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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

Lateral condyle fractures

ED Management | Outpatient/Fracture Clinic Management | Operative Management


ED Management

The following information is for use by medical practitioners and trainees in the Emergency Department  

1. Treatment Pathway
2. What are likely findings on history?
3. What specific information from the patient history should be documented?
4. What are likely findings on clinical exam?
5. What specific findings on the physical exam are important to document?
6. What X-rays should be ordered?
7. What specific features are found on X-ray?
8. How should this fracture be treated in the emergency department?
9. Should this patient be referred urgently to the nearest orthopaedic surgery service on call?
10. Where should this patient be seen for follow-up care?
11. What discharge prescriptions and instructions should be provided?
12. What potential complications could result from this injury or its management?

 

1. Treatment Pathway  

If a lateral condyle fracture is identified on AP and lateral X-rays of the elbow and has <2mm displacement, it is imperative to also obtain an internal oblique elbow X-ray to determine if the maximum displacement is in fact ≥2mm.

Fracture type based on Weiss classification

ED management

Follow-up care

Type 1
Fracture displacement <2mm

  • Analgesia
  • No reduction needed
  • Long-arm backslab with the elbow flexed to 90° and broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheet- Undisplaced lateral condyle fracture (PDF) and Cast Care: Arm or Leg (PDF)
  • Follow up in Fracture Clinic in 1 week.
  • Repeat AP, lateral and internal oblique x-rays of the elbow to assess for interval displacement. If cast material obscures fracture line then consider repeating radiographs after removing backslab.
  • Further follow up appointments in Fracture Clinic at 3 weeks and at 6 weeks after injury

Type 2 and 3
Fracture displacement ≥2mm

  • Long-arm backslab to splint elbow
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for operative management
  • To be determined by treating orthopaedic surgeon

 

 

2. What are likely findings on history?

    Mechanism of injury is usually a fall onto an outstretched hand. Monkey bars are common culprits.  

3. What specific information from the patient history should be documented?

    • Document the date and time of injury.
    • Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention).

4. What are likely findings on clinical exam?

    • Pain and swelling at the lateral elbow and reduced range of motion. 

It is always important to use the uninjured arm as a comparison as pain and swelling around the elbow can be subtle in lateral condyle fractures, which can lead to missed diagnosis and poor outcomes.

 

5. What specific findings on the physical exam are important to document?

    • The presence of skin tenting or fracture blisters
    • The presence of an open fracture (splints placed at outside institutions should be taken down if there is any suspicion of an open fracture to allow adequate inspection of the overlying skin)
    • The presence of a peripheral nerve injury using the SickKids Peripheral Neurovascular Checklist
    • The presence of an arterial injury or limb ischemia using the SickKids Peripheral Neurovascular Checklist
    • The presence of signs or symptoms of compartment syndrome
    • The presence of an injury to the joints or bones above and below the injury (two-level injuries are at increased risk of developing compartment syndrome)

6. What X-rays should be ordered?

  • After splinting the elbow and providing analgesia, AP and lateral elbow X-rays should be ordered. 
  • If a lateral condyle fracture is identified on AP and lateral X-rays of the elbow and has <2mm displacement, it is imperative to also obtain an internal oblique elbow x-ray to determine if the maximum displacement is in fact ≥2mm. 
  • If there are concerns of adjacent injuries above or below the elbow, additional radiographs may be warranted.

7. What specific features are found on X-ray?

If you are unfamiliar with interpreting elbow radiographs, or need a refresher, click here

  • Classification is based on degree of fracture fragment displacement and disruption of the articular surface (Weiss Classification).

         

In type 1 fractures, there is <2mm displacement. Fractures start from the posterolateral aspect of the distal humeral metaphysis and cross the distal physis to approach the articular surface. Fractures can often be difficult to see on AP and lateral X-rays- anterior/posterior fat pad signs should alert the astute physician to look more closely. Occasionally displacement is only appreciated on the internal oblique X-ray.


 

         

In type 2 fractures, there is ≥2mm displacement with congruity of articular surface. An intra-operative arthrogram can help determine the congruity of the articular surface and need for open reduction. Patients under the age of 3 with suspected type 2 or type 3 lateral condyle fractures should be screened in the OR for possible transphyseal distal humerus fractures


 

         

In type 3 fractures, there is ≥2mm displacement without congruity of articular surface.


 

8. How should this fracture be treated in the emergency department?

Type 1 fractures (<2mm displacement):

  • Analgesia:

        Mild Pain

    • Oral: Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.

