Inaccuracy in assessing reduction of humeral condylar fractures using digital radiography and its effect on the decision to return to surgery.

Case history: Medical records of a single veterinary teaching hospital in Giessen, Germany were retrospectively reviewed for dogs presented for medial or lateral humeral condylar fractures (HCF) between 2007 and 2019. Data regarding surgical technique and complications were collected from the medical records. The latter was supplemented through information obtained from telephone interviews with referral veterinarians and from an owner questionnaire completed ≥12 months after surgical repair, which also provided data regarding outcome. Clinical findings: Eighty dogs with 85 HCF were identified: 13 (15.3%) HCF were medial (bilateral in two dogs) and 72 (84.7%) were lateral (bilateral in three dogs). French Bulldogs (n = 19/80; 23.8%) were most commonly affected. Patients were predominantly skeletally immature and light-weight, with a median age at the time of presentation of 3 (min 2, max 118) months and with a median body weight of 6.4 (min 1, max 46) kg. There were 38 female (47.5%) and 42 male (52.5%) dogs. Fractures developed most frequently secondary to minor trauma (67/77; 87.0%). Dogs were presented in 35/84 (41.7%) cases more than 24 hours after fracture occurrence. Treatment and outcome: Surgical treatment was performed in 80/85 (94.1%) HCF. An open reduction and internal fixation approach was chosen in all cases. A transcondylar screw (TS) combined with a supracondylar (SC) K-wire (67/80; 83.8%) was the most frequently used fixation technique. Considering all fracture fixation methods, complications (26/80; 32.5%) were classed as minor in 10 (12.5%), major in 14 (17.5%) and catastrophic in two (2.5%) of the 80 surgically treated HCF. Long-term outcome was excellent in 68.6% (24/35 HCF) and very good in 22.9% (8/35 HCF) of the cases for which follow-up information was obtained. Additionally, owner information revealed that 85.7% of dogs (30/35 HCF) were free of lameness in the long-term. Clinical relevance: This case series demonstrates that surgical repair of lateral and medial HCF with a TS and SC K-wire is a viable option to consider in skeletally immature and light-weight patients. Complications occur frequently after surgical fixation of HCF, but owners can expect a very good to excellent long-term outcome in the majority of cases.

Objective To investigate the effect of the treatment of humeral lateral condyle fracture in children through elbow arthroscopy. Method From July 2003 to May 2008, 128 children with humeral lateral condyle fracture were randomly divided into open reduction group and arthroscopy group, each group of 64 cases. Results All 128 children received 12-24 months of follow up, with average of (18.07 ± 5.63) months. In arthroscopy group, the blood loss averaged(34.6 ± 9.1) ml, incision length of(0.98 ± 0.20) cm, and after the first 3 days the VAS was(3.99 ± 1.33) scores. However, in open reduction group, the blood loss averaged (109.9 ± 18.9) ml, incision length of (5.38 ± 1.30) cm, and the VAS was (7.03 ± 2.80) scores. All those in arthroscopy group were much better than those in open reduction group,the differences were statistically significant (P<0.01 or < 0.05). According to Mayo score, the total fine rate was 85.9%(55/64) in open reduction group, and 98.4%(63/64) in arthroscopy group (P<0.05). About in the incidence of postoperative complications,there were 8 cases of delayed healing, S cases of inside inversion or outside eversion elbow varus deformity, 9 cases of pin tract infection in open reduction group. However there were 1 cage of delayed healing, 2 cases of inside inversion and outside eversion elbow varus deformity, 1 case of pin tract infection in arthroscopy group(P< 0.01). Conclusion Arthroscopy operation has the advantages of the small incision, reset reduction accurate, less complications ,and is an effective method of treating the lateral condyle fractures in children. Key words: Child; Humeral fractures; Arthroscopy; Internal fixators

