Abstract
Background:
Displaced lateral condyle humeral fractures in children are treated operatively to maximize function and growth of the elbow. Traditionally an open approach is used for reduction of the fracture, but recent series have shown promising results with closed reduction. Percutaneous pins are typically used for fixation, no matter the reduction method. This retrospective review compares our experience with early complications after open and closed reduction of these fractures.
Methods:
We retrospectively reviewed charts and radiographs of operatively treated lateral condyle fractures. The Song and Jakob classification systems were utilized to determine fracture severity. High-grade displacement was defined as Song stage 4 and 5, or Jakob type 3. Data was analyzed by fracture type (high-grade or low-grade) and by treatment method to look for differences in complication rates and treatment differences. Complications were defined as delayed union and infection.
Results:
172 fractures were analyzed, 141 were treated open, and 31 were treated closed. There were no statistically significant differences in pin duration, total cast time, additional procedures, or short term complications between the open and closed treatment groups, or the high and low-grade fracture groups. High-grade fractures were more likely to be treated with open reduction (p<0.0001). Pin duration prior to removal was not associated with increased incidence of infection or delayed union.
Conclusions:
Closed reduction and percutaneous pinning of lateral condyle fractures amenable to this treatment does not seem to require any changes in postoperative treatment or alter the incidence of early complications when compared to open procedures.
Level of Evidence:
IV
Introduction
Lateral condyle humeral fractures are the second most common operative pediatric elbow fracture comprising approximately 17% of all distal humeral injuries (Figure 1a). Due to the high incidence of poor functional, cosmetic, and radiographic outcomes of conservative treatment, operative treatment of displaced lateral condyle fractures has been recommended.1 Complications of the injury or subsequent surgery include delayed or nonunion, growth disturbance, lateral condyle overgrowth, limited range of motion, and residual deformity.2
Figure 1a.
– Anteroposterior view of a displaced and rotated lateral condyle humerus fracture.
Traditionally, open reduction with percutaneous pinning (ORPP) was preferred in order to assure anatomic reduction of this physeal, intra-articular fracture.3 In the last decade, there has been renewed interest in alternative approaches such as arthroscopy and closed reduction.4-8 Closed reduction with percutaneous pinning (CRPP) has been shown to provide both reproducible and satisfactory outcomes in minimally-displaced fractures.6,9 In addition, the utility of this approach is also evidenced in more severe injuries, as high-grade fractures have been recently reported to heal uneventfully if reduction within 2mm can be achieved with CRPP.7,8 Closed reduction is attractive as it avoids soft tissue dissection, potentially decreases pain, and limits the risk of superficial scarring. After either closed or open reduction, fixation is most commonly achieved with percutaneous smooth wires which are then left external to the skin or buried just beneath it (Figure 1b, 1c).10-12
Figure 1b.
– Intraoperative arthrogram following closed reduction and percutaneous pinning of the fracture depicted in Figure 1a.
Figure 1c.
– Follow-up anteroposterior view of the healed fracture from Figures 1a and 1b.
Given this recent interest and the promising results of closed reduction, surgeons operating at our institution have attempted closed reduction more frequently for both low and high-grade fractures as described by Song et al (Table 1).7,8 Our providers consist of surgeons who have trained in different locations and have varying perspectives on postoperative immobilization protocols after the treatment of lateral condyle humeral fractures.
Table 1.
Summary of the classification system and treatment algorithm proposed by Song et al.8
| Song stage | Degree of displacement | Fracture pattern | Suggested treatment | Classification for purposes of our study |
|---|---|---|---|---|
| 1 | ≤ 2 mm* | Limited fracture line within metaphysis | Long arm cast | Low grade |
| 2 | ≤ 2 mm* | Lateral gap | Long arm cast or in situ fixation | Low grade |
| 3 | ≤ 2 mm** | Gap as wide laterally as medially | CRPP, if failed proceed to open reduction and internal fixation (ORIF) | High grade |
| 4 | > 2 mm** | Without rotation of fragment | CRPP, if failed proceed to ORIF | High grade |
| 5 | > 2 mm** | With rotation of fragment | ORIF likely | High grade |
As determined on internal oblique and anteroposterior radiographs
as determined on internal oblique or anteroposterior radiographs
For example, some elect to remove the percutaneous pins at 3-4 weeks and continue with casting for an additional 2-3 weeks. Others decide to leave the pins for up to six weeks and subsequently remove the pins and cast simultaneously.
