Chapter 19: Lateral Condylar and Capitellar Fractures of the Distal Humerus

Jeffrey R. Sawyer, James H. Beaty

Chapter Outline

Introduction to Lateral Condylar Fractures of the Distal Humerus

All the physes of the distal humerus are vulnerable to injury, each with a distinct fracture pattern. Next to those of the distal radius, injuries to the distal humeral physes are the most common physeal injuries. The vulnerability of the various physes to injury is altered by age and injury mechanism.1,3 Fractures involving the total distal humeral physis may occur in neonates or within the first 2 to 3 years of life.13,49 Fractures involving the lateral condylar physis occur early, with the average age around 6 years.25,29,32,37 Fractures concerning the medial condylar physis are rare and occur most often in children 8 to 12 years of age (see Chapter 20 for medial condylar fractures).25,32,37 
The specific fracture patterns, incidence, and mechanism of injury are discussed in detail in the following sections dealing with these specific fractures. 

Fractures Involving the Lateral Condylar Physis

Assessment of the Fractures Involving Lateral Condylar Physis

Fractures involving the lateral condyle in the immature skeleton can either cross the physis or follow it for a short distance into the trochlear cartilage. Fractures of the lateral condylar physis, which are less common than supracondylar fractures, constitute 17% of distal humeral fractures. 
Fractures of the lateral condylar physis rarely are associated with injuries outside the elbow region27,30,45 and unlike supracondylar humeral fractures, fractures of the lateral condyle rarely are associated with neurovascular injuries. Within the elbow region, the associated injuries that uncommonly occur with this fracture include dislocation of the elbow (which may be a result of the injury to the lateral condylar physis rather than a separate injury), radial head fractures, and fractures of the olecranon, which are often greenstick fractures. Acute fractures involving only the articular capitellum are rare in skeletally immature patients but are serious injuries that need to be recognized and treated appropriately. 
The diagnosis of lateral condylar physeal injuries may be less obvious both clinically and on radiographs than that of supracondylar fractures (Fig. 19-1), especially if the fracture is minimally displaced. Oblique views of the distal humerus are very helpful in making accurate diagnosis and defining the extent of fracture displacement for treatment decisions. 
Figure 19-1
 
A: Injury film of a 7-year old with a nondisplaced fracture of the lateral condyle (small arrows). Attention was drawn to the location of the fracture because of extensive soft-tissue swelling on the lateral aspect (white arrows). B: Because of the extensive soft-tissue injury, there was little intrinsic stability, allowing the fracture to become displaced at 7 days (arrow).
A: Injury film of a 7-year old with a nondisplaced fracture of the lateral condyle (small arrows). Attention was drawn to the location of the fracture because of extensive soft-tissue swelling on the lateral aspect (white arrows). B: Because of the extensive soft-tissue injury, there was little intrinsic stability, allowing the fracture to become displaced at 7 days (arrow).
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Figure 19-1
A: Injury film of a 7-year old with a nondisplaced fracture of the lateral condyle (small arrows). Attention was drawn to the location of the fracture because of extensive soft-tissue swelling on the lateral aspect (white arrows). B: Because of the extensive soft-tissue injury, there was little intrinsic stability, allowing the fracture to become displaced at 7 days (arrow).
A: Injury film of a 7-year old with a nondisplaced fracture of the lateral condyle (small arrows). Attention was drawn to the location of the fracture because of extensive soft-tissue swelling on the lateral aspect (white arrows). B: Because of the extensive soft-tissue injury, there was little intrinsic stability, allowing the fracture to become displaced at 7 days (arrow).
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Mechanism of Injury

Two mechanisms have been suggested: “push-off” and “pull-off.” The pull-off or avulsion theory has more advocates than the push-off mechanism.33,72 In early studies,72 this injury was consistently produced in young cadavers by adducting the forearm with the elbow extended and the forearm supinated. The push-off mechanism has also been reproduced in cadavers by applying a sharp blow to the palm with the elbow flexed, causing the radial head to push off the lateral condyle. This push-off injury also can result from a direct blow to the olecranon. 
It is likely that both mechanisms can produce this injury. The more common type of fracture, which extends to the apex of the trochlea, probably is a result of avulsion forces on the condyle, with the olecranon's sharp articular surface serving to direct the force along the physeal line into the trochlea. When a child falls forward on his or her palm with the elbow flexed, the radial head is forced against the capitellum and may cause the less common physeal fracture that courses through the ossific nucleus of the capitellum. 

Signs and Symptoms

Compared with the marked distortion of the elbow that occurs with displaced supracondylar fractures, little distortion of the elbow, other than that produced by the fracture hematoma, may be present with lateral condylar fractures. The key to the clinical evaluation of this fracture is the location of soft-tissue swelling and pain concentrated over the lateral aspect of the distal humerus.41 Stage I displacement may produce only local tenderness at the condylar fracture site, which may be increased by flexing the wrist, placing the wrist extensors, which are attached to the fracture fragment, on stretch. The benign appearance of the elbow with some stage I displacements may account for the delay of parents seeking treatment for a child with a minimally displaced fracture. With stage II or III displacement, there often is a hematoma present laterally, and attempted manipulation may result in some local crepitus with motion of the lateral condylar fragment. This obviously would be associated with pain and should be avoided if there is a clear radiographic evidence of a fracture. 

Radiographic Findings

The radiographic appearance varies according to the fracture line's anatomic location and the displacement stage. In the AP view, the metaphyseal fragment or “flake” may be small and seemingly minimally displaced. The degree of displacement may be seen on the true lateral view. In determining whether the articular hinge is intact (i.e., stage I vs. stage II), the relationship of the proximal ulna to the distal humerus is evaluated for the presence of lateral translocation. Oblique views are especially helpful in patients in whom a stage I displacement is suspected but not evident on AP and lateral views. 
To determine the importance of the internal oblique view in the radiographic evaluation of nondisplaced or minimally displaced lateral condylar fractures, Song et al.66 compared the oblique view to standard AP views and found that the amount of displacement differed between the two views in 75% of children. They recommended routine use of an internal oblique view to evaluate the amount of fracture displacement and to assess stability if a lateral condylar fracture is suspected. 
Three groups of nondisplaced and minimally displaced fractures of the lateral condyle have been described and correlated with the risk of late displacement: stable fractures, fractures with an undefinable risk, and fractures with a high risk of later displacement (Table 19-1).19 Arthrography or MRI evaluation has been suggested to identify unstable fractures in the acute setting and to aid in preoperative planning for those with late displacement, delayed union, or malunion. Although not used with all fractures, MRI can be a very useful diagnostic aid to guiding treatment, especially with delayed unions. 
Table 19-1
Risk of Subsequent Displacement of Lateral Humeral Condylar Fractures Immobilized in a Cast
Fracture Type Description Risk Ratio 95% Confidence Interval
Group A (stable) No gap or small gap in radial or radiodorsal aspect of metaphyseal fracture; fracture could not be followed all the way to epiphyseal cartilage 0 0–5.52
Group B (undefinable risk) Same as Group A, but fracture could be clearly observed all the way to epiphyseal cartilage 0.17 6.56–33.65
Group C (high risk) Gap in fracture as wide, or almost as wide, medially as laterally 0.42 15.17–72.33
 

Modified from: Finnbogason T, Karlsson G, Lindberg L, et al. Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop. 1995; 15:442–425.

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A major diagnostic difficulty lies in differentiating a lateral condylar fracture from a fracture of the entire distal humeral physis. In a young child in whom the condyle is unossified, an arthrogram or MRI may be helpful (Figs. 19-2, 19-3, and 19-4).11,27 Ultrasonography, which often can avoid MRI sedation issues, can be used to identify transphyseal separations in young patients. 
Figure 19-2
Unossified lateral condyle.
 
A: AP view. A small ossific nucleus can barely be seen (arrow) in the swollen lateral soft tissues. B: An arthrogram shows the defect left by the displaced lateral condyle (closed arrow). The displaced condyle is outlined in the soft tissues (solid arrow). Note the large cartilaginous fragment that is not visible on radiograph.
A: AP view. A small ossific nucleus can barely be seen (arrow) in the swollen lateral soft tissues. B: An arthrogram shows the defect left by the displaced lateral condyle (closed arrow). The displaced condyle is outlined in the soft tissues (solid arrow). Note the large cartilaginous fragment that is not visible on radiograph.
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Figure 19-2
Unossified lateral condyle.
A: AP view. A small ossific nucleus can barely be seen (arrow) in the swollen lateral soft tissues. B: An arthrogram shows the defect left by the displaced lateral condyle (closed arrow). The displaced condyle is outlined in the soft tissues (solid arrow). Note the large cartilaginous fragment that is not visible on radiograph.
A: AP view. A small ossific nucleus can barely be seen (arrow) in the swollen lateral soft tissues. B: An arthrogram shows the defect left by the displaced lateral condyle (closed arrow). The displaced condyle is outlined in the soft tissues (solid arrow). Note the large cartilaginous fragment that is not visible on radiograph.
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Figure 19-3
Arthrogram of stage I fracture of the lateral condyle (large arrows).
 
Articular surface is intact with no displacement (small arrows).
Articular surface is intact with no displacement (small arrows).
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Figure 19-3
Arthrogram of stage I fracture of the lateral condyle (large arrows).
Articular surface is intact with no displacement (small arrows).
Articular surface is intact with no displacement (small arrows).
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Figure 19-4
 
A: Radiograph of what appears to be a stable type II fracture of the lateral condyle in a 10-year-old child. B: Gradient-echo MRI clearly shows that this is a fracture of the entire distal humeral physis.
A: Radiograph of what appears to be a stable type II fracture of the lateral condyle in a 10-year-old child. B: Gradient-echo MRI clearly shows that this is a fracture of the entire distal humeral physis.
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Figure 19-4
A: Radiograph of what appears to be a stable type II fracture of the lateral condyle in a 10-year-old child. B: Gradient-echo MRI clearly shows that this is a fracture of the entire distal humeral physis.
A: Radiograph of what appears to be a stable type II fracture of the lateral condyle in a 10-year-old child. B: Gradient-echo MRI clearly shows that this is a fracture of the entire distal humeral physis.
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In fractures of the entire distal humeral physis, the proximal radius and ulna usually are displaced posteromedially (Fig. 19-5A). The relationship of the lateral condylar ossification center to the proximal radius remains intact. In true fractures involving only the lateral condylar physis, the relationship of the condylar ossification center to the proximal radius is disrupted (Fig. 19-5B). In addition, displacement of the proximal radius and ulna is more likely to be lateral because of the loss of stability provided by the lateral crista of the distal humerus. 
Figure 19-5
 