Objective To compare the clinical effects and use of open reduction plus Kirschner wire combined with cannulated screw internal fixation and open reduction plus Kirschner wire internal fixation alone in the treatment of lateral humeral condyle fractures. Methods Sixty-four patients with Jacob types Ⅱ or Ⅲ lateral humeral condyle fractures, who stayed in our department between January 2015 and August 2017, were included in the study and divided into two groups according to different treatment methods. Patients who underwent open reduction plus Kirschner wire internal fixation alone were included in the control group (n=30) , and those who underwent open reduction plus Kirschner wire combined with cannulated screw internal fixation were included in the study group (n=34) . The good efficacy rate of treatment, operation time, fracture healing time, incidence of wound infection and complications of fracture re-displacement were compared between the two groups. Results The good efficacy rate of treatment, operation time and fracture healing time in the control group and study group were 83.33% vs 97.06%, (46±13) min vs (50±16) min, and (13.0±2.2) weeks vs (8.7±1.0) weeks, respectively (P<0.05) . Conclusion The effect of open reduction plus Kirschner wire combined with cannulated screw internal fixation for the treating bone displacement due to fresh lateral humeral condyle fractures in children is better compared with open reduction plus Kirschner wire internal fixation alone. Key words: Humeral fractures; Fracture fixation, internal; Kirschner wire; Cannulated screw

Objective To evaluate the significance of ultrasonic examination in determining the stability of minimally displaced or nondisplaced lateral humeral condyle fractures in children. Methods From January 2014 to March 2017, 35 children with minimally displaced or nondisplaced lateral humeral condyle fractures were reviewed. There were 13 girls and 22 boys with an age range of 19-120 months. Transverse cross-section ultrasonography and sagittal section ultrasonography of anterior elbow were used for determining whether or not cartilage hinge was intact. If intact, patients were immobilized in long-arm casts and plain anteroposterior and lateral radiographs were made after 1 week. If disrupted, closed reduction and percutaneous pinning and plain anteroposterior and lateral radiographs were made for 2-3 weeks. For immobilization in long-arm casts and surgical refusal, plain anteroposterior and lateral radiographs were made for 5-7 days. Results Cartilage hinges were intact (n=11) and disrupted (n=24). And 8/24 disrupted children rejected surgery and were immobilized in long-arm casts. Two of them became displaced after 1 week and there were 3 displacements after 2-3 weeks. For 11 intact and 16 operated children, there was no displacement. Conclusions Ultrasonic examination is simple, convenient, accurate and sedation-free for managing lateral humeral condyle fractures in children. It should be routinely applied for early stability evaluations of minimally displaced or nondisplaced lateral humeral condyle fractures in children. Key words: Humeral external condyle fracture; Ultrasonic diagnosis Cartilage hinge; Stability

