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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00648-4
10.1016/j.radcr.2024.07.062
Case Report
Posteromedial elbow dislocation with lateral humeral condyle fracture in children: How to manage? Case report and review of the literature
Bouya Ayoub bouya.ayoub5@gmail.com
ab⁎
Elmokhtari Kamal ab
Zaddoug Omar ab
Benchakroun Mohammed ab
Zine Ali ab
Bouabid Salim ab
a Orthopedic Trauma Service I, Military Training Hospital Mohamed V, Rabat, Morocco
b University Mohamed V of Rabat, Faculty of Medicine and Pharmacy, Rabat, Morocco
⁎ Corresponding author. bouya.ayoub5@gmail.com
23 8 2024
11 2024
23 8 2024
19 11 51745177
28 1 2024
12 7 2024
13 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Posteromedial dislocation of the elbow is a rare entity even exceptional if associated with a lateral condylar fracture. Very few isolated cases are reported in the English literature. We report an additional case of a 14-year-old child admitted for elbow trauma during scholar sport and presented a posteromedial elbow dislocation associated with a fracture of the lateral humeral condyle. The surgical treatment was made by using 3 cortical screws. The results were satisfying including range motion and he has resumed sports activities at 5 months. Elbow dislocation is a rare affection in children. It represents 3% to 6% of elbow injuries. The association of posteromedial elbow dislocation with a Milch type I is remarkably rare. We review the mechanism, classifications, and therapeutic modalities of this injury. Elbow dislocations associated with a lateral condylar fracture are exceptional and need an early reduction followed by an anatomical internal fixation to ensure articular congruity.

Keywords

Children
Elbow dislocation
Fracture dislocation
Lateral condylar fracture
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pmcIntroduction

Elbow dislocations in pediatric patients are relatively uncommon occurrences, with posteromedial varieties being particularly rare and even exceptional when compounded by a lateral condylar fracture [1].The management of posteromedial elbow dislocations necessitates a comprehensive understanding of injury mechanisms, classification systems by both radiologists ans orthopedic surgeons [2].

We report a case of a 14-year-old child who presented a posteromedial elbow dislocation associated with a lateral condylar fracture and discuss classifications and therapeutic modalities. This case highlights the rarity and complexity of such injuries and underscores the importance of meticulous evaluation of the radiographic images and management by orthopedic specialists experienced in pediatric trauma.

Case report

A 14-year-old man, a college student with no medical history, right-handed, admitted to the emergency service after a left elbow trauma. He falls on a stretched and supinated hand on scholar sport. The patient couldn't move his elbow.

The examination found the right arm sustained the left. The elbow was swelling and deformed. Motion attempts were very painful. There were no vascular or nervous abnormalities. The left wrist and shoulder examinations were satisfying.

X-rays revealed a posteromedial elbow dislocation associated with an articular displaced fracture of the distal humerus. This sagittal fracture involved the lateral condylar and respect the hole trochlea; It was a Milch Type I fracture (Fig. 1). Under moderate anesthesia, the elbow had been reduced within 2 hours of the injury.Fig. 1 X-rays showing the posteromedial dislocation associated with the lateral condylar fracture.

Fig 1:

Due to the displacement of this fracture, the staff decided to operate the patient. Within 24 hours after the trauma, the patient was admitted into the operating room. Under general anesthesia, an orthopedic surgeon performed the gesture by a lateral approach. The fragment was reduced and fixed by three 3,5 mm of diameter screws (Fig. 2). The articular congruity was satisfying.Fig. 2 X-rays showing the reduction and internal fixation of the lateral condylar fracture.

Fig 2:

After 3 weeks of immobilization by a posterior splint, the patient debuted passive functional rehabilitation based on flexion-extension motion.

At 5 months, the patient had no pain. Ranges of motion were 150 ° of flexion, 0 ° of extension, 90 ° of pronation, and 85 ° of supination (Fig. 3). The quick DASH score was 0. He resumed sports activities at 5 months. After 2 years of follow-up, there was no change in the clinical and radiological outcomes.Fig. 3 Images showing clinical outcome in 2 years follow up.

Fig 3:

Discussion

In children, elbow dislocation is a rare condition that accounts for 3% to 6% of elbow injuries. The forearm's direction of dislocation serves as a description of this displacement [3]. Elbow dislocations in children are classified based on the direction of dislocation, associated fractures, specific pediatric conditions, the extent of ligamentous injury, timing, and recurrence. The main types of dislocation based on direction include posterior dislocation, which involves the radius and ulna being displaced behind the humerus. The anterior dislocation is rare and involves the forearm bones being displaced in front of the humerus. Medial and lateral dislocations are less common and involve displacement of the forearm bones to the sides of the humerus [4].

