Incidence, risk factors and outcomes of avascular necrosis occurring after humeral lateral condyle fractures

Pediatric Lateral Condyle Fractures With Elbow Dislocation: Revisiting the Song Classification of the Most Severe Injuries

INTRODUCTION

Lateral condyle fractures are the second most common pediatric elbow fracture and are at risk for malunion, nonunion or avascular necrosis. The Song or Jakob classification guides management and risk of complications. However, many lateral condyle fractures have accompanying bony or soft tissue injuries, including elbow dislocations, which are not represented in the current Song or Jakob classification systems. Little is known about the incidence and outcomes of these more complex injuries. The purpose of this study was to describe the largest known case series of these injuries and characterize the incidence and outcomes.

METHODS

Injury, presentation, treatment, and outcome data were retrospectively gathered on pediatric elbow fractures at a single center from November 2007 to October 2017.

RESULTS

Of 4607 pediatric elbow fractures, 492 were lateral condyle fractures, with 30 cases (6.1%) presenting with concomitant elbow dislocation. Predominantly affecting males (76.7%) with a median age of 6.9 years, these injuries often resulted from intermediate energy mechanisms. High rates of coincident neurovascular deficits (23%), skin tenting (13.3%), and polytrauma (13.3%) were observed. All cases were treated surgically, primarily within 24 hours, with no instances of AVN, nonunion, or fixation failure reported. Across the cohort, there were 2 (6.7%) pin tract infections, 2 cases required return to the operating room, and 12 (40.0)% patients requiring outpatient physical therapy for elbow stiffness.

CONCLUSIONS

Lateral condyle fractures with concomitant ulnohumeral dislocation are distinct and unstable injuries requiring prompt inpatient treatment. Current classification systems do not adequately address this fracture-dislocation combination, risking underdiagnosis and potentially delayed reduction of a dislocated elbow. We propose adding a "Song 6" or "Jakob 4" category to existing classifications to ensure these injuries are properly identified and managed. This amendment will improve clinical awareness, facilitate timely intervention, and optimize outcomes for pediatric patients with these complex fractures.

LEVEL OF EVIDENCE

IV.

Osteonecrosis: A disabling disease not to be ignored in asthma and atopic conditions

Osteonecrosis, also referred to as avascular necrosis, is a disease characterized by necrosis or death of a bone secondary to impairment in blood supply. The condition affects the epiphyseal ends of the bones such as the femur and the humerus, but it can also involve the metacarpal and metatarsal bones, the patella, the knee, the vertebrae, and the jaw. A plethora of inflammatory, autoimmune, hematological, thrombotic, and vascular diseases can lead to osteonecrosis. Corticosteroids are intimately linked to the development of osteonecrosis. The frequent use of systemic corticosteroids in patients with asthma, eczema, nasal polyposis, sinusitis, urticaria and angioedema, or anaphylaxis makes this disease of great relevance to the practicing allergist and pulmonologist. Untreated, bone necrosis leads to frustrated bone remodeling and angiogenesis, leading to subchondral fractures and collapse of the articular heads of the bones, and culminating in debilitating osteoarthritis, often requiring arthroplasty. Recent studies have shed light on the molecular mechanisms underlying osteonecrosis and on the role of glucocorticoids. The gold standard test in patients suspected of having the disease is magnetic resonance imaging scanning, with plain radiographs having a lower sensitivity and specificity. Early diagnosis and intervention are essential. The allergist should avoid the frequent use of glucocorticoids and consider early introduction of steroid-sparing alternatives for asthma or sinusitis. Smoking and alcohol ingestion need to be addressed, and the management of glucocorticoid-induced osteoporosis may be helpful. It is essential for allergists to familiarize themselves with the disease and its diagnosis and to consider early referral to an orthopedic surgeon for surgical intervention.

A meta-analysis of closed reduction percutaneous pinning and open reduction with pin fixation of pediatric humeral lateral condylar fracture

Objective

To compare the effectiveness and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation to treat the pediatric humeral lateral condylar fracture.

Methods

Studies comparing closed reduction percutaneous pinning vs. open reduction with pin fixation for treating pediatric lateral humeral condyle fractures were found by searching Pubmed, Embase, the Cochrane Library, and Web of Science databases, including randomized/non-randomized controlled, retrospective case-control, and prospective cohort studies. Furthermore, quality evaluation and data retrieval were conducted after the literature review. A meta-analysis was performed using RevMan 5.4 software to compare both groups' outcome measures.

Results

This Meta-analysis incorporated eight studies with 856 cases. The Meta-analysis found no significant difference in functional outcomes, superficial infection, deep infection, poor fracture union, avascular necrosis of the humeral capitulum, or lateral spur formation between groups. However, the status of unaesthetic scars in the closed reduction percutaneous pinning group was superior.

Conclusions

For pediatric humeral lateral condylar fracture surgical therapy, the efficacy and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation were not significantly different; closed reduction percutaneous pinning offered the benefit of eliminating unaesthetic scar. However, further high-quality research is required to verify the conclusions of this Meta-analysis.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023392451.

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.

Sequelae of childhood elbow fracture

Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.