Slide 122 — Paediatric lateral condyle fracture

Clean FRCS notes with inline figures

•Stem: Patient with fall injury + axial loading to UL, lateral side of elbow pain + swelling

Radiographic description

•Flake of bone over lateral metaphyseal region, no gross mal alignment

•Suspected lateral condyle fracture

•This fracture on Xray is minimally displaced. But I will need to see the articular surface displacement before planning Mx. Can also get an internal oblique XR

•In my centre MRI is readily available, will book urgent MRI to look for articular step.

•If MRI is not available, I can perform arthrogram (inject from posterior to avoid injury to articular surface and major NV bundle)

Classification

Milch classification (stability)

Type / group	Definition / note
1	fracture lateral to trochleocapitellar groove, SH type 4, more stable
2	fracture medial to trochleocapitellar groove, SH type 2 (no cross lateral condyle epiphysis), less stable → worse prognosis

•Jacob (Displacement)

•1 <2mm displacement (can go for conservative if confirmed articular cartilage smooth)

•2 2-4mm displacement (CR +/-

•OR KWF)

•3 severe displacement +/- rotated fragment (OR KWF)

•Another recently validated classification is the Song classification (1-5), 3 or above unstable, need surgery

•1 – limited fracture line within the metaphysis

•2 – lateral gap

•3 - medial and lateral gap

•4 – more than 2mm displacement with no rotation

•5 – rotation

Definitive management

•If there is >2mm displacement in any of the 3 views, will go for OR + KWF

•CR method is by extension + supination to relax muscle pull from common extensor origin. Then varus force + anteromedial force to fracture to reduce it.

•OR: oblique wound over lateral side centered at lateral epicondyle (between BR and triceps),

•[OB: below the skin, dissection to the joint is most often already accomplished by injury]

•avoid dissection to posterior muscle to preserve blood supply.

•Check anterior and lateral cortex smoothness to confirm reduction (not ossified on XR)

•Fix with 2 divergent pins (reduce with joystick method)

Late complication:

•Nonunion, AVN

•Deformity

•Varus due to lateral condyle overgrowth or fish tail deformity (OB: up to 50%)

•Valgus due to lateral condyle AVN and nonunion (OB: 10%)

•Instability (PL subluxation of proximal radius and ulnar)

•If late presentation and cannot reduce without stripping posterior periosteum, may need to accept partially reduced alignment

Mechanism:

•Push off (axial loading by radial head)

•Pull off (common extensor)

Why prone to nonunion?

•poor vascular supply, intra-articular, large pull from extensor

Delay presentation with nonunion with deformity, no pain. What is your management? Will you perform OT?

•Controversial

•Yes due to future valgus + instability + tardy ulnar nerve palsy (Masada JBJS 1990)

•Preop CT to assess fragment size, MRI to rule out AVN

Aim: achieve union

•Debridement + bone graft + screw horizontally (K wire cannot give compression)

•Only debride anterior, leave posterior intact

•Don’t aggressively reduce, risk of AVN and fishtail deformity

•No, can have osteotomy later, watchful waiting. ORIF associated with stiffness, AVN (Jakob et al)

