Abstract
Background: Neglected fractures of the lateral humeral condyle (LHC) are misdiagnosed or insufficiently treated fractures, presenting later than 3 weeks after injury. The management of neglected LHC fractures in children remains controversial. Methods: Twenty-seven children were included in this retrospective study. Charts and medical records were investigated for demographics, time interval between injury and treatment, and type of treatment. Baseline radiographs were assessed for fracture grading and displacement. Final radiographs were investigated for bone healing, avascular necrosis, elbow deformities and growth disturbances. Complications were classified by the Clavien–Dindo–Sink (CDS) system. Outcomes were assessed according to the Dhillon Score (DhiS) and Mayo Elbow Performance Score (MEPS). Results: The mean time from injury to presentation was 27 months. Treatments included nonoperative management (6 patients), “in-situ” fixation (7 patients), open reduction and internal fixation (11 patients) and corrective osteotomy (3 patients). The mean follow-up was 7 years (range: 2–16). Overall, we observed complications in 16 patients (59%); six complications were considered major (22%) and occurred in Weiss Grade 3 fractures, with lateral displacement ≥5 mm. At the latest follow-up, pain and functional scores improved in 23 of 27 patients (85%). Mean MEPS increased from an average of 62 points preoperatively to 98 points postoperatively, while mean DhiS improved on average from 5 to 8 points. CDS score and time interval between injury and treatment were independent predictors of MEPS and DhiS. Conclusion: Our study describes outcomes from a cohort of children undergoing different treatments for neglected LHC fractures. Prolonged time interval between injury and treatment and perioperative major complications negatively impacted the treatment outcomes. Our findings strengthen the requirement for widely agreed guidelines of surgical management in neglected LHC fractures.
Highlights
Despite no evidence-based thresholds for fracture healing have been currently established, it is widely accepted that delayed union is a lateral humeral condyle (LHC) fracture in which no complete bone healing is observed by more than 8 weeks after the initial injury, while nonunion is defined as no progression of bone healing after 3 months [1,5,11,12,13]
Delayed union and nonunion of LHC fractures in children account for 2.5% overall, according to a recent systematic review [1]
We found significant associations between the modified CDS score for complications and the Mayo Elbow Performance Score (MEPS) and Dhillon Score (DhiS) at final follow-up, confirming that poorly treated and neglected LHC fractures can be harmful for long-term elbow function and quality of life, especially in athletic children [5]
Summary
Many nondisplaced LHC fractures may be treated conservatively, fractures with >2 mm displacement are considered unstable, requiring surgical fixation [2,3,4]. Neglected LHC fractures are unrecognized or misdiagnosed fractures that present later than 3 weeks after injury [5,6,7,8,9,10]; misdiagnoses may occur in up to 17% of cases, causing inadequate and/or insufficient conservative management and, malunion, delayed union or nonunion [1]. Delayed union and nonunion of LHC fractures in children account for 2.5% overall, according to a recent systematic review [1]
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