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Fractures around elbow lateral condyle and intercondylar fractures
1) Lateral condyle fractures and intercondylar fractures of the elbow involve fractures around the lower end of the humerus. 2) Lateral condyle fractures, which account for 17% of distal humeral fractures in children, often require fixation to prevent nonunion. Intercondylar fractures in adults involve a T or Y-shaped fracture through the two humeral condyles. 3) Treatment depends on the type and severity of the fracture, ranging from casting for nondisplaced fractures to open reduction and internal fixation for displaced fractures to prevent long-term complications like nonunion and deformity.
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Fractures around elbow lateral condyle and intercondylar fractures
- 1. Fractures around theelbow (Lateral condyle fractures and intercondylar fractures) Dr Siddhartha Sinha, Assistant Professor Department of Orthopaedics HIMSR and HAHC hospital, New Delhi
- 2. Anatomy • Hinge jointwith articulation between • Lower end of the humerus with ulna (humero-ulnar joint) • Head of the radius (humero-radial joint). • Distal humerus is enlarged to form • Trochlea medially, Medial to the trochlea is a prominent process - medial epicondyle • Capitulum laterally, :Lateral to the capitulum is the lateral epicondyle.
- 5. Three bony pointsrelationship • 3 Points • Medial epicondyle, • Lateral epicondyle • Tip of the olecranon • Extension = straight line • Flexion = isosceles triangle • Deranged in • Elbow dislocation • Lateral condyle/ Medial epiondyle # • Intercondylar # elbow (increased base) • Maintained in • Supracondylar fractures • 4th point: Head of radius (palpate in semi flexed elbow in pronation and supination)
- 6. Carrying Angle • Angleformed between arm and forearm on full extension and supination • 11° in males • 14° in females • Evolution so that upper limb can clear body when carrying loads.
- 7. Carrying angle • Increased= Cubitus valgus • Decreased = Cubitus Varus
- 9. Paediatric elbow • Upperextremity fractures 65-75% of all paeditric traumas due to tendency of children to fall on oustretched hand. • Distal humerus # -86% of all elbow # in children • Supracondylar # - Most common • Lateral condyle # • Medial epicondyle # • Physis may be confused for a fracture in children • Good clinical examination • Radiographs of bilateral elbow for comparison
- 10. Ossification around elbow •A) CRMTOL: Mnemonic for the appearance of the ossification centers around the elbow • Capitellum: 6 months to 2 years; includes the lateral crista of the trochlea • Radial head: 4 years • Medial epicondyle: 6 to 7 years • Trochlea: 8 years • Olecranon: 8 to 10 years; often multiple centers, which ultimately fuse • Lateral epicondyle: 12 years • B) Age of fusion of ossification centers
- 11. Radiography of paediatricelbow • Standard AP view • Baumanns angle: the angulation of the physeal line between the lateral condyle and the distal humeral metaphysis. • Humeral- ulnar angle –true carrying angle • Metaphyseal –diaphyseal angle • Special view- • Jones view • Internal and external rotation views
- 12. • Lateral view •Tear drop • Shaft condylar angle • Anterior Humeral line • Coronoid line • Lateral Humerocapitellar angle • Fat pad signs • Olecranon (posterior) • Coronoid (anterior) • Supinator
- 13. Lateral condyle Fractures •17% of all distal humeral fractures in children • Peak age 6yrs • Fracture of necessity- must be fixed as it often leads to non union • Often result in less satisfactory outcomes than supracondylar fractures because: • Diagnosis less obvious and may be missed in subtle cases. • Loss of motion is more severe due to intra-articular nature. • The incidence of growth disturbance is higher
- 14. Anatomy of lateralcondyle fractures • Anatomy • The ossification center of the lateral condyle extends to the lateral crista of the trochlea. • Typically accompanied by a soft tissue disruption • origins of the extensor carpi radialis longus and the brachioradialis muscles • remain attached to the free distal fragment, accounting for initial and late displacement of the fracture. • Disruption of the lateral crista of the trochlea (Milch type II fractures) results in posterolateral subluxation of the proximal radius and ulna with consequent cubitus valgus
- 15. Mechanism of injury •“Pull-off” theory: Avulsion injury occurs by the common extensor origin owing to a varus stress exerted on the extended elbow. • “Push-off” theory: A fall onto an extended upper extremity results in axial load transmitted through the forearm, causing the radial head to impinge on the lateral condyle.