#	lvl	marL	indent	logical	original note line
1	0	0	0	0	Stem: Patient with fall injury + axial loading to UL, lateral side of elbow pain + swelling
2	0	None	None	0	Describe Xray:
3	0	None	None	0	Flake of bone over lateral metaphyseal region, no gross mal alignment
4	0	None	None	0	Suspected lateral condyle fracture
5	0	0	0	0	This fracture on Xray is minimally displaced. But I will need to see the articular surface displacement before planning Mx. Can also get an internal oblique XR
6	0	0	0	0	In my centre MRI is readily available, will book urgent MRI to look for articular step.
7	0	0	0	0	If MRI is not available, I can perform arthrogram (inject from posterior to avoid injury to articular surface and major NV bundle)
8	0	0	0	0	Classification
9	0	0	0	0	Milch classification (stability)
10	0	171450	-171450	1	1: fracture lateral to trochleocapitellar groove, SH type 4, more stable
11	0	171450	-171450	1	2: fracture medial to trochleocapitellar groove, SH type 2 (no cross lateral condyle epiphysis), less stable → worse prognosis
12	0	0	0	0	Jacob (Displacement)
13	0	171450	-171450	1	1 <2mm displacement (can go for conservative if confirmed articular cartilage smooth)
14	0	171450	-171450	1	2 2-4mm displacement (CR +/-
15	0	171450	-171450	1	OR KWF)
16	0	171450	-171450	1	3 severe displacement +/- rotated fragment (OR KWF)
17	0	0	0	0	Another recently validated classification is the Song classification (1-5), 3 or above unstable, need surgery
18	0	0	0	0	1 – limited fracture line within the metaphysis
19	0	0	0	0	2 – lateral gap
20	0	0	0	0	3 - medial and lateral gap
21	0	0	0	0	4 – more than 2mm displacement with no rotation
22	0	0	0	0	5 – rotation
23	0	0	0	0	Definitive management
24	0	0	0	0	If there is >2mm displacement in any of the 3 views, will go for OR + KWF
25	0	0	0	0	CR method is by extension + supination to relax muscle pull from common extensor origin. Then varus force + anteromedial force to fracture to reduce it.
26	0	0	0	0	OR: oblique wound over lateral side centered at lateral epicondyle (between BR and triceps),
27	0	0	0	0	[OB: below the skin, dissection to the joint is most often already accomplished by injury]
28	0	0	0	0	avoid dissection to posterior muscle to preserve blood supply.
29	0	0	0	0	Check anterior and lateral cortex smoothness to confirm reduction (not ossified on XR)
30	0	0	0	0	Fix with 2 divergent pins (reduce with joystick method)
31	0	None	None	0	Late complication:
32	0	None	None	0	Nonunion, AVN
33	0	None	None	0	Deformity
34	0	0	0	0	Varus due to lateral condyle overgrowth or fish tail deformity (OB: up to 50%)
35	1	None	None	1	Valgus due to lateral condyle AVN and nonunion (OB: 10%)
36	0	None	None	0	Instability (PL subluxation of proximal radius and ulnar)
37	0	None	None	0	If late presentation and cannot reduce without stripping posterior periosteum, may need to accept partially reduced alignment
38	0	0	0	0	================================
39	0	None	None	0	Mechanism:
40	0	171450	-171450	1	Push off (axial loading by radial head)
41	0	171450	-171450	1	Pull off (common extensor)
42	0	0	0	0	Why prone to nonunion?
43	0	0	0	0	poor vascular supply, intra-articular, large pull from extensor
44	0	0	0	0	Delay presentation with nonunion with deformity, no pain. What is your management? Will you perform OT?
45	0	171450	-171450	1	Controversial
46	0	171450	-171450	1	Yes due to future valgus + instability + tardy ulnar nerve palsy (Masada JBJS 1990)
47	1	628650	-171450	2	Preop CT to assess fragment size, MRI to rule out AVN
48	1	628650	-171450	2	Aim: achieve union
49	1	628650	-171450	2	Debridement + bone graft + screw horizontally (K wire cannot give compression)
50	2	1085850	-171450	3	Only debride anterior, leave posterior intact
51	1	628650	-171450	2	Don’t aggressively reduce, risk of AVN and fishtail deformity
52	0	171450	-171450	1	No, can have osteotomy later, watchful waiting. ORIF associated with stiffness, AVN (Jakob et al)
53	0	171450	-171450	1	Recent studies suggest surgery is a safe option

