If you are a parent, nanny, grandparent, or caretaker of any kind for children, you know the moment of panic when the child comes running in crying, holding the arm, often in hysterics. Or worse -- someone else comes running in to report that the child in your care is down and something is "wrong." Is it just a minor "owie" that needs a kiss and a hug? Or could it be something more serious like a broken bone at the elbow?
Swelling, bruising, and pain or tenderness that persist are all signs that a medical examination is needed. The physician will take a history to find out what happened (usually a fall or trauma of some kind) and examine the arm. X-rays quickly tell the rest-of-the-story. If there are no obvious broken bones, a CT scan or MRI may be needed to look for soft tissue damage. Sometimes more complex fractures also require this type of more advanced imaging.
Bone fractures in children near a joint (the elbow in this case) raise additional concerns because of the potential to affect the growth plate and thereby stunt growth. If the joint surface is disrupted (no longer lined up properly), treatment is directed toward realigning the bones and joint (called reduction). At the same time, the surgeon will stabilize the bone fracture (i.e., hold the bones together) while healing takes place. Fixation of the fracture is usually done with hardware such as a metal plate, screws, or wires.
In the case of a simple lateral condylarfracture, nonoperative care may be enough. The lateral condyle is the round end of the humerus (upper arm bone) that forms the upper part of the elbow joint. The arm is put in a cast or splint to immobilize it during healing. Close follow-up is important in order to make sure the bones keep their good alignment without displacement (separation), malunion, or malrotation.
Surgery is advised any time there is a disruption in the joint surface, altering the normal elbow anatomy. Exactly what type of surgical procedure is done depends on the severity of the fracture. Surgeons use a special tool called the Jakob classification to determine what type of surgery is needed. This classification scheme defines joint alignment (displaced vs. nondisplaced, malrotated, and whether or not the growth plate was affected).
There are three basic groups in this classification. Jakob I means the fracture is not displaced or separated and can be treated with conservative (nonoperative) care. Jakob II fractures are displaced by more than two millimeters but without any rotation. Jakob III describes a fracture that is separated completely AND rotated. Jakob II and III elbow fractures of the lateral condyle will require surgery to reduce and stabilize them.
As with other bone fractures, these kinds of elbow injuries can be treated with open or closed reduction. The type of fixation device used (plate, screw, pin, wire) depends on the location of the fracture, severity, and whether or not the growth plate has been disrupted. Open reduction is typically required when there is significant malalignment and malrotation. While the patient is still under anesthesia, the surgeon makes sure the joint surfaces are lined up properly and the joint moves fully and freely.
This sounds all so very simple and straightforward but, in fact, the surgery can be very complex and challenging. There may be multiple bone fragments to deal with. The sharp edges of the bone can come in contact with nerve tissue or blood vessels causing further damage. Loss of blood supply to the area will further compromise healing.
Another tool surgeons use to evaluate lateral condylar humeral fractures is an arthrogram. A special contrast dye is injected into the joint that shows the joint surface and any places where the joint doesn't line up. When everything in the joint is where it should be, it's referred to as articular congruity. The arthrogram shows how well the joint surfaces conform to each other (i.e., match up).
In summary, the three most important bits of information about lateral condylar (elbow) fractures in children for surgeons to keep in mind are: 1) Treat Jakob I fractures conservatively with cast immobilization but keep an eye one these for any signs of problems. 2) The goal of all treatment is to restore joint alignment as close to normal as possible. 3) Use hardware to hold fractures together until X-rays show they are stable without malunion or malrotation.
Reference: Kwan Soon Song, MD, and Peter M. Waters, MD. Lateral Condylar Humerus Fractures: Which Ones Should We Fix? In Journal of Pediatric Orthopaedics. June 2012. Supplement. Vol. 32. No. 1. Pp. S5-S9.