The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study With Treatment Algorithm

Abstract

Background: Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. Methods: A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. Results: Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). Conclusion: This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. Level of Evidence: Level IV.

Neglected Fractures of the Lateral Humeral Condyle in Children; Which Treatment for Which Condition?

“…In our series, 22% of patients sustained major complications, in line with previous studies that reported complication rates ranging from 0 to 64%, after treatment of neglected LHC fractures [5][6][7][8][9][10][12][13][14][15][16][17][18]. This rate of complications is far higher than those following fresh fractures [1,[3][4][5]11,21]. We found significant associations between the modified CDS score for complications and the MEPS and DhiS at final follow-up, confirming that poorly treated and neglected LHC fractures can be harmful for long-term elbow function and quality of life, especially in athletic children [5].…”

“…Complications were classified according to the Clavien-Dindo-Sink (CDS) system; those with CDS > 2 were considered major complications [4,22]. Clinical and functional scores were recorded at baseline and at final follow-up.…”

“…Fractures of the lateral humeral condyle (LHC) account for 10-20% of pediatric elbow fractures [1]. Although many nondisplaced LHC fractures may be treated conservatively, fractures with >2 mm displacement are considered unstable, thus requiring surgical fixation [2][3][4].…”

Is biodegradable pin a good choice for lateral condylar fracture of humerus in children

“…Treatment choice for LCF of the humerus depends on the fracture displacement and stability. A modified classification system has been proposed by Song et al [ 13 , 14 ] to clarify the ambiguity of Jakob type I fracture. Indication for surgery includes fractures with equally displaced medial and lateral gaps (Song type III) [ 15 ] and fractures with >2 mm displacement (Song type IV and V).…”

Closed reduction and percutaneous pinning vs open reduction and internal fixation in pediatric lateral condylar humerus fractures displaced by > 4 mm: an observational cross-sectional study

“…Justus et al reported a series of 172 patients with surgically treated LCHFs, where 18% (31) of the cases, including 13 Song stage 4 LCHFs and 4 Song stage 5 LCHFs, were treated with CRPP at the surgeons’ discretion [ 13 ]. However, Ramo et al could not replicate the success of CRPP in Song stage 5 LCHFs in their series [ 14 ]. We previously reported a series of 46 LCHFs displaced by > 2 mm at our institute, where CRPP was attempted with an approximate 75% success rate, even in Song stage 5 cases [ 15 ].…”