Open reduction internal fixation of lateral humeral condyle fractures in children. A series of 105 fractures from a single institution

Comparison of radiological, clinical, and functional results of Jakob type 2 lateral condyle fractures treated with closed reduction and percutaneous pinning versus open reduction and K-wire fixation

Pediatric humerus lateral condyle fractures (PHLCF) are one of the most common fractures among children. PHLCF is approximately 20% of all pediatric elbow fractures. Among the treatment modalities are: nonoperative treatment with splinting, closed reduction with percutaneous K-wire fixation (CRPP), and open reduction with K-wire fixation (ORIF). We aimed to evaluate radiological, functional, and clinical outcomes of Jakob type 2 PHLCF treated either with CRPP or ORIF. We hypothesized that CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF. In this retrospective study, we included patients with Jakob type 2 PHLCF operatively treated in a single center. Patients with multiple fractures or open fractures were excluded from the study. 69 patients between ages 2 and 12 were included and they were divided into two groups. Group 1 included the patients treated with CRPP, whereas Group 2 included the patients treated with ORIF. Demographical, radiological, clinical, and functional parameters were evaluated. Average duration of surgery ( P  < 0.001), initial displacement ( P  = 0.014), and duration of admission ( P  < 0.001) were significantly less in group 1. Group 2 had significantly higher percentage of left-sided injury than group 1 ( P  = 0.038). Average varus deformity score was significantly higher in group 1 ( P  = 0.014). CRPP was associated with shorter duration of surgery and hospital stay. Functional, clinical, and radiological outcomes were identified similar between CRPP and ORIF for Jakob type 2 PHLCF. CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF.

Factors Affecting Lateral Overgrowth in Operatively Treated Lateral Condyle Fractures in Children

BACKGROUND

The most frequent sequelae of pediatric lateral condyle fractures is lateral condyle overgrowth (LCO). The purpose of our study was to investigate LCO in relation to age, quality of reduction, type of fixation, and fracture displacement.

METHODS

We retrospectively analyzed operatively treated lateral condyle fractures in children. The percent change in interepicondylar width (IEW) ((final - initial)/ initial x 100) was used to quantify LCO. IEW was measured from the medial and lateral epicondyles of the distal humerus, using the AP radiographs taken at admission (initial) and follow-up visits (final). The Song classification was used to classify fractures. Fixation was classified as pins, screws or both. The quality of reduction was defined as anatomic or nonanatomic (>2 mm of displacement). Patients were stratified into mild (0% to 10% overgrowth), moderate (10% to 20% overgrowth), and severe (>20% overgrowth) subgroups for further analysis.

RESULTS

Two hundred one patients were included in the study with an average time between initial and final radiograph measurements of 11.32 weeks. There was an average 11.84 %LCO. Using multivariable analysis, three variables demonstrated significant, independent associations with %LCO: age, race, and quality of reduction. Increasing age remained inversely associated with %LCO. Compared with White patients, Black and Asian patients had significantly greater %LCO. Patients with nonanatomic reductions had a significantly greater %LCO compared with anatomic reductions. When patients were stratified into mild, moderate, and severe groups, age in the mild group, nonanatomic reduction in the moderate group, and race in the severe group were found to be independently associated with increased %LCO using multivariable analysis.

CONCLUSIONS

The amount of LCO was found to be related to nonanatomic reduction, younger age, and Black and Asian race. Interestingly, it was not related to the amount of initial displacement or type of hardware used. To date, this is the largest study investigating LCO in surgically treated lateral condyle fractures.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Lateral Condyle Fracture of the Humerus in the Pediatric Age Group: A 10-Year Tertiary Center Experience

Objective Lateral humeral condyle fracture is a relatively common elbow injury among children, which often has a subtle presentation and a high risk of developing complications. This study aimed to discuss the epidemiology of such injury among children presenting to a tertiary hospital emergency room in Riyadh, Saudi Arabia. Other objectives included analyzing possible predictors and risk factors for developing complications in such patients, which will contribute to implementing preventive measures. Methodology This was a single-center, retrospective study conducted on data collected from patients presenting to the pediatric emergency department of a tertiary hospital in Riyadh, Saudi Arabia, from January 1, 2014, to July 2024. Patients under 18 years of age, with a minimum of six months of follow-up and complete data in our medical records, were included. A total of 77 patients were identified by convenience sampling; seven were excluded due to incomplete data or a follow-up period of less than six months. Where appropriate, statistical significance between variables was assessed using Fisher's exact test and Pearson's chi-square test. A P-value cutoff of 0.05 at a 95% confidence interval was used to determine statistical significance. Results This study reviewed 70 cases of lateral condyle fractures of the humerus. The mean age of the patients was 4.34 years, with 42 (60%) being under five years. The majority of patients (36, 51.4%) were male, and 42 (60%) sustained their injuries at home. Most patients (51, 72.78%) presented with types 2 and 3 displacements. Initial management for the majority of patients (52, 74.3%) was surgical. Of the entire sample, 40 (57%) patients had complications, with lateral condyle overgrowth being the most common, followed by cubitus varus and elbow stiffness. Females were found to present with significantly less displacement (P = 0.037). The degree of displacement was found to be a strong predictor of developing fracture nonunion (P = 0.0392) and lateral condyle overgrowth (P = 0.02). Conclusions Our study demonstrates that lateral condyle fractures are associated with a high rate of complications and that surgical intervention is often required for such injuries. A high index of suspicion and physician vigilance is essential, as this injury can be easily missed if it is not displaced. Prompt identification and management are crucial to reduce the risk of subsequent complications.

