Closed Reduction and Internal Fixation of Displaced Unstable Lateral Condylar Fractures of the Humerus in Children

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1 This is an enhance PF from The Journal of Bone an Joint Surgery The PF of the article you requeste follows this cover page. Close Reuction an Internal Fixation of isplace Unstable Lateral Conylar Fractures of the Humerus in Chilren Kwang Soon Song, Chul Hyung Kang, Byung Woo Min, Ki Cheor Bae, Chul Hyun Cho an Ju Hyub Lee J Bone Joint Surg Am. 2008;90: oi: /jbjs.g This information is current as of ecember 8, 2008 Supplementary material Reprints an Permissions Publisher Information Commentary an Perspective, ata tables, aitional images, vieo clips an/or translate abstracts are available for this article. This information can be accesse at Click here to orer reprints or request permission to use material from this article, or locate the article citation on jbjs.org an click on the [Reprints an Permissions] link. The Journal of Bone an Joint Surgery 20 Pickering Street, Neeham, MA

2 2673 COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AN JOINT SURGERY, INCORPORATE Close Reuction an Internal Fixation of isplace Unstable Lateral Conylar Fractures of the Humerus in Chilren By Kwang Soon Song, M, Chul Hyung Kang, M, Byung Woo Min, M, Ki Cheor Bae, M, Chul Hyun Cho, M, an Ju Hyub Lee, M Investigation performe at the epartment of Orthopeic Surgery, Keimyung University, aegu, South Korea Backgroun: Open reuction an internal fixation of a isplace unstable fracture of the lateral conyle of the humerus in a chil usually prouces a goo result. Only a few reports have focuse on close reuction an internal fixation of these fractures. We prospectively stuie close reuction an internal fixation to etermine its usefulness as the initial treatment for isplace unstable fractures of the lateral conyle of the humerus. Methos: We classifie lateral conylar humeral fractures into five groups accoring to the egree of isplacement an the fracture pattern as etermine on four raiographic views an create an algorithm for the treatment of these fractures on the basis of this classification system. We prospectively treate sixty-three unstable fractures (in forty-two boys an twenty-one girls) an assesse the quality of close reuction. Results: Thirteen of seventeen stage-3 fractures were reuce to 1 mm of resiual isplacement. Thirty of forty stage-4 fractures an three of six stage-5 fractures were reuce to 2 mm of isplacement. In ten of forty stage-4 fractures an three of six stage-5 fractures, close reuction to within 2 mm faile an open reuction an internal fixation was performe. There were no major complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest. Conclusions: Close reuction an internal fixation is an effective treatment for unstable isplace lateral conylar fractures of the humerus in many chilren. If fracture isplacement after close reuction excees 2 mm, open reuction an internal fixation is recommene. Level of Evience: Therapeutic Level IV. See Instructions to Authors for a complete escription of levels of evience. Open reuction an internal fixation of isplace unstable lateral conylar humeral fractures in chilren usually prouces goo results, as oes close treatment with a posterior plaster splint or long-arm cast for nonisplace an minimally isplace stable lateral conylar humeral fractures. Several reports have recommene open reuction an internal fixation as the best proceure for unstable fractures to prevent further isplacement, nonunion, an malunion However, only a few reports have focuse on close reuction an internal fixation of lateral conylar humeral fractures 11,12. We believe that satisfactory reuction an secure fixation of a lateral conylar fracture of the humerus in a chil can often be achieve by means of close reuction an internal fixation without the nee for open reuction. We prospectively stuie the use of close reuction an internal fixation as the initial treatment for a group of isplace unstable lateral conylar humeral fractures. Materials an Methos After obtaining informe consent from the patients parents or guarians an the approval of our institutional review boar, we prospectively stuie sixty-three consecutive unstable lateral conylar fractures of the humerus between March 2001 an ecember We exclue forty-three stable isclosure: In support of their research for or preparation of this work, one or more of the authors receive, in any one year, outsie funing or grants of less than $10,000 from ongsan Meical Center, Keimyung University. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. No commercial entity pai or irecte, or agree to pay or irect, any benefits to any research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immeiate families, are affiliate or associate. J Bone Joint Surg Am. 2008;90: oi: /jbjs.g.01227