        Moderate to Severe Pain

    • Intranasal fentanyl (1.5mcg/kg)
    • Intravenous: morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
  • Does not need a reduction in the ED
  • Place in long-arm backslab with the elbow flexed to 90 degrees and broad arm sling

 

Type 2 and 3 fractures (≥2mm displacement):

  • Analgesia:

        Mild Pain

    • Oral: Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.

        Moderate to Severe Pain

    • Intranasal fentanyl (1.5mcg/kg)
    • Intravenous: morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
  • Place in long-arm backslab to splint elbow in position of comfort
  • A formal closed reduction in the ED is NOT advised
  • Keep nil per os (NPO)
  • Urgent referral to nearest orthopaedic surgeon on call for operative management

9. Should this patient be referred urgently to the nearest orthopaedic surgery service on call?

Indications for emergent (within 1 hour) referral to the nearest orthopaedic surgeon on call include:

    • Loss of radial pulse or a cool, white hand
    • Signs or symptoms of compartment syndrome

Indications for urgent (within 4 hours) referral to the nearest orthopaedic surgeon on call include:

    • Type 2 and 3 fractures (≥2mm displacement)
    • Associated nerve injuries
    • Open fracture
    • Adjacent injuries to the forearms or wrist

Patients awaiting orthopaedic assessment in the emergency department should be kept nil per os (NPO) until a decision about surgery is made.

For open fractures, tetanus immunization status should be assessed and appropriate IV antibiotics provided.

 

10. Where should this patient be seen for follow-up care?

Type 1 fractures (<2mm displacement):

    • Repeat AP, lateral and internal oblique X-rays of the elbow to assess for interval displacement. If cast material obscures fracture line then consider repeating radiographs after removing backslab.

Type 2 and 3 fractures (≥2mm displacement):

    • To be arranged by treating orthopaedic surgeon

11. What discharge prescriptions and instructions should be provided?

Type 1 fractures (<2mm displacement):

Type 2 and 3 fractures (≥2mm displacement):

 

12. What potential serious complications could result from this injury or its management?

  • Nonunion/malunion
    • Often due to missed/delayed diagnosis of displaced lateral condyle fractures.
  • Elbow stiffness and decreased range of motion limiting function
  • Growth Disturbance/Arrest:
    • Cubitus Varus:
      • Due to growth stimulation of lateral distal humeral physis after injury or medial distal humeral physeal injury with fracture extending into trochlea.
    • Cubitus Valgus:
      • Often due to missed/delayed diagnosis of displaced lateral condyle fractures
      • May result from lateral growth arrest following severely displacement fractures
  • Tardy Ulnar Nerve Palsy:
    • Gradual and progressive stretching and paralysis of the ulnar nerve due to cubitus valgus.
  • Avascular Necrosis of the Lateral condyle:
    • Mostly seen after surgical open reduction with extensive posterior dissection.

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Outpatient/Fracture Clinic Management

The following information is for use by medical practitioners and trainees in Fracture Clinics or Outpatient clinics.

1. When should this patient be seen in fracture clinic/outpatient clinic?
2. What should be reviewed at each clinic visit?
3. What are common reasons to deviate from the treatment pathway?
4. Does this patient require long-term follow-up?
5. Instructions for parents and SickKids Parent Information Sheets

 

1. When should this patient be seen in fracture clinic/outpatient clinic?

Fracture type based on Weiss classification

First clinic visit

Subsequent follow-up

Type 1

Fracture displacement <2mm

Follow up in Fracture clinic in 1 week with:

Repeat AP, lateral and internal oblique radiographs to assess for interval displacement. If cast material obscures fracture line then consider repeating radiographs after removing backslab.

 

  • At 3 weeks with removal of backslab and repeat AP, lateral and internal oblique radiographs to assess for interval displacement and appropriate callus.
  • At 6 weeks with repeat AP, lateral and internal oblique radiographs to assess for interval displacement and appropriate callus.
  • Subsequent follow-up at 3 months and then at 3 month intervals until clinically and radiographically united and meet criteria for discharge.

Type 2 and 3

Fracture displacement ≥2mm

At 3 weeks post-operative closed/open reduction and percutaneous pinning with:

1. Removal of backslab and K-wires

2. AP, lateral and internal oblique radiographs

3. Clinical Review

4. Begin gentle range of motion exercises

5. Avoid high-risk activities for 12 weeks post-injury

 

  • At 6 weeks with repeat AP, lateral and internal oblique radiographs to assess for interval displacement and appropriate callus.
  • Subsequent follow-up at 3 months and then at 3 month intervals until clinically and radiographically united and meet criteria for discharge.

