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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 650-654

Closed reduction and percutaneous pinning for the treatment of lateral humeral condyle fracture


1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, El-Obour Hospital for Health Insurance, Kafr El-Sheikh, Egypt

Date of Submission12-Nov-2017
Date of Acceptance03-Jan-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Ahmed M Mabrouk
Department of Orthopedic Surgery, El-Obour Hospital for Health Insurance, Kafr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_793_17

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  Abstract 


Objective
The aim of the present study was to evaluate the result of treatment of recent fracture of the lateral humeral condyle in children using closed reduction and percutaneous pinning.
Background
Few reports have focused on closed reduction and internal fixation of fractures of the lateral humeral condyle in children. We prospectively studied closed reduction and internal fixation to determine its usefulness as the treatment for fractures of the lateral condyle of the humerus in children.
Patients and methods
The lateral condylar humeral fractures were classified into three groups according to the degree of displacement and the fracture pattern as determined on four radiographic views (Jacob classification). On the basis of this classification system, we prospectively treated 60 fractures and assessed the quality of closed reduction according to the criteria of Hardacre and colleagues
Results
All six patients of stage 1 fractures were reduced to 1 mm of residual displacement with excellent results. A total of 42, stage 2 fractures were reduced to less than 2 mm of displacement with excellent results and four patients had good results. In six patients of stage 3 had excellent results and two patients had good result. There were no major complications such as early physeal arrest, osteonecrosis of the trochlea or capitellum, nonunion, malunion or osteomyelitis.
Conclusion
Closed reduction and internal fixation is an effective treatment for lateral humeral condylar fractures of the humerus in children. If fracture displacement, after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended.

Keywords: children, closed reduction, fracture, lateral condyle, pinning


How to cite this article:
Neena HA, Habib ME, Mabrouk AM. Closed reduction and percutaneous pinning for the treatment of lateral humeral condyle fracture. Menoufia Med J 2019;32:650-4

How to cite this URL:
Neena HA, Habib ME, Mabrouk AM. Closed reduction and percutaneous pinning for the treatment of lateral humeral condyle fracture. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:650-4. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/650/260924




  Introduction Top


Fractures of the lateral humeral condyle of the humerus comprise 17% of all fractures of the distal end of the humerus in children[1]. In fact, they are the most common distal humeral epiphyseal fractures[2]. These fractures are often missed by the emergency physician[3]. According to the amount of displacement, fractures of the lateral condyle of the humerus are classified into three types. Type I: undisplaced, type II: moderately displaced, and type III: completely displaced and rotated[4],[5]. Proper treatment of fracture of the lateral humeral condyle in children requires recognition of the fact that the injury is an intra-articular transepiphyseal fracture and four factors cause difficulty in treatment. (a) The pull of the extensors of the wrist and fingers originating on the condylar fragment tends to displace and rotate that fragment. This force makes the reduction difficult to be obtained and maintained. (b) The articular surface must be anatomically reconstituted. (c) Segmental injury of the epiphyseal plate increases the possibility for deformity as a result of disturbance of growth. (d) Synovial fluid bathing the fracture line may discourage union[6]. Methods of treatment: (a) nonoperative treatment, (b) operative treatment: (i) closed reduction and percutaneous pinning, or (ii) open reduction and internal fixation.


  Patients and Methods Top


This study included 60 patients with fracture involving the lateral humeral condyle in children admitted to Menoufia University Hospital and El-Obour Insurance Hospital from June 2013 to March 2015. The cases were treated by closed reduction under image intensifier and percutaneous Kirschner wire fixation after approval of the ethical committee of the hospital was taken.

Inclusion criteria

The inclusion criteria were: children below 12 years old, recent trauma within 48 h, closed fracture, complete fracture, fracture can be reduced in closed technique, and mild hematoma around the fracture fragment.

Exclusion criteria

The exclusion criteria were: age above 12 years old, trauma of more than 48 h, open fracture, and fracture that cannot be reduced in closed technique.

Each patient was submitted to clinical and radiological examination. The results were assessed and graded into excellent, good, and poor according to the criteria of Hardacre et al.[6].