3 2674 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN TABLE I Classifications Accoring to egree of isplacement an Fracture Pattern Stage egree of isplacement Fracture Pattern Raiograph Views Use as Basis Stability 1 2 mm Limite fracture line within the metaphysis All 4 views Stable 2 2 mm Lateral gap All 4 views Inefinable 3 2 mm Gap as wie laterally as meially Any of 4 views Unstable 4 >2 mm Without rotation of fragment Any of 4 views Unstable 5 >2 mm With rotation of fragment Any of 4 views Unstable Fig. 1 Illustrations epicting the stages of isplacement of fractures of the lateral conyle of the humerus in chilren. In stage 1, the fracture is stable, isplacement is 2 mm, an the fracture line is limite to within the metaphysis. In stage 2, the fracture is inefinable, isplacement is 2 mm, the fracture line extens to the epiphyseal articular cartilage, an there is a lateral gap. In stage 3, the fracture is unstable, isplacement is 2 mm, an there is a gap that is as wie laterally as it is meially. In stage 4, the fracture is unstable an isplacement is >2 mm. In stage 5, the fracture is unstable an isplacement is >2 mm with rotation. Fig. 2 The treatment algorithm accoring to the stage of fracture isplacement.

4 2675 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Fig. 3-A Fig. 3-B Fig. 3-A Anteroposterior raiograph of the right elbow, showing a stage-3 fracture of the lateral cortex with a minimal lateral gap an 2 mmof isplacement. Fig. 3-B Internal oblique raiograph showing a fracture through the lateral humeral conyle, extening into the joint, with the fracture gap being as wie laterally as it is meially. Fig. 3-C Short T1-weighte inversion recovery magnetic resonance image showing complete fracture of the cartilage. Fig. 3-C (stage-1) an inefinable (stage-2) fractures that ha uniformly goo results after treatment with a long-arm cast uring the stuy perio. All patients in the present stuy were manage by a single peiatric orthopaeic surgeon (K.S.S.), an three experience orthopaeic surgeons (C.H.K., B.W.M., an K.C.B.) measure the amount of fracture isplacement an classifie the fracture pattern three times for each patient over a more than two-week interval with use of a PACS (picture archiving an communications system) network (Marosis, ICOM version 3.0; INFINITT, Seoul, South Korea). Fracture fragment isplacement was measure from the lateral metaphyseal cortex of the istal part of the humerus to the lateral cortex of the

5 2676 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Fig. 4-A Fig. 4-B Fig. 4-A Anteroposterior raiograph of the left elbow, showing an apparent stage-3 fracture with isplacement of 2 mm an a gap as wie laterally as meially. Fig. 4-B Internal oblique raiograph of the same elbow, showing a stage-4 fracture with 7 mm of fracture fragment isplacement. Fig. 4-C Fig. 4- Figs. 4-C an 4- Postoperative anteroposterior (Fig. 4-C) an internal oblique (Fig. 4-) raiographs showing a goo reuction, achieve by close means, an internal fixation with two parallel Kirschner wires.

6 2677 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Fig. 4-E Fig. 4-F Figs. 4-E an 4-F Anteroposterior (Fig. 4-E) an internal oblique (Fig. 4-F) raiographs, mae six months after surgery, showing fracture union. fracture fragment on the anteroposterior, internal oblique, an external oblique raiographic views. The posterior cortex was use to measure isplacement on the lateral raiograph. The greatest isplacement on any single raiograph was recore as the amount of isplacement of the fragment. Observer agreement was measure to etermine interobserver an intraobserver reliability. We calculate the kappa value (k value) to assess interobserver an intraobserver reliability regaring the fracture pattern; a kappa value of 1 inicates complete agreement. The interobserver reliability regaring the measurement of fracture isplacement on the preoperative an postoperative anteroposterior an internal oblique raiographs was very high (range, to for preoperative anteroposterior raiographs, to for preoperative internal oblique raiographs, for postoperative anteroposterior raiographs, an to for postoperative internal oblique raiographs). We ivie the fractures into five groups accoring to the amount of isplacement an the fracture pattern as etermine on the basis of the four raiographic views, with a special emphasis on the internal oblique view (Table I, Fig. 1). Stage 1 inicate a fracture through the lateral humeral conyle with a minimal lateral gap an 2 mm of isplacement. Stage 2 inicate a fracture through the lateral humeral conyle to the epiphyseal articular cartilage with a lateral gap an 2 mm of isplacement. Stage 3 inicate a fracture through the lateral humeral conyle into the joint, a fracture gap that was as wie laterally as it was meially, 2 mm of isplacement, an a high risk of further isplacement. Stage 4 inicate a fracture with >2 mm of isplacement without rotation of the istal fragment. Stage 5 inicate a fracture with >2 mm of isplacement with rotation of the istal fragment. An algorithm was create to treat these fractures on the basis of this classification system (Fig. 2). Fractures with the possibility of further isplacement were efine as unstable an as either isplace (>2 mm of isplacement; i.e., stage-4 an 5 fractures) or minimally isplace ( 2 mm of isplacement with a fracture through the lateral humeral conyle extening into the joint an a fracture gap as wie laterally as meially on any of the four raiographic views; i.e., stage-3 fractures). As a first step, we attempte close reuction an internal fixation for all sixty-three unstable isplace fractures, incluing those that were classifie as stage 3 (Figs. 3-A, 3-B, an 3-C), stage 4 (Figs. 4-A through 4-F), or stage 5 (Figs. 5-A through 5-E). To reuce unstable fractures, traction with a gentle varus force was applie to the elbow while the patient was uner general anesthesia. For stage-3 an 4 fractures, graual irect compression was applie to the fracture fragment anteromeially without the use of Kirschner wires. For stage-5 fractures, an attempt was mae to reposition the rotate fragment by using Kirschner wires as joysticks or by pushing irectly on the fragment. After repositioning, fracture fragment reuction was performe in the same manner as for stage-3 an 4 fractures. A slight valgus

