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SplintER Series: Fracture After a Fall From a Bunk Bed

Posted by Jeffrey Heiferman, MD on

A 6-year-old male presents to the ED after a fall from his 5 foot high bunk bed causing elbow trauma. On exam, there is significant focal swelling, ecchymosis, and tenderness at the lateral left elbow. The forearm, wrist, hand and shoulder are nontender. He is neurovascularly intact. You suspect a fracture and obtain x-rays (Figures 1 and 2).

Figure 1: Initial radiographs in the ED with the elbow slightly flexed.

Figure 2: AP and lateral radiographs of the elbow.

What is your diagnosis?

This patient has a laterally and volarly displaced lateral condyle fracture of the distal humerus with >2mm displacement (Figures 3 and 4).

  • Pearl: Radiographically, the lateral condyle fracture is often seen as a small metaphyseal crescent shaped fragment (sliver of avulsed metaphysis). The epiphyseal component may not be seen if it is not yet ossified. The distal fragment is often displaced or rotated, with alteration of the radiocapitellar alignment.

Figure 3: Initial radiographs in the ED with the elbow slightly flexed. Note the laterally and volarly displaced lateral condyle fracture of the distal humerus (green arrows).

Figure 4: AP and lateral radiographs of the elbow. Note the laterally and volarly displaced lateral condyle fracture of the distal humerus (green arrows).

What is the most common mechanism of injury?

Lateral condyle avulsions are a result of a varus stress involving either a lateral blow to the forearm or a lateral fall with the arm held at the side [1].

  • Pearl: The lateral condyle fracture is the second most common pediatric elbow fracture, accounting for 12-20% of upper extremity fractures [2,3].

What is the management of this injury in the emergency department?

If the fracture is minimally displaced (≤2mm), or nondisplaced, the patient can be managed conservatively, using a long-arm splint with the elbow flexed (60 to 90°) and forearm supinated [3, 4]. This immobilization technique will reduce muscle tension on the lateral condyle. Follow-up in 4-7 days for repeat radiographs and casting is recommended. With conservative treatment, up to 10% of fractures may develop a greater degree of displacement [4].

  • Pearl: If ≥2mm displacement, orthopaedic consultation for surgical stabilization is recommended. Significant laxity in valgus or varus may also require fixation.
  • Pearl: The lateral condyle fracture is immobilized in supination, as opposed to the supracondylar fracture, which is immobilized with the elbow flexed and forearm in a neutral or pronated position.

What are some of the complications associated with a lateral condyle fracture?

Common complications of fractures of the lateral condyle include growth disturbance, nonunion, malunion, and avascular necrosis [3].

  • Pearl: More than 30% of patients with lateral condyle fractures develop cubitus valgus or varus deformity due to subsequent growth arrest or hypertrophy at the fracture site [1].
  • Pearl: A delayed onset ulnar nerve palsy can result from a malunion which causes a progressive cubitus valgus deformity during further periods of growth [5].

Figure 5: Followup radiograph two months after the initial injury, after removal of surgical pins. Note the original fracture site (green arrow).

Check out ALiEM’s Paucis Verbis cards to brush up on other can’t miss orthopedic injuries, and SplintER Series for more elbow cases.

References

  1. Tejwani N, Phillips D, Goldstein RY. Management of lateral humeral condylar fracture in children. J Am Acad Orthop Surg. 2011;19(6):350-358. PMID 21628646
  2. Milch H: Fractures and fracture dislocations of the humeral condyles. J Trauma 1964;4:592-607. PMID 14208785
  3. Abzug JM, Dua K, Kozin S, Herman M. Current Concepts in the Treatment of Lateral Condyle Fractures in Children. JAAOS. 2020; 28(1):e9-e19. PMID 31268870
  4. Shaerf DA, Vanhegan IS, Dattani R. Diagnosis, management and complications of distal humerus lateral condyle fractures in children. Shoulder Elbow. 2018;10(2):114-120. PMID 29560037
  5. Rubin G, Orbach H, Bor N, Rozen N. Tardy Ulnar Nerve Palsy. J Am Acad Orthop Surg. 2019; 27(19):717-725. PMID: 30939566

Author information

Jeffrey Heiferman, MD

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