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C OPYRIGHT Ó 2008 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Closed Reduction and Internal Fixation of Displaced

Unstable Lateral Condylar Fractures of the
Humerus in Children
By Kwang Soon Song, MD, Chul Hyung Kang, MD, Byung Woo Min, MD, Ki Cheor Bae, MD, Chul Hyun Cho, MD,
and Ju Hyub Lee, MD

Investigation performed at the Department of Orthopedic Surgery, Keimyung University, Daegu, South Korea

Background: Open reduction and internal fixation of a displaced unstable fracture of the lateral condyle of the humerus in
a child usually produces a good result. Only a few reports have focused on closed reduction and internal fixation of these
fractures. We prospectively studied closed reduction and internal fixation to determine its usefulness as the initial
treatment for displaced unstable fractures of the lateral condyle of the humerus.
Methods: We classified lateral condylar humeral fractures into five groups according to the degree of displacement and
the fracture pattern as determined on four radiographic views and created an algorithm for the treatment of these fractures
on the basis of this classification system. We prospectively treated sixty-three unstable fractures (in forty-two boys and
twenty-one girls) and assessed the quality of closed reduction.
Results: Thirteen of seventeen stage-3 fractures were reduced to £1 mm of residual displacement. Thirty of forty stage-4
fractures and three of six stage-5 fractures were reduced to £2 mm of displacement. In ten of forty stage-4 fractures and
three of six stage-5 fractures, closed reduction to within 2 mm failed and open reduction and internal fixation was
performed. There were no major complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion,
or early physeal arrest.
Conclusions: Closed reduction and internal fixation is an effective treatment for unstable displaced lateral condylar
fractures of the humerus in many children. If fracture displacement after closed reduction exceeds 2 mm, open reduction
and internal fixation is recommended.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

O
pen reduction and internal fixation of displaced un- achieved by means of closed reduction and internal fixation
stable lateral condylar humeral fractures in children without the need for open reduction. We prospectively studied
usually produces good results, as does closed treatment the use of closed reduction and internal fixation as the initial
with a posterior plaster splint or long-arm cast for nondisplaced treatment for a group of displaced unstable lateral condylar
and minimally displaced stable lateral condylar humeral frac- humeral fractures.
tures. Several reports have recommended open reduction and
internal fixation as the best procedure for unstable fractures to Materials and Methods
prevent further displacement, nonunion, and malunion1-10.
However, only a few reports have focused on closed reduction
and internal fixation of lateral condylar humeral fractures11,12.
A fter obtaining informed consent from the patients’ parents
or guardians and the approval of our institutional review
board, we prospectively studied sixty-three consecutive unsta-
We believe that satisfactory reduction and secure fixation of a ble lateral condylar fractures of the humerus between March
lateral condylar fracture of the humerus in a child can often be 2001 and December 2005. We excluded forty-three stable

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of
less than $10,000 from Dongsan Medical Center, Keimyung University. Neither they nor a member of their immediate families received payments or
other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay
or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the
authors, or a member of their immediate families, are affiliated or associated.

J Bone Joint Surg Am. 2008;90:2673-81 d doi:10.2106/JBJS.G.01227

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TABLE I Classifications According to Degree of Displacement and Fracture Pattern

Degree of Radiograph Views

Stage Displacement Fracture Pattern Used as Basis Stability

1 £2 mm Limited fracture line within the metaphysis All 4 views Stable

2 £2 mm Lateral gap All 4 views Indefinable
3 £2 mm Gap as wide laterally as medially Any of 4 views Unstable
4 >2 mm Without rotation of fragment Any of 4 views Unstable
5 >2 mm With rotation of fragment Any of 4 views Unstable

Fig. 1
Illustrations depicting the stages of displacement of fractures of the lateral condyle of the humerus in children. In stage 1, the fracture is stable,
displacement is £2 mm, and the fracture line is limited to within the metaphysis. In stage 2, the fracture is indefinable, displacement is £2 mm,
the fracture line extends to the epiphyseal articular cartilage, and there is a lateral gap. In stage 3, the fracture is unstable, displacement is £2
mm, and there is a gap that is as wide laterally as it is medially. In stage 4, the fracture is unstable and displacement is >2 mm. In stage 5, the
fracture is unstable and displacement is >2 mm with rotation.