Dislocations can also be classified based on associated fractures. Simple dislocations involve no associated fractures and primarily involve ligamentous injury, while complex dislocations involve associated fractures such as medial epicondyle fractures, radial head fractures, coronoid process fractures, or olecranon fractures [5]. Specific pediatric conditions include nursemaid's elbow (radial head subluxation), a common injury in young children where the radial head slips out of the annular ligament, and Monteggia fracture-dislocation, which involves a fracture of the ulna shaft with dislocation of the radial head and is common in children [6].

The posteromedial type associated with a fracture of the lateral humeral condyle is an uncommon situation [3]. In the literature, very few cases have been described [[1], [2], [3],[6], [7], [8]].

The lateral condylar fracture of the humerus is divided into 2 types by Milch [9]:• Milch I: The fracture line runs laterally to the trochlear groove. The elbow is stable. It is the less common type.

• Milch II: The trochlear groove is traversed by the fracture. The elbow is unstable. It is the more common type.

The association of posteromedial elbow dislocation with a Milch type I is remarkably rare. Hendel and Murnaghan describe each one as a case [7,8]. Tomori reported 2 cases [10]. This singularity identifies the distinctiveness of our report (Table 1).Table 1 Published reports of pediatric patients with posteromedial elbow dislocations and Milch I lateral humeral condylar fractures.

Table 1:Authors	Age/Sex	Jakob classification [11]	Surgical approach	Treatment	Follow-up (mo)	outcome	
Hendel et al. [7]	14/F	3	Lateral	Excision of the lateral condyle	12	Reduction of range motion	
Murnaghan et al. [8]	9/M	3	Lateral	ORIF	4	excellent	
Tomori et al. [10]	1/F	3	posterolateral	ORIF	16	Cubitus varus	
	9/F	3	posterolateral	ORIF	16	Cubitus varus	
ORIF, open reduction and internal fixation.

The incriminated mechanism is adducting the supinated forearm with the elbow in extension [11]. Jakob and al reported in a review published in 1975 a classification describing lateral condyle fracture displacement [11].

Recently, Weiss published a classification with potential therapeutic applications [12]. He proposes 3 categories of lateral condyle displacement. A nondisplaced fracture is type I. Type II matches with a displacement of 2-4 mm. Type III is a displacement of over 4 mm. Weiss believes that a closed reduction and pinning are necessary for a displacement of 2-4 mm, while an open reduction and internal fixation (ORIF) is required for displacements greater than 4 mm.

Elbow dislocations are readily diagnosed on radiographs and generally do not require MRI [13].

The lateral approach is mostly used to reduce and fix lateral condyle fractures. However, the surgeon must pay attention to not disturb the posterior blood supply of the capitulum [14].

Classically, surgeons use an internal fixation by K-wires. Su and al accomplish an internal fixation using absorbable screws and define it as a secure method that enables avoiding a second surgery to remove materials. [15]. However, absorbable screws are expensive and require technical skills making it more difficult than K-wire fixation.

The lateral condylar fractures require a lengthy follow-up of more than a year to check for a growth abnormality [14].

Conclusion

In conclusion, managing posteromedial elbow dislocation with a concurrent lateral condylar fracture in pediatric patients requires a coordinated effort among orthopedic surgeons, radiologists, and rehabilitation specialists. Early and accurate radiographic evaluation is pivotal for precise diagnosis and treatment planning. This collaborative approach ensures timely reduction, anatomical alignment of fractures, and diligent monitoring for complications. By leveraging the expertise of multidisciplinary teams, we can optimize outcomes and minimize long-term sequelae, promoting the restoration of function and quality of life for young patients.

Consent for publication

An informed consent was obtained from the parents of the patient for this publication.

Financial support and sponsorship

Nil.

Author contributions

Ayoub Bouya, Kamal Elmokhtari and omar zaddoug make substantial contributions to acquisition of data, conception and design, and analysis and interpretation of data. Mohammed Benchakroun, Ali Zine and Salim Bouabid participate in revising it critically for important intellectual content and give final approval of the version to be submitted.

Patient consent

Patient gives informed consent for publication.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments: No funding to declare.
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