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Minimally Displaced Humeral Lateral Condyle Fractures

Immobilize or Operate When Stability Is Unclear?

Greenhill, Dustin A., MD; Funk, Shawn, MD; Elliott, Marilyn, BS; Jo, Chan-Hee, PhD; Ramo, Brandon A., MD

Journal of Pediatric Orthopaedics: May/June 2019 - Volume 39 - Issue 5 - p e349–e354
doi: 10.1097/BPO.0000000000001311

Background: Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement.

Methods: In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment.

Results: In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures.

Conclusions: Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in <2 weeks. Benefits of prophylactic pinning include 1 less x-ray and clinic visit in exchange for a clinically insignificant lateral cortex reduction and inherent surgical risks. Compliance, surgical scheduling, and a higher rate of open reduction after displacement should influence early treatment decisions.

Level of Evidence: Level III.

Texas Scottish Rite Hospital for Children, Dallas, TX

No funding was received for this study.

The authors declare no conflicts of interest.

Reprints: Dustin A. Greenhill, MD, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail:

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