#	semantic level	section?	rewritten line
1	0		Stem: Patient with fall injury + axial loading to UL, lateral side of elbow pain + swelling
2	0	yes	Radiographic description
3	1		Flake of bone over lateral metaphyseal region, no gross mal alignment
4	1		Suspected lateral condyle fracture
5	1		This fracture on Xray is minimally displaced. But I will need to see the articular surface displacement before planning Mx. Can also get an internal oblique XR
6	1		In my centre MRI is readily available, will book urgent MRI to look for articular step.
7	1		If MRI is not available, I can perform arthrogram (inject from posterior to avoid injury to articular surface and major NV bundle)
8	0	yes	Classification
9	0	yes	Milch classification (stability)
10	1		1: fracture lateral to trochleocapitellar groove, SH type 4, more stable
11	1		2: fracture medial to trochleocapitellar groove, SH type 2 (no cross lateral condyle epiphysis), less stable → worse prognosis
12	1		Jacob (Displacement)
13	1		1 <2mm displacement (can go for conservative if confirmed articular cartilage smooth)
14	1		2 2-4mm displacement (CR +/-
15	1		OR KWF)
16	1		3 severe displacement +/- rotated fragment (OR KWF)
17	1		Another recently validated classification is the Song classification (1-5), 3 or above unstable, need surgery
18	1		1 – limited fracture line within the metaphysis
19	1		2 – lateral gap
20	1		3 - medial and lateral gap
21	1		4 – more than 2mm displacement with no rotation
22	1		5 – rotation
23	0	yes	Definitive management
24	1		If there is >2mm displacement in any of the 3 views, will go for OR + KWF
25	1		CR method is by extension + supination to relax muscle pull from common extensor origin. Then varus force + anteromedial force to fracture to reduce it.
26	1		OR: oblique wound over lateral side centered at lateral epicondyle (between BR and triceps),
27	1		[OB: below the skin, dissection to the joint is most often already accomplished by injury]
28	1		avoid dissection to posterior muscle to preserve blood supply.
29	1		Check anterior and lateral cortex smoothness to confirm reduction (not ossified on XR)
30	1		Fix with 2 divergent pins (reduce with joystick method)
31	0	yes	Late complication:
32	1		Nonunion, AVN
33	1		Deformity
34	1		Varus due to lateral condyle overgrowth or fish tail deformity (OB: up to 50%)
35	1		Valgus due to lateral condyle AVN and nonunion (OB: 10%)
36	1		Instability (PL subluxation of proximal radius and ulnar)
37	1		If late presentation and cannot reduce without stripping posterior periosteum, may need to accept partially reduced alignment
38	0		——
39	0	yes	Mechanism:
40	1		Push off (axial loading by radial head)
41	1		Pull off (common extensor)
42	0	yes	Why prone to nonunion?
43	1		poor vascular supply, intra-articular, large pull from extensor
44	0	yes	Delay presentation with nonunion with deformity, no pain. What is your management? Will you perform OT?
45	1		Controversial
46	1		Yes due to future valgus + instability + tardy ulnar nerve palsy (Masada JBJS 1990)
47	2		Preop CT to assess fragment size, MRI to rule out AVN
48	2	yes	Aim: achieve union
49	3		Debridement + bone graft + screw horizontally (K wire cannot give compression)
50	3		Only debride anterior, leave posterior intact
51	2		Don’t aggressively reduce, risk of AVN and fishtail deformity
52	1		No, can have osteotomy later, watchful waiting. ORIF associated with stiffness, AVN (Jakob et al)
53	0	yes	Recent studies suggest surgery is a safe option

122. Paediatric lateral condyle fracture

Clean FRCS notes with inline figures

Radiographic description

Classification

Milch classification (stability)

Definitive management

Late complication:

Mechanism:

Why prone to nonunion?

Delay presentation with nonunion with deformity, no pain. What is your management? Will you perform OT?

Aim: achieve union

Recent studies suggest surgery is a safe option

Direct Q&A

avoid dissection to posterior muscle to preserve blood supply.

Nonunion, AVN

poor vascular supply, intra-articular, large pull from extensor

Controversial

Aim: achieve union

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes