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\title{Complex Elbow Trauma in Children: A Rare Case of Posteromedial Dislocation Elbow with Fracture Lateral Humeral Condyle}
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             \author[1]{Dr. Lakshya Prateek  Rathore}

             \author[2]{Naina  Verma}

             \author[3]{Apoorv  Sehgal}

             \author[4]{Virender  Negi}

             \author[5]{Sidharath  Sood}

             \author[6]{Chhewang  Topgia}

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\date{\small \em Received: 7 December 2018 Accepted: 5 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Concomitant fracture of lateral humeral condylar physis along with dislocation of the elbow is a rare entity. There is a paucity of literature on the topic with previous citation being isolated case reports or case series of 3-4 cases. Inasmuch as the treatment of lateral condyle is open reduction internal fixation, it is imperative that standard protocols are followed in order to expect a good outcome. We report a case of 11 year old male child with such an injury who was managed with operative intervention followed by excellent outcome. Subsequently we wish further add upon the existing limited knowledge on the management of this complex injury pattern.

\end{abstract}


\keywords{fracture, dislocation, elbow, lateral condyle, rare, children.}

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\let\tabcellsep& 	 	 		 \par
Introduction solated traumatic dislocation of the elbow in children is a rare injury constituting 3-6\% of all elbow injuries. \hyperref[b0]{1,}\hyperref[b1]{2} Elbow dislocations are usually posterior or posterolateral \hyperref[b2]{3} and they may be associated with fractures like medial epicondyle, coronoid process, radial head and olecranon. Posteromedial dislocation of the paediatric elbow is per se very rare and on top of that their association with a lateral humeral condyle fracture is extremely rare. \hyperref[b3]{4,}\hyperref[b4]{5} We are presenting one such rare case. 
\section[{II.}]{II.} 
\section[{Case Presentation}]{Case Presentation}\par
An 11 year old male child presented to us with a history of injury to his right elbow after fall from bicycle on an outstretched hand. On examination there was diffuse swelling present around the elbow along with deformity with marked tenderness over the lateral condyle without any distal nerovascular deficit. The anteroposterior and lateral radiographs showed posteromedial dislocation of elbow with fracture of the lateral condyle of humerus (Figure  {\ref 1} and Figure  {\ref 2}).\par
Closed reduction of the elbow was performed under intravenous conscious sedation and analgesia. Post reduction radiographs showed Milch type II fracture of humeral condyle (Figure \hyperref[fig_1]{3 and 4}). 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
Postoperative radiographs (figure  {\ref 5 and 6}) showed anatomical reduction with a congruent joint. Wound healed well and sutures were removed after 2 weeks. Serial x-rays showed expected fracture healing and elbow range of motion started after removal of k wire at 6 weeks. Patient showed good recovery and at 10 month follow up (figure \hyperref[fig_2]{7}) patient has a mayo elbow score of 100 and excellent outcome with a stable elbow. Furthermore no complication was observed.\par
IV. 
\section[{Discussion}]{Discussion}\par
In children, elbow dislocation is not very common with peak incidence in the adolescent age group. It is usually classified based on the direction of displacement. Although their association with medial epicondyle fracture is well known which can sometimes be incarcerated in the joint, their concomitant incidence with \#lateral condyle is a very rare occurrence. \hyperref[b1]{2,}\hyperref[b4]{5,}\hyperref[b5]{6,}\hyperref[b11]{12,}\hyperref[b12]{13} Fractures of the lateral condylar physis constitute 16.9\% of distal humeral fractures. \hyperref[b13]{14} Fractures involving the lateral condylar physis occur early, with the average age around 6 years which can fracture both by pull and push-off mechanism after fall on outsretched hand. \hyperref[b14]{15,}\hyperref[b15]{16} Fracture of the lateral condylar physis is usually classified by Milch classification system and I Informed consent was taken from the parents and patient was taken up for surgery. Under general anesthesia elbow was closed reduced and found to be stable throughout range of motion. A standard lateral approach for elbow was used to access the fracture site, reduced under vision and fixed with two smooth K wires. Furthermore, again the elbow was found to be stable. A plaster of Paris above elbow slab was applied. Post-operative period was uneventful.\par
