ORIGINAL ARTICLE
Screw Fixation of Lateral Condyle Fractures: Results of Treatment Eric Shirley, MD, Mary Anderson, BS, Kevin Neal, MD, and John Mazur, MD
Background: Fixation of lateral condyle distal humeral fractures has traditionally been achieved with K-wires. Screw fixation provides the advantage of compression across the fracture site, but the results of screw fixation and risk of iatrogenic physeal damage are not well defined. This study was designed to evaluate the efficacy of screw fixation for lateral condyle fractures. Methods: A retrospective study of patients with lateral condyle elbow fractures treated using screw fixation at a single institution was undertaken. Patients 12 years and younger with isolated fractures were included. Clinical notes were examined for residual symptoms, alignment, range of motion, and complications. Radiographs were reviewed for healing and growth arrest. Results: Ninety-six patients who were treated over a 7-year period met inclusion criteria. Mean patient age was 5.8 years (range, 2 to 12 y). Fifty-four patients required open reduction; 42 patients underwent a closed reduction. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). The overall complication rate was 19% and was 5% when lateral overgrowth was excluded as a complication. Initial fracture union was achieved in 99% of patients. One patient required revision fixation with a bone graft. Hardware was symptomatic with prominence or loss of flexion in 4% of patients. There were no cases of growth arrest or alterations of the carrying angle. For patients with final follow-up >12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). Conclusion: Screw fixation of lateral condyle fractures results in satisfactory union with a low risk of complications at early follow-up. Level of Evidence: This study was a retrospective case series performed to investigate the results of treatment, level IV. Key Words: lateral condyle, fracture, treatment (J Pediatr Orthop 2015;35:821–824)
L
ateral condyle distal humeral fractures are the second most common pediatric elbow fracture and the most common elbow fracture that involves the growth plate.1 Treatment options include nonoperative management with cast immobilization versus surgery. Operative treatment is favored for fractures with displacement of From the Nemours Children’s Clinic, Jacksonville, FL. No sources of funding or conflicts of interest exist to disclose. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Eric Shirley, MD, Nemours Children’s Clinic, 807 Children’s Way, Jacksonville, FL 32207. E-mail: [email protected]. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 8, December 2015
>2 mm. Surgery may also be considered for fractures with less displacement when follow-up cannot be ensured.2 Surgery can be performed by closed,3 arthroscopic-assisted,4,5 or open methods. Fixation is required to maintain the intra-articular alignment and to decrease the risk of malunion or nonunion. Traditionally, surgical fixation has been achieved using K-wires. Advantages of K-wire fixation include minimal risk of physeal or epiphyseal injury and the option for pin removal in the office. Complications of surgery following smooth-pin fixation include pin-site infection, lateral overgrowth, and loss of fixation.2,3,6 Loss of fixation may subsequently place the patient at higher risk for malunion or nonunion. While using more pins has resulted in a lower malunion rate, it is also associated with a greater loss of motion.2 Screw fixation provides the opportunity to improve upon the outcomes of smooth pins by providing superior fixation with subsequent lower rates of lateral overgrowth, fixation loss, and infection. However, the results of screw fixation and subsequent risk of iatrogenic physeal damage are not well defined. The purpose of this study was to build upon the few series7–10 reported in the literature using screw fixation to further establish the efficacy of this treatment.
METHODS After obtaining IRB approval, we used ICD-9 and CPT codes to identify patients who had been surgically treated with screw fixation for lateral condyle fractures between 2005 and 2011. Preoperative radiographs were used to classify fractures according to the system attributed to Jakob et al6: fractures displaced 2 mm of displacement as determined by plain radiographs. Surgery was performed with the patient in the supine position. Closed reduction and screw fixation was performed in selected cases with an intact cartilage hinge and congruent joint surface3 (Figs. 1A–C). Intraoperative arthrograms were used as needed to confirm reduction at the articular surface. When an open reduction was required, a direct lateral approach between the brachioradialis and the triceps at the site of the fracture hematoma was performed. Posterior dissection was minimized. Provisional fixation with K-wires typically preceded definitive fixation, which was achieved using a 4-mm cannulated screw (Figs. 1D–G). Screw placement varied according to surgeon preference; some surgeons placed screws in the metaphysis when the distal metaphyseal fragment was of sufficient size and across the capitellar growth plate when the metaphyseal fragment was too small; other surgeons placed the screw in the position to achieve the best fixation without avoiding the physis. All patients were immobilized in a long-arm cast for varying durations. Some patients were also placed in a
RESULTS Ninety-six patients with lateral condyle fractures who were treated with screw fixation met inclusion criteria. The average age at the time of injury was 5.8 years (range, 2 to 12 y). There were 26 female patients and 70 male patients. Forty-five fractures were classified as type II and 51 as type III. Fifty-eight fractures occurred on the left and 38 on the right. Forty-two patients underwent closed reduction and screw fixation, and 54 patients required open reduction and screw fixation. Screws were placed in the metaphysis in 54 patients, in the periphery of the capitellar physis in 39 patients, and in the middle of the physis in 3 patients. Patients were immobilized in a long-arm cast for a mean 5.1 weeks (range, 1.1 to 10 wk) postoperatively. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). Fracture union after initial treatment was achieved in 99% (95/96) of patients. The mean time to union was 8.0 weeks (range, 3.9 to 13.9 wk). In 1 patient, the screw fixation became unstable and lost reduction 2.5 months after surgery. This patient was a 7-year-old male who presented 2 weeks out from injury and underwent percutaneous screw fixation. Additional surgery with
FIGURE 1. A–G, Preoperative anteroposterior (AP) (A) and lateral (B) radiographs of a 6-year-old boy with type II lateral condyle fracture. Intraoperative lateral view (C) demonstrating fracture instability and displacement. Immediate postoperative AP (D) and lateral (E) radiographs following closed reduction and screw fixation. Absence of angular deformity on 8-year follow-up AP (F) and lateral (G) radiographs at age 14 years.
822 | www.pedorthopaedics.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 8, December 2015
revision fixation and bone grafting was performed, which led to successful healing. Range of motion improved gradually after surgery. Three months postoperatively, 31% of patients had extension deficits (mean, 12 degrees; range, 5 to 30 degrees) and 21% had loss of flexion (mean, 26 degrees; range, 15 to 35 degrees). Between 6 and 12 months after surgery, the mean loss of extension was 3 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 10 degrees (range, 0 to 45 degrees). After 12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees), and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). No patient required a manipulation under anesthesia for functional stiffness. The overall complication rate was 18.8% (18/96). Complications included lateral prominence (13%), symptomatic hardware (4%), and heterotopic ossification (1%). There were no postoperative infections. Hardware was removed in 56/96 patients at an average 25.0 weeks after surgery (range, 6.4 to 152.2 wk). Of the 40 patients who did not undergo hardware removal, 61% did not return to arrange for screw removal despite being advised to do so. The remainder of the patients was advised to return for removal if the screws became symptomatic. Thirteen patients developed lateral overgrowth detectable by physical examination. There were no cases of avascular necrosis or fishtail deformity. None of the patients developed carrying angle asymmetry or a growth arrest during the follow-up period. Follow-up was >3 months in 62 patients, >6 month in 35 patients (mean, 56.3 wk; range, 26.3 to 417.4 wk), and >12 months in 10 patients (mean, 119.6 wk; range, 53.1 to 417.4 wk). In patients less than 8 years of age, who are expected to be at higher risk of developing an angular deformity after fracture, 25 patients (mean age, 5.3 y; range, 2 to 7 y) had >6 months of followup (mean, 63.4 wk; range, 26.3 to 417.4 wk).
