Evaluation and management of condylar elbow fractures in children

INTRODUCTION — This review discusses the evaluation and management of condylar elbow fractures in children. The evaluation and management of supracondylar, epicondylar, and transphyseal elbow fractures are discussed separately. (See "Supracondylar humeral fractures in children" and "Epicondylar and transphyseal elbow fractures in children".)

EPIDEMIOLOGY — Lateral condylar fractures account for up to 15 percent of all elbow fractures in children [1-3]. The peak age of injury is six years [4]. Medial condylar elbow fractures are rare (<1 percent of all elbow fractures in children) and typically occur in children older than eight years of age in whom the medial condylar epiphysis is seen radiographically [4].

PERTINENT ANATOMY — The general anatomy of the elbow is discussed separately. (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Pertinent anatomy'.)

The lateral and medial condyles of the elbow extend distally from the relatively weak supracondylar region (figure 1). Fracture through the lateral condyle can extend into the capitellum, disturbing the articulation with the radial head, or into the unossified trochlea, resulting in elbow instability (figure 2). Medial condylar elbow fractures are the mirror image of lateral condylar fractures with the fracture line typically ending in the trochlear notch (figure 3). When displacement of the medial condyle occurs, the elbow joint also becomes unstable.

Ulnar nerve paresthesia is sometimes seen acutely in patients with medial condylar elbow fractures. Otherwise, condylar elbow fracture patterns do not usually lead to significant neurovascular impingement.

MECHANISM OF INJURY — A fall on an outstretched hand is the typical mechanism of injury for both types of elbow condylar fractures:

●Lateral condylar fractures occur after a fall on an outstretched hand where lateral force to the forearm puts varus stress on the elbow joint. This stress causes soft tissue structures (eg, extensor muscles and lateral collateral ligaments) to avulse the lateral condyle (figure 4) [3]. A lateral condylar fracture may also result from a fall on the palm with the elbow flexed. In this mechanism, the radial head is driven directly into the lateral condyle [3,5].

●A fall on an outstretched hand may lead to shear forces on the medial condyle applied by medial extensor muscles and ulnar collateral ligaments (figure 5) [3]. Medial condylar fractures may also follow a posterior blow to the elbow. This mechanism drives the olecranon directly into the medial condyle [6].

PHYSICAL FINDINGS — The child with a medial or lateral condylar fracture typically has elbow pain and swelling over the medial or lateral elbow with limited range of motion [7]. Careful assessment for open fracture and neurovascular compromise should occur in these patients. In contrast to supracondylar fractures in children, serious neurovascular injury is uncommon with condylar fractures, although medial condylar fractures may be associated with ulnar nerve paresthesia [8]. (See "Supracondylar humeral fractures in children", section on 'Clinical presentation'.)

In addition to the initial evaluation of the patient, the neurovascular status of the limb should be reassessed after manipulation or splinting of the fracture.

RADIOGRAPHIC FINDINGS — Radiographs should be obtained in children who present with localized tenderness or swelling of the elbow and known or suspected trauma. Condylar fractures may require up to four views (AP, lateral, and obliques) to be fully characterized. In consultation with a pediatric radiologist or orthopedist, comparison views with the unaffected elbow may be helpful in children with subtle fractures. (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Plain radiographic views'.)

Lateral and medial condylar fractures have characteristics of Salter-Harris IV physeal fractures because they extend from the metaphysis through the physis and into the epiphysis (figure 6) [4]. Growth arrest is relatively rare with these fractures. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal fracture description'.)

Condylar fractures in young children may require magnetic resonance imaging or arthrography to differentiate lateral condylar from transphyseal fractures. An understanding of the ossification anatomy of the elbow should make the distinction between a medial condylar and a medial epicondylar fracture obvious on plain radiographs. (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Further imaging'.)

Lateral condylar fracture — A commonly used classification system categorizes these fractures based on amount of displacement [3]:

●Stage I – Displaced less than 2 mm (image 1 and image 2)

●Stage II – Displaced 2 to 4 mm (image 3)

●Stage III – Completely displaced and rotated (image 4) [9]

The Milch classification system is also used [3]. However, poor correlation between the preoperative radiographic diagnosis and intraoperative findings using the Milch classification has been demonstrated [10]. Milch described two basic fracture patterns:

●Type I – This less common pattern involves a fracture line that passes through the ossification center of the capitellum and enters the joint lateral to the trochlear groove [11].

