Best Treatment for Elbow Fractures in Children

In this study, orthopedic surgeons compared three ways to treat elbow fractures in children. The specific type of fracture was a lateral condylar fracture of the distal humerus. The distal humerus is at the bottom of the upper arm.

The humerus flares at the bottom on both sides forming a part of the bone called the condyle. The lateral condyle is the bony projection along the outside of the elbow (side farthest away from the body). Fractures of the lateral condyle are fairly common in children. Finding the most effective treatment with the fewest complications is an important goal.

The choices in treatment include: putting the arm in a cast from the hand to the top of the upper arm. That’s called a long arm cast. Casting without surgery is possible when the break is intact and hasn’t separated or displaced.

A second treatment alternative is called closed reduction and internal fixation or CRIF. With CRIF, the break can be lined up (reset) without an incision to cut through the skin and open the arm up. And for fractures that have separated too much and/or shifted so the broken ends no longer line up, the third procedure used is called an open reduction and internal fixation (ORIF). With the open reduction, the surgeon makes an incision down to the bone. The bone is put back together and held in place with wires, plates, and/or screws. The arm is placed in a long arm cast until sufficient healing takes place.

Each of these treatment approaches have their pros and cons. Putting a cast on without wiring or screwing the bones back together has a risk of the bones drifting too far apart. Closed reduction and internal fixation may not bring the bones back as close together as needed. The result can be deformity and change in the carrying angle of the arm. Open reduction with internal fixation (ORIF) is really the most accurate treatment but it is also the most invasive.

A wide range of complications can occur from the treatment of lateral condylar fractures. There can be infections, loss of blood supply to the bone, failure of the bones to knit back together (malunion), or just a very slow process of healing (delayed union).

Sometimes the bones shift even with surgery (CRIF or ORIF). If too much shifting occurs, an elbow deformity can develop that affects the carrying angle of the arm. There are cases where growth is stopped or the opposite (too much bone growth) occurs. Stiffness, loss of motion, weakness, and loss of function are all possible problems that can develop.

So, which one of these treatments works best? Which one has the fewest complications? How can surgeons optimize motion, strength, and function and help the patients get back to as normal as possible? Let’s see what this study of 175 children revealed. Please note: all 175 children were treated by the same surgeon and given the same follow-up care and rehab.

Fourteen patients of the 39 who were put in a long arm cast without surgery ended up with a gap in the fracture site that required surgical fixation. Almost one-fourth of the children had obvious overgrowth of the lateral condyle. It looked funny but didn’t alter their arm function or require surgery to realign the bones.

Lateral overgrowth and bone spur formation occurred most often in the open reduction and internal fixation (ORIF) group. This was the most common complication of ORIF. An increased carrying angle was the second most common complication. Neither of these problems went away even almost two years after the surgery.

For all three types of treatment, elbow range of motion was normal. Remember the 14 children who were initially put in a cast but had to have surgery later because the break was drifting apart? Once they had surgery (either CRIF or ORIF), union occurred without any further problems.

The authors concluded that there was no significant difference in outcomes between fracture types or treatment method. Good-to-excellent results can be expected when treating lateral condylar fractures in children with conservative (nonoperative) care or surgical management. The two major complications (lateral condyle overgrowth and a change in the carrying angle of the elbow) appear to be permanent changes.