Paediatric Lateral Humeral Condyle Fracture ORIF

Indication. A displaced lateral humeral condyle fracture in a child — displacement greater than 2 mm on any radiographic view, a Milch type II pattern through the trochlear groove, or a Weiss type 3 injury (greater than 4 mm displacement or a disrupted articular hinge). All displaced lateral condyle fractures are Salter-Harris IV injuries crossing both the physis and the articular surface, and they are bathed in synovial fluid once displaced — so they behave like an intra-articular injury and will not reliably heal without fixation. Absolute indications - Displacement greater than 2 mm on any radiographic view

• Milch type II fracture through the trochlear groove
• Weiss type 3 injury (greater than 4 mm displacement or disrupted articular hinge)
• Open fracture or associated vascular injury
• Incarcerated fragment blocking motion Relative indications - Weiss type 2 (2 to 4 mm) with equivocal hinge integrity on arthrogram
• Delayed presentation less than 3 weeks with a still-mobile fragment
• Associated radial head or olecranon fracture requiring simultaneous fixation
• Patient or family preference for definitive anatomic reduction over nonoperative care Contraindications. Absolute: established nonunion greater than 12 weeks without preparation for grafting and compression (a different operative plan), or active infection at the surgical site. Relative: a minimally displaced fracture (less than 2 mm) with an intact hinge on advanced imaging, or medical comorbidities precluding anaesthesia in the acute window. Why nonoperative treatment fails when displaced. The lateral condyle fragment has a small metaphyseal component and relies on its posterior soft-tissue pedicle for perfusion. Greater than 2 mm of displacement allows synovial fluid to enter the fracture line, preventing healing and promoting nonunion. Malunion produces progressive cubitus valgus, lateral spur formation and eventual tardy ulnar nerve palsy. Historical series before modern fixation showed nonunion rates approaching 30 to 50 percent when displacement exceeded 2 mm and nonoperative care was pursued. Timing. Ideally operate within 5 to 7 days of injury while the fragment remains mobile and the fracture surfaces are fresh. Surgery after 3 weeks becomes technically more difficult due to early callus and fragment rounding; after 12 weeks it is considered an established nonunion requiring a different strategy. Delayed presentation between 3 and 12 weeks still allows acute-style fixation but needs more aggressive debridement of early callus and careful assessment of fragment viability. The one fixation decision. Every case begins with the same anatomic open reduction; the only real choice is the implant:

Consent specifically for the posterior-hinge AVN risk, pin-tract infection, residual stiffness, a small risk of loss of reduction needing revision, and the late risks of fishtail deformity and tardy ulnar nerve palsy that require follow-up until skeletal maturity. Setup. Supine on a radiolucent table with the arm on a hand table or across the chest; high upper-arm tourniquet; image intensifier on the opposite side so the C-arm swings freely for AP, lateral and oblique views. Loupe magnification (2.5x to 3.5x) and a headlight are essential — articular congruity and nerve protection are the whole game.

The goal: expose the lateral condyle through the Kocher interval with strictly anterior dissection, reduce the articular surface anatomically under direct vision while leaving the posterior soft-tissue hinge completely undisturbed, and stabilise the fragment with divergent K-wires or a compression screw. The exposure — and the discipline of never touching the posterior tissues — is the heart of the operation (and is covered in depth on the Kocher approach to the elbow page).

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Rehabilitation | Phase | Timing | Immobilisation | Therapy / milestones | |-------|--------|----------------|----------------------| | 1 | 0 to 3 weeks | Long-arm cast, elbow 90 degrees, forearm neutral | Weekly radiographs to monitor reduction | | 2 | 3 to 6 weeks | Long-arm cast | Confirm bridging callus before wire removal | | 3 | About 6 weeks | Remove K-wires once callus visible; removable splint | Gentle active-assisted range of motion begins | | 4 | 6 weeks to 3 to 4 months | Removable splint for protection | Formal physiotherapy — terminal extension, supination/pronation | | 5 | 3 to 4 months onward | None | Return to sport once full motion and strength recovered | Patients are followed until skeletal maturity to detect physeal arrest, fishtail deformity and tardy ulnar nerve palsy. Complications

Prevention strategies. Strict anterior-only dissection, anatomic articular reduction confirmed both visually and fluoroscopically, divergent far-cortex-engaging fixation, protected mobilisation only after radiographic union (usually 4 to 6 weeks), and serial radiographs for at least 12 months to detect early physeal disturbance. Special situations

Epidemiology. Lateral condyle fractures are among the most common paediatric elbow fractures, with a peak in children around 5 to 10 years of age. They are notable among paediatric elbow injuries for a high risk of nonunion when displaced, which is what makes them a perennial exam favourite. Osseous and vascular anatomy. The lateral condyle comprises the capitellum and the lateral half of the trochlea. The physis is transverse at this level and the fracture line exits through the articular cartilage of the trochlea in Milch type II injuries. The capitellar ossific nucleus appears at about 1 year of age and the trochlear nucleus at 7 to 8 years, which affects radiographic interpretation in younger children. Critically, the lateral condyle receives its blood supply almost exclusively from posterior structures — the posterior descending branch of the posterior humeral circumflex artery travels along the posterior aspect of the lateral supracondylar ridge and enters the fragment via the posterior periosteum and capsule. Anterior dissection only is mandatory; any posterior elevation risks partial or complete avascular necrosis. Neurological structures at risk. The radial nerve crosses the anterior humerus about 10 to 12 cm proximal to the lateral epicondyle and must be protected if the approach is extended proximally. The posterior interosseous nerve lies within supinator and is at risk only with excessive anterior retraction or distal dissection beyond the radial head. The ulnar nerve is not in the operative field but becomes relevant later because of progressive cubitus valgus and tardy palsy. Soft-tissue envelope. The Kocher interval between anconeus and extensor carpi ulnaris is avascular and provides direct access to the lateral condyle without muscle division. The common extensor origin and lateral collateral ligament complex attach to the lateral epicondyle and may be avulsed with the fragment in displaced injuries.

Key evidence. Jakob and colleagues (1975) established that displacement greater than 2 mm leads to nonunion or malunion in most nonoperatively managed cases and emphasised preservation of the posterior blood supply. Weiss and colleagues (2009) produced the classification that predicts complications and guides treatment — type 3 injuries uniformly require open reduction. Both K-wire and screw constructs achieve greater than 90 percent union when reduction is anatomic and the posterior hinge is preserved. For established nonunion, Toh and colleagues (2002) showed that debridement, bone grafting and stable fixation achieve high union rates with acceptable function.