Trauma About the Elbow II: Other Fractures



Trauma About the Elbow II: Other Fractures


John M. (Jack) Flynn, MD

Jeffrey R. Sawyer, MD1


Guru:











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Lateral Condylar Fractures

Fractures of the lateral condyle of the distal humerus are the second most common fracture about the elbow in children after supracondylar fractures, and have a well-earned reputation for trouble: nonunion, malunion, cubitus varus, and persistent loss of motion. Fortunately, these problems usually are avoidable if the fracture is recognized in a timely fashion and treated with sound principles. To stay out of trouble, remember that in most cases, this is a torn-off block of cartilage with a bit of bone inside, so healing is slower than a metaphyseal fracture (like a supracondylar), articular congruity must be assured, and thoughtful fixation is even more important when dealing with a ball of cartilage. Soft tissue injury (torn/punctured muscle) is typically less severe than with supracondylar fractures, and acute associated neurovascular injury is rare.





LATE PRESENTATION

Traditional teaching suggests that open reduction should not be performed in fractures seen later than 3 weeks, as the risk of poor results from stiffness and osteonecrosis increases. However, if one carefully avoids posterior dissection to maintain blood supply of the distal fragment, good results with open reduction of lateral condylar fractures can be achieved.

A key approach to avoiding trouble in the treatment of late lateral condylar fractures is to not necessarily aim for anatomic reduction; it is preferable to fix it where it lies with no posterior stripping. This technique has been described as “metaphyseal osteosynthesis in situ” in the past. These fractures are similar to a slipped capital femoral epiphysis in that respect. Consider rigid fixation with a screws or screws in compression in late cases to maximize healing and early ROM, while remembering to avoid the olecranon fossa.


OTHER TROUBLE


Lateral condylar fractures heal more slowly than other fractures the pediatric orthopaedist is accustomed to treating. Be patient. It can be 10 or even 12 weeks before solid union. Look on the lateral radiograph for the first signs of healing—a wisp of periosteal new bone from fragment to metaphysis is a great sign that healing is under way. Lateral overgrowth from new bone can give the appearance of cubitus varus—but it is not. Warn parents ahead of time that they may see a lateral prominence when the cast comes off and the arm is atrophied. In some cases, lateral overgrowth is clear (Fig. 7-6). Either way, assure parents it is rarely severe enough to require treatment. Posterior osseous spurs may occur with both operative and nonoperative treatment. These seldom cause any problem other than parental concern over the radiographs (Fig. 7-7). Persistent elbow stiffness is more common following lateral condylar fractures than supracondylar fractures; prepare the family, use physical therapy (PT) after healing, and set expectations that return to sports may be a few months after injury.

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Jan 30, 2021 | Posted by in ORTHOPEDIC | Comments Off on Trauma About the Elbow II: Other Fractures
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