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ORIGINAL ARTICLE

A New Classification System Predictive of Complications in Surgically Treated Pediatric Humeral Lateral Condyle Fractures
Jennifer M. Weiss, MD,*w Sara Graves, BA,*w Scott Yang, BS,*w Elliott Mendelsohn, BS,*w Robert M. Kay, MD,*w and David L. Skaggs, MD*w

Background: The most commonly cited classification system for lateral condyle fractures (Milch) has not been shown to be predictive of outcome or recommend treatment. Purpose: To determine whether a classification system and treatment based on fracture displacement and articular congruity correlates with the complication rate after pediatric lateral humeral condyle fractures. Methods: A retrospective review of all children with lateral condyle fractures treated operatively at one institution from 1996 to 2003 was performed. All fractures were classified by the following system: A Type I fracture is displaced less than 2 mm. In a Type II fracture there is Z2 mm of displacement with intact articular cartilage, as demonstrated by arthrogram (65 patients). In a Type III fracture there is Z2 mm of displacement and the articular surface is not intact (93 patients). The 158 patients with types 2 and 3 fractures underwent surgery and are the focus of this study. Complication rates were compared between groups 2 and 3, and with regard to patient age, length of time between injury and surgery, and duration of casting. Results: The overall complication rate was 25% (39 of 158). The most common complications included radiographic and/or clinical bump (16 of 158 or 10%), and infection treated with oral antibiotics (4 of 158 or 2.5%). There were 6% major complications (10 of 158) defined as those with presumptive long-term effects or requiring reoperation, including 1 nonunion (0.6%). There were no acute complications at the time of injury or surgery. If lateral bump is excluded as a complication, then the overall complication rate is 14.6% (23 of 158). The overall complication rates for types 2 and 3 fractures were statistically significantly different (P<0.03): 11% (7 of 65) for type 2 and 34% (32 of 93) for type 3 fractures. Major complication rates were 1.5% (1 of 65) for type 2 fractures and 10% (9 of 93) for type 3 fractures, whereas minor complications occurred in 9% (6 of 65) of type 2 fractures, and 25% (23 of 93) of type 3 fractures (P = 0.03). There was no correlation between complication rate and patient age, number of days between fracture
From the *Children’s Orthopaedic Center, Children’s Hospital Los Angeles; and wKeck-University of Southern California School of Medicine, Los Angeles, CA. None of the authors received financial support for this study. Reprints: Jennifer M. Weiss, MD, Children’s Orthopaedic Center, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail: jweiss@ chla.usc.edu. Copyright r 2009 by Lippincott Williams & Wilkins

and surgery (all patients were treated within 16 d of their fracture), or duration of casting. We found that all 65 patients with Type II fractures had <4 mm of fracture displacement on pre-operative radiographs, and all fractures Type III fractures had Z4 mm of displacement. This may aid in predicting which fractures can be treated with closed pinning prior to an operative arthrogram. Conclusions: This is the largest series of operatively treated lateral condyle fractures reported in the literature. This classification system and treatment based on fracture displacement and articular congruity predicts the risk of complications, which were more than 3 times as likely to occur in type 3 fractures as type 2 fractures. Key Words: lateral condyle fracture, children, retrospective review, pediatric (J Pediatr Orthop 2009;29:602–605)

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ateral condyle fractures of the distal humerus make up 12% of elbow fractures in children.1 The most commonly cited classification system for lateral condyle fractures (Milch) has not been shown to be predictive of outcome or recommend treatment.2 When lateral condyle fractures are more than 2 to 3 mm displaced, operative treatment is recommended.3,4 Operative intervention consists of percutaneous fixation versus open reduction and fixation, depending on the congruity of the articular surface.5–7 Arthrography has been shown to correlate well with open operative findings in lateral condyle fractures.6 When arthrography confirms congruency of the articular surface, percutaneous pinning has been shown to be a safe and effective treatment for lateral condyle fractures.7 Complications of operative fixation for lateral condyle fractures have been reported to include nonunion, avascular necrosis, premature epiphysial fusion, lateral condylar overgrowth, stiffness, and deformity.8–10 Risk factors for these complications have not been described. The purpose of this study is to determine whether a classification system and treatment based on fracture displacement and articular congruity correlates with a higher rate of complications in lateral condyle fractures.
J Pediatr Orthop 

