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 Open Reduction

A tourniquet placed on the upper arm is inflated before making the skin incision; the authors prefer a sterile tourniquet. An anterolateral incision, typically 3 to 4 cm in length, is made over the fracture site and extending toward the proximal radius. Typically after the skin and subcutaneous tissue dissection, an interval for deep dissection is already created as a result of a rent in the musculature that leads directly to the fracture site. If the fascia is intact, the interval of dissection may either be between the anconeus and extensor carpi ulnas (Kocher approach) or between the extensor digitorum communis and extensor carpi radialis brevis (Kaplan approach). As the fragment is exposed, posterior soft-tissue dissection should be avoided because the blood supply to the distal humerus can be disrupted, potentially leading to osteonecrosis of the fragment. Gentle elevation of the periosteum anteriorly to the most medial and distal extents of the fracture are necessary to ensure visualization and allow anatomic alignment of the joint line; aligning the fracture based on the metaphysis may be misleading because of unrecognized comminution or plastic deformation. The use of a headlight greatly improves visualization across the articular surface.

Reduction and Fixation

A reduction clamp may be useful to maintain reduction before fixation. If the fracture fragment is rotated, a Kirschner wire can be inserted as a joystick to help maneuver the fragment back into alignment. Additional Kirschner wires are then inserted to secure the reduction. The typical pin configuration, in our practice, is two divergent oblique wires combined with a third wire placed transversely from lateral to medial, as described earlier. We prefer, when possible, to place these percutaneously slightly posterior to the skin incision so that the pins, which are cut outside the skin, are not exiting through the incision site. Buried pins and cannulated screws may be placed through the incision or percutaneously away from the incision site. Regardless of the method of fixation, it is critical that fracture stability is achieved and confirmed by visualizing the fracture site and by performing a live fluoroscopic examination while manipulating the elbow.

Cannulated Screw Fixation

Cannulated screw fixation may also be used to stabilize lateral condyle fractures and has been shown to have a lower complication rate than Kirschner wire fixation in select situations.[18] Gilbert et al[21] described inserting a 4.0 or 4.5-mm cannulated screw through the nonarticular lateral portion of the lateral condyle. Screw fixation has some advantages over Kirschner wires, such as providing compression across the fracture and allowing for more anatomic repair of the periosteum. Subsequent surgery for implant removal is necessary in most cases,[19] a disadvantage compared with Kirschner wires that are left outside the skin and removed in the office setting.

processing....