Intra-articular Salter-Harris IV-type injuries of the lateral distal humerus involving the ossific nucleus of the capitellum and lateral condyle; often displacement-prone.
Second most common pediatric elbow fracture after supracondylar fractures; accounts for ~10–20% of elbow fractures in children.
Relevant anatomy
Lateral condyle includes the capitellum and lateral trochlea; articulates with radial head and ulna.
Extensor–supinator muscle origin (ECRL/B, ED) and lateral collateral ligament complex attach near the lateral epicondyle → deforming forces promoting displacement.
Ossification centers follow “CRITOE”; lateral epicondyle appears around 11 years, fuses by 12–14 years.
Epidemiology & mechanism
Peak incidence 5–8 years; slight male predominance.
Typical mechanism: FOOSH (fall onto an outstretched hand) with varus or valgus load and forearm supination, causing shearing across the lateral condyle; less often direct trauma.
Frequently low-energy falls during play or sports (playground, park, trampolines).
Clinical presentation
Lateral elbow pain, localized swelling and tenderness over lateral condyle.
Often minimal deformity compared with supracondylar fractures; neurovascular status usually intact.
Child may still move elbow partially; pain with varus/valgus stress or wrist extension.
High suspicion required in a limping, relatively comfortable child with lateral tenderness after fall.
Imaging
AP, lateral, and internal oblique views of elbow are recommended.
Internal oblique projection best demonstrates minimally displaced fractures; standard AP/lateral can miss them.
Look for:
Fracture line from metaphysis → physis → articular surface (capitellum/trochlea).
Amount of lateral and posterior displacement.
Joint incongruity or rotational malalignment.
Ultrasound or MRI may help in occult injuries but are rarely required if oblique x-rays are adequate.
Classification
Milch classification (based on fracture line relation to trochlear groove).
Type I: fracture line lateral to trochlear groove; elbow stability relatively preserved.
Type II: fracture line extends medially into trochlear groove; more unstable.
Weiss / Song (displacement-stability based)
Type 1: <2 mm displacement; intact cartilaginous hinge (stable).
Type 2: >2 mm but <4 mm; articular cartilage intact (unstable but reducible closed).
Type 3: ≥4 mm displacement and/or articular incongruity (unstable; often rotated).
Treatment algorithms currently rely heavily on displacement and stability rather than Milch type alone.
Treatment principles – general
This is an intra-articular fracture: anatomic articular reduction is critical to avoid nonunion, fishtail deformity, and degenerative changes.
Even small displacement can progress over time; early accurate diagnosis and close follow-up are essential.
Nonoperative management
Indications
Weiss / Song type 1: <2 mm displacement on all views with intact cartilaginous hinge, stable elbow.
Method
Long-arm cast with elbow 90° flexion, forearm neutral.
Follow-up radiographs (including oblique view) at 5–7 days to ensure no displacement.
Outcomes
Good to excellent functional results when displacement remains <2 mm until union.
However, 5–18% of apparently minimally displaced fractures may secondarily displace → emphasizes need for early repeat imaging.
Operative management
Indications
Displacement ≥2 mm on any view or progression of displacement during follow-up.
Articular incongruity or rotational displacement.
Open fracture or associated elbow dislocation.
Late presentation with nonunion or malunion requiring corrective surgery.
Surgical options
Closed reduction and percutaneous pinning (CRPP)
Suitable for 2–4 mm displaced but otherwise stable fractures with intact articular hinge.
Reduction maneuvers: varus/valgus stress, forearm rotation, gentle traction; confirm on fluoroscopy and sometimes arthrogram.
Open reduction and internal fixation (ORIF)
Indicated when closed reduction fails or displacement ≥4 mm / articular surface disrupted.
Lateral approach to distal humerus, protect posterior blood supply and LCL complex.
Fixation with 2–3 smooth K-wires or cannulated screw(s) across the fragment.
Postoperative care
Immobilization in cast or splint for ~4–6 weeks, then gradual ROM.
K-wire removal usually at 4–6 weeks after radiographic union is evident.
Complications
Nonunion
Relatively high risk if displacement missed or inadequately reduced.
May present with lateral pain, instability, or deformity; some radiographic nonunions are asymptomatic.
Lateral spur / overgrowth
Very common radiographic finding; usually asymptomatic and cosmetic only.
Malunion and deformity
Cubitus valgus or varus deformity due to growth disturbance or malreduction.
Fishtail deformity (central trochlear osteonecrosis) described after displaced injuries or late reconstruction.
Stiffness
Loss of motion (esp. extension) if immobilization prolonged or reduction imperfect.
Avascular necrosis of capitellum / trochlea
Rare but serious; risk increased with extensive dissection, repeated manipulations, or hardware crossing physis.
Outcomes & evidence
Early anatomic reduction and stable fixation (when indicated) → high union rates and excellent long-term function in most series.
Delayed diagnosis or secondary displacement increases risk of nonunion and deformity; however, corrective osteotomy and late ORIF can still provide functional improvement.
References:
Martins T, Tiwari V, Marappa-Ganeshan R. Pediatric Lateral Humeral Condyle Fractures. In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 9, 2024.
Álvarez Muñoz M, García de la Blanca JC, Anchía MV, Martí Ciruelos R, Calvo Calvo S, Menéndez Crespo MT. Management of Acute Lateral Humeral Condyle Fractures in Children. Children (Basel). 2024;11(12):1421. Published 2024 Nov 25. doi:10.3390/children11121421