A: Total distal humeral physeal fracture in a 2-year old. The lateral condyle (closed arrow) has remained in line with the proximal radius. The proximal radius, ulna, and lateral condyle have all shifted medially (open arrow). B: Displaced fracture of the lateral condyle in a 2-year old. The relationship of the lateral condyle (closed arrow) to the proximal radius is lost. Both the proximal radius and ulna (open arrow) have shifted slightly laterally.
A: Total distal humeral physeal fracture in a 2-year old. The lateral condyle (closed arrow) has remained in line with the proximal radius. The proximal radius, ulna, and lateral condyle have all shifted medially (open arrow). B: Displaced fracture of the lateral condyle in a 2-year old. The relationship of the lateral condyle (closed arrow) to the proximal radius is lost. Both the proximal radius and ulna (open arrow) have shifted slightly laterally.
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Figure 19-5
A: Total distal humeral physeal fracture in a 2-year old. The lateral condyle (closed arrow) has remained in line with the proximal radius. The proximal radius, ulna, and lateral condyle have all shifted medially (open arrow). B: Displaced fracture of the lateral condyle in a 2-year old. The relationship of the lateral condyle (closed arrow) to the proximal radius is lost. Both the proximal radius and ulna (open arrow) have shifted slightly laterally.
A: Total distal humeral physeal fracture in a 2-year old. The lateral condyle (closed arrow) has remained in line with the proximal radius. The proximal radius, ulna, and lateral condyle have all shifted medially (open arrow). B: Displaced fracture of the lateral condyle in a 2-year old. The relationship of the lateral condyle (closed arrow) to the proximal radius is lost. Both the proximal radius and ulna (open arrow) have shifted slightly laterally.
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Classification

Lateral condylar physeal fractures can be classified by either the fracture line's anatomic location or by the amount of displacement. 
Anatomic Location.
The Milch classification, based on whether or not the fracture extends through (type I) or around (type II) the capitellar ossific nucleus, is used infrequently because of its poor reliability and poor predictive value79 and is primarily of historic interest. Salter and Harris59 classified lateral condylar physeal injuries as a form of type IV injuries in their classification of physeal fractures. Because the fracture line starts in the metaphysis and then courses along the physeal cartilage, a lateral condylar humeral fracture has some of the characteristics of both type II and IV injuries. A true Salter–Harris type IV injury through the ossific nucleus of the lateral condyle is rare. Although lateral condylar fractures are similar to Salter–Harris type II and IV fractures, treatment guidelines follow those of a type IV injury: open reduction and internal fixation of displaced intra-articular fractures. The Salter–Harris classification is of little clinical use and is debatable as to the accuracy of terminology, because the fracture exits the joint in the not-yet-ossified cartilage of the trochlea. 
Stages of Displacement.
The amount of fracture displacement has been described by Jakob et al.33 in three stages (Fig. 19-6).75 In the first stage, the fracture is relatively nondisplaced, and the articular surface is intact (Fig. 19-6A, B). Because the trochlea is intact, there is no lateral shift of the olecranon. In the second stage, the fracture extends completely through the articular surface (Fig. 19-6C, D). This allows the proximal fragment to become more displaced and can allow lateral displacement of the olecranon. In the third stage, the condylar fragment is rotated and totally displaced laterally and proximally, which allows translocation of both the olecranon and the radial head (Fig. 19-6E, F). 
Figure 19-6
Stages of displacement.
 
A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
 
(A, C, E: Adapted from: Jakob R, Fowles JV, Rang M, et al. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br. 1975; 57(4):430–436.)
A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
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A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
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Figure 19-6
Stages of displacement.
A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
(A, C, E: Adapted from: Jakob R, Fowles JV, Rang M, et al. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br. 1975; 57(4):430–436.)
A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
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A, B: Stage I displacement—articular surface intact. C, D: Stage II displacement—articular surface disrupted. E, F: Stage III displacement—fragment rotated.
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Weiss et al.79 modified this classification based on fracture displacement and disruption of the cartilaginous hinge (Fig. 19-7). Type I fractures are displaced less than 2 mm; type II fractures are displaced more than 2 mm but have an intact cartilaginous hinge; and type III fractures are displaced more than 2 mm and do not have an intact cartilaginous hinge. In their series of 158 types II and III fractures, they found that all type II fractures had less than 4 mm of displacement on initial radiographs and all type III fractures had more than 4 mm of displacement. This classification was found to be predictive of complications, with both the major and minor complication rates correlating with fracture type. 
Figure 19-7
Classification of lateral humeral condylar fractures.
 
Type I, less than 2 mm of displacement; type II, 2 mm or more of displacement and congruity of the articular surface; type III, more than 2 mm of displacement and lack of articular congruity.
 
(Reprinted with permission from: Weiss JM, Graves S, Yang S, et al. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009; 29:602–605.)
Type I, less than 2 mm of displacement; type II, 2 mm or more of displacement and congruity of the articular surface; type III, more than 2 mm of displacement and lack of articular congruity.
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Figure 19-7
Classification of lateral humeral condylar fractures.
Type I, less than 2 mm of displacement; type II, 2 mm or more of displacement and congruity of the articular surface; type III, more than 2 mm of displacement and lack of articular congruity.
(Reprinted with permission from: Weiss JM, Graves S, Yang S, et al. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009; 29:602–605.)
Type I, less than 2 mm of displacement; type II, 2 mm or more of displacement and congruity of the articular surface; type III, more than 2 mm of displacement and lack of articular congruity.
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Soft-Tissue Injuries.
The fracture line usually begins in the posterolateral metaphysis, with a soft-tissue tear in the area between the origins of the extensor carpi radialis longus and the brachioradialis muscle. The extensor carpi radialis longus and brevis muscles remain attached to the distal fragment, along with the lateral collateral ligaments of the elbow. If there is much displacement, both the anterior and posterior aspects of the elbow capsule are usually torn. This soft-tissue injury, however, usually is localized to the lateral side and may help identify a minimally displaced fracture. More extensive soft-tissue swelling at the fracture site may indicate more severe soft-tissue injury,41,54 which may indicate that the fracture is unstable and prone to late displacement. 
Displacement of the Fracture and Elbow Joint.
The degree of displacement varies according to the magnitude of the force applied and whether the cartilaginous hinge of the articular surface remains intact.31 If the articular surface is intact, the resultant displacement of the condylar fragment is simply a lateral tilt hinging on the intact medial articular surface. If the fracture is complete, the fragment can be rotated and displaced in varying degrees; in the most severe fractures, rotation is almost full 180 degrees, so that the lateral condylar articular surface opposes the denuded metaphyseal fracture surface. In addition to this coronal rotation of the distal fragment, rotation can also occur in the horizontal plane.81 The lateral margin is carried posteriorly, and the medial portion of the distal fragment rotates anteriorly. 
Because the usual fracture line disrupts the lateral crista of the trochlea, the elbow joint may be unstable, creating the possibility of posterolateral subluxation of the proximal radius and ulna. Thus, the forearm rotates along the coronal plane into valgus, and there may also be lateral translocation of the lateral condyle with the radius and ulna (Fig. 19-8). This concept of lateral translocation is important in the late reconstruction of untreated fractures. 
Figure 19-8
Angular deformities.
 
A: Capitellar fracture. B: Fracture extending into the trochlea.
A: Capitellar fracture. B: Fracture extending into the trochlea.
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Figure 19-8
Angular deformities.
A: Capitellar fracture. B: Fracture extending into the trochlea.
A: Capitellar fracture. B: Fracture extending into the trochlea.
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In physeal fractures, where the fracture line traverses the lateral condylar epiphysis, the elbow remains reasonably stable because the trochlea remains intact. Total coronal rotation of the condylar fragment can occur with this injury. The axial deformity that results is pure valgus without translocation (Fig. 19-8). 
This posterolateral elbow instability with the lateral condylar physeal injury has led to a mistaken concept that this injury is associated with a primary dislocation of the elbow,12 which is rarely the case. The posterolateral instability of the elbow is usually a result of the injury, not a cause of it. The displacement of the joint is through the fracture.57 

Treatment Options for Lateral Condylar Fractures

Fractures involving the lateral condylar physis can be treated with immobilization alone, closed reduction and percutaneous pinning, or open surgical reduction depending on the degree of displacement and amount of instability. 

Nonoperative Treatment of Lateral Condylar Fractures

Immobilization

Minimally displaced fractures (<2 mm) are stable and have intact soft-tissue attachments that prevent displacement of the distal fragment. About 40% of lateral condylar physeal fractures are nondisplaced, are not at risk for late displacement, and can be treated with immobilization alone.33 If the fracture line is barely perceptible on the original radiographs, including internal oblique views (stage I displacement), the chance for subsequent displacement is low. Immobilization of nondisplaced or minimally displaced (less than 2 mm) fractures in a posterior splint or cast is adequate.4,5,7,10,69 Radiographs are obtained during the first 3 weeks after injury to ensure that rare late displacement does not occur (Table 19-2). 
 
Table 19-2
Lateral Condylar Fractures
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Table 19-2
Lateral Condylar Fractures
Nonoperative Treatment Following Successful Closed Reduction
Indications Relative Contraindications
Stable articular reduction <2 mm of displacement Inability to obtain acceptable reduction
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Operative Treatment of Lateral Condylar Fractures

Closed Reduction and Percutaneous Pinning

When a lateral condylar fracture is displaced more than 2 mm, closed or open reduction is required to restore anatomic alignment of the joint and physis. Several techniques have been described for initial closed reduction, with the recommended elbow position ranging from hyperflexion to full extension. However, clinical experience and experimental studies indicate that closed reduction is best achieved with the forearm supinated and the elbow extended. Placing a varus stress on the extended elbow allows easier manipulation of the fragment. Unfortunately, it is difficult to maintain reduction of a displaced lateral condylar fracture with closed techniques, and thus, closed reduction alone is not generally recommended for treating displaced lateral condylar fractures. 
Mintzer et al.46 advocated percutaneous reduction and fixation for unstable, moderately displaced lateral condylar fractures (Jakob type II). Standard closed reduction with thumb pressure on the fracture fragment, elbow flexion, forearm supination, and wrist dorsiflexion usually results in an aligned fracture. An alternative method that is quite reliable is to add percutaneous pin reduction from the lateral column. The smooth pins are then advanced across the fracture site to the opposite cortex to obtain stability.44,46 Anatomic alignment of the joint and fracture stability are confirmed by stress testing and arthrography. If a satisfactory reduction cannot be obtained, then reduction can be achieved and maintained by open reduction and internal fixation. 
Expected Outcomes of Percutaneous Reduction and Pinning.
Song et al.66 reported good results in 46 (73%) of 63 unstable lateral condylar fractures, 53 of which were treated with closed reduction and percutaneous pinning. They formulated a treatment algorithm based on a five-stage classification system that considered degree of displacement and fracture pattern (Figs. 19-9 and 19-10). Closed reduction was attempted in all fractures, regardless of the amount of displacement. If closed reduction was successful (n = 53), then percutaneous fixation was used. If closed reduction failed to achieve less than 2 mm of displacement, open reduction and internal fixation was performed (n = 10). These authors suggested that open reduction is not necessary for all lateral condylar fractures. They listed three elements as essential to obtaining good results with percutaneous reduction and pinning treatment: (1) accurate interpretation of the direction of fracture displacement (mainly posterolaterally, not purely laterally) and the amount of displacement of the fracture fragment, (2) routine intraoperative confirmation of the reduction on both AP and internal oblique radiographs, and (3) maintenance of the reduction with two parallel percutaneous, smooth Kirschner wires (K-wires). 
Figure 19-9
Stages of displacement of fractures of the lateral humeral condyle in children.
 
Stage I, stable fracture with 2 mm or less of displacement and fracture line limited to within the metaphysis. Stage II, indefinable fracture with 2 mm or less of displacement and fracture line extending to the epiphyseal articular cartilage; there is a lateral gap. Stage III, unstable fracture with 2 mm or less of displacement and a gap that is wide laterally as medially. Stage IV, unstable fracture with displacement of more than 2 mm. Stage V, unstable fracture with displacement of more than 2 mm with rotation.
 
(Reproduced with permission from: Song KS, Kang CH, Min BW, et al. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2008; 90:2673–2681.)
Stage I, stable fracture with 2 mm or less of displacement and fracture line limited to within the metaphysis. Stage II, indefinable fracture with 2 mm or less of displacement and fracture line extending to the epiphyseal articular cartilage; there is a lateral gap. Stage III, unstable fracture with 2 mm or less of displacement and a gap that is wide laterally as medially. Stage IV, unstable fracture with displacement of more than 2 mm. Stage V, unstable fracture with displacement of more than 2 mm with rotation.
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Figure 19-9
Stages of displacement of fractures of the lateral humeral condyle in children.
Stage I, stable fracture with 2 mm or less of displacement and fracture line limited to within the metaphysis. Stage II, indefinable fracture with 2 mm or less of displacement and fracture line extending to the epiphyseal articular cartilage; there is a lateral gap. Stage III, unstable fracture with 2 mm or less of displacement and a gap that is wide laterally as medially. Stage IV, unstable fracture with displacement of more than 2 mm. Stage V, unstable fracture with displacement of more than 2 mm with rotation.
(Reproduced with permission from: Song KS, Kang CH, Min BW, et al. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2008; 90:2673–2681.)
Stage I, stable fracture with 2 mm or less of displacement and fracture line limited to within the metaphysis. Stage II, indefinable fracture with 2 mm or less of displacement and fracture line extending to the epiphyseal articular cartilage; there is a lateral gap. Stage III, unstable fracture with 2 mm or less of displacement and a gap that is wide laterally as medially. Stage IV, unstable fracture with displacement of more than 2 mm. Stage V, unstable fracture with displacement of more than 2 mm with rotation.
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Figure 19-10
Treatment algorithm based on stage of fracture displacement described in Fig. 19-9.
 
(Reproduced with permission from Song KS, Kang CH, Min BW, et al. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2008; 90:2673–2681.)
(Reproduced with permission from 


Song KS,

Kang CH,

Min BW
, et al.
Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children.
J Bone Joint Surg Am.
2008;
90:2673–2681.)
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Figure 19-10
Treatment algorithm based on stage of fracture displacement described in Fig. 19-9.
(Reproduced with permission from Song KS, Kang CH, Min BW, et al. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2008; 90:2673–2681.)
(Reproduced with permission from 


Song KS,

Kang CH,

Min BW
, et al.
Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children.
J Bone Joint Surg Am.
2008;
90:2673–2681.)
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More recently, Song and Waters67 described closed percutaneous manipulation of 24 completely displaced and rotated fractures (Jakob type III) followed by percutaneous pinning. In this series, closed reduction was successful in 18 (75%). Excellent results were obtained in 17 of the 18 patients; one patient had a good result. It should be noted that this technique is technically difficult, and the authors admit that it has a difficult learning curve; these results have not yet been reproduced at any other institution (Table 19-3). 
 
Table 19-3
Lateral Condylar Fractures
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Table 19-3
Lateral Condylar Fractures
Closed Reduction Percutaneous Pinning
Indications Contraindications
Anatomic reduction with closed reduction Inability to obtain adequate reduction
Arthrographic confirmation of articular congruity Unstable fracture that cannot be maintained with percutaneous pins
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Open Reduction and Internal Fixation

Because of the risk of poor functional and aesthetic results with closed reduction methods in unstable fractures, open reduction has traditionally been the advocated treatment method for unstable and irreducible fractures with stage II and stage III displacement.9,10,12,29,33,34,44,47,58,63,68,75,80,84 About 60% of all fractures involving the lateral condylar physis are types II and III fractures.33,79 
Open reduction is performed through a lateral incision, usually under tourniquet control. There usually is a large hematoma just beneath the skin that requires superficial subcutaneous exposure for evacuation. the joint is exposed anteriorly through the fracture site, with care taken to preserve the soft-tissue attachments of the posterior extensor–supinator muscle origins. Extensive posterolateral soft-tissue dissection risks osteonecrosis of the condyle and so dissection is performed anteriorly with minimal soft-tissue stripping. Adequate visualization of the trochlea is required for an anatomic reduction of the joint. 
Most investigators recommend fixation with smooth K-wires in children or screws and/or plates in adolescents nearing skeletal maturity. A report from Germany showed better maintenance of reduction with the use of compressive (threaded) K-wires (“screw-wires”) than with standard K-wires.82 Use of compressive K-wires is not widespread, and further study is necessary to determine their efficacy and safety (Table 19-4). 
 
Table 19-4
Lateral Condylar Fractures
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Table 19-4
Lateral Condylar Fractures
Open Reduction Internal Fixation
Indications Contraindications
Type III fracture with articular malangulation and malrotation Able to obtain an adequate reduction and stabilize it with percutaneous reduction and pinning
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Expected Outcomes of Pin or Screw Internal Fixation.
Smooth pins are the most frequently used method of fragment fixation.7,22,33,69,75,80,84 The passage of a smooth wire through the physis does not result in any growth disturbance,18,40 which may be due to the fact that the cross-sectional area of the pins is small relative to the surface area of the physis and because only 20% of humeral growth occurs through the distal humeral physis. 
The pins should start in the metaphysis if the metaphyseal fragment is large enough and diverge as much as possible to enhance the stability of fixation. When there is only a small metaphyseal fragment, the pins can be safely placed across the physis. 
When adequate reduction and internal fixation are carried out within the first few days after the injury, the results are uniformly good. The key, however, is to be sure that the reduction of the joint is anatomic. Surgery alone does not ensure a good result unless an anatomic reduction is obtained and the fixation is secure enough to maintain the reduction. 
Early surgical intervention is essential, because organization of the clot with early fibrin development makes it difficult to achieve a reduction without extensive soft-tissue dissection in fractures that are treated late. The pins can be buried or left protruding through the skin with a low incidence of infection. Leaving pins buried requires a second operative procedure, even though it usually can be accomplished with a local anesthetic or outpatient sedation. A recent comparison of pins left outside or below the skin found that, while exposed pins had a slightly higher infection rate, buried pins had higher rates of pin migration, symptomatic implants, and protrusion through the skin and increased treatment cost.39 
Screw fixation has been used less frequently in children because of concerns about growth arrest. Sharma et al.60 reported painless, full range of elbow motion in 36 of 37 children who had displaced lateral condylar fractures fixed with partially threaded 4-mm AO cancellous screws. In a series of 62 patients, Li and Xu39 found lower rates of infection (0% vs. 17%), lateral prominence (13% vs. 37%), and loss of motion (6% vs. 30%) in patients treated with open reduction and fixation with cannulated screws compared to those treated with K-wires. Although the two groups were similar, the type of fixation was not randomized. 

Author's Preferred Treatment for Lateral Condylar Fractures

Immobilization

If the fracture is minimally displaced on all three radiographic views (i.e., the metaphyseal fragment is less than 2 mm from the proximal fragment on AP, lateral, and internal oblique views) and the clinical signs also indicate there is reasonable soft-tissue integrity, we immobilize the elbow in a long arm cast with the forearm in neutral rotation and the elbow flexed 60 to 90 degrees. Radiographs are taken within the first week after the fracture with the cast removed and the elbow extended. If there is no displacement, the radiographs are repeated once again during the next 1 to 2 weeks. Immobilization is continued until fracture union is apparent, usually between 4 and 6 weeks after injury. 
In some fractures with more than the allowable 2 mm of displacement (type II injury), the fracture pattern is such that the articular cartilage appears intact. If there is any question about the stability at the time of the fracture, MRI can be obtained or the extremity can be examined with the patient under general anesthesia. If examination is performed in the operating room, gentle varus stress views with the forearm supinated and the elbow extended should be taken to determine if the fracture displaces significantly. Intraoperative arthrography can also be used to determine the stability of the nonossified articular cartilage. Usually in these circumstances, percutaneous pins are placed to maintain articular alignment until healed. 

Percutaneous Pins

For fractures with stage II displacement (2 to 4 mm), reduction and percutaneous pin fixation are done because open reduction often is not necessary in these circumstances and closed reduction alone is too risky for redisplacement (Fig. 19-11). If there are concerns about reduction or stability after percutaneous pinning, varus stress radiography and elbow arthrography are performed. 
Figure 19-11
Stage II fracture of the lateral condyle.
 