Method of treatment

A total of 60 children with fractures of the lateral humeral condyle treated by closed reduction under image intensifier and percutaneous Kirshner wire fixation.

General anesthesia is applied to the patient. The patient is placed in a supine position so that the shoulder lies over the edge of the table. To reduce unstable fractures, traction with a gentle varus force was applied to the elbow. For stage 2 fractures, gradual direct compression was applied to the fracture fragment anteromedially. For stage 3 fractures, an attempt was made to reposition the rotated fragment by using Kirschner wires as joysticks or by pushing directly on the fragment. A slight valgus force was applied to the elbow, with the forearm supinated and the elbow slightly extended, to maintain reduction. The fracture reduction was confirmed to be within 2 mm, especially on the internal oblique radiographs. Percutaneous pinning with two or more smooth Kirschner wires was performed. We used 1.2-mm-diameter Kirschner wires for patients younger than 3 years of age, 1.4-mm-diameter wires for those between 3 and 5 years of age, and 1.8-mm diameter wires for those older than 5 years of age. If we could not reduce the fragment to within 2 mm as shown on any of the four radiographic views, open reduction and internal fixation was performed. A long-arm cast was applied in all cases and was left in place for 4–6 weeks. We removed the pins 4–5 weeks after the surgery. At the time of the last follow-up, the degree of fracture displacement, elbow range of motion, radiographic changes, and clinical symptoms were evaluated. Results were graded according to the criteria suggested by Hardacre et al.[6] [Table 1],[Table 2],[Table 3],[Table 4].
Table 1: Relation between end results and age of patients

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Table 2: Relation between end results and the side affected

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Table 3: The relation between the end result and the Jacob classification

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Table 4: The relation between the end result and time of radiological union

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  Results Top


According to the criteria of assessment of the results described by Hardacre et al.[6], the overall results of the whole material were as follows: 54 (90%) patients had excellent results and, six (10%) patients had good results.

It was found that the young patients aged below 3 years gave excellent result. In patients aged between 3 and 5 years, 28 gave excellent results; in patients aged between 5 and 7 years 18 patients gave excellent results; and four gave good results. In patients aged 7 and 9 years, six patients gave excellent results and two patients gave good results. The figures obtained were found to be significant; the youngest patients gave the best results [Table 1].

It was found that first stage patients under Jacob classification were six patients who all gave excellent results; patients with second stage were 42 patients who gave excellent results; and four patients gave good results. Of the patients with third stage of displacement, six patients gave excellent results and two patients gave good results. The figures obtained were found to be of significant relation. There is significant correlation between the stage of fracture and the end results, with the low-stage fracture giving best results [Table 3].

Complications

(a) Limitation of elbow movements: incomplete extension was found in four patients, extension loss was 15° from full extension in second stage only. (b) Cubitus varus was detected in two patients with 10° in third stage only with full range of movement. (c) Lateral protrusion was observed in 16 patients with overgrowth of lateral condyle without affection of movement. (d) There were a total of 12 (20%) cases of pin-tract infection in the form of looseness and discharge. They were cleared off of infection within 1 week after removal of the wires without affection of the results.

Case 1

A male child, 3 years old with fracture of the left lateral humeral condyle Jacob stage 2, following a fall hurting his left elbow.

[Figure 1]a Preoperative radiography anteroposterior view shows fracture of the lateral humeral condyle, stage 2.
Figure 1: Radiograph of the fracture involving the left lateral humeral condyle in a male child of 3 years old. (a) Preoperative radiographies, (b) postoperative radiographies, (c and d) united fracture 6 months after surgery.

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[Figure 1]b Postoperative radiography anteroposterior view shows good reduction and stable fixation by two Kirschner wires.

[Figure 1]c Follow-up radiography anteroposterior view 6 months postoperative shows united fracture of lateral humeral condyle.

[Figure 1]d Follow-up radiography lateral view 6 months postoperative shows united fracture of the lateral humeral condyle.


  Discussion Top


Fracture of the lateral humeral condyle is the second most frequent fracture of the elbow in children. This diagnosis may be less obvious both clinically and radiographically. As with other elbow fractures in children, a poorly treated, lateral condylar fracture is more likely to result in loss of elbow motion. Initial diagnosis of fracture of the lateral humeral condyle in children is very important to prevent complications[7],[8].

