Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards, he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…
Epidemiology
This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.
History
The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain in the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.
Examination
Please have a look at our post on elbow examination for tips on how to fully assess a child’s elbow.
Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and, therefore, likely instability. Tenderness is typically limited to the lateral aspect, and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.
It is important to carefully examine the joints below and above the injured area. Don’t forget to examine the rest of the child for other injuries.
Remember to be suspicious of non-accidental injury in cases with inconsistencies in the history and injury type.
Investigations
AP and lateral X-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views, but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for details on this, see CRITOE). The ossification centres appear on X-rays in the order of Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at 8-12 years old and fuses at 12-14 years old.
The paediatric elbow is mainly cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.
The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.
The most commonly associated fractures are the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.
Lateral condyle fractures can be classified depending on their X-ray appearance.
Classification
There are several different classification methods, the most common of which are listed below.
| Milch Classification | |
| Type 1 | The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint |
| Type 2 | The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable. |
| Jakob Classification | ||
| Stage 1 | <2mm displacement, which indicates intact cartilaginous hinge | |
| Stage 2 | 2-4mm of displacement | |
| Stage 3 | >4mm displacement with rotation of the fragment |
Immediate treatment in the ED
Provide immediate, adequate analgesia to the child before any examination or investigation.
If the fracture is open, conservatively manage the wound and consider tetanus status and antibiotics.
Keep the child nil by mouth as they may need urgent surgery.
Treatment following imaging
Treatment depends on the degree of displacement of the fracture.
Due to the high complication rate of these fractures, all lateral condylar fractures should be referred to the on-call orthopaedic team while in the Emergency Department.
| Jakob classification | Treatment option | Follow up |
| Stage 1 (<2mm of displacement) | Conservative management with immobilisation with above elbow cast to 90 degrees. | Weekly imaging in fracture clinic with the cast in place for 4-6 weeks. |
| Stage 2 and 3 (> 2mm with or without rotation) | These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation. | 3-6 weeks in above-elbow cast and orthopaedic follow up. |
Areas of controversy
Serial radiographs are often recommended in conservative management for minimallly or undisplaced lateral condylar fractures. A systematic review by Tan et al. 2018 found that serial X-rays have no clinical significance. However, if the one-week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.
Potential complications
This fracture is associated with a high rate of complications, usually developing later during the healing process.
The reduction must be accurate. If there is malunion, the fragment does not adequately unite, or the epiphyseal plate is damaged, then complications may occur:
- Stiffness is the most common complication, usually fully resolving by 48 weeks.
- Delayed union occurs if the fracture has not healed after six weeks. This usually occurs if the fracture is visible at two weeks.
- Non-union is more likely when delayed union occurs.
- Cubitus valgus deformity occurs with lateral physeal growth arrest.
- Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
- Avascular necrosis may develop 1-3 years after the fracture.
Do not miss bits
Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed, as shown by Tan et al. 20181).
There is a high complication rate, so we mustn’t miss these fractures.
William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed four weeks later, and his joint mobility continues improving.
References
Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5
Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.
Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.
Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric
Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.
