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

Technique of Closed Reduction and Fixation

Reduction

Fracture reduction is achieved by flexing the elbow and applying traction to the forearm with a gentle varus force to the elbow. To hold the reduction, a valgus force is applied to the elbow with the forearm positioned in supination.[4] In our experience, fractures that are displaced but hinged at the joint line are most amenable to closed reduction, but displaced fractures with malrotation may also be successfully reduced in a closed manner in some cases.[4] Reduction may also be assisted by using a Kirschner wire as a joystick to manipulate the fragment. Fracture reduction is confirmed using fluoroscopy, often with an intraoperative arthrogram to better delineate the articular surface reduction. Once the reduction is confirmed, 0.062" Kirschner wires are inserted percutaneously to stabilize the fracture. Alternatively, a cannulated screw (3.0 to 4.5 mm based on the size of the elbow) may be placed through a small incision to achieve fixation.

Pin Configuration

The use of two parallel Kirschner wires placed perpendicular to the fracture line may allow for fracture displacement and sliding of the fragment laterally.[17] Therefore, two diverging pins with bicortical fixation are ideally inserted from the distal lateral portion of the fragment, with one traveling parallel to the joint line, and the second aimed approximately 60° vertically toward the proximal medial metaphysis of the humerus.[17] Kirschner wires may pass through the capitellum ossification center if necessary.[18] Some surgeons routinely use a third Kirschner wire, which increases fracture stability during axial loading and elbow rotation[17] (Figure 5).

Figure 5.

AP fluoroscopic view of an intraoperative elbow with one pin parallel to the joint line and two divergent bicortical pins.

Postoperative Care

The Kirschner wires are left in place for a minimum of 3 to 4 weeks after reduction. Evidence suggests leaving the Kirschner wires exposed is more cost effective because the wires can be removed in an outpatient setting, and there are less long-term complications despite the theoretical increased risk of infections with exposed pins.[19] A recent meta-analysis showed no significant differences between exposed versus buried Kirschner wires regarding infection rates, total complications, delayed union, or revision surgery rates.[20] Therefore, we prefer to leave the Kirschner wires exposed for easy removal in an office setting at 4 weeks after surgery; a cast is then reapplied for an additional 2 to 4 weeks depending on radiographic healing and resolution of fracture site tenderness.

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