Fig. 2
The treatment algorithm according to the stage of fracture displacement.
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Fig. 3-A Fig. 3-B

Fig. 3-A Anteroposterior radiograph of the right elbow, showing a stage-3

fracture of the lateral cortex with a minimal lateral gap and £2 mm of
displacement. Fig. 3-B Internal oblique radiograph showing a fracture
through the lateral humeral condyle, extending into the joint, with the
fracture gap being as wide laterally as it is medially. Fig. 3-C Short
T1-weighted inversion recovery magnetic resonance image showing
complete fracture of the cartilage.

Fig. 3-C

(stage-1) and indefinable (stage-2) fractures that had uniformly the fracture pattern three times for each patient over a more
good results after treatment with a long-arm cast during the than two-week interval with use of a PACS (picture archiving
study period. All patients in the present study were managed by and communications system) network (Marosis, DICOM
a single pediatric orthopaedic surgeon (K.S.S.), and three ex- version 3.0; INFINITT, Seoul, South Korea). Fracture fragment
perienced orthopaedic surgeons (C.H.K., B.W.M., and K.C.B.) displacement was measured from the lateral metaphyseal cor-
measured the amount of fracture displacement and classified tex of the distal part of the humerus to the lateral cortex of the
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Fig. 4-A Fig. 4-B

Fig. 4-A Anteroposterior radiograph of the left elbow, showing an apparent stage-3 fracture with displacement of £2 mm and a gap as wide laterally
as medially. Fig. 4-B Internal oblique radiograph of the same elbow, showing a stage-4 fracture with 7 mm of fracture fragment displacement.

Fig. 4-C Fig. 4-D

Figs. 4-C and 4-D Postoperative anteroposterior (Fig. 4-C) and internal oblique (Fig. 4-D) radiographs showing a good reduction, achieved by
closed means, and internal fixation with two parallel Kirschner wires.
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Fig. 4-E Fig. 4-F

Figs. 4-E and 4-F Anteroposterior (Fig. 4-E) and internal oblique (Fig. 4-F) radiographs, made six months after surgery, showing fracture union.

fracture fragment on the anteroposterior, internal oblique, and laterally as it was medially, £2 mm of displacement, and a high
external oblique radiographic views. The posterior cortex was risk of further displacement. Stage 4 indicated a fracture with
used to measure displacement on the lateral radiograph. The >2 mm of displacement without rotation of the distal frag-
greatest displacement on any single radiograph was recorded as ment. Stage 5 indicated a fracture with >2 mm of displacement
the amount of displacement of the fragment. with rotation of the distal fragment.
Observer agreement was measured to determine inter- An algorithm was created to treat these fractures on the
observer and intraobserver reliability. We calculated the kappa basis of this classification system (Fig. 2). Fractures with the
value (k value) to assess interobserver and intraobserver reli- possibility of further displacement were defined as unstable
ability regarding the fracture pattern; a kappa value of 1 indicates and as either displaced (>2 mm of displacement; i.e., stage-4
complete agreement. The interobserver reliability regarding the and 5 fractures) or minimally displaced (£2 mm of displace-
measurement of fracture displacement on the preoperative and ment with a fracture through the lateral humeral condyle ex-
postoperative anteroposterior and internal oblique radiographs tending into the joint and a fracture gap as wide laterally as
was very high (range, 0.911 to 0.928 for preoperative antero- medially on any of the four radiographic views; i.e., stage-3
posterior radiographs, 0.980 to 0.985 for preoperative internal fractures). As a first step, we attempted closed reduction and
oblique radiographs, 0.890 for postoperative anteroposterior internal fixation for all sixty-three unstable displaced fractures,
radiographs, and 0.787 to 0.807 for postoperative internal ob- including those that were classified as stage 3 (Figs. 3-A, 3-B,
lique radiographs). and 3-C), stage 4 (Figs. 4-A through 4-F), or stage 5 (Figs. 5-A
We divided the fractures into five groups according to the through 5-E).
amount of displacement and the fracture pattern as determined To reduce unstable fractures, traction with a gentle varus
on the basis of the four radiographic views, with a special em- force was applied to the elbow while the patient was under general
phasis on the internal oblique view (Table I, Fig. 1). Stage anesthesia. For stage-3 and 4 fractures, gradual direct compres-
1 indicated a fracture through the lateral humeral condyle with sion was applied to the fracture fragment anteromedially without
a minimal lateral gap and £2 mm of displacement. Stage 2 the use of Kirschner wires. For stage-5 fractures, an attempt was
indicated a fracture through the lateral humeral condyle to the made to reposition the rotated fragment by using Kirschner
epiphyseal articular cartilage with a lateral gap and £2 mm of wires as joysticks or by pushing directly on the fragment. After
displacement. Stage 3 indicated a fracture through the lateral repositioning, fracture fragment reduction was performed in
humeral condyle into the joint, a fracture gap that was as wide the same manner as for stage-3 and 4 fractures. A slight valgus
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Fig. 5-A Fig. 5-B