displacement stages are divided into three parts. Our patient had Milch type 2 fracture pattern with stage 3 of displacement which is in concert with reportings in most of the previous studies. This is an easily discernible fact since the lateral crista support is lost in Milch type2 fracture patterns allowing for dislocation. However some have reported Milch type1 fracture patterns also in this type of injury. \hyperref[b17]{17,}\hyperref[b18]{18} As was described by Morrey in his study that primarily a varus force causes such a complex injury where body is falling over the elbow medially as compared from laterally. \hyperref[b19]{19} The position of the forearm has been widely advocated as supinated with fracture occurring due to pull of the long extensor muscles of the forearm. \hyperref[b20]{20} Here one may argue that in a \#lateral condyle Milch type 2 which is an unstable configuration distal part is likely to displace laterally as was originally described by late Dr Henry Milch (figure \hyperref[fig_3]{8}) and later in many studies. \hyperref[b11]{12,}\hyperref[b21]{21} The displacement in this rare complex injury has been characteristically described as postermedial in previous reports \hyperref[b3]{4,}\hyperref[b22]{22,} {\ref 23,}\hyperref[b23]{24} as was the case in our patient. Furthermore newer studies are indicating towards a concomitant injury in up to three-fourth of the cases. \hyperref[b24]{25} Alignment between the radial head and capitellum is an important guideline for diagnosing different types of elbow injuries in children. Displaced fracture of lateral condyle will misalign this relationship and so will a dislocation, however not so much in injuries occurring superior to the elbow joint. \hyperref[b25]{26,}\hyperref[b26]{27} In our case the alignment was maintained which was attributed to the intact lateral collateral ligament as was found peroperatively. Similar findings have been reported in previous studies also. \hyperref[b27]{28} Fixation of displaced lateral condyle fractures is standard protocol to avoid late complications notably the non-union, osteonecrosis of trochlea and angular deformities. \hyperref[b8]{9} Most studies have reported management protocol as prompt closed reduction which was done immediately following xrays under conscious sedation and analgesia. This is followed by open reduction and internal fixation with smooth k wires since it is a Salter-Harris type 4 injury and has shown excellent result in the past. \hyperref[b3]{4,}\hyperref[b28]{29,}\hyperref[b29]{30,}\hyperref[b30]{31} A good reduction under vision and a stable elbow are likely to give satisfactory results.\par
V. 
\section[{Conclusion}]{Conclusion}\par
The posteromedial dislocation of the elbow associated with fracture of the lateral humeral condyle is a rare injury and is not difficult to treat. A good concentric reduction of dislocation and good fixation of lateral condyle fracture is mainstay of the treatment of these injuries in isolation or in combination. The knowledge of probable associated injuries helps in anticipation and detection leading to optimal management. 
\section[{Ethical issues}]{Ethical issues}\par
Informed consent taken for surgery and future publication.    \begin{figure}[htbp]
\noindent\textbf{3}\includegraphics[]{image-2.png}
\caption{\label{fig_1}Figure 3}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7}\includegraphics[]{image-3.png}
\caption{\label{fig_2}Figure 7 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8}\includegraphics[]{image-4.png}
\caption{\label{fig_3}Figure 8 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-5.png}
\caption{\label{figure5}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-6.png}
\caption{\label{figure6}}\end{figure}
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\bibitem[Sharma et al. ()]{b21}\label{b21} 	 		‘Outcome of lateral humeral condylar mass fractures in children associated with elbow dislocation or olecranon fracture’.  		 			H Sharma 		,  		 			M Sibinski 		,  		 			D A Sherlock 		.  	 	 		\textit{Int Orthop}  		2007.  	 
\bibitem[Rovinsky et al. ()]{b18}\label{b18} 	 		‘Pediatric elbow dislocation associated with a milch type I lateral condyle fracture of the humerus’.  		 			D Rovinsky 		,  		 			C Ferguson 		,  		 			A Younis 		,  		 			N Y Otsuka 		.  	 	 		\textit{J Orthop Trauma}  		1999. 13 p. .  	 
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\bibitem[Van Haaren et al. ()]{b4}\label{b4} 	 		‘Posterolateral dislocation of the elbow with concomitant fracture of the lateral humeral condyle: case report’.  		 			E R Van Haaren 		,  		 			A B Van Vugt 		,  		 			P J Bode 		.  	 	 		\textit{J Trauma}  		1994. 36 p. .  	 
\bibitem[Pouliart and Boeck ()]{b29}\label{b29} 	 		‘Posteromedial dislocation of the elbow with associated intraarticular entrapment of the lateral epicondyle’.  		 			N Pouliart 		,  		 			De Boeck 		,  		 			H 		.  	 	 		\textit{J Orthop Trauma}  		2002. 16 p. .  	 
\bibitem[Kirkos et al.]{b9}\label{b9} 	 		‘Posteromedial Dislocation of the Elbow with Lateral Condyle Fracture in Children’.  		 			John M Kirkos 		,  		 			A Md; Theodore 		,  		 			Beslikas 		,  		 			A Vasilios 		,  		 			Papavasiliou 		.  	 	 		\textit{Clinical Orthopaedics and Related Research Number}  		408 p. .  	 
\bibitem[Kirkos et al. ()]{b3}\label{b3} 	 		‘Posteromedial dislocation of the elbow with lateral condyle fracture in children’.  		 			J M Kirkos 		,  		 			T A Beslikas 		,  		 			V A Papavasiliou 		.  	 	 		\textit{Clin Orthop Relat Res}  		2003. 408 p. .  	 
\bibitem[Posteromedial Dislocation of the Elbow with Lateral Condyle Fracture in Children Pen-Gang Cheng1, Wei-Ning Chang2,3, Matthew N. Wang1,4 J Chin Med Assoc (2009)]{b10}\label{b10} 	 		‘Posteromedial Dislocation of the Elbow with Lateral Condyle Fracture in Children Pen-Gang Cheng1, Wei-Ning Chang2,3, Matthew N. Wang1,4’.  	 	 		\textit{J Chin Med Assoc}  		February 2009. 72  (2) .  	 
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\end{bibitemlist}
 			 		 	 
\end{document}