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Volume 29, Number 6, September 2009

which occurred in a type 3 fracture (0.08% (7 of 93) in type 3 fractures. The left side was fractured in 103 of the elbows (65%) and right side in 55 of the elbows (35%). length of time between injury and surgery.90% 8. Fluoroscopy was used intraoperatively to help assess fracture reduction and pin placement. Six of these minor complications occurred in patients with type 2 fractures. TABLE 1.5%). as demonstrated by arthrogram (65 patients).com | 603 . Figure 1 illustrates these 3 types of fractures. If lateral bump is excluded as a complication.6%).60% 3.03): 11% (7 of 65) for type 2 and 34% (32 of 93) for type 3 fractures.) The complication rates for types 2 and 3 fractures were not statistically significant in this scenario (P = 0. Postoperatively. September 2009 A Classification System for Lateral Condyle Fractures MATERIALS AND METHODS A retrospective review of all children with lateral condyle fractures treated operatively at one institution from 1996 to 2003 was performed. In a Type III fracture there is Z2 mm of displacement and the articular surface is not intact (93 patients). Of the 93 type 3 fractures. In a Type II fracture there is Z2 mm of displacement with intact articular cartilage.2). and Type 3 fracture: Z2 mm of displacement and lack of articular congruity. fracture displacement was evaluated.50% FIGURE 1.J Pediatr Orthop  Volume 29.60% 0. The longest period of time between fracture and surgery was 16 days.60% 3% 0. Either 2 or 3 6. an open reduction and internal fixation was performed. There were 29 minor complications (29 of 158 or 18%). In the 65 patients with type 2 fractures. Of the 65 type 2 fractures.15): 12% (8 of 65) for type 2 and 16% (15 of 93) for type 3 fractures. Complications Major Complications Avascular necrosis Malunion Loss of reduction requiring reoperation Nonunion requiring reoperation Refracture Stiffness Minor Complications Infection treated with PO antibiotic Keloid Radiographic and clinical bump Radiographic bump Ulcer Granuloma 1 5 1 1 1 1 6 2 3 13 1 4 0. If the articular surface was congruent. 10% of patients with type 3 fractures had a major complication.20% 0. Of the 65 type 2 fractures that were treated operatively. If there was uncertainty as to the congruity of the articular surface. These complication rates are statistically significantly different (P<0. There was no correlation between the number of days between fracture and surgery and complication rate. there were 10 complications (15%).pedorthopaedics. and with regard to patient age. All fractures were classified by the following system: A Type I fracture is displaced less than 2 mm.80% 1. There is no statistical significance between complication rates of types 2 and 3 fractures if lateral bump is excluded as a complication (P = 0. and either 2 or 3 k-wires were placed in a divergent pattern to stabilize the fracture. Type 2 fracture: with Z2 mm displacement and congruity of the articular surface. Number 6. The surgical technique is as follows: First. There were 39 complications. Reproduced with permission of Children’s Orthopaedic Center. with a complication rate of 25%. the first radiographic assessment was at 1 week after surgery to assure that the fracture reduction was maintained.60% 0. If the articular surface was not congruent. Complications are detailed in Table 1. 23 occurred in patients with type 3 fractures.30% 1. Complication rates were compared between groups 2 and 3.60% 2. These displaced despite casting. 9 (9 of 65 or 14%) were initially type 1 fractures.6% (23 of 158.60% 0. 101 patients (64%) were boys. There were 10 major complications (10 of 158 or 6%).2-mm k-wires were placed in a divergent manner from a lateral entry point. The other 9 major complications occurred in patients with type 3 fractures. and duration of casting. less than 2 mm displacement. there was one major complication (1. then closed reduction and pinning were performed. RESULTS Of the 158 operative lateral condyle fractures reviewed. There was no correlation between complication rate and age of the patient. The overall complication rates for types 2 and 3 fractures were statistically significantly different (P<0. then the minor complication rate in type 2 fractures was 1% (6 of 65) and 0. If a lateral bump is excluded as a complication.03). The 158 patients with types 2 and 3 fractures underwent surgery and are the focus of this study. defined as those with presumptive long-term effects or requiring reoperation. Los Angeles. a refracture. and 57 patients (36%) were girls. there were 29 complications (31%). There was one nonunion. Seventy percent of the children underwent surgery within 3 days of their fracture. an arthrogram was performed. The articular surface was directly visualized and reduced. Type 1 fracture. There was no fracture date available for 11 patients (11 of 158 or 7%). r 2009 Lippincott Williams & Wilkins www. then the overall complication rate is 14.