Aims To compare the accuracy of radiography and CT to diagnose anatomical surgical reduction of lateral humeral condylar fractures using an ex vivo canine model. Methods Ten right and left pairs of thoracic limbs were obtained from fresh canine cadavers. Lateral humeral condylar fractures were created and reduced, with or without an articular step-off (0-, 1-, 2-, 3-mm in a caudal or distal direction), and stabilised using a transcondylar screw and a supracondylar pin. Mediolateral and craniocaudal radiographs of each limb were taken, followed by CT imaging in a sagittal, dorsal, and transverse plane. All images were assessed for malreduction by 11 board-certified specialists. The accuracy of assessment was modelled using multivariable mixed logistic regression, and consistency between assessors was assessed with Gwet's first order agreement coefficient (AC1). Results The regression indicated that the estimated mean probability of an accurate assessment of anatomical reduction was 0.83 (95% CI = 0.56–0.96) and 0.81 (95% Cl = 0.51–0.97) for radiographs and CT scans, respectively. There was no evidence that the size of the articular step influenced the probability of correctly identifying a malreduction (p = 0.18), but the correct identification of malreduction depended on its direction and the type of imaging modality (p < 0.001). Distal malreductions were reliably diagnosed for both radiographs and CT, with estimated mean probability of incorrect diagnosis of 0.005 (95% Cl = 0.001–0.037) and 0.029 (95% Cl = 0.003–0.2), respectively. However, for caudally malreduced fractures, the model estimated the mean probability of misdiagnosis by radiographs was 0.58 (95% CI = 0.5–0.76) compared to 0.012 (95% CI = 0.001–0.104) for CT scans. Overall inter-reviewer agreement was moderate to substantial (Gwet's AC1 = 0.64; 95% CI = 0.55–0.74). Agreement for distal malreductions was significantly higher than for caudal malreductions and slightly higher for CT scans than for radiographs. Highest agreement was seen in reviewers using CT scans to correctly identify malreductions or radiographs for identifying distal malreductions. Conclusion Radiographs and CT were accurate for detecting distal malreductions and identifying anatomically reduced fractures. Radiographs incorrectly assessed caudal malreduction in more than half the cases. Overall, there was good inter-observer agreement between the two types of imaging, except when using radiography to identify caudal malreductions. Clinical significance CT was found to accurately assess articular step-offs in both directions (caudal, distal), showing that this modality is more reliable than radiographs for assessing multidirectional articular misalignments. Abbreviations GLMM: Generalised linear mixed model; Gwet’s AC1: Gwet’s first order autocorrelation coefficient; MCP: Medial coronoid process; PTOA: Post-traumatic osteoarthritis

Lateral humeral condyle (LC) fractures are the second most common pediatric elbow fractures. Traditionally, displaced fractures have been treated with open reduction although recent studies have demonstrated successful outcomes of closed reduction for similar injuries. This study investigates the outcomes comparing open and closed reduction in a large cohort of children with moderately displaced (Song classification types 1 to 4) lateral humeral condyle fractures. Retrospective data from patients aged between 1 and 12 years treated for lateral condyle fractures was collected from 6 academic level 1 trauma centers between 2005 and 2019. Data was collected on patient demographics, radiographic parameters, reduction type, type of hardware fixation, and fracture patterns. Complications recorded include infections, reoperations for nonunion, osteonecrosis, and elbow stiffness. An initial 762 fractures were identified. After excluding Song 5 cases, a total of 480 fractures met inclusion criteria, with 202 (42%) treated with closed reduction and 278 (58%) treated with open reduction. Demographics and injury characteristics were similar across the 2 reduction cohorts. After propensity score matching, delayed healing (52% vs. 28%; OR: 2.88, 95% CI: 1.97-4.22; P <0.0001) and stiffness (22% vs. 10%; OR 2.42, 95% CI: 1.42-4.13; P =0.0012) were significantly higher in the open reduction group. No differences in the rates of infection or nonunion (3% CR and 1% OR) were noted between the 2 groups. This study demonstrates that moderately displaced lateral condyle fractures requiring open reduction are more likely to have elbow stiffness and delayed healing when compared with the ones treated with closed reduction. For these reasons, we propose attempting closed reduction techniques as the first line of treatment in moderately displaced lateral humeral condyle fractures (if anatomic articular reduction can be achieved) to attain better patient outcomes.

Background: Lateral humeral condylar fractures in children are considered the second most common type of fractures in pediatric elbows after supracondylar fracture. Conservative treatment of these types of fracture usually fails. Open reduction and internal fixation of these types of fractures has been the treatment of choice with regard to anatomical reduction and stable internal fixation. Complications of open reduction range from mild complications, such as scars of the skin incision, to severe, such as avascular necrosis of the lateral condyle. Closed reduction and percutaneous fixation of the fracture may give the same results as open reduction with regard to reduction and healing of the fracture but without the complications of open reduction. Methods: This prospective interventional study was conducted in 60 patients who had lateral humeral condylar fractures. Patients were grouped into two equal groups: one group was managed by closed reduction and internal fixation (CRIF), and the second group was managed by open reduction and internal fixation (ORIF). Results: The two groups were compared after the operation and 1-year follow-up. There was no difference between the two groups with regard to fracture healing and complications, with the exception of complications of wound healing and skin scarring after open reduction. Conclusions: Closed reduction and percutaneous pinning of lateral humeral condylar fractures gave the same results in bone healing without the complications of skin-incision healing that were found in open reduction. Level of Evidence: Level III.