●Type II – This more common pattern involves a fracture line that passes medial to the trochlear groove. There is potential elbow instability because the radius and ulna can displace laterally with the fragment [12,13].

Medial condylar fracture — These fractures represent a Salter-Harris IV physeal injury (figure 5 and figure 7) [3]. They are further classified as [6]:

●Type I – Greenstick or impacted fracture

●Type II – Complete fracture with intraarticular extension but minimal articular gap

●Type III – Displaced and rotated fragment

INITIAL TREATMENT — Immediate therapy consists of pain management, application of a splint for comfort, and elevation of the arm above the level of the heart [2]. Orthopedic consultation is recommended for condylar fractures with ≥2 mm of displacement to determine appropriate intervention.

Analgesia and immobilization — For children with condylar fractures, initial therapy consists of pain management and immobilization [2]. All children with fractures should be assessed for pain and receive appropriate analgesia. (See "Pain in children: Approach to pain assessment and overview of management principles", section on 'Severity assessment'.)

●Parenteral analgesia (eg, intravenous morphine 0.1 to 0.15 mg/kg, maximum single dose: 10 mg) is most appropriate for initial pain control in patients with moderate to severe pain and should be given prior to radiographic evaluation. Oral analgesia (eg, ibuprofen 10 mg/kg) may suffice for patients who have suffered a nondisplaced condylar fracture. We suggest that the clinician avoid the oral route for patients likely to require sedation or general anesthesia for fracture reduction or repair. In most circumstances, pain relief will result in an improved ability to assess the apprehensive child.

●Immobilization enhances patient comfort and prevents further fracture displacement. The arm should be splinted "as it lies" (typically with the elbow flexed 20 to 30 degrees) using prefabricated splinting material or eight layers of plaster with under cast padding (eg, Webril). A loosely applied elastic bandage (eg, Ace wrap) holds the splint in place. Neurovascular status should be checked before and after splinting.

Orthopedic consultation — Prompt orthopedic consultation should be obtained in the following circumstances:

●Condylar fractures with ≥2 mm of displacement

●Open fracture

●Fracture with neurovascular compromise

Definitive care — Definitive treatment varies for each type of condylar fracture.

Lateral condylar fractures — Treatment is guided by displacement [10,14].

●Stage I (minimal) displacement – Most minimally displaced fractures (<2 mm) can be treated with cast application and early follow-up (image 2). The elbow should be casted at 90 degrees with the forearm in pronation. Since up to 15 percent of these fractures can displace over time [15], close, serial follow-up by an orthopedist with pediatric expertise is stressed. Magnetic resonance imaging (MRI) may be a useful tool to further evaluate fractures to guide surgical decisions [16], but it is not routine. Operative treatment consisting of closed or open reduction and internal fixation is performed if displacement is noted in follow-up (image 1).

●Stage II (moderate) displacement – Closed reduction with percutaneous pinning or open reduction and internal fixation may be employed for fractures with 2 to 4 mm of displacement (image 3) [17-19].

●Stage III (severe) displacement – Fractures that are >4 mm displaced and/or rotated usually require open reduction and internal fixation (image 4) [20-22].

Medial condylar fractures — Type I (greenstick or impacted) and nondisplaced type II (intraarticular) fractures may be treated with cast immobilization with the elbow in flexion and the forearm in neutral position with respect to supination and pronation.

Open reduction and internal fixation is recommended for displaced type II fractures (medial condyle displacement >2 mm) and for type III (displaced and rotated) medial condylar fractures [17].

FOLLOW-UP CARE — Initially nondisplaced and minimally displaced (<2 mm) lateral condylar elbow fractures are unstable despite adequate immobilization by splinting or casting. For this reason, orthopedic follow-up should occur three to four days after initial care [4]. Healing of the lateral condyle can take longer than other elbow fractures, and pediatric orthopedic experts have noted that 6 to 12 weeks of immobilization may be required for successful closed treatment [14,21,23].

Weekly orthopedic evaluation is appropriate for children with nondisplaced medial condylar fractures.

Children who have received operative care (closed reduction with percutaneous pinning or open reduction with internal fixation) should be admitted for 24 to 48 hour observation of neurovascular status and soft tissue compartments. Once discharged, these patients are followed closely and may require weekly orthopedic evaluation with radiographs to determine the optimal timing for subsequent hardware removal. Also, range of motion exercises and/or physical therapy are recommended for these injuries.