Ipsilateral Distal Both Bone Forearm and Lateral Humeral Condyle Fractures With Posterolateral Elbow Dislocation: A Rare Injury in a Child

Lateral humeral condyle fractures are common in children, but concomitant elbow dislocation is rare. This case report involves a 10-year-old girl with an ipsilateral distal both-bone forearm fracture and a lateral humeral condyle fracture accompanied by a posterolateral elbow dislocation. Closed reduction of the elbow was performed in the emergency department without delay, and the patient was operated on as soon as possible. Closed reduction percutaneous pinning (CRPP) was performed for the distal radius fracture. The Weiss type III lateral humeral condyle fracture was reduced through a lateral approach, and fixation was performed using divergent pinning with two Kirschner wires. K-wires were removed, and the motion was initiated postoperatively in the fourth week. The patient obtained favorable postoperative results and regained full range of motion in both the elbow and wrist. Any complications, such as nonunion, malunion, cubitus varus, or avascular necrosis, were not observed.

Less common than expected: late displacement after minimally displaced pediatric lateral condyle fractures of the elbow

The incidence of late displacement among pediatric lateral condyle fractures has been described as 1.3-26%. However, prior studies are limited by small cohort sizes. The aim of this study was to determine the rate of late displacement and delayed union among lateral condyle fractures following immobilization in a large cohort and to establish additional radiographic criteria to help surgeons choose between immobilization and operative fixation for minimally displaced fractures. We performed a dual-center retrospective study of patients with lateral condyle fractures between 1999 and 2020. Patient demographics, injury mechanism, time to orthopedic presentation, duration of cast immobilization, and complications following casting were recorded. There were 290 patients with lateral condyle fractures included. The initial management in 61% of patients (178/290) was nonoperative, of which four had delayed displacement at follow-up and two developed delayed union requiring surgery (failure in 6/178, 3.4%). The mean displacement on the anteroposterior view was 1.3 ± 1.1 mm and the lateral view was 0.50 ± 1.0 mm in the nonoperative cohort. In the operative cohort, the mean displacement on AP was 6.6 ± 5.4 mm and the lateral view was 5.3 ± 4.1 mm. Our analysis found the rate of late displacement in patients treated with immobilization was lower than previously reported (2.5%; 4/178). The mean displacement on the lateral film in the cast immobilization cohort was 0.5 mm, suggesting that necessitating near anatomic alignment on the lateral film to consider nonoperative management may lead to a lower incidence of late displacement than previously reported. Level of evidence: Level III, retrospective comparative study.

Closed reduction and percutaneous pinning for treatment of unstable lateral condyle fractures of the humerus in children

Objective

In the past, obviously displaced lateral condyle fractures of the humerus in children were treated satisfactorily with open reduction and internal fixation (ORIF). However, in recent years, more studies have mentioned closed reduction and percutaneous pinning (CRPP) of these fractures.

Methods

In this retrospective investigation, the radiographic and clinical results of patients with these fractures that were initially managed with CRPP were newly classified. We classified these fractures into three groups according to the degree and pattern of fracture displacement as identified on four radiographic images. In Type I, the fracture is unstable and displacement is ≥2 mm; In Type II degree I, the fracture is unstable and displacement is >2 mm, with single rotation of fragment; In Type II degree II, the fracture is unstable and displacement is >2 mm, with single rotation of fragment, with rotation of fragment and antero-proximal displacement; In Type III, the fracture is unstable and displacement is >2 mm, with posterior dislocation of elbow joint. We also designed an algorithm for closed reduction of these fractures according to this new classification.