To report the progression of a humeral intracondylar fissure (HIF) into a lateral humeral condylar fracture and successful treatment in a cat. Case report. One 8-year-old, male, neutered, Maine coon crossbreed cat. A lateral humeral condylar fracture occurred in a cat with no history of trauma. A partial HIF was identified by computed tomography of the contralateral elbow, progressing to fracture 279 days later. Both fractures were repaired surgically at the time of their diagnoses. Both lateral humeral condylar fractures were repaired with a transcondylar lag screw and caudolaterally applied locking plate. These repairs led to bone union and full return to function of surgically treated limbs. Eight hundred thirty-six days after initial presentation, a nontraumatic transverse patella fracture was diagnosed, which combined with a clinical history of extraction of retained deciduous canines supports a diagnosis of patellar fracture and dental anomaly syndrome (PADS). Evidence of progression of HIF to fracture in a cat with PADS has implications for management of elbow-related lameness in this species. In this report, we seek to alert practitioners to the potential for HIF to be seen in cats and that cats presenting for humeral condylar fracture should undergo further assessment for patella and other fractures as well as dental anomalies. Key features of PADS may not be present at the time of initial assessment.

Combined fractures of the lateral condyle of the humerus and the ipsilateral ulnar olecranon are rarely seen in children. Therefore, the mechanism and suitable treatments remain debatable. This study describes the possible mechanism of combined humeral lateral condyle and ipsilateral ulnar olecranon fractures and presents the treatment results. Children diagnosed with combined fractures of the humeral lateral condyle and ipsilateralulnar olecranon from July 2010 to July 2020 were retrospectively analyzed. Humeral lateral condyle fractures were treated with open reduction and internal fixation with bioabsorbable pins. Ulnar olecranon fractures were treated with closed reduction and percutaneous pinning with K-wires for Mayo type IA fractures and with tension-band wiring or a locking plate for Mayo type IIA fractures. The postoperative function and appearance of the elbow were evaluated using the Flynn criteria and Mayo Elbow Performance Score (MEPS) at follow-up. The cohort comprised 19 patients aged from 4 to 11 years. Bony compression and avulsion by attached muscles and ligaments may be the leading factors causing the combined injuries, as the children fell with an outstretched and supinated elbow. The average follow-up time was 33 months. High MEPS of >90 indicated that good to excellent results were obtained without complications. This study proposed a reasonable hypothesis for the mechanism of combined humeral lateral condyle and ipsilateral ulnar olecranon fractures in children. Satisfactory outcomes were achieved with bioabsorbable pins for lateral condyle fractures and closed reduction and percutaneous pinning with K-wires, tension-band wiring, or locking plate for olecranon fractures.