7 2678 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Fig. 5-A Fig. 5-B Figs. 5-A an 5-B Anteroposterior raiograph (Fig. 5-A) an internal oblique raiograph (Fig. 5-B) showing a severely isplace fracture with rotation of the fracture fragment. This fracture is classifie as a stage-5 (unstable) fracture. force was applie to the elbow, with the forearm supinate an the elbow slightly extene, to maintain the reuction. After the fracture reuction was confirme to be within 2 mm, especially on the internal oblique, anteroposterior, an lateral raiographs, percutaneous pinning with two parallel smooth Kirschner wires was performe. We use 1.2-mm-iameter Kirschner wires for patients younger than three years of age, 1.4-mm-iameter wires for those between three an five years of age, an 1.8-mmiameter wires for those oler than five years of age. If we coul not reuce the fragment to within 2 mm as shown on any of the four raiographic views, open reuction an internal fixation was performe. A long-arm cast was applie in all cases an was left in place for four weeks. We remove the pins four to five weeks after surgery. At the time of the latest follow-up, we evaluate the egree of fracture isplacement, elbow range of motion, raiographic changes (incluing osteophyte formation an hypertrophy of the capitellum), an clinical symptoms. Results were grae accoring to the criteria suggeste by Haracre et al. 7. Results Atotal of sixty-three fractures were evaluate (see Appenix). The patients inclue forty-two boys an twentyone girls with an average age of six years an four months (range, twenty-one months to eleven years an three months). Thirty-five fractures involve the right elbow, an twenty-eight involve the left elbow. The average time from the injury to surgery was 2.4 ays (range, zero to fourteen ays). The average uration of followup was twenty-five months (range, one year an three months to six years). Seventeen of the sixty-three fractures were stage 3, forty were stage 4, an six were stage 5. The average amount of initial isplacement was 3.5 mm (range, 0 to 33 mm) on the anteroposterior raiograph an 4.5 mm (range, 0.5 to 27 mm) on the internal oblique raiograph. For the entire group, the average amount of postoperative isplacement was <1 mm on both the anteroposterior an the internal oblique raiographs. Thirteen (76%) of the seventeen stage-3 fractures were reuce to 1 mm of resiual isplacement. Thirty (75%) of the forty stage-4 fractures an three (50%) of the six stage-5 fractures were reuce to 2 mm of resiual isplacement. All of these fractures (representing forty-six of all sixty-three fractures) were stabilize with percutaneous Kirschner wires. The remaining four stage-3 fractures were treate with in situ pin fixation without further attempts at reuction. In the cases of the remaining ten stage-4 fractures an three stage-5 fractures, close reuction to within 2 mm faile an open reuction an internal fixation was performe. Minor complications inclue eleven instances of osteophyte formation without any subjective symptoms an four

