FRACTURE LATERAL CONDYLE OF HUMURUS IN CHILDREN

Mechanism of injury and pathology

• fall on the hand with the elbow extended

and forced into varus.

• A large fragment, which includes the lateral condyle, breaks off and is pulled upon by the attached wrist extensors. (Sometimes there is a compression, rather than avulsion, mechanism of injury.)

• In severe injuries the elbow may dislocate posterolaterally; the condyle is ‘capsized’ by muscle pull and remains capsized while the elbow reduces spontaneously.

• Because the condylar epiphysis is largely cartilaginous, the bone fragment may look deceptively small on x ray

• The fracture is important for two reasons:

• (a) it may damage the growth plate

• (b) it always involves the joint.

Clinical features

• The elbow is swollen and deformed

• There is tenderness over the lateral condyle.

• Passive flexion of the

wrist (pulling on the extensors) may be painful

X RAY

• AP view

• Lateral view

• Oblique view must be included or else full extend of fracture may not be visualised.

CLASSIFICATION

• Milch

• Type I: A fracture lateral to the trochlea: the elbow joint is not involved and is stable.(SH type 2)

• Type II: A fracture through the middle of the trochlea: this injury is more common; the

elbow is unstable as the radius and ulna are

carried along with the fragment..

Contd.

• The fragment is often grossly displaced and

capsized, and it may carry with it a triangularpiece of the metaphysis. Remember that thefragment (partly cartilaginous) is much largerthan it seems on x ray.(SH Type 4)

Milch type 1 and type 2

treatment

• If there is no displacement the arm can besplinted in a backslab with the elbow flexed 90degrees, the forearm neutral and the wristextended (this position relaxes the extensormechanism which attaches to the fragment).However, it is essential to repeat the x-rayafter 5 days to make sure that the fracture hasnot displaced.The splint is removed after 2weeks and exercisesare encouraged.

• A displaced fracture requires accurate reduction and

internal fixation. If the fragment is only moderately

displaced (hinged), it may be possible to manipulate it

into position by extending the elbow and pressingupon the condyle, and then fixing the fragment with

percutaneous pins. If this fails, and for all separated

fractures, open reduction and internal fixation with

pins is required. The arm is immobilized in a cast; cast

and pins are removed after 3 or 4 weeks.

COMPLICATIONS

• Non-union and malunion: If the condyle is left capsized, non-union is inevitable; with growth the elbow becomes increasingly valgus, and ulnar nerve palsy is then likely to develop.

• Recurrent dislocation Occasionally condylardisplacement results in posterolateraldislocation of the elbow

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