging modality that can help visualize fracture displacement in younger children and has mainly been reported in small case series.[10]

Figure 4.

Coronal MRI view of a lateral humeral condylar fracture with a disrupted cartilaginous hinge at the distal humeral joint line. The arrow points to the fracture line extending into the articular surface.

Arthroscopy

Arthroscopy can directly visualize the articular surface to provide a more precise diagnosis and treatment plan and can also be used to aid with fracture reduction.[11–13] Perez Carro et al[11] demonstrated that arthroscopically assisted reduction decreases soft-tissue destruction, total radiation exposure, and recovery time. Complications associated with elbow arthroscopy include fluid extravasation, compartment syndrome, deep infections, heterotopic ossification, and nerve injury.[11,12] The evidence supporting the use of arthroscopy is limited, and further investigation in a prospective or randomized setting is warranted.[11–13]

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