Lateral condyle fractures in children: evaluation of classification and treatment.

OBJECTIVE: To compare intra-operative findings of fractures of the lateral condyle of the humerus in children with existing pre-operative radiographic classification. DESIGN: Prospective, consecutive. SETTING: Large urban hospital. PATIENTS: 25 consecutive displaced lateral condyle (humerus fractures) in 25 children diagnosed on biplanar radiographs. INTERVENTION: Open reduction and internal fixation through a lateral approach to the elbow. MAIN OUTCOME MEASUREMENTS: Anatomic variations of the lateral condyle of the distal humerus based upon intra-operative observations; comparison of findings with pre-operative radiographic classification. RESULTS: Three anatomic types were identified: 1) nine fractures exited on the medial side of the capitellum in the capitello-trochlear groove (36%), 2) eleven fractures exited beyond the capitello-trochlear groove through the trochlear epiphysis (44%), and 3) five fractures extended across the physis medially (20%). No fracture appeared to transverse the ossified portion of the capitellum (Milch Type I). The Milch anatomic classification was found to be inaccurate in 52% of the fractures. CONCLUSION: Intraoperative findings did not correlate with the presumed preoperative radiographic diagnosis in the majority of cases. A heightened awareness of the limitations of this traditional classification system is required for operative decision.

The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring open reduction and internal fixation.

The purpose of this study was to examine the use of an anterior incision of the meniscus for exposure of tibial plateau fractures. We studied 27 fractures of the proximal tibia treated with open reduction and internal fixation (ORIF). There were nine unicondylar fractures (five A-O B2; four A-O B3) fixed with plates and screws and 18 bicondylar fractures (seven A-O C1; five A-O C2; six A-O C3) fixed with combination internal and external fixation. Length of follow-up averaged 26 months. All patients were treated with an anterior incision of the meniscus and retraction with the condyle. Of the 18 bicondylar fractures, nine severely displaced fractures were found to have peripherally detached menisci. Unicondylar fractures did not display this finding. After fixation, menisci were repaired at the periphery and sewn to the original anterior insertion. The repair begins posteriorly and advances the cartilage to ensure anatomic placement. There were four medial and 23 lateral menisci in this series. Ten patients underwent knee arthroscopy 6 months to 2 years post-ORIF as a routine procedure during hardware removal. All menisci were found to be healed to the periphery and were stable. There were no gross tears. In one patient, the anterior meniscal incision could be visualized. No patients developed mechanical symptoms either in postoperative rehabilitation or postoperative follow-up at a maximum of 6 years. All patients had > 125 degrees of motion. Less motion when compared with the normal knee was felt to be related to more complex fracture patterns. In conclusion, the anterior meniscal incision allows for excellent exposure of severe proximal tibia fractures. This technique allows for anatomic meniscal repair and early rehabilitation. Arthroscopic examination confirms peripheral meniscal healing. No patient experienced clinical symptoms of meniscal pathology.

Surgical stabilization of humeral shaft fractures due to gunshot wounds.

Humeral shaft fractures resulting from gunshot wounds are challenging injuries to treat. The results of surgical stabilization depend upon the appropriate indication and operative techniques. Compression plating, intramedullary fixation, and external fixation are discussed.

Displaced pilon fractures. An update.

In the past, displaced pilon (hammer) fractures were considered to be inoperative. When principles for open reduction and internal fixation of pilon fractures were developed, encouraging surgical results emerged. This article deals with the classification, treatment, technique of fixation, and care of this type of fracture.