Background:Lateral humeral condyle fractures are the second most common elbow fracture in children. Displaced and rotated fractures require stabilization and reduction. Kirschner wires (K-wires) are most commonly used in the fixation of these fractures. Here, we introduce a new fixation method that uses an absorbable screw. We aim to determine if it is feasible to treat lateral humeral condyle fractures with an absorbable screw by comparing functional outcomes following absorbable screw fixation vs. K-wire fixation.Methods:Between May 2007 and September 2010, 86 patients were treated with absorbable screws (43 patients) or K-wire (43 patients). All patients had been diagnosed with lateral condyle fractures that were classified as either Jacob type II (unstable) or III. One absorbable screw (3.5 mm-diameter) was used for fixation in 1 group, while two 1.6 to 1.8 mm K-wires were used in the other group. Patients were followed 6 months about the elbow function according to Broberg and Morrey standard. On 5–7 years, the patients were followed about the carrying angle (valgus deformities and varus deformities), range of motion (flexion loss and extension loss), prominent lateral condyle, symptomatic implants, and fishtail deformity.Results:Anatomic reduction was achieved in all patients. Each group had one radial nerve injury that were present preoperatively. Nerve function recovered spontaneously within 3 to 4 weeks of surgery in both patients. No patient developed necrosis of the capitulum in both groups. Nine patients in K-wires group and 2 in absorbable screw group developed symptomatic implants (P = .048). On the sixth month, there was no significant difference on elbow function according to Broberg and Morrey standard. On 5 to 7 years (average, 6.7 ± 1.3 years), valgus deformities was 6.8 ± 1.2 vs 5.7 ± 0.8, varus deformities was 7.2 ± 1.5 vs 5.1 ± 1.9, flexion loss was 12.4 ± 2.2 vs 9.5 ± 3.1, extension loss was 11.1 ± 3.1 vs 10.2 ± 2.7, prominent lateral condyle was 27.9% vs 37.2%, fishtail deformity was 7.3% vs 4.9%, no significant difference between these groups.Conclusions:Open reduction with absorbable screw fixation is feasible and safe for the treatment of lateral condyle fractures of the humerus in children.Level of Evidence:Therapeutic III.

Objective To compare the efficacies of displaced ≤2 mm fractures of lateral humeral condyle percutaneous fixation versus conservative treatment. Methods A total of 114 cases of displaced ≤2 mm lateral humeral condyle fractures were recruited 5 study units during January 2010 to December 2015. Inclusion criteria included lateral humeral condylar fracture within 1 week and radiology showed a distance of fracture displacement ≤2 mm. Plaster in neutral rotation and 90 degrees of elbow flexion (group A, n=41) and percutaneous Kirschner wire fixation or absorbable bone rod (group B, n=73) were performed. Results During an average follow-up period of 1.2 years (5 months to 4 years), 41/114 children received conservative treatment. There were 11 cases of fracture re-displacement in groups A and C while none in group B. Fracture re-displacement cases in group C had open reduction and fixation with Kirschner wire or compression screw. According to the Dhillon scoring system, the outcomes were excellent for all cases in group B and 30 cases in group A and fair for all cases in group C. Significant differences existed between group C (1.82±0.4) and A, B (2.93±0.25 & 2.89±0.31) (P<0.05). In group C, there were early epiphyseal closure (n=1) and skin irritation (n=1). There was no onset of such complications as infection or skin necrosis. Conclusions Displaced ≤2 mm fractures of lateral humeral condyle are prone to re-displacement after conservative treatment. Both safe and mini-invasive, early percutaneous fixation may prevent the occurrences of re-displacement and early epiphyseal closure. Key words: Humeral fracture; Internal fixators; Multicenter Study

Pediatric lateral humeral condyle fractures are common injuries. Current treatment recommendations include nonoperative treatment for nondisplaced Milch type 1 fractures; however, truly nondisplaced fractures may be rare. Although closed reduction and percutaneous pinning under arthrographic visualization are most commonly used, anatomical reconstitution of the articular surface may require a lateral Kocher approach. This approach may compromise the vascularity of the distal fragment. To avoid this catastrophic complication while still obtaining anatomical articular surface reduction, we have investigated a new technique in which the lateral condyle fracture is reduced arthroscopically, allowing visualization of the articular surface without the soft tissue dissection required with open approaches. The fracture is then percutaneously pinned and immobilized as previously recommended. Six skeletally immature patients with lateral humeral condyle fractures underwent arthroscopic reduction and percutaneous pinning. The mean age of the patients was 48 months (range, 21-69 months). There were 2 girls and 4 boys. Surgery was performed on 4 left and 2 right elbows. The mean follow-up was 32 weeks (range, 21-44 weeks). Postoperatively, all patients were placed in a long arm cast for 4 weeks. Pins and casts were removed at 4 weeks, and motion was begun. Elbow radiographs were evaluated for fracture healing, articular congruity, malunion, growth disturbance, and presence of avascular necrosis. Range of motion, function, pain, and cosmetic deformity were recorded. All patients had full active and passive range of motion. There was no difference in range of motion compared with the contralateral side (P < 0.05). All fractures healed radiographically by 4 weeks. There were no cases of nonunion or malunion. No patients developed cubitus varus. One patient developed radiolucency of the capitellum. There were no other complications. Arthroscopic reduction and percutaneous fixation of pediatric lateral humeral condyle fractures may offer a safe and effective alternative to open treatment with decreased soft tissue stripping and a possibly decreased risk of malunion or avascular necrosis. Level IV.

