Minimally displaced pediatric humerus lateral condyle fractures: risk factors for displacement and outcomes of delayed surgery

Abstract

The purpose of this study was to identify risk factors for management failure in pediatric minimally displaced lateral condyle fractures of the distal humerus (LCHFx) and compare outcomes between initial nonoperative and operative cohorts. A retrospective chart review of LCHFx was conducted to identify children treated with displacement <2 mm and initial nonoperative management. Classification and Regression Trees (CART) were constructed to identify predictors for failure of nonoperative management (further displacement requiring operative intervention). One hundred forty nonoperative children met initial inclusion. CART analysis identified the internal oblique measurement of pre-treatment fracture displacement of >1.2 mm to be the most predictive of nonoperative failure. Fractures with displacement of >1.2 mm had a 58.3% rate of failure compared to 1.3% for those <1.2 mm of initial displacement (P < 0.001). Thirty-seven percent of nonoperative children required revision treatment compared to only 12% of operative children (P = 0.034). LCHFx with minimal displacement (1–2 mm) have a relatively high risk for failure when initially managed without surgery and should either be monitored closely or considered for early operative management when appropriate.

Intraoperative arthrography favorably impacts the early outcome of operatively managed fractures of the lateral humeral condyle displaced 1–5 mm in children

“…Whereas eight patients were managed with closed reduction and pinning and avoided open reduction after an arthrogram revealed an intact articular hinge. This is particularly advantageous in avoiding the complications associated with ORIF where CRPP can be safely performed with minimal complication rates [ 5 , 11 , 12 , 15 ]. The opposite applies, for instance, in a patient with < 2 mm of displacement and a disrupted articular hinge requiring ORIF.…”

“…Perhaps, a lower threshold of displacement should be considered, particularly given the higher complication rate in delayed management after initial conservative management. The latter, which often includes ORIF after non-operative failure, carries higher risks of complications including; nonunion, malunion, angular deformities [ 5 , 12 , 16 , 17 ]. The lower threshold toward early operative management has been similarly been advocated for in a recent study by Edmonds et al, denoting a significantly higher risk of non-operative failure for fractures with a displacement of > 1.2 mm [ 12 ].…”

“…The latter, which often includes ORIF after non-operative failure, carries higher risks of complications including; nonunion, malunion, angular deformities [ 5 , 12 , 16 , 17 ]. The lower threshold toward early operative management has been similarly been advocated for in a recent study by Edmonds et al, denoting a significantly higher risk of non-operative failure for fractures with a displacement of > 1.2 mm [ 12 ]. In addition, they report a 37% rate of revision treatment (late displacement) in the non-operative group.…”

“…Further, there is growing evidence that has demonstrated a considerably higher rate of failure in conservatively managing fractures displaced > 1.2 mm, further advocating for early intervention in LHF displaced < 2 mm [ 12 ]. In addition, while Weiss et al utilized the arthrogram to assess fractures displaced 2–4 mm, there is a paucity of data on the utility of this technique in fractures displaced < 2 mm and > 4 mm.…”

Clinical value of MRI in evaluating and diagnosing of humeral lateral condyle fracture in children

“…Qi et al [1] stated that frontal and lateral radiographs of the elbow are still the first choice when diagnosing humeral lateral condyle fractures (HLCF). In contrary to the former, Bland et al [2] reported that the internal oblique radiograph (IOR) is the most reliable and useful view to measure HLCF displacement and Edmonds et al [3] identified that it is the most predictive view of subsequent displacement, compared to the antero-posterior (APR), lateral (LR) and external oblique view. Edmonds et al [3] reported that 13 of 140 fractures with < 2 mm displacement at diagnosis displaced within a mean 7-day follow-up, requiring delayed surgery, which resulted in good clinical outcomes and low complication rates, no different to those who had early surgery.…”