Lateral epicondyle fracture (elbow)
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Lateral epicondyle fractures of the elbow are rare epicondylar fractures. They are much rarer than medial epicondyle fractures and represent avulsion of the lateral epicondyle. They are usually seen in the setting of other injuries 1-3.
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These fractures are avulsion fractions of the ossification center of the lateral condyle, and as such are sometimes referred to as a lateral epicondyle avulsion fracture; either term is acceptable. They are distinct from a lateral condyle fracture which is a very different fracture despite the similar name.
Incidence typically peaks in the pediatric age group (6-7 years of age) 7.
In children, these injuries are believed to occur due to sudden traction on the common extensor origin by the extensor musculature. In adults, lateral epicondylar fractures are usually due to a direct blow 2.
Plain films usually suffice in both making the diagnosis and determining treatment.
The key to correctly interpreting pediatric elbow injuries is an understanding of the order and age at which the various secondary centers of ossification become visible (see ossification centers of the elbow).
Before the apophysis begins to ossify (10-11 years of age), soft tissue swelling may be the only finding, and the degree of displacement cannot be evaluated on plain films.
When ossification is present then care must be taken in not over-calling separation, on account of the apophysis beginning its ossification laterally, and as such the gap between the ossified component and the rest of the humerus can be considerable 2. Comparison to the contralateral elbow may be of benefit.
Certainly, if the ossification center is displaced such that it lies distal to the growth plate between the metaphysis and center of ossification for the capitellum, then significant displacement is present.
It should also be noted that in children the ossification center can undergo up to 180° of rotation such that the physeal surface is most superficial 3.
As the late sequelae, there may be lateral spurring (especially in children) 5.
Some authors suggest a better detection rate with 20° tilted or internal oblique radiographs 6,9.
When reporting these injuries, care should be taken to ensure that one is not looking at normal ossification of the lateral epicondyle. If satisfied that it is indeed displaced then the degree of displacement should be commented upon, as well as whether or not the ossification center is within the joint. Any rotation of the center of ossification should also be commented upon.
The other centers of ossification of the elbow should be reviewed to ensure that they are age-appropriate.
Treatment and prognosis
Undisplaced or minimally displaced injuries can be treated conservatively 1.
In significantly displaced fractures, rigid internal fixation allowing early mobilization is an option, although conservative management for these patients also is an option 1,2. Even if a pseudoarthrosis occurs (non-union) most patients are asymptomatic; if symptoms do occur later, surgical intervention can be carried out 1,2.
If the ossification is displaced into the joint then operative intervention is required 2.
In general, young patients have little subsequent impairment. An injury to the growth plate between the lateral epicondylar center of ossification and the rest of the humerus does not contribute to bone length; growth arrest is therefore not an issue 1.
- 1. Laer LV. Pediatric Fractures and Dislocations. TIS. (2004) ISBN:1588906809. Read it at Google Books - Find it at Amazon
- 2. Beaty JH, Rockwood CA, Kasser JR. Rockwood and Wilkins' fractures in children. Lippincott Williams & Wilkins. (2009) ISBN:1582557845. Read it at Google Books - Find it at Amazon
- 3. Schatzker J, Tile M. The Rationale of Operative Fracture Care. Springer Verlag. (2005) ISBN:3540228500. Read it at Google Books - Find it at Amazon
- 4. Kobayashi Y, Oka Y, Ikeda M et-al. Avulsion fracture of the medial and lateral epicondyles of the humerus. J Shoulder Elbow Surg. 9 (1): 59-64. J Shoulder Elbow Surg (link) - Pubmed citation
- 5. Pribaz JR, Bernthal NM, Wong TC et-al. Lateral spurring (overgrowth) after pediatric lateral condyle fractures. J Pediatr Orthop. 32 (5): 456-60. doi:10.1097/BPO.0b013e318259ff63 - Pubmed citation
- 6. Imada H, Tanaka R, Itoh Y et-al. Twenty-degree-tilt radiography for evaluation of lateral humeral condylar fracture in children. Skeletal Radiol. 2010;39 (3): 267-72. doi:10.1007/s00256-009-0708-8 - Pubmed citation
- 7. Saraf SK, Khare GN. Late presentation of fractures of the lateral condyle of the humerus in children. Indian J Orthop. 2011;45 (1): 39-44. doi:10.4103/0019-5413.67119 - Free text at pubmed - Pubmed citation
- 8. Chapman VM, Grottkau BE, Albright M et-al. Multidetector computed tomography of pediatric lateral condylar fractures. J Comput Assist Tomogr. 29 (6): 842-6. J Comput Assist Tomogr (link) - Pubmed citation
- 9. Song KS, Kang CH, Min BW et-al. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2007;89 (1): 58-63. doi:10.2106/JBJS.E.01387 - Pubmed citation