COMPLICATIONS — Nonunion (image 5) is a more common complication of lateral condylar fractures than other pediatric elbow fractures but is still rare (about 1 to 2 percent of surgically repaired fractures) [24,25]. A nonunion may lead to progressive displacement and proximal migration of the fragment. These events increase valgus deformity and may result in an ulnar nerve palsy that occurs many years after the injury [12,20]. Once recognized, prompt surgical treatment of a nonunion is suggested. Before 12 weeks post-injury, anatomical reduction and percutaneous pinning can be used to fix a minimally displaced nonunion with good results [17,26]. After 12 weeks post-injury, attempted reduction of a displacing nonunion is not recommended because of the risk for avascular necrosis. An open approach with bone grafting and internal fixation may be required at this stage [21,27].

Post-operative infection is described in about 1 to 2 percent of patients undergoing surgical repair of lateral humeral condylar fractures and is associated with percutaneous pinning of the fracture [24,25].

A rare complication of lateral condylar fractures is a "fishtail deformity" (image 6) [28]. This term describes the inverted U or V shape resulting from the continued growth of the medial and lateral portions of the physis after premature closure of the central portion. It has been attributed to avascular necrosis [29]. Because the distal humerus contributes little to the overall longitudinal growth of the humerus, length discrepancy is uncommon [12]. Although this deformity is generally well tolerated in children, future deformity could be minimized by surgical arrest of the remainder of the physis with little to no functional length discrepancy expected [29].

Other complications of lateral condylar fractures include cubitus valgus or varus deformity (image 7 and figure 8), ulnar nerve palsy, and formation of lateral spurs [10].

Potential complications of medial condylar fractures include nonunion, physeal injury, avascular necrosis, cubitus varus or valgus deformity, ulnar nerve palsy, and loss of elbow motion [3,4].

OUTCOMES — The prognosis for long-term outcome and function following condylar elbow fractures is good if the fracture is diagnosed and treated in a timely manner. However, if missed, lateral or medial condylar fractures may result in nonunion and elbow deformity (cubitus valgus or varus), stiffness, or delayed ulnar nerve palsy (image 7 and figure 8) [30-33].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Elbow fracture (The Basics)" and "Patient education: How to care for your child's cast (The Basics)")

●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS — Lateral condylar elbow fractures are the second most common elbow fractures in children. Medial condylar elbow fractures are rare (<1 percent of elbow fractures). Early recognition and proper management of these fractures is essential to avoid elbow deformity and functional impairment caused by nonunion. (See 'Epidemiology' above and 'Complications' above.)

●Fall on an outstretched hand is a typical mechanism of injury for both medial and lateral condylar elbow fractures (figure 4 and figure 5). (See 'Mechanism of injury' above.)

●The child with a medial or lateral condylar elbow fracture has elbow pain and swelling over the medial or lateral elbow with limited range of motion. Neurovascular compromise is unusual. (See 'Physical findings' above.)

●Initial treatment consists of pain management, application of a splint for comfort, elevation of the arm above the level of the heart, and radiographic evaluation. (See 'Initial treatment' above.)

●Condylar fractures may require up to four views (AP, lateral, and obliques) to be fully characterized. Comparison views with the unaffected elbow may be helpful in children with subtle fractures. Condylar elbow fractures in young children (<5 years of age) often require magnetic resonance imaging or arthrography to differentiate lateral condylar from transphyseal fractures or medial condylar from medial epicondylar fractures. (See 'Radiographic findings' above and "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Plain radiographic views'.)

●Classification of condylar elbow fractures based on the amount of radiographic displacement guides further care, including the need for orthopedic consultation at the time of the emergency department visit and operative care (figure 2). (See 'Lateral condylar fracture' above and 'Medial condylar fracture' above.)

●Prompt orthopedic consultation should be obtained in children with condylar elbow fractures that have ≥2 mm of displacement on radiograph, open fractures, or fractures with neurovascular compromise (image 3 and image 4). (See 'Orthopedic consultation' above and 'Definitive care' above.)

●Displaced lateral condylar fractures and most medial condylar fractures require open reduction and internal fixation. (See 'Definitive care' above.)