Figs. 5-A and 5-B Anteroposterior radiograph (Fig. 5-A) and internal oblique radiograph (Fig. 5-B) showing a severely displaced fracture with
rotation of the fracture fragment. This fracture is classified as a stage-5 (unstable) fracture.

force was applied to the elbow, with the forearm supinated and fractures involved the right elbow, and twenty-eight involved the
the elbow slightly extended, to maintain the reduction. After the left elbow. The average time from the injury to surgery was 2.4
fracture reduction was confirmed to be within 2 mm, especially days (range, zero to fourteen days). The average duration of follow-
on the internal oblique, anteroposterior, and lateral radiographs, up was twenty-five months (range, one year and three months to
percutaneous pinning with two parallel smooth Kirschner wires six years).
was performed. We used 1.2-mm-diameter Kirschner wires for Seventeen of the sixty-three fractures were stage 3, forty
patients younger than three years of age, 1.4-mm-diameter were stage 4, and six were stage 5. The average amount of initial
wires for those between three and five years of age, and 1.8-mm- displacement was 3.5 mm (range, 0 to 33 mm) on the antero-
diameter wires for those older than five years of age. posterior radiograph and 4.5 mm (range, 0.5 to 27 mm) on the
If we could not reduce the fragment to within 2 mm as internal oblique radiograph. For the entire group, the average
shown on any of the four radiographic views, open reduction amount of postoperative displacement was <1 mm on both the
and internal fixation was performed. A long-arm cast was ap- anteroposterior and the internal oblique radiographs. Thirteen
plied in all cases and was left in place for four weeks. We re- (76%) of the seventeen stage-3 fractures were reduced to £1 mm
moved the pins four to five weeks after surgery. At the time of of residual displacement. Thirty (75%) of the forty stage-4
the latest follow-up, we evaluated the degree of fracture dis- fractures and three (50%) of the six stage-5 fractures were re-
placement, elbow range of motion, radiographic changes (inclu- duced to £2 mm of residual displacement. All of these fractures
ding osteophyte formation and hypertrophy of the capitellum), (representing forty-six of all sixty-three fractures) were stabi-
and clinical symptoms. Results were graded according to the lized with percutaneous Kirschner wires. The remaining four
criteria suggested by Hardacre et al.7. stage-3 fractures were treated with in situ pin fixation without
further attempts at reduction. In the cases of the remaining ten
Results stage-4 fractures and three stage-5 fractures, closed reduction to

A total of sixty-three fractures were evaluated (see Appen-

dix). The patients included forty-two boys and twenty-
one girls with an average age of six years and four months (range,
within £2 mm failed and open reduction and internal fixation
was performed.
Minor complications included eleven instances of oste-
twenty-one months to eleven years and three months). Thirty-five ophyte formation without any subjective symptoms and four
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Fig. 5-C Fig. 5-D

Figs. 5-C and 5-D Postoperative anteroposterior radiograph (Fig. 5-C)

and lateral radiograph (Fig. 5-D) showing an anatomic reduction,
achieved by closed means, and internal fixation with two parallel
Kirschner wires. Fig. 5-E Anteroposterior radiograph, made five months
after surgery, showing fracture union.

Fig. 5-E
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instances of mild hypertrophy of the capitellum with no change traoperative confirmation of the reduction status or osteone-
in the carrying angle. There were no serious complications crosis caused by excessive soft-tissue dissection.
such as osteonecrosis of the trochlea or capitellum, nonunion, Only a few reports have focused on percutaneous pin
malunion, or early physeal arrest. According to the criteria of fixation of these fragments. Mintzer et al. reported good results
Hardacre et al.7, the clinical result was excellent in forty-four after percutaneous pin fixation of twelve lateral condylar frac-
(96%) of the forty-six patients undergoing closed reduction tures with displacement in excess of 2 mm11. They believed that
and pin fixation, good in two patients (4%), and poor in no the method is appropriate for selected fractures with 2 to 4 mm
patients. of displacement and an arthrographically demonstrated con-
Thus, forty-six (73%) of the sixty-three unstable frac- gruent joint space. Foster et al. reported that percutaneous pin
tures of the lateral humeral condyle were reduced and stabi- fixation of nondisplaced and minimally displaced fractures is
lized with good results and no serious complications with use an acceptable alternative in any situation in which close clinical
of our treatment algorithm. and radiographic follow-up cannot be ensured12. It was often
our personal experience that many fractures that were treated
Discussion with open reduction and internal fixation could be reduced by

A fracture of the lateral condyle of the humerus is the second

most frequent fracture of the elbow in children. This di-
agnosis may be less obvious both clinically and radiographically.
closed means. Because it appeared that open reduction and
internal fixation was not always necessary for these displaced
fractures, we conducted the present study.
As with other elbow fractures in children, a poorly treated lateral The present study showed a high success rate (73%) in
condylar fracture is more likely to result in a substantial func- association with closed reduction and pin fixation for the
tional loss of elbow motion1. treatment of unstable displaced fractures. While others have
Treating a minimally displaced fracture may be difficult reported that closed reduction and internal fixation is not
primarily because it is difficult to determine whether the distal recommended for the treatment of Jakob stage-3 displaced and
fracture fragment is prone to further displacement. The com- rotated lateral condylar fractures1 (which are classified as stage-
mon practice of using only anteroposterior and lateral elbow 5 fractures in our system), we achieved excellent results in
radiographs does not always provide adequate information to three of six such fractures with use of closed reduction and pin
allow one to determine fracture stability, to prevent further
fixation (Figs. 5-A through 5-E). We acknowledge that the
displacement, and to identify an optimal treatment method for
number of cases is small and that additional prospective studies
these fractures1,4,5,10,12-14. Many other studies, such as magnetic
are needed to further evaluate this approach for the treatment
resonance imaging, arthrography, stress tests, and ultrasonog-
of fractures with an unstable and rotated fragment. It is our
raphy, have been suggested as additional methods to evaluate
impression that the reasons for our high success rate with
fracture stability15-19. However, the routine use of these modalities
closed reduction and internal fixation were (1) the accurate in-
may not be warranted because of their cost and the need for
terpretation of the direction of fracture displacement (mainly
sedation of the patient.
The importance of the internal oblique radiograph for posterolaterally, not purely laterally) and the amount of dis-
the diagnosis of fracture stability and the amount of dis- placement of the fracture fragment on the basis of our classifi-
placement at the site of lateral condylar fractures of the hu- cation system, (2) routine intraoperative confirmation of the
merus in children has been well established13; in the present reduction on both anteroposterior and internal oblique radio-
study, we have suggested a new system for the classification of graphs, and (3) maintenance of the reduction with two parallel
these fractures with use of the internal oblique view. Our re- percutaneous Kirschner wires.
sults strongly imply that the failure of assessment of stability The present study demonstrates that fracture classifica-
with use of previous radiographic criteria was due to the ex- tion on the basis of four elbow radiographs, with an emphasis
clusion of the findings from the internal oblique radiograph. on the internal oblique view, is useful for determining fracture
We classified these fractures according to the degree of dis- fragment stability and the optimal treatment method and that
placement and the fracture pattern demonstrated on all four closed reduction and pin fixation often results in effective
radiographic views. treatment for unstable displaced lateral condylar fractures of the
Generally, there has been uniform agreement regarding humerus in children.
the need for open reduction and internal fixation of displaced
fractures of the lateral condylar physis. Because it is difficult to Appendix
maintain the reduction of a displaced lateral condylar fracture A table showing clinical details on all study subjects is
and because of the high prevalence of poor functional and available with the electronic versions of this article, on
cosmetic results associated with closed reduction and casting, our web site at jbjs.org (go to the article citation and click on
open reduction and internal fixation has become the most ‘‘Supplementary Material’’) and on our quarterly CD/DVD
widely advocated method for the treatment of unstable fractures (call our subscription department, at 781-449-9780, to order
with Jakob stage-2 or 3 displacement1-10. However, even patients the CD or DVD). n
who are managed with open reduction and internal fixation NOTE: This study was partially supported by the research-promoting grant from the Keimyung
University Dongsan Medical Center. The authors thank Katharine O’Moore-Klopf for providing
may have development of malunion because of a lack of in- editorial assistance.
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Kwang Soon Song, MD Ju Hyub Lee, MD

Chul Hyung Kang, MD Department of Orthopedic Surgery, School of Medicine,
Byung Woo Min, MD Keimyung University, 194 Dong san dong,
Ki Cheor Bae, MD Daegu 700-712, South Korea.
Chul Hyun Cho, MD E-mail address for K.S. Song: skspos@dsmc.or.kr

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