A: AP radiograph shows 4 mm of displacement with fracture line extending to nonossified trochlea (arrow). B: Intraoperative fluoroscopic image after pinning shows intact articular surface.
A: AP radiograph shows 4 mm of displacement with fracture line extending to nonossified trochlea (arrow). B: Intraoperative fluoroscopic image after pinning shows intact articular surface.
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Figure 19-11
Stage II fracture of the lateral condyle.
A: AP radiograph shows 4 mm of displacement with fracture line extending to nonossified trochlea (arrow). B: Intraoperative fluoroscopic image after pinning shows intact articular surface.
A: AP radiograph shows 4 mm of displacement with fracture line extending to nonossified trochlea (arrow). B: Intraoperative fluoroscopic image after pinning shows intact articular surface.
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Open Reduction

If the fracture is completely displaced, malrotated, and/or grossly unstable (stage III), open reduction and internal fixation are indicated. We prefer open reduction and internal fixation of all fractures with stage III displacement. It is important that open reduction is performed within a few days after the injury. The standard lateral Kocher approach provides sufficient exposure of the fragment. Often, a tear in the aponeurosis of the brachioradialis muscle laterally leads directly to the fracture site. Extreme care must be taken to avoid dissection near the posterior portion of the fragment because this is the entrance of the blood supply of the lateral condylar epiphysis. 
A posterolateral approach has been recommended because of proposed advantages of excellent exposure with minimal dissection and improved cosmetic results because of more posterior placement of the surgical scar. This approach requires special care to avoid excessive dissection of the posterior soft-tissue attachments. 
The quality of the reduction is determined by evaluating the fracture line along the anterior aspect of the articular surfaces. This usually can be determined by direct observation. Often there is plastic deformation of the metaphyseal bone on the displaced fragment, and reduction based on this can result in joint incongruity. We prefer to use smooth parallel to slightly divergent K-wires just medial to the condylar fragment to maintain the reduction (Fig. 19-12). The wires penetrate the skin through a separate stab incision posterior to the main incision. A long arm cast is applied with the elbow flexed 90 degrees and the forearm in neutral or slight pronation. The cast and pins are removed in 4 weeks if there is adequate healing on radiographs. Early active motion is started at that time. If necessary, pin removal can be delayed 1 to 2 weeks to allow further healing in older children. 
Figure 19-12
Fixation of lateral condylar fracture with two smooth K-wires placed in divergent configuration.
Flynn-ch019-image012.png
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Technique of Open Reduction and Internal Fixation of Lateral Humeral Condylar Fractures

The elbow is exposed through a 5- to 6-cm lateral approach, placing two-thirds of the incision above the joint and one-third distal (Fig. 19-13). In the interval between the brachioradialis and the triceps, the dissection is carried down to the lateral humeral condyle. The joint's anterior surfaces are exposed by separating the fibers of the common extensor muscle mass. Soft-tissue detachment is limited to only that necessary to expose the fragment, the fracture, and the joint; the posterior soft tissues are left intact. With widely displaced fractures, these soft tissues often are already stripped and the surgeon can follow the fracture hematoma directly into the joint. Care must be taken to prevent injury to the distal humeral articular surface, which often is rotated into the wound. Retracting the antecubital structures exposes the anterior joint surface. A small metacarpal retractor can be passed across the joint to the opposite side, taking care to protect the ulnar nerve medially. The trochlea and fracture site are inspected. The displacement and the size of the fragment are always greater than is apparent on the radiographs because much of the fragment is cartilaginous. The fragment usually is rotated as well as displaced. The joint is irrigated to remove blood clots and debris, the articular surface and the metaphyseal fragment are reduced accurately, and the reduction is confirmed by observing the articular surface, particularly at the trochlea. The position is held with a small tenaculum, bone holder, towel clip, or percutaneous pins as “joysticks.” Two smooth K-wires are inserted in a parallel or slightly divergent configuration, across the physis, and into the humeral metaphysis, penetrating the medial cortex of the humerus. Occasionally a third lateral pin, more parallel to the joint surface, is used if greater stability is required. The reduction and the position of the internal fixation are checked by direct observation as well as by AP, lateral, and oblique radiographs before wound closure. The ends of the wires are cut off to allow easy removal. The arm is placed in a posterior splint or bivalved long arm cast with the elbow flexed 90 degrees. 
Figure 19-13
Lateral approach for open reduction and internal fixation of a lateral humeral condylar fracture of the left elbow.
 
The approach is made through the brachioradialis–triceps interval; an anterior retractor is used to expose the joint surface. Note the large unossified articular fragment.
The approach is made through the brachioradialis–triceps interval; an anterior retractor is used to expose the joint surface. Note the large unossified articular fragment.
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Figure 19-13
Lateral approach for open reduction and internal fixation of a lateral humeral condylar fracture of the left elbow.
The approach is made through the brachioradialis–triceps interval; an anterior retractor is used to expose the joint surface. Note the large unossified articular fragment.
The approach is made through the brachioradialis–triceps interval; an anterior retractor is used to expose the joint surface. Note the large unossified articular fragment.
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The cast is worn for 4 to 6 weeks after surgery until the fracture is healed. The pins can be removed at 4 to 6 weeks if union is progressing. Gentle active motion of the elbow usually is then resumed and continued until full range of motion returns. 

Complications

If an adequate reduction is obtained promptly and maintained with solid fixation, results are uniformly good. In supracondylar fractures, an incomplete reduction may result in an aesthetic deformity, but functional results are generally good. In contrast, with displaced fractures of the lateral condylar physis and joint surface, a marginal reduction can result in both aesthetic deformities and functional loss of motion.70 The complications that affect the outcome can be classified as either biologic or technical. Biologic problems occur as a result of the healing process, even if a perfect reduction is obtained. These problems include spur formation with pseudocubitus varus or a true cubitus varus. The technical aspects include failure to recognize a displaced fracture, immobilization treatment of an unstable fracture that displaces in a cast, internal fixation of a malreduced articular fracture fragment, and osteonecrosis due to extensive posterior soft-tissue dissection. 
Lateral Spur Formation
Lateral condylar spur formation is one of the most common sequelae after a fracture involving the lateral condylar physis.36,79 The spur occurs after both nonoperative and operative treatment. In a review of 175 patients, Koh et al.36 found overall rates of lateral spur formation of 77% radiographically and 22% clinically; the spurs persisted at a mean of 20 months after fracture. Spur formation was more frequent after displaced fractures (Jakob types II and III) and those treated with percutaneous pinning or open reduction and internal fixation than in those treated with cast immobilization. Pribaz et al.56 found a similar frequency of 73% development of lateral spurs in 212 consecutive lateral condylar fractures and also correlated spur development with the amount of initial displacement and with surgical treatment. 
After nonoperative treatment, lateral spurs result from the minimal displacement of the metaphyseal fragment and usually have a smooth outline. In patients with no real change in carrying angle, the lateral prominence of the spur may produce an appearance of mild cubitus varus (pseudovarus). In patients in whom a true cubitus varus develops, the presence of the lateral spur accentuates the varus alignment. The spur that occurs after operative treatment has a more irregular outline and is hypothesized to be the result of hypertrophic bone formation from open reduction and internal fixation (Fig. 19-14). During open reduction, care should be taken to limit the amount of dissection and to carefully replace the lateral periosteal flap of the metaphyseal fragment to lessen the amount of lateral spur. 
Figure 19-14
 
A: Considerable soft tissue dissection was performed in the process of open reduction of this lateral condylar fracture. B: At 2 months after surgery, there is a large irregular spur formation secondary to periosteal new bone formation from the extensive dissection.
 
(From: Wilkins KE. Residuals of elbow fractures. Orthop Clin N Am. 1990; 21:289–312, with permission.)
A: Considerable soft tissue dissection was performed in the process of open reduction of this lateral condylar fracture. B: At 2 months after surgery, there is a large irregular spur formation secondary to periosteal new bone formation from the extensive dissection.
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Figure 19-14
A: Considerable soft tissue dissection was performed in the process of open reduction of this lateral condylar fracture. B: At 2 months after surgery, there is a large irregular spur formation secondary to periosteal new bone formation from the extensive dissection.
(From: Wilkins KE. Residuals of elbow fractures. Orthop Clin N Am. 1990; 21:289–312, with permission.)
A: Considerable soft tissue dissection was performed in the process of open reduction of this lateral condylar fracture. B: At 2 months after surgery, there is a large irregular spur formation secondary to periosteal new bone formation from the extensive dissection.
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Before treatment of lateral condylar fractures, the parents should be told that either lateral overgrowth with mild cubitus varus or lateral spur with pseudovarus is very likely to develop, regardless of the treatment method. They should be told that this mild deformity usually is not of functional significance and often resolves over the next 1 to 2 years. 
Elbow Stiffness
Elbow stiffness can occur following lateral condylar fractures, but most patients regain full elbow range of motion within 4 to 6 months after cast removal.8,76 Bernthal et al.,8 in a study of 141 patients with lateral condylar fractures, found that at a mean of 29 weeks there was no difference in range of motion between surgically and nonsurgically treated patients; however, surgically treated patients took longer (up to 18 weeks) to regain their motion arc. They also found that increased patient age, length of immobilization, and need for surgical treatment were independently correlated with greater loss of motion at final follow-up. 
Cubitus Varus
Reviews of lateral condylar fractures show that a surprising number heal with some residual cubitus varus angulation (Fig. 19-15).23,30,44,48,58,62,64,74 In some series, the incidence of cubitus varus is as high as 40%,23,64 and the deformity seems to be as frequent after operative treatment as after nonoperative treatment.58,64 The exact cause is not completely understood. It can be due to an inadequate reduction, growth stimulation of the lateral condylar physis from the fracture insult, or a combination of both (Fig. 19-16).64 
Figure 19-15
Cubitus varus.
 
A: Follow-up radiograph of a boy whose lateral condylar fracture was treated nonoperatively and healed with a mild varus angulation. B: Clinical appearance of deformity (arrow).
A: Follow-up radiograph of a boy whose lateral condylar fracture was treated nonoperatively and healed with a mild varus angulation. B: Clinical appearance of deformity (arrow).
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Figure 19-15
Cubitus varus.
A: Follow-up radiograph of a boy whose lateral condylar fracture was treated nonoperatively and healed with a mild varus angulation. B: Clinical appearance of deformity (arrow).
A: Follow-up radiograph of a boy whose lateral condylar fracture was treated nonoperatively and healed with a mild varus angulation. B: Clinical appearance of deformity (arrow).
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Figure 19-16
True varus.
 
A: The injury film with a minimally displaced fracture (arrow). This 5-year-old child was treated with immobilization until the fracture was healed. B: Five years later, the patient had a persistent cubitus varus (arrow) that remained clinically apparent. The carrying angle of the uninjured right elbow measured 5 degrees of valgus; the injured elbow had 10 degrees of varus.
 
