Lateral Condyle Fractures – Approach to Nonunion
Clearly, there is a propensity for these to go on to nonunion.
The controversy in treating them late all surrounds the issue of causing iatrogenic avascular necrosis of the piece.
– some say that they would not treat if seeing the kid 3 weeks after injury.
– others feel that it is safe to treat them even if seen first at 6-8 weeks post injury
– if beyond 12 weeks, it is not recommended that you attempt reduction of the significantly displaced fracture – the AVN rate is too high
If less than 2 mm displaced – percutaneous pin the thing and immobilize, Do not open it.
If displaced, then you’ve got a few things to think about
– fix in situ and accept the deformity; anticipate the need to do an osteotomy later to correct the cubitus valgus.
– attempt a reduction and increase the risk of AVN
– if you are going to do the reduction and ORIF, then DO NOT dissect into the posterior soft tissue attachments of the lateral condyle.
So on the exam, these are the considerations that you should describe
– time after injury – 3-8 weeks probably okay to do try reduction; beyond 12 weeks you DEFINITELY go for in situ fusion.
– amount of displacement
– the risk of AVN if you attempt reduction and strip the posterior soft tissues
– the risk of progressive cubitus valgus and tardy ulnar nerve palsy if you fix in situ.
My approach. This case gets referred to a surgeon with pediatric orthopaedic experience, or I do it with my “senior partner” who has pediatric orthopaedic experience.
If the lateral condyle is minimally displaced
– IN SITU percutaneous pin or cannulated screws (depending on size of patient) for rigidity and stability only. No reduction. Do it all closed with image intensifier.
If the lateral condyle is displaced and the elbow is in valgus
– medial approach first – transpose the ulnar nerve
– lateral Kocher approach, staying anteriorly – bone graft the condyle (from olecranon) and fix in situ
– once healed and range of motion is good, then come back for corrective varus osteotomy.