This fracture affects boys more than girls, left elbow more than the right, and better prognosis in young children than older children[9].

Fractures with minimal displacement treated with plaster fixation may show more displacement inside the plaster. Internal oblique view is the most important view that shows displacement of the fracture fragment[10].

Treating a minimally displaced fracture may be difficult primarily because it is difficult to determine whether the distal fracture fragment is prone to further displacement. The common practice of using only anteroposterior and lateral elbow radiographs does not always provide adequate information to allow the physician to determine fracture stability, to prevent further displacement, and to identify an optimal treatment method for these fractures. Many other studies, such as magnetic resonance imaging, arthrography, stress tests, and ultrasonography, have been suggested as additional methods to evaluate fracture stability. However, the routine use of these modalities may not be applicable because of their cost and the need for sedation of the patient[11].

Generally, there has been uniform agreement regarding the need for open reduction and internal fixation of displaced fractures of the lateral condylar physis of the humerus. Because it is difficult to maintain the reduction of a displaced lateral condylar fracture and because of the high prevalence of poor functional and cosmetic results associated with closed reduction and casting, open reduction and internal fixation have become the most widely advocated method for the treatment of unstable fractures with Jacob stage 2 or 3. However, even patients who are treated with open reduction and internal fixation may have development of malunion because of a lack of intraoperative confirmation of the reduction status, osteonecrosis caused by excessive soft-tissue dissection, infection of the wound, or bad cosmetic correction of the wound scar.

Only a few reports have focused on percutaneous pin fixation of these fractures. Mintzer et al.[12] reported good results after percutaneous pin fixation of 12 lateral condylar fractures with displacement in excess of 2 mm. They believed that this method is appropriate for selected fractures with 2–4 mm of displacement and an arthrographically demonstrated congruent joint space. Foster et al.[13] reported that percutaneous pin fixation of nondisplaced and minimally displaced fractures is an acceptable alternative in any situation in which close clinical and radiographic follow-up cannot be ensured.

Song and colleagues[4],[11] showed a high success rate (73%) in association with closed reduction and pin fixation for the treatment of unstable displaced fractures, while others have reported that closed reduction and internal fixation is not recommended for the treatment of Jacob stage 3 displaced and rotated lateral condylar fractures. Song and colleagues achieved excellent results in three of six rotated fractures with use of closed reduction and pin fixation. He acknowledges that the number of cases is small and that additional prospective studies are needed to further evaluate this approach for the treatment of fractures with an unstable and rotated fragment. It is our impression that the reasons for our high success rate with closed reduction and internal fixation were (a) the accurate interpretation of the direction of fracture displacement (mainly posterolaterally, not purely laterally), (b) routine intraoperative confirmation of the reduction on both anteroposterior and internal oblique radiographs, and (c) maintenance of the reduction with two parallel percutaneous Kirschner wires.

In a comparative study between closed reduction and percutaneous pinning versus open reduction and internal fixation in children for stage 2 lateral condyle humerus fractures displaced greater than 2 mm, Andrew et al.[14] and Silva et al.[15], recommended closed reduction and internal fixation is a viable alternative for the treatment of pediatric lateral condyle fractures with limited initial displacement (between 2 and 4 mm). In addition to the obvious cosmetic advantage of avoiding a scar, it is associated with decreased surgical times and does not significantly increase the incidence of complications[10],[16].

Some of the complications of the fracture of the lateral humeral condyle are unavoidable resulting from the original trauma. Inaccurate reduction may lead to limitation of movement. Fracture of the lateral humeral condyle tends to displace posterolaterally and not pure lateral. Closed reduction of the lateral humeral condyle fracture needs early management of the patient within 48 h; otherwise, hematoma makes reduction of the fragment difficult. Closed reduction and internal fixation of the lateral humeral condyle fracture is a simple, rapid, and minimally invasive technique and the patients regain range of motion early and is recommended whenever possible in all types of fractures except if there is a difficulty in reduction[4]. Open reduction and internal fixation of the lateral humeral condyle fracture has indication when closed reduction fails.