DISCUSSION Screw fixation of lateral condyle fractures is an appealing option to decrease the risks of fixation loss and lateral overgrowth associated with smooth-pin fixation; however, there are only a few series in the literature to support this practice.7–10 Sharma et al7 reported 37 children (mean age, 5 y; range, 3 to 12 y) treated with open reduction and partially threaded, 4-mm screw fixation. In 4 cases, the screws penetrated the periphery of the physis. Screws were routinely removed at 8 to 10 weeks postoperatively. One patient developed a delayed union due to technical error. Eleven percent of patients developed varus deformity, all
Screw Fixation of Lateral Condyle Fractures: Results of Treatment Eric Shirley, MD, Mary Anderson, BS, Kevin Neal, MD, and John Mazur, MD
Background: Fixation of lateral condyle distal humeral fractures has traditionally been achieved with K-wires. Screw fixation provides the advantage of compression across the fracture site, but the results of screw fixation and risk of iatrogenic physeal damage are not well defined. This study was designed to evaluate the efficacy of screw fixation for lateral condyle fractures. Methods: A retrospective study of patients with lateral condyle elbow fractures treated using screw fixation at a single institution was undertaken. Patients 12 years and younger with isolated fractures were included. Clinical notes were examined for residual symptoms, alignment, range of motion, and complications. Radiographs were reviewed for healing and growth arrest. Results: Ninety-six patients who were treated over a 7-year period met inclusion criteria. Mean patient age was 5.8 years (range, 2 to 12 y). Fifty-four patients required open reduction; 42 patients underwent a closed reduction. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). The overall complication rate was 19% and was 5% when lateral overgrowth was excluded as a complication. Initial fracture union was achieved in 99% of patients. One patient required revision fixation with a bone graft. Hardware was symptomatic with prominence or loss of flexion in 4% of patients. There were no cases of growth arrest or alterations of the carrying angle. For patients with final follow-up >12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). Conclusion: Screw fixation of lateral condyle fractures results in satisfactory union with a low risk of complications at early follow-up. Level of Evidence: This study was a retrospective case series performed to investigate the results of treatment, level IV. Key Words: lateral condyle, fracture, treatment (J Pediatr Orthop 2015;35:821–824)
L
ateral condyle distal humeral fractures are the second most common pediatric elbow fracture and the most common elbow fracture that involves the growth plate.1 Treatment options include nonoperative management with cast immobilization versus surgery. Operative treatment is favored for fractures with displacement of From the Nemours Children’s Clinic, Jacksonville, FL. No sources of funding or conflicts of interest exist to disclose. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Eric Shirley, MD, Nemours Children’s Clinic, 807 Children’s Way, Jacksonville, FL 32207. E-mail: [email protected]. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 8, December 2015
>2 mm. Surgery may also be considered for fractures with less displacement when follow-up cannot be ensured.2 Surgery can be performed by closed,3 arthroscopic-assisted,4,5 or open methods. Fixation is required to maintain the intra-articular alignment and to decrease the risk of malunion or nonunion. Traditionally, surgical fixation has been achieved using K-wires. Advantages of K-wire fixation include minimal risk of physeal or epiphyseal injury and the option for pin removal in the office. Complications of surgery following smooth-pin fixation include pin-site infection, lateral overgrowth, and loss of fixation.2,3,6 Loss of fixation may subsequently place the patient at higher risk for malunion or nonunion. While using more pins has resulted in a lower malunion rate, it is also associated with a greater loss of motion.2 Screw fixation provides the opportunity to improve upon the outcomes of smooth pins by providing superior fixation with subsequent lower rates of lateral overgrowth, fixation loss, and infection. However, the results of screw fixation and subsequent risk of iatrogenic physeal damage are not well defined. The purpose of this study was to build upon the few series7–10 reported in the literature using screw fixation to further establish the efficacy of this treatment.
METHODS After obtaining IRB approval, we used ICD-9 and CPT codes to identify patients who had been surgically treated with screw fixation for lateral condyle fractures between 2005 and 2011. Preoperative radiographs were used to classify fractures according to the system attributed to Jakob et al6: fractures displaced 2 mm of displacement as determined by plain radiographs. Surgery was performed with the patient in the supine position. Closed reduction and screw fixation was performed in selected cases with an intact cartilage hinge and congruent joint surface3 (Figs. 1A–C). Intraoperative arthrograms were used as needed to confirm reduction at the articular surface. When an open reduction was required, a direct lateral approach between the brachioradialis and the triceps at the site of the fracture hematoma was performed. Posterior dissection was minimized. Provisional fixation with K-wires typically preceded definitive fixation, which was achieved using a 4-mm cannulated screw (Figs. 1D–G). Screw placement varied according to surgeon preference; some surgeons placed screws in the metaphysis when the distal metaphyseal fragment was of sufficient size and across the capitellar growth plate when the metaphyseal fragment was too small; other surgeons placed the screw in the position to achieve the best fixation without avoiding the physis. All patients were immobilized in a long-arm cast for varying durations. Some patients were also placed in a
RESULTS Ninety-six patients with lateral condyle fractures who were treated with screw fixation met inclusion criteria. The average age at the time of injury was 5.8 years (range, 2 to 12 y). There were 26 female patients and 70 male patients. Forty-five fractures were classified as type II and 51 as type III. Fifty-eight fractures occurred on the left and 38 on the right. Forty-two patients underwent closed reduction and screw fixation, and 54 patients required open reduction and screw fixation. Screws were placed in the metaphysis in 54 patients, in the periphery of the capitellar physis in 39 patients, and in the middle of the physis in 3 patients. Patients were immobilized in a long-arm cast for a mean 5.1 weeks (range, 1.1 to 10 wk) postoperatively. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). Fracture union after initial treatment was achieved in 99% (95/96) of patients. The mean time to union was 8.0 weeks (range, 3.9 to 13.9 wk). In 1 patient, the screw fixation became unstable and lost reduction 2.5 months after surgery. This patient was a 7-year-old male who presented 2 weeks out from injury and underwent percutaneous screw fixation. Additional surgery with
FIGURE 1. A–G, Preoperative anteroposterior (AP) (A) and lateral (B) radiographs of a 6-year-old boy with type II lateral condyle fracture. Intraoperative lateral view (C) demonstrating fracture instability and displacement. Immediate postoperative AP (D) and lateral (E) radiographs following closed reduction and screw fixation. Absence of angular deformity on 8-year follow-up AP (F) and lateral (G) radiographs at age 14 years.
822 | www.pedorthopaedics.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 8, December 2015
revision fixation and bone grafting was performed, which led to successful healing. Range of motion improved gradually after surgery. Three months postoperatively, 31% of patients had extension deficits (mean, 12 degrees; range, 5 to 30 degrees) and 21% had loss of flexion (mean, 26 degrees; range, 15 to 35 degrees). Between 6 and 12 months after surgery, the mean loss of extension was 3 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 10 degrees (range, 0 to 45 degrees). After 12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees), and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). No patient required a manipulation under anesthesia for functional stiffness. The overall complication rate was 18.8% (18/96). Complications included lateral prominence (13%), symptomatic hardware (4%), and heterotopic ossification (1%). There were no postoperative infections. Hardware was removed in 56/96 patients at an average 25.0 weeks after surgery (range, 6.4 to 152.2 wk). Of the 40 patients who did not undergo hardware removal, 61% did not return to arrange for screw removal despite being advised to do so. The remainder of the patients was advised to return for removal if the screws became symptomatic. Thirteen patients developed lateral overgrowth detectable by physical examination. There were no cases of avascular necrosis or fishtail deformity. None of the patients developed carrying angle asymmetry or a growth arrest during the follow-up period. Follow-up was >3 months in 62 patients, >6 month in 35 patients (mean, 56.3 wk; range, 26.3 to 417.4 wk), and >12 months in 10 patients (mean, 119.6 wk; range, 53.1 to 417.4 wk). In patients less than 8 years of age, who are expected to be at higher risk of developing an angular deformity after fracture, 25 patients (mean age, 5.3 y; range, 2 to 7 y) had >6 months of followup (mean, 63.4 wk; range, 26.3 to 417.4 wk).
DISCUSSION Screw fixation of lateral condyle fractures is an appealing option to decrease the risks of fixation loss and lateral overgrowth associated with smooth-pin fixation; however, there are only a few series in the literature to support this practice.7–10 Sharma et al7 reported 37 children (mean age, 5 y; range, 3 to 12 y) treated with open reduction and partially threaded, 4-mm screw fixation. In 4 cases, the screws penetrated the periphery of the physis. Screws were routinely removed at 8 to 10 weeks postoperatively. One patient developed a delayed union due to technical error. Eleven percent of patients developed varus deformity, all
