THE TREATMENT OF LATERAL CONDYLE FRACTURES IN CHILDREN

Abstract

Aims and Objectives Lateral condyle fractures can be difficult diagnose and the treatment still remains controversial. It is well known that these fractures are prone to a number of complications, both early and late. The aim of this paper was to review the treatment practice of lateral condyle fractures presenting to a children’s hospital fracture unit over the past 5 years to identify any consistency in the management of these fractures. We also aimed to try and determine if a particular treatment method was more favourable than others in terms of complications and the need for further surgery with a view to developing a treatment protocol.

Methods: We conducted a chart and x-ray review of all lateral condyle fractures treated operatively from December 1998 to August 2004. We recorded patients’ age, sex, side of injury and month of injury. The fractures were classified according to the Milch classification. We also measured the preoperative and postoperative fracture displacement. We recorded the nature of surgery (Examination Under Anaesthetic (EUA) and casting, Manipulation Under Anaesthetic (MUA) and wiring and Open Reduction and wiring). We documented whether the wires were percutaneous or buried. Length of time in cast and length of time to wire removal were also noted. Finally any complications and the need for further surgery were documented.

Results: 90 patients were identified. 72% were male and 28% female, with an average age of 5.6. 28% of injuries were right sided, 72% were left sided. 21 (23%) patients were Milch Type 1 fractures and 66 (73%) were Type II fractures. Preoperative fracture classification was unavailable for 3 patients. In 78 patients we were able to determine the initial fracture displacement. 8 (9%) patients were displaced < 2 mm, 18 (20%) were displaced 2–4 mm and 52 (58%) were displaced > 4 mm. 7 patients (10%) had associated elbow dislocations – all of these were Milch type II fractures. 5 patients had EUA and casting, 19 had MUA and K wiring and 63 had open reduction and wiring. In the 19 patients who had MUA and K wiring, 13 were percutaneous and 6 were buried. In the open reduction and wiring group 59 patients had their wires buried and 6 were percutaneous. 1 patient did not have that information recorded.

The average time in cast was 41 days. In those with buried wires average length of time to wire removal was 63 days. Average percutaneous wire removal was at 42 days. For the 5 patients undergoing EUA and casting residual displacement was < 2 mm in all. 2 of these patients (40%) had complications of lateral spur formation and delayed union. For the 19 having MUA and k wiring, 14 had a post op displacement of< 2 mm and 5 had 2–4 mm displacement. 3 of the 14(21%) had the complications of spur formation, pin site infection and wire prominence. 2/5 (40%) of those with residual displacement of 2–4 mm developed complications, 1 patient had ulceration of wires through the skin and another had loss of position requiring further surgery.

In the patients treated with open reduction and wiring 51 had a residual displacement of < 2 mm, 14 had 2–4 mm residual displacement and 1 remained displaced > 4 mm. 11/51 (22%) in the first category developed complications. 6 were problems with the wires, 1 lost position requiring re-operation, 1 lateral spur development. 2 malunions and 1 delay in ossification of the lateral condyle. In the 2–4 mm group 8/14 (57%) developed complications. – 2 wire ulcerations, 2 wound infections, 1 non-union and 3 malunions. Finally the 1 patient with residual displacement > 4 mm developed a malunion requiring further operative intervention.

In total 5 patients had further surgery - 1 patient for wire prominence 2 for loss of position and 2 patients required corrective surgery for malunion.

Conclusion: This study highlights the variety in treatment methods for these fractures. Complications occurred in all treatment groups. The short term complications such as wire problems and initial loss of position had no long term sequelae. All malunions occurred in the open reduction and wiring group, despite 2 patients having post operative fracture displacement of < 2 mm. The patient with a non union was a late referral but underwent open reduction and wiring at our unit and subsequently healed. We recommend that displaced fractures should be reduced either closed or open and all fractures should be secured with k wires to prevent loss of position. These should be bent and buried allowing them to remain insitu for 3 months. Postoperative casting should be for 6 weeks. These fractures need to be followed closely at fracture clinic for the short and long term problems they can develop.