Background

In 1883, Stimson first described the fracture patterns in lateral condyle fractures in his
book Treatise on Fractures.[1] He described the fracture as beginning in the lateral metaphysis
proximal to the condyle, coursing distally, and exiting through the articular surface through
the medial trochlear notch or through the capitellotrochlear groove. In 1955, Milch
recognized the significance of these fracture patterns as they related to elbow stability.[2] Thus,
the fracture patterns of the lateral condyle bear his name and are classified as either Milch I
or Milch II fractures.[3, 4, 5]
Problem
The distal humerus is primarily cartilage at the age when these injuries typically occur, and
knowledge of the secondary centers of ossification is necessary to understand the possible
fracture patterns. Due to incomplete ossification, the fracture may appear subtle on
radiographs as it courses through the cartilage anlage, as depicted in the images below.

Normal contralateral elbow.

Note the subtle fracture line.

The physis of the lateral condyle extends into the trochlear notch of the distal humerus (see
image below). Therefore, in some fractures, the lateral crista of the trochlea may be part of
the fracture fragment, leading to an unstable humeral ulnar articulation.

Diagram of intact distal humerus.

The difficulties related to treatment of this fracture are both biologic and technical. Biologic
problems are a result of the healing process and may occur with appropriate treatment and
anatomic reduction. These problems include lateral spur formation with pseudo cubitus varus
and true cubitus varus. Technical difficulties are the result of errors in management and may
result in nonunion, malunion, valgus angulation, avascular necrosis, or a combination of these
conditions.
One study found the current clinical imaging modality, radiography, may have a reduced
sensitivity and inability to detect true displacement (see Imaging Studies).[6] The reduced
precision of the radiographs may affect fracture management. For example, a patient who
requires surgery (as indicated) may be treated with immobilization due to failure of the
radiograph to illustrate the true fracture displacement (see Complications). A high clinical
suspicion of a displaced fracture may require further diagnostic studies, possibly using MRI
or arthrography (see Indications).
Epidemiology
Frequency
Lateral condyle fractures, as depicted in the image below, account for 17% of all distal
humerus fractures and 54% of distal humeral physeal fractures. The frequency of lateral
condyle fractures peaks in children aged 6 years. Most fractures occur in children aged 5-10
years. Cases have been reported in patients as young as 2 years and as old as 14 years.

Lateral condyle fracture, additional view. The fracture may be subtle and can sometimes be
missed.
Etiology
Two theories of the mechanism of injury for this fracture exist. The first is the pull-off theory,
in which avulsion of the lateral condyle occurs at the origin of the extensor/supinator
musculature. This may occur as a varus stress is applied to the extended elbow with the
forearm supinated. This is thought to be the most common mechanism of injury. The second
is the push-off theory, in which a fall onto the extended hand leads to impaction of the radial
head into the lateral condyle, causing the fracture.[7]
Previous
Pathophysiology
The lateral condyle fracture is a Salter-Harris IV fracture pattern and follows physeal injury
principles. For more information about injuries of the growth plate, see Salter-Harris
Fractures. The fracture fragments in these patients are primarily cartilaginous as a result of
the young age of the patients. The radiographic interpretation may be misleading because the
visible fragment appears smaller than the actual size and, in addition, the amount of
displacement is not appreciated.
In lateral condyle fractures, the displacement is greater than appreciated, and incongruity of
the articular surface is present. Fractures with minimal displacement must be carefully
monitored, as they have a high tendency to displace. Once these displaced fractures
consolidate in a malunited position, treatment is difficult, dangerous, and fraught with

complications. For these reasons, surgical reduction should be performed and is

recommended within the first 48 hours postfracture.
Presentation
Children usually present with a history of a fall onto an extended arm. Patients present with
pain and associated elbow swelling. Physical examination demonstrates a swollen elbow,
pain greatest over the lateral condyle, and refusal of the patient to actively move the elbow.
Occasionally, crepitus is present in an unstable fracture pattern. Significant deformity may
indicate an elbow dislocation.
Indications
Operative management is essential for all displaced fractures and in those demonstrating joint
instability or the potential for delayed joint instability.
Stage I, or type I, lateral condyle fractures with less than 2 mm of displacement may be
treated with immobilization. If there is a question of stability or the possibility of delayed
displacement in these type I fractures, percutaneous pinning is recommended. If the degree of
fracture displacement is questioned, anatomic reduction and surgical stabilization is needed.
Open reduction is indicated for all displaced type II and type III fractures.
Contraindications
Fractures that are not greatly displaced and are identified on a delayed basis greater than 3
weeks should not undergo surgical intervention. Healing has progressed to a point that
extensive dissection would be required to achieve reduction leading to a high incidence of
avascular necrosis of the lateral condyle.

Lateral Condyle Fracture - Pediatric

Author: Evan Watts
Topic updated on 05/09/15 9:18pm
Introduction

Fractures involving the

Epidemiology

lateral condyle of the humerus

o incidence

17% of

all distal humerus fractures in the

pediatric population

o demographics

typically occurs in patients aged 5-10 years old

o location

most commonly are Salter-Harris IV fracture patterns of the lateral condyle

Pathophysiology
o mechanism of injury

pull-off theory

push-off theory

avulsion fracture of the lateral condyle that results from the pull of the common
extensor musculature

fall onto an outstretched hand causes impaction of the radial head into the latera
condyle causing fracture

Prognosis
o outcomes have historically been worse than supracondylar fractures

articular nature, missed diagnosis, and higher risk of malunion/nonunion

Classification

Milch Classification
Type I
Fracture line is lateral to trochlear groove
Type II

Fracture line into trochlear groove

Fracture Displacement Classification

Type 1

<2mm, indicating intact cartilaginous hinge

Type 2

2-4mm, displaced joint surface

Type 3

>4mm, joint displaced and rotated

Presentation

History
o fall onto an outstetched hand

Symptoms
o lateral elbow pain
o mild swelling

Physical exam
o inspection

exam may lack the obvious deformity often seen with supracondylar fractures

swelling and tenderness are usually limited to the lateral side

o motion

may have increased pain with resisted wrist extension/flexion

may feel crepitus at the fracture site

Imaging

Radiographs
o recommended views

AP, lateral, and oblique views of elbow

internal oblique view most accurately shows maximum displacement and fractu
pattern

o optional views

contralateral elbow for comparison when ossification is not yet complete

routine elbow stress views are not recommended due to risk of fracture displacement

o findings

fracture fragment most often lies posterolateral which is best seen on internal oblique v

CT scan
o indication

improved ability to assess the fracture pattern in all planes

o findings

CT has limited ability to evaluate the integrity of articular cartilage

may require sedation to perform the test

MRI
o indication

provides the ability to assess the cartilaginous integrity of the trochlea

o findings

increased expense

may require sedation to perform the test

Differential

Pediatric Elbow Injury Frequency

Fracture Type
% elbow injuries Peak Age
Supracondylar fractures
41%
7
Radial Head subluxation
28%
3
Lateral condylar physeal fractures
11%
6
Medial epicondylar apophyseal
fracture
8%
11
Radial Head and Neck fractures
5%
10
Elbow dislocations
5%
13
Medial condylar physeal fractures
1%
10
Treatment

Nonoperative
o long arm casting

Requires OR
majority
rare
majority
minority
minority
rare
rare

indications

only indicated if < 2 mm of displacement, which indicates the cartilaginous hin

most likely intact

sub-acute presentation (>4 weeks)

technique

cast with elbow at 90 degrees and forearm supination

weekly follow up

radiographs out of cast may be useful

total length of casting is 3-7 weeks

Operative
o CRPP

indications

some authors suggest CRPP for all lateral condylar fractures

with < 2 mm of displacement

ability to maintain fracture fragment in a position to prevent

late displacement

technique

closed reduction performed by providing a varus elbow force

and pushing the fragment anteromedial

divergent pin configuration most stable

third pin may be used in transverse plane to prevent fragment

derotation

arthrogram can confirm joint congruity

o open reduction and fixation

indications

if > 2mm of displacement

any joint incongruity

fracture non-union

technique

direct lateral approach

avoid dissection of posterior aspect of lateral condyle (source

of vascularization)

percutaneous or subcutaneous pins may be used for fixation

single screw may also be used with non-unions +/- bone

grafting

AVN
o posterior dissection can result in lateral condyle osteonecrosis
o may also occur in the trochlea

Nonunion/malunion
o caused from delay in diagnosis and improper treatment
o may result in cubitus valgus and tardy ulnar nerve palsy

Tardy ulnar nerve palsy

o slow, progressive paralysis of the ulnar nerve
o caused by stretching of the nerve, as is seen with cubitus valgus
o usually late finding, presenting many years after initial fracture

Lateral overgrowth/prominence (spurring)

o in up to 50% of cases regardless of treatment, families should be counseled in

advance
o lateral periosteal alignment will prevent this from occurring

o presence of spurring is correlated with greater initial fracture displacement

Growth arrest with or without angular deformity

Unsatisfactory appearance of surgical scar

Late elbow presentation or deformity

o cubitus varus deformity is most common in nondisplaced and minimally
displaced fractures
o cubital valgus less common, but more likely with significant deformities that
cause physeal arrest
o controversy whether to treat subacute fractures (week 3-12) nonoperatively or
surgically
o most deformities can be corrected after skeletal maturation with a
supracondylar osteotomy