Parents should be warned about pseudovarus 

 

 2. What should be reviewed at each clinic visit?

  • At 1 week appointment (Type 1 fractures only):
    • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist
    • Review radiographs for interval displacement
      • If cast material obscures fracture line then consider repeating radiographs after removing backslab
      • Consider surgical intervention (e.g. closed reduction and percutaneous pinning) if interval displacement
  • At 3 week appointment:
    • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist
    • Review radiographs for absence of interval displacement and adequate callus formation
      • Consider surgical intervention (e.g. percutaneous compression screw) if interval displacement
      • Place back in above elbow cast if concerned about inadequacy of callus formation
    • If k-wires have been removed at this appointment- examine insertion sites
    • Warn parents about pseudovarus
  • At 6 week appointment:
    • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist
    • Review radiographs for absence of interval displacement and adequate callus formation
      • Consider surgical intervention (e.g. percutaneous compression screw) if interval displacement
      • Place back in above elbow cast if concerned about inadequacy of callus formation
    • Warn parents about pseudovarus  
  • At 3 month and subsequent appointments:
    • Assess patient for clinical union (i.e. fracture site non-tender to palpation)
    • Assess radiographs for radiographic union
    • Assess radiographs for growth disturbance
    • Document range of motion
    • Document coronal alignment

 

3. What are common reasons to deviate from the treatment pathway?

Common reasons to deviate from the treatment pathway include:

    • Displacement beyond acceptable limits for continued non-operative management:
      • These patients should be evaluated by an orthopaedic surgeon for consideration of operative management
    • Delayed union or non-union:
      • These patients should be evaluated by an orthopaedic surgeon for consideration of operative management
    • Decreased elbow range of motion limiting function
      • These patients may require physiotherapy or evaluation by an orthopaedic surgeon
    • Growth disturbance
      • Cubitus Varus: Due to growth stimulation of lateral distal humeral physis after injury or medial distal humeral physial injury with fractures extending into trochlea.
      • Cubitus Valgus:

        1. Often due to missed/delayed diagnosis of displaced lateral condyle fractures

        2. May result from lateral growth arrest following severely displacement fractures

        3. May lead to progressive valgus deformity and can lead to a tardy ulna nerve palsy
    • Avascular Necrosis of the Lateral condyle:
      • Mostly seen after surgical open reduction with extensive posterior dissection.

4. Does this patient require long-term follow-up?

  • Patients with delayed or non-union, malunion, growth disturbance, decreased elbow range of motion, or avascular necrosis may warrant long-term follow-up provided by a pediatric orthopaedic surgeon
  • After 6 months, a patient can be discharged from future follow up when they have met the following discharge criteria:

    • No tenderness at the fracture site
    • Radiographic union
    • Painless, near normal range of motion
    • No growth disturbance

5. Instructions for parents and SickKids Parent Information Sheet (PDF)

 

 

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Operative Management

The following information is for use by Orthopaedic Surgeons and trainees in the Operating Room.

1. What are the indications for operative management?
2. Should this patient be referred to a paediatric orthopaedic surgeon for management?
3. What particular risks should be brought up during the consent discussion?
4. How urgently does this fracture need to be surgically managed?
5. What operative equipment is required?
6. How should the operating room be setup?
7. What are the general surgical techniques and goals of managing this fracture?
8. How should this fracture be managed post-operatively?
9. What are the expected outcomes and potential complications specific to this fracture?

 

Pearl: Patients under the age of 3 with suspected type 2 or type 3 lateral condyle fractures should be screened in the OR for a possible transphyseal distal humerus fracture. If a transphyseal distal humerus fracture is diagnosed, non-accidental injury must be considered.

 

1. What are the indications for operative management?

Fractures with ≥2mm displacement

Pearl: Fractures presenting after 2 weeks require special consideration and may benefit from consultation with a paediatric orthopaedic surgeon

 

2. Should this fracture be referred to a fellowship-trained paediatric orthopaedic surgeon for management?

Not necessarily. The closed and open management of these fractures is within the skill set of a general orthopaedic surgeon

 

3. What particular risks should be brought up during the consent discussion?

General risks with this fracture: 

  • Nonunion/malunion
    • Often due to missed/delayed diagnosis of displaced lateral condyle fractures
    • Operative management decreases the risk of non-union from 30% to <1%
  • Pseudovarus: Approximately 75% of patients have bony overgrowth at the lateral distal humerus
  • Elbow stiffness and decreased range of motion limiting function
  • Growth Disturbance/Arrest:
    • Cubitus Varus: Due to growth stimulation of lateral distal humeral physis after injury or medial distal humeral physeal injury with fracture extending into trochlea.
    • Cubitus Valgus:
      • Often due to missed/delayed diagnosis of displaced lateral condyle fracture
      • May result from lateral growth arrest following severely displacement fractures
  • Tardy Ulnar Nerve Palsy:
    • Gradual and progressive stretching and paralysis of the ulnar nerve due to cubitus valgus.
  • Avascular Necrosis of the Lateral condyle:
    • Mostly seen after surgical open reduction with extensive posterior dissection.