This study provides a unique opportunity to retrospectively evaluate institutional experiences and short-term morbidity with CRPP and ORPP in association with early complications and variations in postoperative management.
Methods
After approval from the Institutional Review Board, a retrospective chart review was performed on pediatric patients (1-13 years old) who underwent operative treatment for displaced lateral condyle humeral fractures. Only patients with sufficiently complete medical records were used in this analysis.
Closed or open reduction was performed at the discretion of the surgeon. When closed reduction was attempted for high-grade fractures, the technique described by Song et al. (consisting of closed manipulation supplemented by percutaneous joysticking) was employed.8 An intraoperative arthrogram was used to evaluate the reduction after percutaneous pin fixation. If the reduction failed or was found to be suboptimal, open reduction was performed. No matter the reduction method, long-arm immobilization (casting) and pins were placed for 4-6 weeks prior to removal at the discretion of the operating surgeon.
The following variables were collected and subsequently analyzed: age at surgery, sex, height and weight, injury date, operative date and time, method of treatment, arthrogram images, number of pins, time to pin removal and latest clinical and radiographic follow-up, complications (including infection and delayed or malunion), healing type (normal or delayed), length of immobilization, and need for additional operation.
Fractures were classified by a single reviewer (CJ) both with the Jakob and Song radiographic classifications (Table 1 and Table 2) under the direction of the senior author (SDM).8,13 The senior author performed random sampling of the data to ensure the accuracy of radiographic classification. Both CJ and SM referenced the original studies periodically during imaging review for quality-control. Fracture displacement was determined using both anteroposterior and internal oblique radiographs, with the maximal grade of displacement (usually seen on the interior oblique view) recorded (Figure 2a and 2b). High-grade displacement was classified as either Jakob type 3 or Song stage 4 and 5. The data were analyzed by method of treatment (open versus closed), and fracture displacement (high-grade versus low-grade).
Table 2.
Jakob classification of lateral condyle fractures13
| Classification | Description | Classification for purposes of our study |
|---|---|---|
| Type 1 | Non-displaced; fracture line does not cross through articular surface | Low grade |
| Type 2 | Minimally displaced; fracture line extends to the articular surface; there is no rotation or displacement of the capitellum | Low grade |
| Type 3 | Completely displaced; fracture line extends through the articular surface and there is rotation or displacement of the capitellum | High grade |
Figure 2a.
– Anteroposterior view of lateral condyle fracture
Figure 2b.
– Internal oblique view of the lateral condyle fracture depicted in figure 2a allowing improved visualization of the degree of displacement
The continuous variables were summarized by mean and standard deviation, and compared via the Wilcoxon rank test. The categorical variables were summarized by counts and percentages, and were compared via Fisher’s exact test. Statistical significance was set at p<0.05. A patient with either an abnormal healing type or an infection related to the surgery or surgical site was considered to have a complication.
Results
235 patients underwent treatment for lateral condyle humeral fractures during the study interval. 63 patients were excluded due to incomplete medical records and/ or follow up data. In total, 172 patients (ages 1-13 years old) were included in this study. 31 (18%) were treated with CRPP and 141 (82%) were treated with ORIF. A summary of variables compared by treatment type is depicted in Table 3.
Table 3.