the question may be asked as to whether fracture displacement alone can be used for classification and treatment. Number 6. Patients with complications averaged 33 days in a cast. Another weakness of the study is that this classification system is based on the amount of radiographic displacement. The average number of days in a cast was 33.2 The Jakob classification describes a type 1 fracture as nondisplaced. The complication rate reported in this study (25%) falls in the mid-range of rates reported in the literature. and this was the same for patients with decreased and full range of motion. One weakness of this study is the short duration of follow-up. Of the 19 patients with limited range of motion. but the elbow does not dislocate. This separation is important in counseling families preoperatively. we used a very stringent definition of complications here.12 Furthermore. which accounts for almost half or 46% (16 of 35) of the complications. largely because complication rates associated with the operative treatment of lateral condyle fractures vary greatly. no statistical correlation between fracture type and range of motion. with 3 weeks being the minimum. The limited range of motion was documented in 19 patients (17%). September 2009 The range of motion data were available for 109 patients.2. previous work by Mirsky et al16 has described the limitations of the Milch classification in operative decision making. This represents displacement on the initial radiographs.14 Previous classification systems were based on the prediction of displacement (Finnbogason) and sought to predict displacement of the actual elbow (Milch).com 2009 Lippincott Williams & Wilkins . a type B fracture as complete but nondisplaced. ranging from 6 weeks to 6 months. this 4 mm cut-off was not a clinical criterion prospectively used for opening a fracture or doing an arthrogram by the treating surgeons.11. as did patients without complications. In addition. All 65 patients with Type II fractures had <4 mm of fracture displacement on pre-operative radiographs and all fractures Type III fractures had Z4 mm of displacement. Overall complication rates occurred in 34% of patients with type 3 fractures (32 of 95) and 11% (7 of 65) of those with type 2 injuries. true displacement is not known. As we found that all 65 patients with Type II fractures had <4 mm of fracture displacement on preoperative radiographs.5% in type 2 fractures). This study examines a classification system and results of treatment based on the degree of fracture displacement and presence of articular congruity. not the displacement at the time of injury. including a radiographic or clinical bump. Radiographic review did not reveal any complications related to poor pin placement or configuration. may not be known. Whether the higher complication rate in type 3 fractures may be attributable to the articular displacement. Thomas et al15 reported that late review revealed 61% of children had an abnormal elbow shape after sustaining a lateral condyle fracture. However. or to the open reduction is open to speculation. and all Type III fractures had Z4 mm of displacement. either.12. and a type C fracture has a fracture displacement as wide medially as it is laterally. a type 2 fracture is complete. increased extent of initial energy. The authors cautioned that intraoperative findings did not correlate with the presumed preoperative radiographic diagnosis based on the Milch classification system. The fracture may displace. A Milch type 2 fracture exits medial to the trochlear groove. Thus. The range of motion did not correlate with casting duration. The average follow-up for patients with a limited range of motion was 70 days.12 These classification systems were not designed to dictate treatment or to predict outcome. There was. and a type 3 fracture has a rotated capitellum. Some complications.2. Existing lateral condyle fracture classification systems do not recommend treatment or predict the outcome. there were only 4 patients with 4 mm of r 604 | www.pedorthopaedics. Operatively treated displaced lateral condyle fractures with the articular surface intact (type 2) had half the complications of displaced fractures without articular continuity. and 2 cases of avascular necrosis in 28 patients. The radius and ulna can laterally displace. There were no complications reported among this group of patients. Higher complication rates are reported by Ruthorford. Mohan et al13 also reported no complications among 20 patients who underwent open reduction with internal fixation of displaced lateral condyle fractures via posterolateral approach. 6 cases of cubitus varus. either. Complication rates did not correlate with duration of casting.’’ Although the overall complication rate is considerable at 25%. The full range of motion was achieved in 90 (83%) of these children. but it was rather noted in retrospective review. DISCUSSION The background on other lateral condyle classification systems is as follows. Arthrograms were not performed on patients with Z4 mm of displacement.11 The Finnbogason classification describes a type A fracture as incomplete. Mintzer et al7 reported on 12 cases of lateral condyle fractures with greater than 2 mm of displacement and incongruent artictular surfaces. including premature physeal closure. The likelihood of a major complication with presumptive long-term effects or requiring reoperation is only 6% (10% in type 3 and 1. who underwent closed reduction with percutaneous pinning. Follow-up ranged from 3 weeks to 2 years. which he attributed to overgrowth of the lateral condyle and excessive formation of bone. 13 sustained type 3 fractures. however. Skak et al10 reported a complication rate of 32% with 1 nonunion. Complications in this study have been separated into ‘‘major’’ (those requiring return to the operating room or resulting in long-term problems) and ‘‘minor. The Milch classification defines a type I fracture as lateral to the trochlear groove. Range of motion did not correlate with type of fracture.14 who saw 10 malreductions and 2 fishtail deformities among 39 patients (31% complication rate).Weiss et al J Pediatr Orthop  Volume 29.