Objective To investigate the effect of different treatment on children with grade Ⅰ and grade Ⅱ humeral lateral condyle fracture. Methods From Oct. 1996 to Apr. 2008, 39 children of with grade Ⅰ and grade Ⅱ humeral lateral condyle fractures were cured with different treatments including ORIP and expectant treament. Results All cases were followed up for 3 months to 50 months (average 16 months). The fineness rate was 95% in onestage operation group, but it was 66.7% in postpone operation group. Conclusions The fineness ration in onestage operation group is better than in postpone operation group. Key words: Humeral lateral condyle fracture; Children

Objective To investigate the early diagnosis and treatment strategies of lateral condylar fractures of humerus in children.Methods From July 2010 to July 2012,15 patients with humeral lateral condyle fractures were treated with open reduction and internal fixation with Kirschner wires in our hospital.The treatment outcomes were assessed using Flynn functional criteria and radiographical assessment of osteoarthritis or heterotopic ossification around the elbow.Results All the patients were follow-up for a mean time of 18.5 months (range,13 to 27 months).Bony healing was achieved in all the patients,within an average of 2.0 months (range,1.4 to 2.7 months).No nonunion and delayed union were observed in X-ray films.According to Flynn criteria,the results were excellent in 13 cases and good in 2 cases.Conclusion Displaced humerus lateral condyle fracture is easy to be misdiagnosed or missed because ossification occurs late in children.The fracture therefore doesn't show on X-rays.Early diagnosis is important in order to reduce various deformities and complications.Open reduction and crossed Kirschner wire fixation can lead to satisfactory reduction and firm fixation with fewer complications.At present it is an ideal method for treatment of lateral condylar fracture of humerus in children. Key words: Child; Humerus fractures; Early diagnosis; Lateral condyle

To investigate the efficacy of '20 degrees -tilt anteroposterior (A-P) radiography' in the assessment of lateral condylar fractures of the distal humerus. Eighteen children with lateral humeral condylar fractures were studied. Every child underwent conventional A-P and lateral radiography, and six children underwent multi-detector computed tomography (MDCT). For the investigation of 20 degrees -tilt radiography, ten children with lateral humeral condylar fractures had conventional and 20 degrees -tilt A-P and lateral radiography both preoperatively and postoperatively. Fragment dislocation was measured at the lateral and medial margins of the fracture on both the conventional A-P and 20 degrees -tilt A-P radiographs. The lateral condylar fragment was triangular and was most prominent posteriorly. The fracture line was typically tilted approximately 20 degrees to a reference line perpendicular to the long axis of the humerus in the lateral view. The extent of dislocation at the lateral and medial margins of the fracture site by 20 degrees -tilt A-P radiography (9.3 +/- 3.6 mm and 5.6 +/- 2.5 mm) was significantly wider than that measured by the conventional method (6.8 +/- 4.1 mm and 2.0 +/- 1.5 mm ), which may influence treatment. Twenty-degree-tilt A-P radiography may more precisely demonstrate fragment dislocation than standard radiographs and may influence patient treatment.