Medial Condylar Fracture of the Elbow Workup
- Author: John D Kelly, IV, MD; Chief Editor: Craig C Young, MD more...
Laboratory studies are not generally indicated for diagnosing condylar fractures of the elbow.
- Standard elbow radiographs, which include anteroposterior and lateral projections, are often sufficient to diagnose a fracture in the acutely injured elbow. Additional views (eg, oblique projections) are rarely required.
- The decision to obtain elbow radiographs is based on the history of the injury and the physical examination findings from the patient. Clinical decision rules, such as the Ottawa ankle and foot rules (commonly used in emergency medicine), that help identify which patients with acute traumatic elbow injuries need radiographs have not yet been developed.
- Radiographs should be performed on patients who exhibit joint swelling and tenderness of the bony landmarks, crepitus, or restricted and painful range of motion of the elbow following trauma.
- In condylar fractures, the radiograph typically reveals widening of the intercondylar distance. Although the fracture fragment may be displaced proximally, it is generally seen inferior and posterior to its normal position.
- In young children, medial condylar fractures may be difficult to diagnose radiographically if the injury occurs before ossification of the trochlea. Clinically and radiographically, the injury may be misinterpreted as a fracture of the medial epicondyle.
- In older children, a metaphyseal fragment may be visualized, indicating condylar involvement. The presence of a pathologic fat pad, either a large anterior fat pad (sail sign) or a posterior fat pad, often indicates an intra-articular injury. Isolated fractures of the medial epicondyle are extra-articular injuries and are not commonly associated with the presence of a posterior fat pad sign. In the clinical context of acute elbow trauma without an obvious fracture on the radiograph, a pathologic fat pad is often associated with the presence of an occult fracture.
- Plain films may be difficult to interpret in pediatric patients, and comparison views of the uninjured extremity may help to differentiate a fracture from a secondary ossification center.
- Radiographically, medial condylar fractures are classified the same as lateral condylar fractures. Fracture classification is primarily based on the location of the fracture line. In adults, Milch classifies medial condylar fractures into 2 types (type I or type II) depending on whether the lateral wall of the trochlea remains attached to the humerus.
- Type I fractures are more common. In this type of injury, the fracture line originates at the depth of the trochlear groove and ascends obliquely toward the supracondylar ridge. In type I fractures, the lateral trochlear ridge remains with the intact condyle, maintaining mediolateral stability.
- Type II fractures originate in the capitulotrochlear sulcus, thus leading to mediolateral instability of the elbow.
- The Milch classification can also be applied to pediatric medial condylar fractures.
- A Milch type I fracture is a Salter-Harris type II fracture. In this injury, the fracture line runs between the common physeal line, separating the medial and lateral condylar ossification centers.
- A Milch type II fracture is a Salter-Harris type IV fracture. The fracture line traverses the medial aspect of the lateral condylar ossification center.
- Classification of medial condyle fractures in children is further subdivided based on the displacement of the fracture as described by Kilfoyle. Three fracture patterns have been described.
- Kilfoyle type I is a nondisplaced fracture through the medial condylar metaphysis extending down to the physis. Type I fractures do not extend into the articular surface.
- Kilfoyle type II fractures are also nondisplaced. The fracture line extends through the articular surface of the medial condylar physis.
- Kilfoyle type III fractures involve displacement and rotation of the distal condylar fracture fragment.
Arthrography: On occasion, an elbow arthrogram may be used to help the physician clarify a fracture that is difficult to visualize because of an unossified condyle.
Ultrasonography and magnetic resonance imaging: These studies have also been used to further evaluate the unossified epiphysis in patients with traumatic elbow injuries.
- Distention of the elbow joint by an acute traumatic hemarthrosis is often painful; its presence may limit proper evaluation of the injured elbow. Therapeutic arthrocentesis to relieve a painful posttraumatic effusion is considered an acceptable practice. Diagnostically, arthrocentesis may help identify an occult fracture based on the presence of fat globules mixed with the aspirated blood.
- Elbow arthrocentesis should be performed using an aseptic technique. The elbow is approached laterally through the radiohumeral joint. The elbow should be mostly extended, and the forearm should be held in a neutral position. The depression between the radial head and the lateral epicondyle of the humerus should be palpated. The needle is inserted just distal to the lateral epicondyle and is directed medially. Some authors recommend flexing the elbow to 90° and pronating the forearm prior to inserting the needle.
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