which were more than 3 times as likely to occur in type 3 fractures as type 2 fractures. Deformity after fracture of the lateral humeral condyle in children. Arora A. 1975. Karlsson G. Lateral condyle fractures in children: evaluation of classification and treatment. Thomas DP.9:691–696. In summary.57:430–436.21:565–569. Displaced lateral condyle fractures of the distal humerus. et al.0-mm AO cancellous screws. 4. 9. Usefulness and accuracy of arthrography in management of lateral humeral condyle fractures in children. Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children.11:117–120. 1985. Flynn JC. Swiontkowksi MF. Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability. Mohan N. J Orthop Trauma. Rang M.22:8–11. et al. Fractures and fracture dislocations of the humeral condyles. J Bone Joint Surg Am. Mirsky EC. Brown DJ. et al. 1985. 2001. r 2009 Lippincott Williams & Wilkins www. 1997. 16. J Pediatr Orthop.17:306–308. J Bone Joint Surg Br. Karas EH. 1990. Olsen SD. we cannot draw conclusions as to the usefulness of arthrograms or the possibility of closed reduction and pinning in fractures with Z4 mm of displacement. J Pediatr Orthop. 13. Horn BD.10: 142–152. et al. d’Amato C.com | 605 . Waters PM. Hunter JB. Fractures of the lateral humeral condyle in children. J Orthop Trauma. J Trauma. 2000. This classification system based on fracture displacement and articular congruity predicts the risk of complications. 14. Mathur NC. J Pediatr Orthop. Crisci K. so we cannot claim that all fractures with Z4 mm of displacement are type III fractures with a non-intact articular surface from our data. Fowles JV. 2001.10:317–321. et al. 7.82:643–645. Percutaneous pinning in the treatment of displaced lateral condyle fractures. 15. Marzo JM. Strong M. Hasler CC. J Pediatr Orthop.J Pediatr Orthop  Volume 29. Prevention of growth disturbances after fractures of the lateral humeral condyle in children. this is the largest series of operatively treated lateral condyle fractures reported in the literature.4:592–607. 5.14:462–465. Observations concerning fractures of the lateral humeral condyle in children. Skak SV. Sharma JC. Lateral condylar fractures of the humerus in children: fixation with partially threaded 4. Cole WG. Mintzer CM. Smaabrekke A. 1995. Similarly. Colton CL. Bhandari M.pedorthopaedics. Number 6. Sullivan JA. Nonunion of slightly displaced fractures of the lateral humeral condyle in children: an update. von Laer L. 6. Lindberg L. The posterolateral approach to the distal humerus for open reduction and internal fixation of fractures of the lateral condyle in children. In this retrospective series there were no fractures with Z4 mm of displacement in which an arthrogram was performed. 1994.5:16–22. 2002. J Pediatr Orthop B. Finnbogason T. J Pediatr Orthop B. Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: a prospective radiographic investigation of fracture stability. 12. 2001. 1964. et al. Milch H.15:422–425. et al. Howard AW. Ruthorford A.67:851–856. Herman MJ. Lateral humeral condylar fractures in children. Jakob R. J Pediatr Orthop. REFERENCES 1.39:1129–1133. 1989. 1995. Tornetta P. 8. J Pediatr Orthop. Gross RH. 3. Foster DE.10:123–130. September 2009 A Classification System for Lateral Condyle Fractures fracture displacement in this series. 10. This may be a worthy topic for a future prospective study. J Pediatr Orthop. 2. J Bone Joint Surg Br. 11. J Trauma. Weiner LS. 2003.