Abstract
Background:
Temporary elbow stiffness is often seen after a lateral condylar fracture of the distal end of the humerus in children. There are scant scientific data available to assess the expected time frame for return of elbow motion after these injuries. The purpose of this study is to provide a prospective, longitudinal evaluation of elbow motion in a large group of pediatric patients undergoing treatment for a lateral condylar fracture of the distal end of the humerus.
Methods:
We prospectively evaluated 141 patients with lateral humeral condylar fractures at a mean age of 5.2 years and with a mean follow-up of twenty-nine weeks. The patients were treated with cast immobilization, percutaneous pinning, or open reduction and internal fixation on the basis of the initial displacement. Elbow motion was followed longitudinally at clinic visits. Relative arc of motion was calculated as a percentage of the motion of the normal, contralateral elbow.
Results:
The mean relative arc of motion at the time of cast removal was 44%, reaching 84% by week 12. By weeks 18, 24, 36, and 48, the relative arc of motion reached 87%, 90%, 93%, and 97%, respectively. Compared with fractures treated without surgery, those treated surgically had a significantly lower absolute arc of motion from the time of cast removal (p = 0.018) and up to eighteen weeks after the injury (p < 0.001); however, no significant difference was observed at eighteen weeks or beyond. For patients treated surgically, no significant difference in relative arc of motion was observed between the patients with closed or open reductions. The age of the patient (hazard ratio = 0.87, p = 0.008), length of immobilization (hazard ratio = 0.79, p = 0.03), and severity of the fracture (hazard ratio = 0.40, p < 0.0001) were independent predictors of recovery of elbow motion after a lateral humeral condylar fracture in children.
Conclusions:
An initial rapid recovery in elbow motion can be expected after a lateral humeral condylar fracture in a child, with progressive improvements for up to one year after the injury. This recovery is slower if the patient is older, has a longer period of immobilization, and has a more severe injury.
Level of Evidence:
Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.
Lateral condylar fractures of the humerus are a common injury in children, accounting for approximately 17% of all pediatric elbow fractures1. Displaced pediatric lateral condylar fractures can result in both physeal and articular incongruity. Nearly anatomic reduction is required to avoid the late sequelae of nonunion, deformity, and arthritis1. Nondisplaced fractures are usually treated with cast immobilization, but close follow-up is required as later fracture displacement is a well-documented complication2. Minimally displaced fractures are generally treated with closed reduction and percutaneous pinning (CRPP), while more widely displaced lateral condylar fractures require open reduction and internal fixation (ORIF)3-5. Regardless of treatment, however, temporary elbow stiffness invariably occurs after these injuries and is concerning to both parents and surgeons. While recent interest has been devoted to studying elbow motion after supracondylar humeral fractures in children6,7, there is a paucity of literature reviewing the longitudinal return of elbow motion following pediatric lateral condylar fractures. To our knowledge, no previous study has prospectively followed the recovery of elbow motion after pediatric lateral condylar fractures and assessed the associated risk factors. The single study reviewing the recovery of elbow motion after pediatric lateral condylar fractures that we found is a retrospective series with very few patients8.
Our goal with this study was to provide a longitudinal, prospective evaluation of elbow motion after both nonsurgical and surgical treatment of pediatric lateral condylar fractures. We hypothesized that older age, severe fractures, and open surgical treatment would be risk factors for a delay in recovery of elbow motion.
From March 1, 2007, to September 30, 2008, we prospectively examined a consecutive cohort of 169 children who presented to our urgent care center with a fracture of the lateral condyle of the distal end of the humerus. Patients were enrolled as part of a prospective, institutional review board-approved study on pediatric elbow fractures. As part of this study, multiple radiographic and clinical variables, including age, sex, side of injury, type of fracture, amount of displacement, type of treatment, complications of treatment, and elbow motion, were prospectively recorded.
Of the 169 elbows enrolled in the study, twenty-eight elbows in twenty-eight patients were excluded; one elbow was excluded because the patient sustained a fracture of the contralateral elbow within the treatment period and the remaining twenty-seven elbows were excluded because they had been followed for less than seven weeks. To optimize follow-up, patients who missed clinic appointments received three separate telephone calls and finally a certified letter with rescheduled appointment information. Therefore, a total of 141 elbows in 141 patients were included in the present study.