Specific to operative management:

    • Closed reduction:
      • Pin tract infection with K wires
    • Open reduction:
      • Infection
      • Increased risk of avascular necrosis of the Lateral condyle
        • Mostly seen after surgical open reduction with extensive posterior dissection
      • Scar

 

4. How urgently does this fracture need to be surgically managed?

A closed, neurovascularly intact lateral condyle fracture can be managed during daytime hours but preferably within 48hours of the injury. However, patient outcomes are not adversely affected with treatment delays of up to 2 weeks.

Indications for urgent surgical management (SickKids Priority 2): 

    • Associated elbow dislocations 
    • Neurovascular compromise 
    • Open fractures


5. What operative equipment is required?

  • Regular operating table with radiolucent arm table
  • Intraoperative fluoroscopy
  • Arthrogram dye
  • Kirschner wire set with wire driver
  • Tourniquet*
    • Consider the use of a sterile tourniquet in young children to increase size of sterile field
  • Basic orthopaedic set up*
  • Bone reduction forceps*
  • Diathermy*
  • Head lamp*
  • Langenbeck Retractors*
  • Hohmann retractors*
  • 3.5mm or 4.0mm partially-threaded cannulated screw set and washers†

 

* To be opened only if open reduction or neurovascular exploration required
† As an alternative to K-wire fixation based on surgeon preference

 

6. How should the operating room be setup?

The patient should be brought down the operating table so that his head is level with the arm table. This will ensure that the patients head does not inadvertently roll off the side of the operating table during the traction, manipulation and reduction of the fracture.

 

7. What are the general goals and surgical techniques of managing this fracture?

Goals: Obtain and maintain an anatomic articular reduction until union

Surgical Technique:

Pearl: If there is uncertainty as to the congruity of the articular surface, an arthrogram can be performed. It is easiest to inject the arthrogram dye posteriorly through the triceps tendon into the olecranon fossa. 

Pearl: Fractures with ≥4mm displacement will likely not have congruity of the articular surface and will require an open reduction to obtain an anatomic reduction.

 

Type 2 Fractures:

Obtaining a closed reduction:

  • The surgeon’s thumb is placed on the posterolateral aspect of the lateral condyle and applies an anteromedially directed force to reduce fracture fragment whilst simultaneously flexing the elbow
  • Alternatively, k-wires can be inserted into the fracture fragment and used to obtain a reduction

 

 

Maintaining a closed reduction:
 

  • Using 1.6mm or 2.0mm k-wires:

                        

    • From a lateral entry point, insert 2 or 3 percutaneously placed k-wires in a divergent configuration that engage the medial cortices
    • Wires should be bent 90 degrees without stressing the fracture fixation, cut 1cm proximally to make removal easier.

 

Pearl: A post-fixation arthrogram helps demonstrate articular congruity that obviates the need for an open reduction

 

  • Using a percutaneous partially-threaded 3.5mm or 4.0mm screw and washer:
    • Pass through metaphyseal aspect of fracture
    • Direct screw perpendicular to fracture line
    • Engage far cortex to ensure adequate compression

 

 

Type 3 Fractures:

Obtaining an open reduction:

  • Lateral approach to elbow: Avoid posterior dissection as to keep blood supply to lateral condyle undisturbed

 

Pearl: If you can't feel the landmarks, it is wise to check the location of the fracture by fluoroscopy to make sure your incision is actually centred over the fracture line

 

  • Obtain enough exposure to visualize articular surface medial to fracture line:
    • Langenbeck or Hohmann retractors placed across articular surface to elevate capsule anteriorly
    • Place a varus force to open lateral joint space
    • Clear the fracture site of fracture hematoma
    • Obtain anatomic reduction of the fragment and assess articular congruity visually and tactilely with a McDonald elevator

 

Pearl: A head lamp is invaluable during this open reduction
Pearl:
Placing two small k-wires into the fracture fragment to use as joy-sticks will aid in fracture reduction 

 

Maintaining an open reduction:

  • Using 1.6mm or 2.0mm k-wires: