Pediatric T-Condylar Humerus Fractures: A Systematic Review.

BACKGROUND: The pediatric T-condylar humerus fracture is different from its adult counterpart, and its rarity makes general consensus for treatment algorithms difficult to define. Pediatric orthopaedic surgeons tend to think of this fracture as a supracondylar humerus fracture with intra-articular extension. The transition age at which this injury resembles the adult distal humerus fracture and less so the pediatric supracondylar humerus fracture with intra-articular extension is unclear. The goal of this study is to synthesize the literature and identify factors associated with good and poor outcomes of these problematic injuries in children and adolescents. METHODS: We searched EMBASE, COCHRANE, and Medline computerized literature databases from the earliest date available in the database to 2014 using the following search term including variants and pleural counterparts: pediatric T-condylar humerus fracture. A final database of individual patients was assembled from the literature. Outcomes were rated using the method described by Jarvis and colleagues. Where possible the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification was used to stratify outcomes. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes. RESULTS: Patients with a triceps-splitting approach had improved Jarvis outcome scores compared with the other operative approaches as well as the best arc of motion at follow-up. In addition, 6/25 triceps split patients were 10 years old or younger compared with 3/38 Bryan-Morrey patients and 0/23 osteotomy patients. No patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association C3 fractures were treated with a triceps-splitting approach. When an articular approach was used, the Morrey Slide led to similar range of motion and functional outcomes as an olecranon osteotomy (P=0.616). However, the olecranon osteotomy resulted in more approach-related complications (P<0.001). An approach-related complication was associated with a poor outcome in 42% of cases. CONCLUSIONS: Pediatric T-condylar humerus fractures requiring an open approach may benefit from less invasive approaches such as the triceps split approach where the fracture pattern allows. Younger children are more amenable to less invasive means of fracture reduction and fixation. If an articular reduction is required, the aggregated literature suggests that the Morrey slide offers equivalent results to the olecranon osteotomy but with fewer approach-related complications. An olecranon osteotomy can be considered in cases of articular comminution. LEVEL OF EVIDENCE: Level IV-therapeutic.