Standard anteroposterior, lateral, and internal rotation oblique radiographs of the affected elbow were made by an experienced technician and uploaded into our digital radiology package (version 3.4.0.38, OfficePACS; Stryker Imaging, Flower Mound, Texas). Fracture fragment displacement was measured from the lateral metaphyseal cortex of the distal part of the humerus to the lateral cortex of the fracture fragment on the anteroposterior and internal rotation radiographs, and along the posterior cortex on the lateral radiograph, with use of the method described by Song et al.9. The greatest displacement on any single radiograph was documented as the displacement of the fragment. All measurements were made with use of the measuring tool available in our PACS (picture archiving and communication system). The fractures were classified with use of the Milch classification system10.
Patients were divided into three treatment groups on the basis of the amount of fracture displacement (Fig. 1). Children with fractures displaced <2 mm were placed in a long arm cast at approximately 90° of flexion and maximum supination, without manipulation, and were followed closely (the nonoperative group included seventy-six patients; 53.9%). For fractures with an initial displacement of between 2 and 5 mm, an initial attempt at closed reduction was performed with the patient under general anesthesia. The fractures in which the postreduction displacement was <2 mm were treated with closed reduction and percutaneous pinning (the CRPP group included fourteen patients; 9.9%). The fracture was assessed with an intraoperative arthrogram after closed reduction to ensure that no substantial articular gap or step-off was present. All fractures with >2 mm of postreduction displacement and those with an initial displacement of >5 mm were treated with open reduction and internal fixation (the ORIF group included fifty-one patients; 36.2%). All fractures were therefore reduced to within 2 mm of an anatomic position. For percutaneous pinning, two or three Kirschner wires (0.062-in [1.575-mm] diameter) were used. Surgery was performed at a mean (and standard deviation) of 3.7 ± 3.0 days after injury.
Flowchart illustrating patient enrollment, excluded patients, and distribution of treatment groups from the patient cohort. LCF = lateral condylar fracture, CRPP = closed reduction and percutaneous pinning, and ORIF = open reduction and internal fixation.
The postoperative protocol for surgically treated fractures was identical for patients in the CRPP and ORIF groups. Patients were initially managed with a splint, with the elbow in approximately 90° of flexion. Patients were seen as outpatients one week after the surgical procedure, and the affected elbow was placed into a long arm cast with 90° of elbow flexion. During the follow-up visit in the third week, the Kirschner wires were removed and the affected elbow was placed back in a long arm cast for an additional three weeks. After cast removal, active motion of the affected elbow was encouraged although strenuous activities were restricted for an additional month. No physical therapy was prescribed. Patients were followed radiographically and clinically with serial appointments until the elbow was noted to be radiographically healed and asymptomatic and its motion was =90% of the motion of the unaffected, contralateral elbow.
Elbow motion was measured in the flexion-extension plane by a pediatric orthopaedic surgeon, using a goniometer calibrated in 1° increments. Measurements were made at the time of cast removal and during all subsequent clinic visits. The motion of the contralateral elbow was measured with use of the same technique as a control, for comparison. The relative arc of motion and relative maximum flexion of the affected elbow were calculated as percentages of arc of motion and maximum flexion of the normal, contralateral elbow, respectively.
For the unadjusted statistical analysis of absolute arc of motion, follow-up visits were grouped into intervals ending with weeks 6, 12, 18, 24, 36, 48, and >48. The three treatment groups were compared at each follow-up visit with an analysis of variance test or a Fisher exact test, as appropriate, with a 0.05 level of significance. Following preliminary evaluation of the results, the data were analyzed in an adjusted fashion with use of Kaplan-Meier survivorship curves and the Cox proportional hazards multivariate survivorship model. A successful result was defined by the injured elbow achieving =90% of the motion of the contralateral, normal elbow. Our survivorship analysis was designed to determine which treatment group reached the desired outcome first. Unlike an analysis of survivorship with death as the outcome, a hazard ratio of >1 or a survivorship curve to the left of the others is the desired result in this study. With use of the Cox proportional hazards model, a multivariate regression analysis was performed to determine if age, sex, duration of immobilization, and severity of fracture (as assessed by the amount of displacement) were independently related to failure to reach a successful result. The magnitudes of associated risk factors are presented as hazard ratios, with significance assumed as p < 0.05.
Source of Funding
There was no external funding for this study.
Of the 141 fractures included, eighty-eight (62.4%) were in boys and fifty-three (37.6%) were in girls; eighty-one (57.4%) were on the left arm and sixty (42.6%) were on the right arm. The mean age (and standard deviation) of the children at the time of injury was 5.2 ± 2.5 years (range, 0.2 to 14.9 years), and the mean duration of follow-up was 29.2 ± 22.3 weeks (range, 7.7 to 115.9 weeks) (Table I). Seven fractures (5%) were Milch type 1, and 134 (95%) were Milch type 2. The mean initial displacement was 0.8 mm for patients in the nonoperative group, 2.7 mm for patients in the CRPP group, and 5.6 mm for patients in the ORIF group (p < 0.00001).
Absolute Arc of Motion
At the time of cast removal, the mean arc of motion was 64°. By week 12 (after the injury), the mean arc of motion was 123°. By weeks 18, 24, 36, and 48, the mean arc of motion was 127°, 132°, 138°, and 143°, respectively (Table II). While the greatest improvement was seen between weeks 6 and 12, continued improvement was observed through week 48. Compared with patients treated nonoperatively, patients treated operatively (both CRPP and ORIF) had a significantly decreased range of elbow motion at all time points up until eighteen weeks (Fig. 2). However, no significant differences were observed at eighteen weeks or beyond.
Graph illustrating the mean absolute arc of motion (in degrees) over time for each treatment group. P values represent analysis-of-variance testing among the three data points at each time point with p < 0.05 considered significant. CRPP = closed reduction and percutaneous pinning, and ORIF = open reduction and internal fixation.
Relative Arc of Motion
Regarding relative arc of motion, the mean arc was 44% (95% confidence interval [CI], 41% to 47%) of that of the contralateral, unaffected elbow at the time of cast removal. At twelve, eighteen, twenty-four, thirty-six, and forty-eight weeks after the injury, the mean relative arc of motion was 84% (95% CI, 80% to 87%), 87% (95% CI, 83% to 90%), 90% (95% CI, 87% to 93%), 93% (95% CI, 91% to 97%), and 97% (95% CI, 95% to 100%), respectively. At the time of final follow-up, 128 (90.8%) of the 141 patients had achieved a relative arc of motion of at least 80% of that of the contralateral elbow, and 106 patients (75.2%) had achieved at least a 90% relative arc of motion. With use of the achievement of a 90% relative arc of motion as an end point, both the CRPP and ORIF groups had a significant delay in achieving elbow motion compared with the nonoperative group (p < 0.001) (Fig. 3).
Kaplan-Meier survival curves for the time needed to reach 90% of normal elbow motion. The value of each curve represents the probability of not having reached 90% of the motion of the normal, contralateral elbow. CRPP = closed reduction and percutaneous pinning, and ORIF = open reduction and internal fixation.
Absolute and Relative Maximum Flexion
The mean absolute maximum flexion was 112° at the time of cast removal. At twelve, eighteen, twenty-four, thirty-six, and forty-eight weeks after the injury, the mean absolute flexion was 131°, 132°, 134°, 136°, and 140°, respectively. The mean relative flexion was 80% (95% CI, 79% to 81%) at cast removal, and increased to 94% (95% CI, 93% to 96%) at twelve weeks, 95% (95% CI, 94% to 97%) at eighteen weeks, 97% (95% CI, 95% to 99%) at twenty-four weeks, 98% (95% CI, 97% to 100%) at thirty-six weeks, and 99% (95% CI, 98% to 101%) at forty-eight weeks after the injury. With use of the achievement of 90% maximum flexion as the end point, the CRPP and ORIF groups had significantly lower relative maximum flexion compared with the nonoperative group (p = 0.002).
Absolute Extension
The mean flexion contracture at the time of cast removal was 47° (95% CI, 44° to 50°). By twelve, eighteen, and twenty-four weeks after the injury, the mean flexion contracture was 9° (95% CI, 6° to 11°), 5° (95% CI, 2° to 8°), and 2° (95% CI, 1° of hyperextension to 5° of flexion contracture), respectively. By thirty-six weeks, the mean maximum extension was 1° of hyperextension (95% CI, 2° of flexion contracture to 5° of hyperextension), and, by forty-eight weeks, extension reached 3° of hyperextension (95% CI, 0° to 5° of hyperextension). On visits at more than forty-eight weeks after the injury, injured elbows were able to reach a mean maximum extension of 9° of hyperextension (95% CI, 6° to 11° of hyperextension).
Subgroup Analysis
Multivariate regression analysis, adjusted for the values of the unaffected, contralateral elbow and follow-up time, demonstrated that the age of the patient (hazard ratio, 0.87; p = 0.008), the length of immobilization (hazard ratio, 0.79; p = 0.027), and the need for surgical treatment (hazard ratio, 0.40; p < 0.0001) were independent predictors of the longitudinal recovery of elbow motion after a lateral humeral condylar fracture (Table III). The amount of initial displacement was not found to be an independent predictor of elbow motion recovery within the treatment groups (hazard ratio, 0.99; p = 0.656).
Complications
In the overall study cohort, eight patients (5.7%) had documented complications. One patient in the nonoperative group had skin irritation from the cast. The remaining complications occurred in seven (13.7%) of the fifty-one patients in the ORIF group. In that group, four patients (7.8%) had osteonecrosis of the capitellum and one patient (2.0%) each had osteonecrosis of the trochlea, a deep infection requiring irrigation and debridement, and a superficial pin-site infection. No patient was noted to have nonunion or loss of reduction. The final mean arc of elbow motion in patients with complications was 136° ± 13.1°, whereas the final mean motion in patients without complications was 137° ± 17.1° (p = 0.86).
Managing patient, parent, and surgeon expectations during the treatment and follow-up of lateral humeral condylar fractures in children is often challenging. Temporary elbow stiffness is omnipresent after these fractures, and there is little scientific literature to rely on to assess the expected timeframe for return of motion. To our knowledge, this is the only prospective, longitudinal studying assessing the recovery of elbow motion in children after lateral condylar fractures and constitutes one of the largest cohorts of lateral condylar fractures reported.
This study demonstrates that, while the largest gains in elbow motion and maximum elbow flexion occur in the initial weeks after cast removal, continued gains in both measures occur up to forty-eight weeks after the original injury. This study shows that patients who are older, are managed with a longer period of immobilization, and have more severe injuries (requiring surgery) need additional time to recover elbow motion. Finally, patients undergoing closed reduction and percutaneous pinning had a similar recovery of elbow motion as those undergoing open reduction, but had fewer complications.
Previously, Wang et al.8, in a small, retrospective case series of sixteen pediatric lateral condylar fractures, reported that the affected elbow achieved 90% of relative motion (compared with the contralateral extremity) at a mean of five weeks after cast removal. No correlation was found between the recovery of motion and the severity of the fracture, the type of treatment, or the age of the patient. It is likely that the lack of correlation was due to the limited number of patients.
The complication rates in our study provide support for the recent classification system for lateral condylar fractures described by Weiss et al.11. We noted seven complications in our ORIF group compared with just one in the nonoperative group and none in the CRPP group. These results are similar to those reported by Weiss et al., providing further evidence that a classification system based on displacement correlates well with complication rates, and may be of more clinical value than previous classification systems.
While we documented a final range of motion in elbows with complications that was similar to that in elbows with no complications, these data should be viewed with caution. The group of patients who developed a complication is too small to have sufficient power to draw conclusions. The long-term implications of these complications, especially for the patients with osteonecrosis, cannot be minimized. It is likely that functional deficits may develop later, outside the evaluation period of this study. Our group recently had published a prospective study of the return of elbow motion following pediatric supracondylar humeral fractures6. For the purpose of comparison, the data on absolute arc of motion obtained in the present study was plotted against that of children treated for a supracondylar humeral fracture in the study by Spencer et al.6 (Fig. 4). Lateral condylar fractures appear to have a slower rate of recovery of elbow motion than supracondylar humeral fractures. While a comparison of the etiology, mechanical properties, and healing potential of supracondylar humeral fractures and lateral condylar fractures is beyond the scope of this investigation, it is hypothesized that the intra-articular nature of lateral condylar fractures plays a role in the slower recovery of elbow motion. This study is limited by a relatively short follow-up time. While our mean follow-up time of twenty-nine weeks is longer than most studies of pediatric fractures, it does not permit definitive assessment of the so-called final condition. Additionally, our measurements of elbow motion were not blinded. While goniometer measurements of elbow motion have been shown to be highly reproducible12, we cannot exclude the possibility of bias in the measurements. However, we believe the multiple measurements made at different clinic visits and the lack of incentive in differentiating positive outcomes among groups minimizes the effect any bias may have had. Finally, we must acknowledge that the 90% cutoff used for a "successful" outcome on our survival plots is arbitrary. There is no clear number at which a patient can be said to have a truly successful outcome. The objective of the study was to follow improvements longitudinally and compare them among groups, with methods that had been previously used6,8.
Graph illustrating mean absolute arc of motion (in degrees) over time for both operatively and nonoperatively treated lateral condylar fractures (LCF) and supracondylar humeral fractures (SCHF). While all injuries follow a pattern of rapid return of motion followed by progressive improvement up to one year, elbows with lateral condylar fractures have a slower return of motion than those with supracondylar humeral fractures.
In summary, the present study demonstrates an initial rapid recovery of elbow motion after cast removal in children with lateral humeral condylar fractures, followed by continued improvements up until at least a year after the injury. The recovery is slower in patients who are older, require surgical treatment of the fracture, and are managed with a longer period of cast immobilization. Finally, patients undergoing open reduction and internal fixation can expect a similar return of elbow motion as those undergoing closed reduction and percutaneous pinning, although there is potentially a higher prevalence of complications with open reduction and internal fixation.
Beaty
JH;
Kasser
JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus, osteonecrosis of the trochlea, and t-condylar fractures. : Beaty
JH;
Kasser
JR, editors. Rockwood and Wilkins’ fractures in children
. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. 591-660.
Pirker
ME;
Weinberg
AM;
Höllwarth
ME;
Haberlik
A. Subsequent displacement of initially nondisplaced and minimally displaced fractures of the lateral humeral condyle in children. J Trauma.
2005;58:1202-7.[CrossRef][PubMed]
Mintzer
CM;
Waters
PM;
Brown
DJ;
Kasser
JR. Percutaneous pinning in the treatment of displaced lateral condyle fractures. J Pediatr Orthop.
1994;14:462-5.[CrossRef][PubMed]
Song
KS;
Kang
CH;
Min
BW;
Bae
KC;
Cho
CH;
Lee
JH. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am.
2008;90:2673-81.[CrossRef][PubMed]
Sullivan
JA. Fractures of the lateral condyle of the humerus. J Am Acad Orthop Surg.
2006;14:58-62.[PubMed]
Spencer
HT;
Wong
M;
Fong
YJ;
Penman
A;
Silva
M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint Surg Am.
2010;92:904-10.[CrossRef][PubMed]
Zionts
LE;
Woodson
CJ;
Manjra
N;
Zalavras
C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res.
2009;467:2007-10.[CrossRef][PubMed]
Wang
YL;
Chang
WN;
Hsu
CJ;
Sun
SF;
Wang
JL;
Wong
CY. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma.
2009;23:120-5.[CrossRef][PubMed]
Song
KS;
Kang
CH;
Min
BW;
Bae
KC;
Cho
CH. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am.
2007;89:58-63.[CrossRef][PubMed]
Milch
H. Fractures and fracture dislocations of the humeral condyles. J Trauma.
1964;4:592-607.[CrossRef][PubMed]
Weiss
JM;
Graves
S;
Yang
S;
Mendelsohn
E;
Kay
RM;
Skaggs
DL. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop.
2009;29:602-5.[CrossRef][PubMed]
Armstrong
AD;
MacDermid
JC;
Chinchalkar
S;
Stevens
RS;
King
GJ. Reliability of range-of-motion measurement in the elbow and forearm. J Shoulder Elbow Surg.
1998;7:573-80.[CrossRef] [PubMed]