- 16. Clinical evaluation • Pain •Swelling • Tenderness to palpation • Crepitus • Painful range of motion • Pain on resisted wrist extension
- 17. Radiographic Evaluation • AP,lateral, and oblique views of the elbow • Varus stress views may accentuate displacement of the fracture. • Radiological D/D: • Lateral condyle fracture • Fracture of the entire distal humeral physis • Arthrogram: assess relationship of lateral condyle to proximal radius and distinguish from complete distal humeral physeal fracture • MRI – • Appreciate the direction of the fracture line and the pattern of fracture. • Not routinely done
- 18. Classification of lateralcondyle fractures • Milch • Type I • The fracture line courses lateral to the trochlea and into the capitellar–trochlear groove. • Salter-Harris type IV fracture: the elbow is stable because the trochlea is intact • Less common. • Type II: • The fracture line extends into the apex of the trochlea. • Salter-Harris type II fracture • Elbow is unstable because the trochlea is disrupted; • More common
- 19. Classification • Stages ofdisplacement (Jakob et al) • Stage 1: Fracture relatively non displaced, articular surface intact, trochlea intact, no lateral shift of olecranon • Stage 2: Fracture extends completely through the articular surface, proximal fragment displaced, lateral shift of olecranon • Stage 3 condylar fragment rotated, displaced laterally and proximally, translocation of olecranon and radial head.
- 20. Treatment • Non operative •Non-displaced or minimally displaced fractures (Jakob stage I; <2 mm) • Simple immobilization in a posterior splint or long arm cast with the forearm in neutral position and the elbow flexed to 90 degrees • This is maintained for 3 to 6 weeks until there is healing of the fracture, after which range-of-motion exercises are instituted.
- 21. • Closed reduction •Varus force as well as supination and extension may be attempted • Jakob type II fractures. • If articular reduction is achieved hold with percutaneous wires in order to prevent displacement. • An arthrogram can be performed to ensure a reduction was achieved. • Closed reduction is often difficult because of medial soft tissue swelling • Not routinely done
- 22. • Open Reduction •Stages II and III fractures. • Open reduction using lateral approach and fixation with K wires • Postoperative immobilization -long arm casting/slab with the forearm in neutral rotation and the elbow flexed to 90 degrees for 3 to 4 weeks • After 3-4 weeks pins and the cast may be discontinued and active range-of- motion exercises instituted. • If treatment is delayed (>3 to 6 weeks) • closed treatment regardless of displacement, • High incidence of osteonecrosis of the trochlea and significant joint stiffness from extensive dissection with late open reduction
- 23. Complications of lateralcondyle fractures 1. Nonunion: • Wide displacement of fragment and soft tissue interposition • “ Pull of extensors” attached to fragment • Treatment: Early cases- ORIF, Late cases- Manage consequences like deformity and instability
- 24. • Angular deformity: •Cubitus valgus may result from overgrowth of the medial condyle. • Treatment of cubitus valgus: • Mild – no t/t • Moderate to severe deformity- supracondylar osteotomy
- 25. 3. Late ulnarnerve palsy (tardy Ulnar nerve palsy) due to cubitus valgus (late complicaition) 1. C/o tingling and numbness in the distribution of ulnar nerve 2. T/t : Anterior transposition of ulnar nerve in front of the medial epicondyle to prevent friction 4. Osteonecrosis: 1. After open reduction and internal fixation, with extensive soft tissue dissection 5. Ulnar neuropathy: 1. Early, related to trauma 2. More commonly, late, related to the development of angular deformities or scarring. 3. Symptoms may be addressed with ulnar nerve transposition.
- 26. Intercondylar fractures • 2ndcommon distal humerus fractures in adults (1st= extraarticular # distal humerus) • T or Y shape of fracture line • Comminution common
- 27. Mechanism of injury •Fall on elbow driving olecranon into distal humerus splitting the two condyles due to the action of the flexors (medially ) and extensors (laterally) and rotation around the horizontal axis
- 28.
- 29. Treatment • Nonoperative Management •Nondisplaced fractures, • Elderly patients with displaced fractures • Severe osteopenia and comminution • Patients with significant comorbid conditions precluding operative management. • Cast immobilization: • Not preferred due to inadequate fracture reduction and prolonged immobilization. • “Bag of bones”: • The arm is placed in a collar and cuff with as much flexion as possible after initial reduction is attempted; gravity traction helps effect reduction. The idea is to obtain a painless “pseudarthrosis,” which allows for motion.
- 30. Operative management • Preferredtreatment • Aim to restore joint surfaces, columns and tie arch Open reduction and internal fixation • Interfragmentary screws • Dual plate fixation: • one plate medially and another plate placed posterolaterally • 90 degrees from the medial plate or two plates on either column • 180 degrees from one another • Total elbow arthroplasty (cemented, semiconstrained): • This may be considered in markedly comminuted fractures and with fractures in osteoporotic bone. • Postoperative care: Early range of motion of the elbow is essential unless fixation is tenuous
- 31. Complications • Posttraumatic arthritis: •articular injury at time of trauma • failure to restore articular congruity. • Failure of fixation: • Loss of motion (extension): • With prolonged periods of immobilization. • Range of motion exercises should be instituted as soon as the patient is able to tolerate therapy, • Heterotopic bone • Neurologic injury (up to 15%): The ulnar nerve is most commonly injured during surgical • exposure. • Nonunion of osteotomy: 5% to 15% • Infection