(From: Wilkins KE. Residuals of elbow trauma in children. Orthop Clin N Am. 1990; 21:289–312, with permission.)
A: The injury film with a minimally displaced fracture (arrow). This 5-year-old child was treated with immobilization until the fracture was healed. B: Five years later, the patient had a persistent cubitus varus (arrow) that remained clinically apparent. The carrying angle of the uninjured right elbow measured 5 degrees of valgus; the injured elbow had 10 degrees of varus.
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Figure 19-16
True varus.
A: The injury film with a minimally displaced fracture (arrow). This 5-year-old child was treated with immobilization until the fracture was healed. B: Five years later, the patient had a persistent cubitus varus (arrow) that remained clinically apparent. The carrying angle of the uninjured right elbow measured 5 degrees of valgus; the injured elbow had 10 degrees of varus.
(From: Wilkins KE. Residuals of elbow trauma in children. Orthop Clin N Am. 1990; 21:289–312, with permission.)
A: The injury film with a minimally displaced fracture (arrow). This 5-year-old child was treated with immobilization until the fracture was healed. B: Five years later, the patient had a persistent cubitus varus (arrow) that remained clinically apparent. The carrying angle of the uninjured right elbow measured 5 degrees of valgus; the injured elbow had 10 degrees of varus.
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The cubitus varus deformity rarely is severe enough to cause concern or require further treatment. This is probably because it is a pure coronal varus angulation rather than the horizontal anterior rotation along with the sagittal extension of the distal humerus that make the cubitus varus after supracondylar fractures a less acceptable deformity. Some investigators have noted that children with cubitus varus deformities can have pain, decreased range of motion, epicondylitis, and problems with sports such as sidearm pitching, swimming, judo, and push-ups. 
Cubitus Valgus
Cubitus valgus is much less common after united lateral condylar fractures than cubitus varus. It has rarely been reported to result from premature epiphysiodesis of the lateral condylar physis.75 As with cubitus varus, it usually is minimal and rarely of clinical or functional significance. If cubitus valgus is symptomatic, it can be treated with a medial closing wedge osteotomy or dome osteotomy and internal fixation or with osteotomy and gradual distraction through an external fixator.55 
The more difficult type of cubitus valgus associated with nonunions is discussed in the next section on nonunions. 

Delayed Union and Nonunion

Some of these fractures may go unrecognized or untreated for a prolonged period. Even in modern medical settings, elbow injuries may be treated as “sprains,” and the diagnosis of a displaced lateral condylar fracture is not made, especially in young children. Thus, patients can present weeks later with a delayed union or months or even years later with a nonunited or malunited fracture fragment. 
Delayed Union
Delayed union, in contrast to nonunion or malunion, occurs in a fracture in which the fracture fragments are in satisfactory position but union of the lateral condylar fragment to the metaphysis is delayed. Various reasons have been suggested for delayed union of lateral condylar fractures, including poor circulation to the metaphyseal fragment21 and bathing of the fracture site by articular fluid, which inhibits fibrin formation and subsequent callus formation.29 It is most likely that a combination of these two factors, in addition to the constant tension forces exerted by the extensor musculature arising from the condylar fragment, are responsible for delayed union. 
This complication is most common in patients treated nonoperatively. The symptoms and clinical examination determine the appropriate treatment. If on clinical examination the fragment is stable, the elbow is nontender, the range of elbow motion increases progressively, and the position of the fragment remains unchanged on radiographs, the fracture usually heals (Fig. 19-17). Lateral spur formation or cubitus varus is relatively common with these late healing fractures. The need for further treatment depends on the presence of significant symptoms, limited motion, or risk of further displacement that may disrupt the joint surface and cause functional impairment. If there is any question as to the integrity of the joint surface, an MRI or arthrogram may help determine any loss of continuity and the need for surgical treatment. 
Figure 19-17
Delayed union and cubitus varus.
 
A: Stage III lateral condylar fracture in a 7-year-old boy was treated in a cast. B: Seven months later, delayed union with malunion of the fracture and cubitus varus deformity was present.
A: Stage III lateral condylar fracture in a 7-year-old boy was treated in a cast. B: Seven months later, delayed union with malunion of the fracture and cubitus varus deformity was present.
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Figure 19-17
Delayed union and cubitus varus.
A: Stage III lateral condylar fracture in a 7-year-old boy was treated in a cast. B: Seven months later, delayed union with malunion of the fracture and cubitus varus deformity was present.
A: Stage III lateral condylar fracture in a 7-year-old boy was treated in a cast. B: Seven months later, delayed union with malunion of the fracture and cubitus varus deformity was present.
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Most minimally displaced fractures with no significant displacement of the condylar fragment will ultimately unite with long-term immobilization.20,29 Percutaneous pinning can expedite the healing. Screw fixation with bone grafting can be done if union appears unlikely by immobilization or pin fixation alone.34 
Controversy exists as to whether elbow function can be improved by a late open reduction and internal fixation of the nonunited, malaligned fracture fragment. Delayed open reduction (more than 3 weeks after injury) has a risk of osteonecrosis and further loss of elbow motion.14,33,69,85 Osteonecrosis of the fragment is believed to be due to the extensive soft-tissue dissection necessary to replace the fragment anatomically (Fig. 19-18), and a transarticular approach with olecranon osteotomy has been recommended to avoid this.10,83 The key to preventing osteonecrosis is to recognize the course of the blood supply to the lateral condyle. Only a small portion of the condyle is extra-articular, and the vessels that supply the lateral condylar epiphysis penetrate the condyle in a small posterior nonarticular area28 (Fig. 19-19). careful late open reduction through a lateral approach generally is recommended to prevent the complications of nonunion and/or malunion. 
Early (A) and long-term (B) follow-up.
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Figure 19-18
Osteonecrosis of the lateral condyle after lateral condylar fracture in a 10-year-old boy.
Early (A) and long-term (B) follow-up.
Early (A) and long-term (B) follow-up.
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Figure 19-19
Asymptomatic nonunion of a lateral condyle in a 19-year-old military recruit.
 
Because the patient had a completely normal and asymptomatic range of motion in his nondominant extremity, operative stabilization was not thought to be necessary.
Because the patient had a completely normal and asymptomatic range of motion in his nondominant extremity, operative stabilization was not thought to be necessary.
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Figure 19-19
Asymptomatic nonunion of a lateral condyle in a 19-year-old military recruit.
Because the patient had a completely normal and asymptomatic range of motion in his nondominant extremity, operative stabilization was not thought to be necessary.
Because the patient had a completely normal and asymptomatic range of motion in his nondominant extremity, operative stabilization was not thought to be necessary.
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Nonunion
True nonunion occurs in patients with progressive displacement of the fragment or late of initial treatment of a displaced fracture. The mobile fragment can be palpated, or the patient has weakness or pain in the elbow. If the fracture is displaced and is not united by 12 weeks, it is considered a nonunion.20 
Nonunion can occur with or without angular deformity. Many patients with nonunions and minimal fragment displacement have no angulation and remain relatively asymptomatic for many activities of daily living (Fig. 19-19). Weakness or symptoms can occur when the arm is used for high-performance activities. Because they are not significantly displaced, these fractures often can be stabilized with minimal extra-articular dissection using a combination of screw fixation and a laterally placed bone graft. 
Nonunion with subsequent fragment displacement is more common after nonfixation treatment of unstable fractures with stage II and III displacement. If the fragment is mobile, it tends to migrate proximally with a subsequent valgus elbow deformity. Nonunion can lead to a cubitus valgus deformity, which in turn, is associated with the development of a tardy ulnar nerve palsy. All of these nonunions have articular incongruity. 
Nonunion seems to occur when the distal fragment is displaced enough to allow the condylar fragment's cartilaginous articular surface to oppose the bony surface of the humeral metaphysis. In such a situation, union is impossible. Stable internal fixation with percutaneously placed pins or cannulated screws has been recommended for impending, minimally displaced nonunions.20,52 For late displaced nonunions, staged procedures have been described52: (1) ulnar nerve transposition and bone grafting and fixation in situ of the lateral condyle followed by (2) distal humeral osteotomy to correct angulation once the nonunion is healed and elbow range of motion is regained. 
The most common sequela of nonunion with displacement is the development of a progressive cubitus valgus deformity. The fragment migrates both proximally and laterally, giving not only an angular deformity but also lateral translocation of the proximal radius and ulna (Fig. 19-20). Lateral translocation is not as likely to develop in the more lateral type of these fractures because the lateral crista of the trochlea is intact (Fig. 19-21). 
Figure 19-20
 
A: A 10-year-old boy with cubitus valgus resulting from a fracture of the lateral condylar physis with nonunion. B: Nonunion with cubitus valgus. Radiograph showing both angulation and translocation secondary to nonunion of the condylar fragment.
A: A 10-year-old boy with cubitus valgus resulting from a fracture of the lateral condylar physis with nonunion. B: Nonunion with cubitus valgus. Radiograph showing both angulation and translocation secondary to nonunion of the condylar fragment.
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Figure 19-20
A: A 10-year-old boy with cubitus valgus resulting from a fracture of the lateral condylar physis with nonunion. B: Nonunion with cubitus valgus. Radiograph showing both angulation and translocation secondary to nonunion of the condylar fragment.
A: A 10-year-old boy with cubitus valgus resulting from a fracture of the lateral condylar physis with nonunion. B: Nonunion with cubitus valgus. Radiograph showing both angulation and translocation secondary to nonunion of the condylar fragment.
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Figure 19-21
Nonunion without translocation.
 
Despite nonunion, elbow stability was maintained because the lateral crista of the trochlea had remained intact (arrow). Valgus angulation also developed.
Despite nonunion, elbow stability was maintained because the lateral crista of the trochlea had remained intact (arrow). Valgus angulation also developed.
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Figure 19-21
Nonunion without translocation.
Despite nonunion, elbow stability was maintained because the lateral crista of the trochlea had remained intact (arrow). Valgus angulation also developed.
Despite nonunion, elbow stability was maintained because the lateral crista of the trochlea had remained intact (arrow). Valgus angulation also developed.
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Surgical treatment of the nonunion deformity of the lateral condylar fragment is difficult and requires correcting two problems. First, articular cartilage may be opposing the distal humeral metaphysis, and union seldom can be obtained without mobilizing the fragments and applying an internal compressive device. The second problem is correcting the angular deformity (Fig. 19-22). 
Figure 19-22
With fracture through the capitellum sparing the trochlea, an angular deformity can be corrected with a closing wedge osteotomy.
 
(Adapted and reprinted with permission from: Milch HE. Fractures and fracture-dislocations of the humeral condyles. J Trauma. 1964; 4:592–607.)
(Adapted and reprinted with permission from: 


Milch HE
.
Fractures and fracture-dislocations of the humeral condyles.
J Trauma.
1964;
4:592–607.)
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Figure 19-22
With fracture through the capitellum sparing the trochlea, an angular deformity can be corrected with a closing wedge osteotomy.
(Adapted and reprinted with permission from: Milch HE. Fractures and fracture-dislocations of the humeral condyles. J Trauma. 1964; 4:592–607.)
(Adapted and reprinted with permission from: 


Milch HE
.
Fractures and fracture-dislocations of the humeral condyles.
J Trauma.
1964;
4:592–607.)
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X
To prevent progression of cubitus valgus deformity and subsequent ulnar nerve dysfunction, Shimada et al.61 recommended osteosynthesis for nonunion of lateral humeral condylar fractures in children because union is easily achieved, the range of motion is maintained, ulnar nerve function remains intact, and remodeling of the articular surfaces can be expected. They noted that bone grafting is essential to bridge the defect, to obtain congruity of the joint and to promote union; damage to the blood supply should be avoided to prevent osteonecrosis. To avoid the development of osteonecrosis after delayed (1 to 3 weeks) open reduction and internal fixation of acute fractures, Wattenbarger et al.78 accepted malreduction rather than stripping the soft tissue off the lateral condylar fragment to achieve a more anatomic reduction. For fractures with more than 1 cm of displacement, the position of the fragment often was improved very little by surgery, but all fractures were united, alignment of the arm was good, and no child had developed osteonecrosis at an average 6-year follow-up. 
Tien et al.73 described a technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal humerus through a single posterior incision. They recommended this procedure for minimally displaced, established lateral condylar nonunions with a cubitus valgus deformity of 20 degrees or more, especially when the deformity is progressing, is complicated by a concurrent ulnar neuropathy, or is in patients with elbow instability or elbow pain during sports activities. They listed as a contraindication to the procedure a lateral condylar nonunion associated with radiographic evidence of prominent displacement and rotation. In situ fixation of the nonunion is recommended because the extensive soft-tissue stripping required for mobilization and reduction of the fracture fragments results in devascularization of the fragment, which can cause osteonecrosis, loss of motion, and persistent nonunion. 