Results

We retrospectively analyzed the radiographic and clinical results of 37 unstable fractures (in 22 boys and 15 girls) that were treated with closed reduction. Twenty-one of 25 (84.0%) type I fractures, which could have been reduced to within 2 mm of residual displacement, were treated with closed reduction and pinning with 2 or 3 Kirschner wires (K wires). Three of 5 (60.0%) type II degree I, 3 of 4 (75.0%) type II degree II, and 3 of 3 (100%) type III fractures were treated with CRPP. In 4 of 25 (16.0%) type I, 2 of 5 (40.0%) type II degree I and 1 of 4 (25.0%) type II degree II fractures, closed reduction failed, so ORIF was implemented. There were no complications, such as nonunion, osteonecrosis of the capitellum, superficial or deep infection, malunion, cubitus varus or valgus, or early physeal arrest.

Conclusion

Although the management of type III fractures may not be more difficult than type II fractures with a rotated fracture fragment, as elbow dislocations are usually easy reducible. This retrospective study showed that type III fractures should not be ignored as a lateral condyle fracture that can be cured with CRPP and that lateral humeral condyle fractures with obvious displacement and rotation can be initially treated with CRPP to achieve satisfactory recovery of the elbow. Kirschner wire (K wire) fixation is recommended to avoid reoperation or anesthesia for hardware removal.

Lateral Humeral Condyle Fractures in Pediatric Patients

Lateral humeral condyle fractures are frequently seen in pediatric patients and have a high risk of unfavorable outcomes. A fall on the outstretched arm with supination of the forearm is the most common trauma mechanism. A physical examination combined with additional imaging will confirm the diagnosis. Several classifications have been described to categorize these fractures based on location and comminution. Treatment options depend on the severity of the fracture and consist of immobilization in a cast, closed reduction with percutaneous fixation, and open reduction with fixation. These fractures can lead to notable complications such as lateral condyle overgrowth, surgical site infection, pin tract infections, stiffness resulting in decreased range of motion, cubitus valgus deformities, 'fishtail' deformities, malunion, non-union, avascular necrosis, and premature epiphyseal fusion. Adequate follow-up is therefore warranted.

Open reduction of pediatric lateral condyle fractures: a systematic review

INTRODUCTION

Lateral condyle fractures are the second most common pediatric elbow fracture. There exist multiple options for internal fixation including buried K-wires, unburied K-wires, and screw fixation. Our study aims to review the current literature and determine if fixation strategy affects outcomes to include fracture union, postoperative range of motion, and need subsequent surgery.

METHODS

A systematic review of Pubmed, MEDLINE, and EMBASE databases was performed. Included articles involve pediatric patients with displaced lateral condyle fractures treated with internal fixation that reported outcomes to include union rates and complications.

RESULTS

Thirteen studies met inclusion criteria for a total of 1299 patients (472 buried K-wires, 717 unburied K-wires, and 110 screws). The patients' average age was 5.8 ± 0.6 years, male (64%), and had 16.3 months of follow-up. No differences in union and infection rates were found. Unburied K-wires had the shortest time to union and the greatest elbow range of motion postoperatively.

CONCLUSIONS

Our systematic review demonstrates similar outcomes with union and infection rates between all fixation techniques. Unburied K-wires demonstrated a shorter time to union and the greatest postoperative range of motion. Additionally, unburied K-wires may be removed in clinic, decreasing the cost on the healthcare system.

EVIDENCE

Level 3.

Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures

Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.

Current Concepts in the Treatment of Lateral Condyle Fractures in Children

Lateral condyle fractures of the humerus are the second most common fracture about the elbow in children. The injury typically occurs as a result of a varus- or valgus-applied force to the forearm with the elbow in extension. Plain radiographs are sufficient in making the diagnosis; however, an elbow arthrogram permits optimal visualization of the articular surface in minimally displaced fractures. Traditionally, nonsurgical management is indicated for fractures with ≤2 mm of displacement and a congruent articular surface. Closed reduction and percutaneous pinning is performed for fractures with >2 mm of displacement with an intact cartilaginous hinge at the articular surface. Open reduction and internal fixation is often necessary for fractures with ≥4 mm of displacement or if there is articular incongruity. Complications include malunion, delayed presentation, fishtail deformity, lateral spurring, and growth arrest. Evolving management concepts include relative indications for surgical management, the optimal pin configuration, and the use of cannulated screw and bioresorbable fixation.

Incidence, Risk Factors, and Definition for Nonunion in Pediatric Lateral Condyle Fractures

INTRODUCTION

Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition.

METHODS

A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment.

RESULTS

A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union.

CONCLUSION

Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases.

LEVEL OF EVIDENCE

Level IV-retrospective case review.

