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INDICATION
HOW TO FIX A
LATERAL CONDYLE
FRACTURE
Practical tips for percutaneous screw
fixation
Visible gap on plain films
Virtually undisplaced lateral condyle fractures can be
treated in an above elbow cast only but need to be
monitored carefully and immobilised for a minimum of 6
weeks.
If a gap is visible with significant soft tissue swelling1,
fixation is recommended to avoid progression of
displacement or late complication of non-union/malunion.
Severely displaced lateral condyle fractures need open
reduction and screw fixation (lateral or postero-lateral
approach, not part of this Pocket guide)
IMAGING
SETUP
The setup is similar to
supracondylar fixation:
Arm table with head-ring and
patient's head on arm table
High arm tourniquet (if
conversion to open reduction
necessary)
C-arm at foot end
Screens opposite operating
table (see sketch)
EQUIPMENT
Partially threaded
cannulated cancellous screws
(4.0 mm, range 28-40 mm)
Smooth guide wire 1.3 mm
(avoid threaded wires
as risk of ulnar nerve injury reported)
Cannulated drill bit (2.5 or 2.7 mm), screw driver
Power tool
General ortho tray
Silicone dressing and gauze
Wool and Crepe bandage
Plaster of Paris
PREPARATION
Before skin preparation, the reducibility is
checked.
Especially medially hinged fragments are
amenable to the percutaneous technique,
but intra-articular fractures might reduce as
well.If the fragment does not line up or is
rotated, open approach is necessary.
Internal oblique view
The degree of displacement
is best appreciated in the
internal oblique view and
should always be requested.
Cannulated cancellous screw kit
Alignment check
STEPS
The
elbow is flexed
in forearm supination (assistant), as
pronation causes pull on the fragment.The blunt end of
the guide wire is held against the skin lateral to the tip of
the olecranon aiming for the lateral corner of the distal
humerus.
Hence, Icheck entry point on
Jones view
and external
rotation lateral view (Internal rotation will displace the
fragment).
The entry point is posterior to the capitellum,aiming the
the wire slightly anterior (perpendicular to fracture line).
The wire does not need to engage with the medial
cortex. Once the position is satisfactory, the length is
measured, at least 4-6 mm subtracted, depending on
the gap size, to allow for compression across the
fracture site.The near cortex is then carefully drilled
and the screw advanced and compression achieved.We
do not normally use awasher.
PRE-AND POST OP IMAGES
The skin mark of the wire acts as marker for
the stab incision. The aim is to transfix the
small metaphyseal fragment proximal to the
physis right at the corner of the lateral distal
humerus (see yellow arrow), passing the
wire into the lateral column avoiding the
olecranon fossa but staying low enough for
cancellous bone purchase.
POSTOP
After infiltration of local anaesthetic,the stab incision can be
closed with absorbable sutures.
The elbow is then immobilized for 4 weeks in an above
elbow lightweight cast after which it can be mobilized with
gentle exercise and avoidance of impact sports for another
6-8 weeks.
Screw can be removed at 3-6 months only if symptomatic
Complications1:
Stiffness 8%,Superficial wound infection 3%, Metalwork
failure or exposure 2%, Malunion 2%
SCREW
Screw fixation vs. K-wire fixation (n=101 vs. 235)1:
0
%
vs. 5.1
%
Non-union
0
%
vs. 2
%
Wound infection requiring further
surgery
1Ganeshalingam R, Donnan A, Evans O, Hoq M, Camp
M, Donnan L. Lateral condylar fractures of the
humerus in children. Bone Jt J. 2018;100B(3):387–95
.
Disclaimer: Level 5 evidence, personal view on management only, please refer to local guidelines and expertise