8 2679 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Fig. 5-C Fig. 5- Figs. 5-C an 5- Postoperative anteroposterior raiograph (Fig. 5-C) an lateral raiograph (Fig. 5-) showing an anatomic reuction, achieve by close means, an internal fixation with two parallel Kirschner wires. Fig. 5-E Anteroposterior raiograph, mae five months after surgery, showing fracture union. Fig. 5-E

9 2680 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN instances of mil hypertrophy of the capitellum with no change in the carrying angle. There were no serious complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest. Accoring to the criteria of Haracre et al. 7, the clinical result was excellent in forty-four (96%) of the forty-six patients unergoing close reuction an pin fixation, goo in two patients (4%), an poor in no patients. Thus, forty-six (73%) of the sixty-three unstable fractures of the lateral humeral conyle were reuce an stabilize with goo results an no serious complications with use of our treatment algorithm. iscussion Afracture of the lateral conyle of the humerus is the secon most frequent fracture of the elbow in chilren. This iagnosis may be less obvious both clinically an raiographically. As with other elbow fractures in chilren, a poorly treate lateral conylar fracture is more likely to result in a substantial functional loss of elbow motion 1. Treating a minimally isplace fracture may be ifficult primarily because it is ifficult to etermine whether the istal fracture fragment is prone to further isplacement. The common practice of using only anteroposterior an lateral elbow raiographs oes not always provie aequate information to allow one to etermine fracture stability, to prevent further isplacement, an to ientify an optimal treatment metho for these fractures 1,4,5,10, Many other stuies, such as magnetic resonance imaging, arthrography, stress tests, an ultrasonography, have been suggeste as aitional methos to evaluate fracture stability However, the routine use of these moalities may not be warrante because of their cost an the nee for seation of the patient. The importance of the internal oblique raiograph for the iagnosis of fracture stability an the amount of isplacement at the site of lateral conylar fractures of the humerus in chilren has been well establishe 13 ; in the present stuy, we have suggeste a new system for the classification of these fractures with use of the internal oblique view. Our results strongly imply that the failure of assessment of stability with use of previous raiographic criteria was ue to the exclusion of the finings from the internal oblique raiograph. We classifie these fractures accoring to the egree of isplacement an the fracture pattern emonstrate on all four raiographic views. Generally, there has been uniform agreement regaring the nee for open reuction an internal fixation of isplace fractures of the lateral conylar physis. Because it is ifficult to maintain the reuction of a isplace lateral conylar fracture an because of the high prevalence of poor functional an cosmetic results associate with close reuction an casting, open reuction an internal fixation has become the most wiely avocate metho for the treatment of unstable fractures with Jakob stage-2 or 3 isplacement However, even patients who are manage with open reuction an internal fixation may have evelopment of malunion because of a lack of intraoperative confirmation of the reuction status or osteonecrosis cause by excessive soft-tissue issection. Only a few reports have focuse on percutaneous pin fixation of these fragments. Mintzer et al. reporte goo results after percutaneous pin fixation of twelve lateral conylar fractures with isplacement in excess of 2 mm 11. They believe that the metho is appropriate for selecte fractures with 2 to 4 mm of isplacement an an arthrographically emonstrate congruent joint space. Foster et al. reporte that percutaneous pin fixation of nonisplace an minimally isplace fractures is an acceptable alternative in any situation in which close clinical an raiographic follow-up cannot be ensure 12. It was often our personal experience that many fractures that were treate with open reuction an internal fixation coul be reuce by close means. Because it appeare that open reuction an internal fixation was not always necessary for these isplace fractures, we conucte the present stuy. The present stuy showe a high success rate (73%) in association with close reuction an pin fixation for the treatment of unstable isplace fractures. While others have reporte that close reuction an internal fixation is not recommene for the treatment of Jakob stage-3 isplace an rotate lateral conylar fractures 1 (which are classifie as stage- 5 fractures in our system), we achieve excellent results in three of six such fractures with use of close reuction an pin fixation (Figs. 5-A through 5-E). We acknowlege that the number of cases is small an that aitional prospective stuies are neee to further evaluate this approach for the treatment of fractures with an unstable an rotate fragment. It is our impression that the reasons for our high success rate with close reuction an internal fixation were (1) the accurate interpretation of the irection of fracture isplacement (mainly posterolaterally, not purely laterally) an the amount of isplacement of the fracture fragment on the basis of our classification system, (2) routine intraoperative confirmation of the reuction on both anteroposterior an internal oblique raiographs, an (3) maintenance of the reuction with two parallel percutaneous Kirschner wires. The present stuy emonstrates that fracture classification on the basis of four elbow raiographs, with an emphasis on the internal oblique view, is useful for etermining fracture fragment stability an the optimal treatment metho an that close reuction an pin fixation often results in effective treatment for unstable isplace lateral conylar fractures of the humerus in chilren. Appenix A table showing clinical etails on all stuy subjects is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation an click on Supplementary Material ) an on our quarterly C/V (call our subscription epartment, at , to orer the C or V). n NOTE: This stuy was partially supporte by the research-promoting grant from the Keimyung University ongsan Meical Center. The authors thank Katharine O Moore-Klopf for proviing eitorial assistance.