  Conclusion Top


Factors affecting the results of closed reduction and internal fixation in the treatment of fracture involving the lateral humeral condyle in children: accepted reduction by closed technique needs mild hematoma as it makes reduction difficult. Effect of accuracy of the reduction: as it is the most important factor which may affect the results, and as most of the complications can be avoided by accurate reduction and good fixation. Effect of postoperative immobilization: the lower the stage of the fracture the better the results were; younger patients gave more satisfactory results than older patients. Closed reduction and internal fixation is an effective method for the management of recent fracture involving the lateral humeral condyle in children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bauer AS, Bae DS, Brustowicz KA, Waters PM. Intra-articular corrective osteotomy of humeral lateral condyle malunions in children: early clinical and radiographic results. J Pediatr Orthop 2013; 33:20–25.  Back to cited text no. 1
    
2.
Canale ST, Beaty JH. Fractures and dislocations in children. Chapter 33. In: Canale ST, Beaty JH, editors. Campbell's operative orthopaedics. 11th ed. Part 11. Philadelphia, Pennsylvania: Mosby Elsevier; 2008. p. 1499-517.  Back to cited text no. 2
    
3.
Marcheix PS, Vacquerie V, Longis B, Peyrou P, Fourcade L, Moulies D. Distal humerus lateral condyle fracture in children: when is the conservative treatment a valid option? Orthop Traumatol Surg Res 2011; 97:304–307.  Back to cited text no. 3
    
4.
Song KS, Kang CH, Min BW, Bae KC, Cho CH, Lee JH. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg 2008; 90:2673–2681.  Back to cited text no. 4
    
5.
Saraf SK, Khare GN. Late presentation of fractures of the lateral condyle of the humerus in children. Indian J Orthop 2011; 45:39–44.  Back to cited text no. 5
    
6.
Hardacre JA, Nahigian SH, Froimson AI, Brown JE. Fractures of the lateral humeral condyle of humerus in children. J Bone Joint Surg (Am) 1971; 53-a: 1083–1095.  Back to cited text no. 6
    
7.
Jacob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg (Br) 1975; 57:430–436.  Back to cited text no. 7
    
8.
Rutherford A. fractures of the lateral condyle of humerus in children. J Bone Joint Surg (Am) 1985; 76-a: 851–856.  Back to cited text no. 8
    
9.
Blount WP, Schalz I, Cossidy RH. Fracture of the elbow in children. JAMA 1951; 140:695–704.  Back to cited text no. 9
    
10.
Khafaga FAM. Comparative study between the result of surgical treatment of fractures of the lateral humeral condyle in children type II by closed reduction and percutaneous pinning versus open reduction and internal fixation [thesis MCh Orth]. Alexandria University, Faculty of Medicine; Alexandria, Egypt 2003.  Back to cited text no. 10
    
11.
Song KS, Kang CH, Min BW, Bae KC, Cho CH. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am 2007; 89:58–63.  Back to cited text no. 11
    
12.
Mintzer CM, Water PM, Brown DJ, Kasser JR. Percutaneous pinning ln the treatment of displaced lateral humeral condyle fractures. Pediatr Orthop 1994; 14:462–465.  Back to cited text no. 12
    
13.
Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop 1985; 5:16–22.  Back to cited text no. 13
    
14.
Andrew T, Lissette S, Vidyadhar V, Tracey P. Closed reduction and percutaneous pinning versus open reduction and internal fixation for type II lateral condyle humerus fractures in children displaced >2 mm. J Pediatr Orthop 2016; 36:8.  Back to cited text no. 14
    
15.
Silva M, Cooper SD. Closed reduction and percutaneous pinning of displaced pediatric lateral condyle fractures of the humerus: a Cohort study. J Pediatr Orthop 2015; 35:661–665.  Back to cited text no. 15
    
16.
Elnabres MA. Evaluation of the result of open reduction and internal fixation of displaced fractures lateral humeral condyle in children [thesis MCh Orth]. University of Alexandria, Faculty of Medicine, Alexandria, Egypt. 1980; 20–25.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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