Author's Preferred Treatment of Lateral Condylar Nonunions

We distinguish between fractures seen late (more than 7 to 14 days after injury) and established nonunions (usually from 3 months to several years after injury). In all late presenting fractures, we strive to obtain fracture union without loss of elbow motion and perhaps avoiding osteonecrosis of the lateral condyle through a careful open reduction and internal fixation. 
Treating an established nonunion of a lateral humeral condylar fracture poses a more difficult dilemma. If no treatment is rendered, a progressive cubitus valgus deformity may occur with growth. Patients usually are asymptomatic initially, except for those with high-demand athletic or labor activities. A mild flexion contracture of the elbow is present, but the cubitus valgus deformity initially can be more aesthetic than functional. The danger in this approach is failure to recognize that late deformity and tardy ulnar nerve palsy can occur. If surgery is performed for an established nonunion, the potential risks of osteonecrosis and loss of elbow motion must be carefully considered. 
We believe the criteria outlined by Flynn et al.20,21 are helpful in determining if surgical treatment is appropriate for an established nonunion: 
  •  
    A large metaphyseal fragment
  •  
    Displacement of less than 1 cm from the joint surface
  •  
    An open, viable lateral condylar physis
It is also helpful to distinguish between three distinct clinical situations. First, for an established nonunion with a large metaphyseal fragment, minimal migration, and an open lateral condylar physis, we recommend modified open reduction, screw fixation, and a lateral extra-articular bone graft. This technique is markedly different from the surgical treatment of an acute lateral condylar fracture. The metaphyseal fragment of the lateral condyle and the distal humeral metaphysis are exposed, but no attempt is made to anatomically realign the articular surface. Intra-articular dissection and posterior dissection should be avoided to help prevent osteonecrosis and any further loss of elbow motion. The metaphyseal fragments are débrided by gently removing any interposed fibrous tissue. The lateral condylar fragment usually can be moved distally a small distance for improved apposition and alignment. The metaphyseal fragments are firmly apposed, and a screw is used to fix the fragments with interfragmentary compression. Bone graft can be placed between the metaphyseal fragments before compression and then laterally after fixation. The elbow is immobilized in 80 to 90 degrees of flexion until motion is no longer a risk for displacement (Fig. 19-23). 
Figure 19-23
 
A: Established nonunion with a large metaphyseal fragment. B: After fixation with a cancellous screw and bone grafting of the metaphyseal fragment.
A: Established nonunion with a large metaphyseal fragment. B: After fixation with a cancellous screw and bone grafting of the metaphyseal fragment.
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Figure 19-23
A: Established nonunion with a large metaphyseal fragment. B: After fixation with a cancellous screw and bone grafting of the metaphyseal fragment.
A: Established nonunion with a large metaphyseal fragment. B: After fixation with a cancellous screw and bone grafting of the metaphyseal fragment.
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Second, in patients with a nonunion who have aesthetic concerns because of their malalignment but no functional complaints, treatment is similar to that for cubitus varus deformity after a supracondylar humeral fracture. If the patient and family desire, a supracondylar osteotomy can be performed.43 Rigid internal fixation should be used if possible to allow early motion. 
Third, patients with asymptomatic nonunion, cubitus valgus deformity, and symptomatic tardy ulnar nerve palsy can be treated with anterior transposition of the ulnar nerve. However, isolated ulnar nerve transposition rarely is done alone and usually is done in conjunction with corrective osteotomy. 

Growth Disturbance: Fishtail Deformity

Two types of “fishtail deformity” of the distal humerus may occur. The first is more common and is a sharp-angled wedge (Fig. 19-24). It is believed that this type of malformation is caused by persistence of a gap between the lateral condylar physis ossification center and the medial ossification of the trochlea.75,80 Because of this gap, the lateral crista of the trochlea may be underdeveloped, which may represent a small “bony bar” in the distal humeral physis.30 Thus, this may be both an articular malunion and minor growth disturbance problem. Despite some reports of loss of elbow motion and functional pain with this type of fishtail deformity,50,75 most investigators4,7,14,23 have not found this type of radiographic deformity to cause major functional deficiencies. Arthroscopic debridement of the articular flap has been used in symptomatic individuals.77 
Figure 19-24
An angular “fishtail” deformity that persisted in this 14-year-old boy after operative treatment of a lateral condylar fracture, which occurred 6 years previously.
Flynn-ch019-image024.png
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The second type of fishtail deformity is a gentler, smooth curve. It is believed to be associated with osteonecrosis or larger growth arrest of the lateral part of the medial crista of the trochlea.48 The mechanisms of the development of this type of deformity are discussed in the section on osteonecrosis of the trochlea (Chapters 1720). 

Neurologic Complications

Neurologic complications can be divided into two categories: acute nerve problems at the time of the injury and/or treatment and delayed neuropathy involving the ulnar nerve (the so-called tardy ulnar nerve palsy). 

Acute Nerve Injuries

Reports of acute nerve injuries associated with this injury are rare. McDonnell and Wilson44 reported a case of transient radial nerve paralysis after an acute injury. Smith and Joyce,63 reported two patients with posterior interosseous nerve injury after open reductions of the lateral condylar fragment, both of whom recovered spontaneously. 

Tardy Ulnar Nerve Palsy

Tardy ulnar nerve palsy as a late complication of fractures of the lateral condylar physis is well known, especially after the development of cubitus valgus from malunion or nonunion of fractures of the lateral condylar physis.26 The symptoms usually are gradual in onset. Motor loss occurs first, with sensory changes developing somewhat later.26 In Gay and Love's26 series of 100 patients, the average interval of onset was 22 years. 
Various treatment methods have been advocated, ranging from anterior transposition of the ulnar nerve (originally the most commonly used procedure) to simple in situ decompression of the cubital tunnel. We prefer subcutaneous anterior transposition of the nerve. As noted in the nonunion section, there are times when the nerve surgery is part of a more extensive reconstruction. 

Physeal Arrest

Physeal arrest may merely be premature fusion of the various secondary ossification centers with little or no deformity. Because only 20% of humeral growth occurs in the distal physis, physeal arrest seldom causes any clinically significant angular or length deformities. 

Malunion

If not properly reduced and stabilized, the fragment can unite in an undesirable position. Cubitus valgus has been reported to occur as a result of malunion of the fracture fragments.75 Malunion can result in the development of a bifid lateral condyle that may not be symptomatic if the malalignment is minor (Fig. 19-25). Late osteotomy is complicated but can improve the situation if there is marked articular malalignment, loss of motion, and pain.6 
Figure 19-25
 
A: Injury film of a 7-year old who sustained a fracture of the capitellum that spared the trochlea and was treated with cast immobilization alone. B: Radiograph taken 2 years later showed complete fusion of the condylar epiphysis to the metaphysis, with the development of a “bifid” condyle.
A: Injury film of a 7-year old who sustained a fracture of the capitellum that spared the trochlea and was treated with cast immobilization alone. B: Radiograph taken 2 years later showed complete fusion of the condylar epiphysis to the metaphysis, with the development of a “bifid” condyle.
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Figure 19-25
A: Injury film of a 7-year old who sustained a fracture of the capitellum that spared the trochlea and was treated with cast immobilization alone. B: Radiograph taken 2 years later showed complete fusion of the condylar epiphysis to the metaphysis, with the development of a “bifid” condyle.
A: Injury film of a 7-year old who sustained a fracture of the capitellum that spared the trochlea and was treated with cast immobilization alone. B: Radiograph taken 2 years later showed complete fusion of the condylar epiphysis to the metaphysis, with the development of a “bifid” condyle.
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Osteonecrosis

Osteonecrosis of the condylar fragment may be iatrogenic and is most commonly associated with the extensive dissection necessary to effect a late reduction or from loss of the blood supply at the time of injury.29,33,44 Partial osteonecrosis has been described in an essentially nondisplaced fracture of the lateral condylar physis that had a radiographic appearance and clinical course similar to those of osteochondritis dissecans.80 Osteonecrosis is rare in fractures of the lateral condylar physis that receive little or no initial treatment and result in nonunion.33,81 
Overly vigorous dissection of fresh fractures can result in osteonecrosis of either the lateral condylar ossification center23,53 or, rarely, the metaphyseal portion of the fragment, leading to nonunion (Fig. 19-26). If the fracture unites, osteonecrosis of the lateral condyle reossifies over many years, much like Legg–Calvé–Perthes disease in the hip. Residual deformity can result in loss of motion, deformity, and/or pain. 
Figure 19-26
Osteonecrosis and nonunion developed in this child after extensive dissection and difficulty in obtaining a primary open reduction.
 
A: Injury film. B: Two years later, there was extensive bone loss in the metaphysis and a nonunion of the condyle.
A: Injury film. B: Two years later, there was extensive bone loss in the metaphysis and a nonunion of the condyle.
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Figure 19-26
Osteonecrosis and nonunion developed in this child after extensive dissection and difficulty in obtaining a primary open reduction.
A: Injury film. B: Two years later, there was extensive bone loss in the metaphysis and a nonunion of the condyle.
A: Injury film. B: Two years later, there was extensive bone loss in the metaphysis and a nonunion of the condyle.
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Ipsilateral Injuries

Fractures of the lateral condyle have been associated with elbow dislocations,10 ulnar shaft fractures,45 and fractures of the medial epicondyle. A lateral condylar fracture may be misdiagnosed as an elbow dislocation. Loss of the lateral crista can make the elbow unstable and allow the proximal radius or ulna to translocate laterally. This is a part of a normal pathologic condition associated with completely displaced lateral condylar fractures. In a true elbow dislocation, the proximal radius and ulna are displaced not only medially or laterally but also proximally (Fig. 19-27). 
Figure 19-27
Ipsilateral injury.
 
A: AP radiograph of an 8-year-old boy with a true posteromedial elbow dislocation (open arrow) and a lateral condylar fracture. B: A small fracture of the coronoid process of the ulna (closed arrow) confirms the primary nature of the elbow dislocation on the lateral radiograph.
A: AP radiograph of an 8-year-old boy with a true posteromedial elbow dislocation (open arrow) and a lateral condylar fracture. B: A small fracture of the coronoid process of the ulna (closed arrow) confirms the primary nature of the elbow dislocation on the lateral radiograph.
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Figure 19-27
Ipsilateral injury.
A: AP radiograph of an 8-year-old boy with a true posteromedial elbow dislocation (open arrow) and a lateral condylar fracture. B: A small fracture of the coronoid process of the ulna (closed arrow) confirms the primary nature of the elbow dislocation on the lateral radiograph.
A: AP radiograph of an 8-year-old boy with a true posteromedial elbow dislocation (open arrow) and a lateral condylar fracture. B: A small fracture of the coronoid process of the ulna (closed arrow) confirms the primary nature of the elbow dislocation on the lateral radiograph.
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Fractures of the Capitellum

Fractures of the capitellum involve only the true articular surface of the lateral condyle. This includes, in some instances, the articular surface of the lateral crista of the trochlea. Generally, this fragment comes from the anterior portion of the distal articular surface. These fractures are rare in children. In their review of 2,000 elbow fractures in children, Marion and Faysse42 found only one fracture of the capitellum. Since then, this fracture has been frequently reported in older adolescents.24,35,40,42,51 Although verified fractures of the capitellum have not been described in children under 12 years of age, there have been two reports2,15 of so-called anterior sleeve fractures of the lateral condyles, both in 8-year olds (Fig. 19-28). These fractures involved a good portion of the anterior articular surface, although technically they could not be classified as pure capitellar fractures because they contained nonarticular epicondylar and metaphyseal portions in the fragment. 
Figure 19-28
Fracture of the capitellum.
 
A: Osteochondral fracture of the capitellum in an 8-year-old girl. Note the small fleck of bone (arrows), which indicates possible osteochondral fragment. B: Healed fracture with articular congruity, restoration of cartilage space, and no osteonecrosis.
 
(From: Drvaric DM, Rooks MD. Case report. Anterior sleeve fracture of the capitellum. J Orthop Trauma. 1990; 4:188–192, with permission.)
A: Osteochondral fracture of the capitellum in an 8-year-old girl. Note the small fleck of bone (arrows), which indicates possible osteochondral fragment. B: Healed fracture with articular congruity, restoration of cartilage space, and no osteonecrosis.
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Figure 19-28
Fracture of the capitellum.
A: Osteochondral fracture of the capitellum in an 8-year-old girl. Note the small fleck of bone (arrows), which indicates possible osteochondral fragment. B: Healed fracture with articular congruity, restoration of cartilage space, and no osteonecrosis.
(From: Drvaric DM, Rooks MD. Case report. Anterior sleeve fracture of the capitellum. J Orthop Trauma. 1990; 4:188–192, with permission.)
A: Osteochondral fracture of the capitellum in an 8-year-old girl. Note the small fleck of bone (arrows), which indicates possible osteochondral fragment. B: Healed fracture with articular congruity, restoration of cartilage space, and no osteonecrosis.
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This fracture often is difficult to diagnose because there is little ossified tissue. It is composed mainly of pure articular surface from the capitellum and essentially nonossified cartilage from the secondary ossification center of the lateral condyle. 

Classification of Capitellar Fractures

Two fracture patterns have been described. The first is the more common Hahn–Steinthal type,71 which usually contains a rather large portion of cancellous bone of the lateral condyle. The lateral crista of the trochlea is also often included (Fig. 19-29). The second, or Kocher–Lorenz, type is more of a pure articular fracture with little if any subchondral bone attached and may represent a piece of articular cartilage from an underlying osteochondritis dissecans. This type of fracture is rare in children.2,65 
Figure 19-29
Fracture of the capitellum in a 13-year-old girl.
 
A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows).
A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows).
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Figure 19-29
Fracture of the capitellum in a 13-year-old girl.
A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows).
A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows).
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Assessment of Capitellar Fractures

The most commonly accepted mechanism is shearing of the anterior articular surface of the lateral condyle by the radial head.24 The presence of cubitus hyperextension or cubitus valgus seems to predispose the elbow to this fracture pattern. 
Often swelling is minimal, and the presence of the fragment restricts flexion. If the fragment is large, it may be readily apparent on a lateral radiograph (Fig. 19-30). On an AP radiograph, however, the fragment may be obliterated by the overlying distal metaphysis (Fig. 19-29). If the fragment is small, it is often hard to see on plain radiographs. Oblique views may be necessary to show the fragment. In younger children, arthrography or MRI may be required to diagnose this rare fracture. Often CT or MRI scans are used to confirm the diagnosis and plan operative fixation. 
Figure 19-30
 
A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
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A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
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Figure 19-30
A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
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A, B: Fracture of the capitellum in a 14-year-old boy. A: Injury film, lateral view, shows the large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar (solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the AP view, only a faint outline of the fragment is seen (arrows). C, D: After open reduction and fixation with two small cannulated screws through a lateral approach.
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Because the mechanism is postulated to be a pushing off of the capitellum by the radial head, it stands to reason that there may be an associated radial head or neck fracture;35 associated injuries of the proximal radius were reported in 31% of adults and children with capitellar fractures.51 

Treatment Options for Capitellar Fractures

Excising the fragment and open reduction and reattachment are the two most common forms of treatment. Closed reduction is not likely to be successful. 

Excision of the Fragment

Through an open arthrotomy, the fragment can be either excised or reattached. Excision can be successful in very young patients, late presenting small fractures, and osteochondritis dissecans lesions that no longer fit back in place.24,42 In these circumstances, motion and rehabilitation can be initiated early. Even when large fragments are excised, joint instability does not appear to be a problem.24 In patients in whom treatment is delayed, although the results are not as good as when treatment is provided immediately after injury, improvement in function can be expected, even with late excision. 

Reattachment of the Fragment

A large fragment in an older child or adolescent is indicative of an intra-articular fracture, for which reduction is recommended. The stability of the fracture is provided by wires or screws inserted through the posterior surface of the lateral condyle. The major risk of open reduction and internal fixation is osteonecrosis of the reattached fragment. Satisfactory results have been reported with fixation with K-wires, Herbert screws, cannulated screws,38 compression screws,16,17 and even sutures.65 An advantage of compression screw fixation is that it may not require later removal and allows for earlier motion. Advantages cited for suture fixation include a low risk of growth arrest, sufficient stability to allow immediate postoperative motion, avoidance of implant removal, and facilitation of the acquisition of high-quality postoperative MR images to evaluate healing. 

Author's Preferred Treatment for Capitellar Fractures

If the fragment is large, if the fracture is acute, and if an anatomic reduction can be achieved with a minimum of open manipulation or dissection, then we prefer to reattach it with two small cannulated screws inserted from posterior to anterior through a lateral approach. Enough bone must be present in the capitellar fragment to engage the screw threads, and if possible, countersink the heads of the screws (Fig. 19-30). If the fracture is old, if there is any comminution of the fragment, or if there is little bone in which to engage the screw threads, we excise the fragment, perform microfracture of the bony surface, and start early motion. 

Complications in Capitellar Fractures

The major complication is osteonecrosis of the fragment. This occurs only in fractures in which the capitellar fragment is retained. Posttraumatic degenerative arthritis can occur whether the fragments are excised or retained. Many patients who are treated operatively or nonoperatively can expect to lose some range of motion, but this loss is not always of functional or aesthetic significance. It is important to emphasize to the parents before the onset of treatment that some motion may be lost regardless of the treatment method. 

References

1.
Adams JE. Injury to the throwing arm. A study of traumatic changes in the elbow joints of boy baseball players. Calif Med. 1965; 102:127–132.
2.
Agins HJ, Marcus NW. Articular cartilage sleeve fracture of the lateral humeral condyle capitellum: A previously undescribed entity. J Pediatr Orthop. 1984; 4:620–622.
3.
Albright JA, Jokl P, Shaw R, et al. Clinical studies of baseball players: Correlation of injury to throwing arm with method of delivery. Am J Sports Med. 1978; 6:15–21.
4.
Badelon O, Bensahel H, Mazda K, et al. Lateral humeral condylar fractures in children: A report of 47 cases. J Pediatr Orthop. 1988; 8:31–34.
5.
Bast SC, Hoffer MM, Aval S. Nonoperative treatment for minimally and nondisplaced lateral humeral condyle fractures in children. J Pediatr Orthop. 1998; 18:448–450.
6.
Bauer AS, Bae DS, Brustowicz KA, et al. Intra-articular corrective osteotomy of humeral lateral condyle malunions in children: Early clinical and radiographic results. J Pediatr Orthop. 2013; 33:20–25.
7.
Beaty JH, Wood AB. Fractures of the lateral humeral condyle in children. Paper presented at: The annual meeting of the American Academy of Orthopedic Surgeons; January 18, 1985; Las Vegas, NV.
8.
Bernthal NM, Hoshino CM, Dichter D, et al. Recovery of elbow motion following pediatric lateral condylar fractures of the humerus. J Bone Joint Surg Am. 2011; 93:871–877.
9.
Blount WP, Schulz I, Cassidy RH. Fractures of the elbow in children. JAMA. 1951; 146:699–704.
10.
Böhler L. The Treatment of Fractures. New York, NY: Grune & Stratton; 1956.
11.
Chessare JW, Rogers LF, White H, et al. Injuries of the medial epicondyle ossification center of the humerus. AJR Am J Roentgenol. 1977; 129:49–55.
12.
Conner AN, Smith MG. Displaced fractures of lateral humeral condyle in children. J Bone Joint Surg Br. 1970; 52:460–464.
13.
DeLee JC, Wilkins KE, Rogers LF, et al. Fracture separation of the distal humeral epiphysis. J Bone Joint Surg Am. 1980; 67:46–51.
14.
Dhillon KS, Sengupta S, Singh BJ. Delayed management of fracture of the lateral humeral condyle in children. Acta Orthop Scand. 1988; 59:419–424.
15.
Drvaric DM, Rooks MD. Anterior sleeve fracture of the capitellum. J Orthop Trauma. 1990; 4:188–192.
16.
Elkowitz SJ, Kubiak EN, Polatsch D, et al. Comparison of two headless screw designs for fixation of capitellum fractures. Bull Hosp Jt Dis. 2003; 61:123–126.
17.
Elkowitz SJ, Polatsch DB, Egol KA, et al. Capitellum fractures: A biomechanical evaluation of three fixation methods. J Orthop Trauma. 2002; 16:503–506.
18.
Fahey JJ, O'Brien ET. Fracture-separation of the medial humeral condyle in a child confused with fracture of the medial epicondyle. J Bone Joint Surg Am. 1971; 53:1102–1104.
19.
Finnbogason T, Karlsson G, Lindberg L, et al. Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop. 1995; 15:422–425.
20.
Flynn JC, Richards JF Jr. Nonunion of minimally displaced fractures of the lateral condyle of humerus in children. J Bone Joint Surg Am. 1971; 53:1096–1101.
21.
Flynn JC, Richards JF Jr, Saltzman RI. Prevention and treatment of nonunion of slightly displaced fractures of the lateral humeral condyle in children. J Bone Joint Surg Am. 1975; 57:1087–1092.
22.
Fontanetta P, Mackenzie DA, Rosman M. Missed, maluniting, and malunited fractures of the lateral humeral condyle in children. J Trauma. 1978; 18:329–335.
23.
Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985; 5:16–22.
24.
Fowles JV, Kassab MT. Fracture of the capitulum humeri, treatment by excision. J Bone Joint Surg Am. 1974; 56:794.
25.
Fowles JV, Kassab MT. Displaced fracture of medial humeral condyle in children. J Bone Joint Surg. 1980; 62:1159–1163.
26.
Gay JR, Love JG. Diagnosis and treatment of tardy paralysis of the ulnar nerve. J Bone Joint Surg. 1947; 29:1087–1097.
27.
Griffith JF, Roebuck DJ, Cheng JC, et al. Acute elbow trauma in children: Spectrum of injury revealed by MR imaging not apparent on radiographs. AJR Am J Roentgenol. 2001; 176:53–60.
28.
Haraldsson S. Osteochondrosis deformans juvenilis capituli humeri including investigation of intra-osseous vasculature in distal humerus. Acta Orthop Scand Suppl. 1959; 38:1–232.
29.
Hardacre JA, Nahigian SH, Froimson AI, et al. Fracture of the lateral condyle of humerus in children. J Bone Joint Surg Am. 1971; 53:1083–1095.
30.
Herring JA, Fitch RD. Lateral condylar fracture of the elbow. J Pediatr Orthop. 1986; 6:724–727.
31.
Horn BD, Herman MJ, Crisci K, et al. Fractures of the lateral humeral condyle: Role of the cartilage hinge in fracture stability. J Pediatr Orthop. 2002; 22:8–11.
32.
Houshian S, Mehdi B, Larsen MS. The epidemiology of elbow fracture in children: Analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci. 2001; 6:312–315.
33.
Jakob R, Fowles JV, Rang M, et al. Observations concerning fractures of the lateral humeral condyles in children. J Bone Joint Surg Br. 1975; 57(4):430–436.
34.
Jeffrey CC. Nonunion of epiphysis of the lateral condyle of the humerus. J Bone Joint Surg Br. 1958; 40:396–405.
35.
Johansson J, Rosman M. Fracture of the capitulum humeri in children: A rare injury, often misdiagnosed. Clin Orthop Relat Res. 1980; 146:157–160.
36.
Koh SH, Seo SW, Kim KM, et al. Clinical and radiographic results of lateral condylar fracture of the distal humerus in children. J Pediatr Orthop. 2010; 30:425–429.
37.
Landin LA, Danielsson LG. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986; 57:309–312.
38.
Letts M, Rumball K, Bauermeister S, et al. Fractures of the capitellum in adolescents. J Pediatr Orthop. 1997; 17:315–320.
39.
Li WC, Xu RJ. Comparison of Kirschner wires and AO cannulated screw internal fixation for displaced lateral humeral condyle fracture in children. Int Orthop. 2012; 36:1261–1266.
40.
Ma YZ, Zheng CB, Zhou TL, et al. Percutaneous probe reduction of frontal fractures of the humeral capitellum. Clin Orthop Relat Res. 1984; 183:17–21.
41.
Major NM, Crawford ST. Elbow effusions in trauma in adults and children: Is there an occult fracture? AJR Am J Roentgenol. 2002; 178:413–418.
42.
Marion J, Faysse R. Fracture du capitellum. Rev Chir Orthop. 1962; 48:484–490.
43.
Masada K, Kawai H, Kawabata H, et al. Osteosynthesis for old, established nonunion of the lateral condyle of the humerus. J Bone Joint Surg Am. 1990; 72:32–40.
44.
McDonnell DP, Wilson JC. Fracture of the lower end of the humerus in children. J Bone Joint Surg Am. 1948; 30:347–358.
45.
Menkowitz M, Flynn JM. Floating elbow in an infant. Orthopedics. 2002; 25:185–186.
46.
Mintzer CM, Waters PM, Brown DJ, et al. Percutaneous pinning in the treatment of displaced lateral condyle fractures. J Pediatr Orthop. 1994; 14:462–465.
47.
Morin B, Fassier F, Poitras B, et al. Results of early surgical treatment of fractures of the lateral humeral condyle in children. Rev Chir Orthop Reparatrice Appar Mot. 1988; 74:129–131.
48.
Morrissey RT, Wilkins KE. Deformity following distal humeral fracture in childhood. J Bone Joint Surg Am. 1984; 66(4):557–562.
49.
Moucha CS, Mason DE. Distal humeral epiphyseal separation. Am J Orthop. 2003; 32:497–500.
50.
Nwakama AC, Peterson HA, Shaughnessy WJ. Fishtail deformity following fracture of the distal humerus in children: Historical review, case presentations, discussion of etiology, and thoughts on treatment. J Pediatr Orthop B. 2000; 9:309–318.
51.
Palmer I. Open treatment of transcondylar T fracture of the humerus. Acta Chir Scand. 1961; 121:486–490.
52.
Papandrea R, Waters PM. Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop Relat Res. 2000; 370:115–126.
53.
Papavasiliou VA, Beslikas TA. Fractures of the lateral humeral condyle in children–an analysis of 39 cases. Injury. 1985; 16:364–366.
54.
Petit P, Sapin C, Henry G, et al. Rate of abnormal osteoarticular radiographic findings in pediatric patients. Am J Roentgenol. 2001; 176:987–990.
55.
Piskin A, Tomak Y, Sen C, et al. The management of cubitus varus and valgus using the Ilizarov method. J Bone Joint Surg Br. 2007; 89:1615–1619.
56.
Pribaz JR, Bernthal NM, Wong TC, et al. Lateral spurring (overgrowth) after pediatric lateral condyle fractures. J Pediatr Orthop. 2012; 32:456–460.
57.
Rovinsky D, Ferguson C, Younis A, et al. Pediatric elbow dislocations associated with a Milch type I lateral condyle fracture of the humerus. J Orthop Trauma. 1999; 13:458–460.
58.
Rutherford AJ. Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am. 1985; 67:851–856.
59.
Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg. 1963; 45:587–632.
60.
Sharma JC, Arora A, Mathur NC, et al. Lateral condylar fractures of the humerus in children: Fixation with partially threaded 4.0-mm AO cancellous screws. J Trauma. 1995; 39:1129–1133.
61.
Shimada K, Masada K, Tada K, et al. Osteosynthesis for the treatment of nonunion of the lateral humeral condyle in children. J Bone Joint Surg Am. 1997; 79:234–240.
62.
Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B. 2001; 10:142–152.
63.
Smith FM, Joyce JJ III. Fracture of lateral condyle of humerus in children. Am J Surg. 1954; 87:324–329.
64.
So YC, Fang D, Orth MC, et al. Varus deformity following lateral humeral condylar fracture in children. J Pediatr Orthop. 1985; 5:569–572.
65.
Sodl JF, Ricchetti ET, Huffman GR. Acute osteochondral shear fracture of the capitellum in a twelve-year-old patient. A case report. J Bone Joint Surg Am. 2008; 90:629–633.
66.
Song KS, Kang CH, Min BW, et al. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus. J Bone Joint Surg Am. 2008; 90:2673–2681.
67.
Song KS, Waters PM. Lateral condylar humerus fractures: Which ones should we fix? J Pediatr Orthop. 2012; 32(suppl 1):S5–S9.
68.
Song KW, Shin YW, Wug C, et al. Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010; 24:434–438.
69.
Speed JS, Macey HB. Fracture of humeral condyles in children. J Bone Joint Surg. 1933; 15:903–919.
70.
Stans AA, Maritz NG, O'Driscoll SW, et al. Operative treatment of elbow contracture in patients 21 years of age or younger. J Bone Joint Surg Am. 2002; 84-A:382–387.
71.
Steinthal D. Die Isolirte Fraktur der Eminentia Capitata im Ellenbogengelenk. Zentralbl F Chir. 1898; 15:17–20.
72.
Stimson LA. A Practical Treatise on Fractures and Dislocations. Philadelphia, PA: Lea Brothers & Co.; 1900.
73.
Tien YC, Chen JC, Fu YC, et al. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. Surgical technique. J Bone Joint Surg Am. 2006; 88(suppl 1 Pt 2):191–201.
74.
van Vugt AB, Severijnen RV, Festern C. Fractures of the lateral humeral condyle in children: Late results. Arch Orthop Trauma Surg. 1988; 107:206–209.
75.
Wadsworth TG. Premature epiphyseal fusion after injury of capitulum. J Bone Joint Surg Br. 1964; 46:46–49.
76.
Wang YL, Chang WN, Hsu CJ, et al. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma. 2009; 23:120–125.
77.
Waters PM, Bae DS. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:316–337.
78.
Wattenbarger JM, Gerardi J, Johnson CE. Late open reduction internal fixation of lateral condyle fractures. J Pediatr Orthop. 2002; 22:394–398.
79.
Weiss JM, Graves S, Yang S, et al. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009; 29:602–605.
80.
Wilson JN. Fracture of external condyle of humerus in children. Br J Surg. 1936; 18:299–316.
81.
Wilson PD. Fracture of the lateral condyle of humerus in children. J Bone Joint Surg. 1936; 18:299–316.
82.
Wirmer J, Kruppa C, Fitze G. Operative treatment of lateral humeral condyle fractures in children. Eur J Pediatr Surg. 2012; 22:289–294.
83.
Yang WE, Shih CH, Lee ZL, et al. Anatomic reduction of old displaced lateral condylar fractures of the humerus in children via a posterior approach with olecranon osteotomy. J Trauma. 2008; 64:1281–1289.
84.
Zeir FG. Lateral condylar fracture and its many complications. Orthop Rev. 1981; 10:49–55.
85.
Zionts LE, Stolz MR. Late fracture of the lateral condyle of the humerus. Orthopedics. 1984; 7:541–545.