Summary of patient variables by treatment (open vs. closed)
| Variable | Treatment | |||
|---|---|---|---|---|
| Closed (N = 31) | Open (N = 141) | Overall (N = 172) | P-value | |
| Mean ± SD | Mean ± SD | Mean ± SD | ||
| Age at injury (years) | 5.16 ± 2.15 | 5.29 ± 2.27 | 5.26 ± 2.25 | 0.94 |
| Height (cm) | 110 ± 15.1 | 112 ± 15.7 | 111.52 ± 15.59 | 0.64 |
| Weight (kg) | 21.9 ± 7.83 | 24.7 ± 12.6 | 24.18 ± 11.91 | 0.42 |
| Pin duration (weeks) | 4.91 ± 0.7 | 5.13 ± 1.07 | 5.09 ± 1.01 | 0.46 |
| Total length of immobilization (weeks) | 4.94 ± 0.73 | 5.37 ± 1.36 | 5.29 ± 1.28 | 0.19 |
| Count (%) | Count (%) | Count (%) | ||
| Gender | 0.54 | |||
| Female | 9 (29) | 50 (35.5) | 59 (34) | |
| Male | 22 (71) | 91 (64.5) | 113 (66) | |
| Additional Operation | 0.59 | |||
| No | 31 (100) | 136 (96) | 167 (97) | |
| Yes | 0 (0) | 5 (4) | 5 (3) | |
| Stage | <0.0001 | |||
| High* | 17 (55) | 119 (84.5) | 136 (79) | |
| Low | 14 (45) | 22 (15.5) | 36 (21) | |
| Immobilization following pin removal? | 1.00 | |||
| No | 17 (55) | 78 (55) | 95 (55) | |
| Yes | 14 (45) | 63 (45) | 77 (45) | |
| Healing type | 1.00 | |||
| Normal | 31 (100) | 140 (99) | 171 (99.5) | |
| Delayed | 0 (0) | 1 (1) | 1 (0.5) | |
| Infection | 1.00 | |||
| No | 29 (93.5) | 130 (92) | 159 (92) | |
| Yes | 2 (6.5) | 11 (8) | 13 (8) | |
| Complication | 1.00 | |||
| No | 29 (93.5) | 129 (91.5) | 158 (92) | |
| Yes | 2 (6.5) | 12 (8.5) | 14 (8) | |
| Song stage | <0.0001 | |||
| 2 | 2 (6) | 1 (1) | 3 (2) | |
| 3 | 12 (39) | 21 (15) | 33 (19) | |
| 4 | 13 (42) | 36 (25) | 49 (28) | |
| 5 | 4 (13) | 83 (59) | 87 (51) | |
| Jakob type | <0.0001 | |||
| 1 | 1 (3) | 1 (1) | 2 (1) | |
| 2 | 23 (74) | 50 (35) | 73 (42) | |
| 3 | 7 (23) | 90 (64) | 97 (56) | |
Song score 4 or 5, or Jakob’s type 3, all others considered low-grade
The demographic data was similar between the two groups (age, weight, and gender). There was no statistically significant difference in complication rates, pin duration, total time of immobilization (with and without percutaneous pins), and the need for additional operation. On average, surgically inserted pins remained in place for 4.92 and 5.11 weeks for closed and open reduction respectively (p=0.16). The mean length of total clinical and radiographic follow up for our patient population was 18.17 and 16.13 weeks respectively.
The summary of the variables compared by degree of displacement (high or low grade) is displayed in Table 4. Only the method of treatment was shown to be significantly different between the high grade and low grade fractures. High-grade fractures (Jakob type 3 or Song stage 4 and 5) were more likely to be treated with ORPP (p<0.0001).
Table 4.
Summary of patient variables by degree of displacement (high vs. low grade)
| Variable | Degree of Displacement | |||
|---|---|---|---|---|
| High* (N = 136) | Low (N = 36) | Overall (N = 172) | P-value | |
| Mean ± SD | Mean ± SD | Mean ± SD | ||
| Age at injury (years) | 5.31 ± 2.13 | 5.1 ± 2.67 | 5.26 ± 2.25 | 0.47 |
| Height (cm) | 112 ± 14.8 | 111 ± 19 | 111.52 ± 15.59 | 0.72 |
| Weight (kg) | 24.1 ± 11.9 | 24.3 ± 12 | 24.18 ± 11.91 | 0.98 |
| Pin duration (weeks) | 5.17 ± 1.04 | 4.78 ± 0.83 | 5.09 ± 1.01 | 0.085 |
| Total length of immobilization (weeks) | 5.37 ± 1.35 | 4.99 ± 0.88 | 5.29 ± 1.28 | 0.18 |
| Count (%) | Count (%) | Count (%) | ||
| Gender | 0.33 | |||
| Female | 44 (32) | 15 (42) | 59 (34) | |
| Male | 92 (68) | 21 (58) | 113 (66) | |
| Method of treatment | <0.0001 | |||
| Closed | 17 (12.5) | 14 (39) | 31 (18) | |
| Open | 119 (87.5) | 22 (61) | 141 (82) | |
| Additional Operation | 0.59 | |||
| No | 131 (96) | 36 (100) | 167 (97) | |
| Yes | 5 (4) | 0 (0) | 5 (3) | |
| Immobilization following pin removal? | 0.85 | |||
| No | 76 (56) | 19 (53) | 95 (55) | |
| Yes | 60 (44) | 17 (47) | 77 (45) | |
| Healing type | 1.00 | |||
| normal | 135 (99) | 36 (100) | 171 (99.5) | |
| delayed | 1 (1) | 0 (0) | 1 (0.5) | |
| Infection | 0.31 | |||
| No | 124 (91) | 35 (97) | 159 (92) | |
| Yes | 12 (9) | 1 (3) | 13 (8) | |
| Complication | 0.31 | |||
| No | 123 (90) | 35 (97) | 158 (92) | |
| Yes | 13 (10) | 1 (3) | 14 (8) | |
Song score 4 or 5, or Jakob’s type 3, all others considered low-grade
There were 14 complications (8% of total patients) between the two treatment cohorts (13 infections and one delayed union). Two incidences of infection occurred in the CRPP cohort (both were superficial). The remaining 11 infections occurred in the ORPP group and were primarily superficial although there was one documented case of osteomyelitis and another report of wound dehiscence. The single delayed union was a high-grade fracture treated with ORPP. There were no neurologic deficits documented in the perioperative period. Five patients (3% of total) required a second procedure to address their infection (n=4) or refracture (n=1); all underwent ORPP initially. There was no significant association between postoperative pin duration (prior to removal) and incidence of complication (pin duration: 5.0 ± 1.1 versus 5.1 ± 1.0 weeks for patients with and without complications respectively).