10 2681 C LOSE R EUCTION AN INTERNAL F IXATION OF L ATERAL C ONYLAR H UMERAL FRACTURES IN C HILREN Kwang Soon Song, M Chul Hyung Kang, M Byung Woo Min, M Ki Cheor Bae, M Chul Hyun Cho, M Ju Hyub Lee, M epartment of Orthopeic Surgery, School of Meicine, Keimyung University, 194 ong san ong, aegu , South Korea. aress for K.S. Song: skspos@smc.or.kr References 1. Beaty JH, Kasser JR, eitors. Rockwoo an Wilkins fractures in chilren. 6th e. Philaelphia: Lippincott Williams an Wilkins; Canale ST, eitor. Campbell s operative orthopaeics. 10th e. St. Louis: Mosby; Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral conyle in chilren. J Bone Joint Surg Br. 1975;57: Baelon O, Bensahel H, Maza K, Vie P. Lateral humeral conylar fractures in chilren: a report of 47 cases. J Peiatr Orthop. 1988;8: Flynn JC. Nonunion of slightly isplace fractures of the lateral humeral conyle in chilren: an upate. J Peiatr Orthop. 1989;9: Conner AN, Smith MG. isplace fractures of the lateral humeral conyle in chilren. J Bone Joint Surg Br. 1970;52: Haracre JA, Nahigian SH, Froimson AI, Brown JE. Fractures of the lateral conyle of the humerus in chilren. J Bone Joint Surg Am. 1971;53: Crabbe WA. The treatment of fracture-separation of the capitular epiphysis. J Bone Joint Surg Br. 1963;45: Launay F, Leet AI, Jacopin S, Jouve JL, Bollini G, Sponseller P. Lateral humeral conyle fractures in chilren: a comparison of two approaches to treatment. J Peiatr Orthop. 2004;24: Flynn JC, Richars JF Jr. Non-union of minimally isplace fractures of the lateral conyle of the humerus in chilren. J Bone Joint Surg Am. 1971;53: Mintzer CM, Waters PM, Brown J, Kasser JR. Percutaneous pinning in the treatment of isplace lateral conyle fractures. J Peiatr Orthop. 1994;14: Foster E, Sullivan JA, Gross RH. Lateral humeral conylar fractures in chilren. J Peiatr Orthop. 1985;5: Song KS, Kang CH, Min BW, Bae KC, Cho CH. Internal oblique raiographs for iagnosis of nonisplace or minimally isplace lateral conylar fractures of the humerus in chilren. J Bone Joint Surg Am. 2007; 89: Finnbogason T, Karlsson G, Linberg L, Mortensson W. Nonisplace an minimally isplace fractures of the lateral humeral conyle in chilren: a prospective raiographic investigation of fracture stability. J Peiatr Orthop. 1995;15: Horn B, Herman MJ, Crisci K, Pizzutillo P, MacEwen G. Fractures of the lateral humeral conyle: role of the cartilage hinge in fracture stability. J Peiatr Orthop. 2002;22: Kamegaya M, Shinohara Y, Kurokawa M, Ogata S. Assessment of stability in chilren s minimally isplace lateral humeral conyle fracture by magnetic resonance imaging. J Peiatr Orthop. 1999;19: Marzo JM, Amato C, Strong M, Gillespie R. Usefulness an accuracy of arthrography in management of lateral humeral conyle fractures in chilren. J Peiatr Orthop. 1990;10: Milch H. Fractures an fracture islocations of the humeral conyles. J Trauma. 1964;4: Vocke-Hell AK, Schmi A. Sonographic ifferentiation of stable an unstable lateral conyle fracture of the humerus in chilren. J Peiatr Orthop B. 2001;10: