Correspondence:
Dr C Rex,
1, Barton Avenue,
Urmston, Manchester, M41 5PS
UK
Key words: fracture, radial head, fracture management
This is reported for the successful management of the rarest combination of medial condyle fracture with the radial head dislocation. To our knowledge there has been only one report of similar injury described, that was diagnosed late and had poor result.
Six-year-old girl had a fall on her right elbow and presented with swelling and pain in the elbow. The diagnosis was missed in the first place though the Xray showed undisplaced medial condyle fracture with radiocapitellar malalignment (Fig 1). She was given an above elbow back slab and reviewed at two weeks. The check Xray at this time showed obvious dislocation of the radial head with rotational malalignment of the condyle of the humerus (Fig 2).
Open reduction was contemplated by medial approach after isolating the ulnar nerve. A large medial condyle fragment was identified with articular irregularity and forward rotation of the fragment. The condyle was mobilised with difficulty by clearing the soft callus. Good reduction was obtained and fixed with two smooth K wires, one passed obliquely and other horizontally (Fig 3). The radial head was reduced closely and found stable on supination-pronation movements. The patient was immobilised with an above elbow plaster slab in 90 degrees of flexion and supination of the forearm. At the end of 4 weeks, the K wires were removed and active elbow exercises started (Fig 4). The patient regained full range of elbow flexion-extension and forearm supination-pronation at the end of three months. One year down the line the patient was symptoms free and discharged.
Fracture of medial condyle of humerus is a rare entity in children that accounts for only 1.5% of fractures of the elbow joint 6,7 and sometimes it is "once in a lifetime" an orthopaedic surgeon sees this fracture. Though it is rare it can give rise to serious problems if not diagnosed early and treated appropriately (4,9).
Two specific mechanisms 6 are most frequently reported; one is a direct blow to the posterior proximal ulna with the elbow flexed forcing articular surface of olecranon into the trochlear incisure as a wedge, splitting off the medial condyle. The second mechanism is fall on outstretched hand with elbow extended and supinated, the wrist dorsiflexed avulsing the medial condyle because of contraction of forearm flexors and valgus strain.
The recognised complications are limited movement of the elbow, especially terminal extension; growth arrest at the physeal plate due to malunion producing cubitus varus deformity, as most are Salter Harris type 4 fractures, and rarely non-union of the fracture (2,3,5,8). Very rarely avascular necrosis of the lateral aspect of the medial condyle produces fishtail deformity (6).
In addition to all these problems intrinsic to this fracture the force necessary to produce this fracture can produce more injury to surrounding parts and one must carefully look for associated injuries 1. In our case, dislocation of the radial head would have been easily missed to produce sinister result if we would not have reviewed earlier. We can find only one earlier report of similar injury by Bensahel (1) that was diagnosed late and had poor result. It is a good principle to closely follow (with in a week with check Xray) any elbow fractures in children in order to prevent inadequate or delayed treatment.