Paediatric lateral humeral condylar fracture outcomes at twelve years follow-up as compared with age and sex matched paired controls

INTRODUCTION

Lateral humeral condylar fractures are the second most common elbow fractures in children. We present the long-term clinical and radiographic results.

MATERIAL AND METHODS

All children (<16 years) in the geographic catchment area with lateral condylar fracture were asked to participate and 32 (76.2%) patients enrolled. Clinical and functional results are compared with randomly selected but age and sex matched normal controls at 12.4 years (range 10.6 to 16.0).

RESULTS

Unsatisfactory clinical outcomes were found in 40.6% of the fracture cases vs. 6.3% controls (P = 0.003), according to Flynn's criteria. Flexion-extension range of motion was decreased >5° in 13 cases (40.6%) and in four controls (12.5%, P = 0.013). One in four (N = 8, 25%) of the cases showed cubitus varus >5° and 15.7% (N = 5) had cubitus valgus >5°, compared to one cubitus valgus (3.1%) in controls (P = 0.002).

CONCLUSION

The majority of the adolescent and young adult patients (59.4%) with a previous paediatric lateral humeral condylar fracture had recovered well and showed good or excellent overall outcomes according to Flynn's criteria for elbow assessment after a mean of 12.4 years post-injury. Long-term sequelae was unchanged regardless of treatment.

Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation for Type II Lateral Condyle Humerus Fractures in Children Displaced >2 mm

BACKGROUND

The optimal treatment for pediatric lateral condyle fractures displaced >2 mm, but with little joint displacement is unclear. The purpose of this study was to assess clinical and radiographic outcomes and complication rates of patients undergoing open reduction internal fixation (ORIF) versus closed reduction and percutaneous pin fixation (CRPP) of lateral condyle fractures with >2 mm of displacement and no obvious articular surface incongruity.

METHODS

A retrospective review of all children with acute lateral condyle fractures with 2.1 to 5.0 mm of displacement treated from 2006 to 2014 was performed. A total of 74 patients were treated who met inclusion criteria; 51 underwent ORIF and 23 underwent CRPP. No differences existed between the 2 groups with respect to age, sex, extremity, mechanism of injury, time to treatment, fracture displacement, or fracture classification. Charts and radiographs were reviewed and the following parameters were documented: operating room time, time to union, return to activities, magnitude of lateral spurring, and complications. Major complications were defined as those with presumptive long-term effects or requiring reoperation.

RESULTS

All fractures healed within 12 weeks of surgery, regardless of treatment type and no differences were observed in time to union between groups. OR time averaged 30 minutes faster for the CRPP group (P<0.001). Nearly 10% of patients in each group developed elbow stiffness, requiring formal therapy. The overall complication rates were 25% for the ORIF group and 13% for the CRPP group (P=0.36). No major complications were observed in the CRPP group, whereas 3 (6%) were observed in the ORIF group, including 1 case of avascular necrosis, 1 case of osteomyelitis with an associated premature physeal closure, and 1 refracture requiring surgery.

CONCLUSIONS

Surgical treatment of lateral condyle fractures displaced >2 mm, but with no significant articular surface incongruity has good outcomes with both CRPP and ORIF. CRPP, however, minimizes surgical time, avoids an incision and is thus our preferred treatment approach when joint congruity can be confirmed.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Screw versus pin fixation with open reduction of pediatric lateral condyle fractures

Good results have been described for lateral condyle fractures treated by open reduction and fixation using Kirschner wires or screws. We, in our level III retrospective comparison clinical research study, retrospectively reviewed 84 patients (43 K-wire, 41 screw fixation; average age 5.6 years, average follow-up 6.8 months). With K-wires there were three nonunions (average time to union 9.6 weeks). With screws, all fractures healed (average of 7.8 weeks). Screw fixation patients spent fewer days in a cast and had a greater range of motion at the last follow-up. Screw fixation is associated with fewer nonunions and faster time to union, but a secondary procedure for removal is required.

Buried versus unburied Kirschner wires in the management of paediatric lateral condyle elbow fractures: a comparative study from a tertiary centre

There is little consensus on whether Kirschner wire (K-wire) burial is preferable in the management of paediatric lateral humeral condyle fractures. We identified 124 patients from May 2008 to August 2014. Sixty received buried K-wires and 64 received unburied wires. We found no significant difference in the infection rates between groups, but a high rate of skin erosion (23%) in the buried group, with a subsequent high rate of infection in this subgroup (40%). We found a strong association of wire erosion following early surgery. There is a considerable cost saving associated with using unburied wires. We therefore recommend the routine use of unburied wires.