Discussion
Closed reduction and percutaneous fixation of displaced lateral condyle fractures is an attractive option for fractures amenable to this treatment. This study corroborates the findings of other recent studies exploring this treatment alternative.
Silva and Cooper recently published a prospective series of 191 lateral condyle fractures, 28 of which were treated with CRPP. A CRPP approach was only utilized for fractures with 2-4 mm of displacement. There was no significant difference in postoperative range of motion, complications, fracture healing, or incidence of poor outcomes when compared to ORPP.6
An extensive retrospective review by Weiss et al over a period of seven years, reported an overall complication rate of 25% (including radiographic and/or clinical bumps, infections, and delayed or nonunion). They proposed a classification system based on degree of displacement and articular congruency. It was determined that complication rates were increased (three times greater) in complete fractures compared to those with an intact articular surface (hinge).
Song, et al. prospectively studied a classification system and treatment algorithm in 63 displaced lateral condyle fractures. Their classification system designated fracture displacement on a scale from one (least severe) to five (most severe) (Table 1). They reported their experience with stages 3-5. CRPP was initially attempted for all of these fractures, but open reduction was deemed necessary if reduction within 2 mm of normal anatomic orientation could not be achieved. Of the 17 stage 3 fractures, 13 (76%) were treated with CRPP. Of the 40 stage 4 fractures, 30 (75%) were treated with CRPP. Of the six stage 5 fractures, three (50%) were treated with CRPP.8 We chose to use this classification system in our study because of the high degree of interobserver and intraobserver reliability, and because it used well-defined descriptors of displacement and rotation. The same group later reported successful CRPP of 18 of the 24 (75%) completely displaced and rotated fractures (Song type 5, and Jakob type 3), further demonstrating the utility of the technique for higher-grade injuries.7
Given the documented success of the CRPP approach, we sought to examine the variation in surgical technique at our own institution and explore any associations with complication rates or the need for different postoperative management. This analysis reports experience with high and low-grade lateral condyle fractures treated with CRPP and ORPP in the hands of multiple surgeons. We were especially interested in the infection rate, duration of pin fixation and immobilization (i.e. postoperative treatment protocols), and incidence of delayed union. There were no significant differences in postoperative treatment or complications between the two operative approaches.
There are limitations of this study which must be acknowledged. First, the follow up period is too short to determine the incidence of osteonecrosis, growth disturbance (i.e. resulting cubitus varus or valgus), fishtail deformity, or other long term complications. Additionally, the short follow-up necessitated including patients who had incomplete, but appropriate healing as judged by the treating physician. This means we could have potentially missed some of the delayed unions in this review. Second, the retrospective study design suffers from typical limitations including the lack of a standardized treatment protocol (for example guiding initial treatment with CRPP versus ORPP) and follow up documentation. Because of the short follow up, we could not document range of motion or other functional outcomes, which are of interest when comparing the effectiveness of closed and open techniques.
Conclusions
In our experience, high-grade displaced lateral condyle fractures were more likely to be treated with open reduction. Whether compared by treatment type or severity of fracture-displacement, there were no statistically significant differences in patient demographics, postoperative pin duration and cast immobilization time, and short-term complications, or reoperation.
This study presents low-level evidence demonstrating that CRPP and ORPP can follow the same postoperative immobilization protocol without subsequent variation in the incidence of complications such as infection or delayed union. More prospective and comparative data is needed to determine if closed reduction should be used more widely for the routine treatment of displaced lateral condyle fractures.
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