Diagnosis and treatment of lateral to medial diagonal injury of the elbow in children: Concomitant lateral condyle and olecranon fractures

doi:10.21203/rs.3.rs-5297014/v1

Purpose

Lateral condylar (LC) and olecranon (OC) fractures occurring concurrently on one side are rare phenomena with limited scientific literature. Our study aims to evaluate the radiologic, clinical and functional consequences of lateral to medial injury of the elbow (LAMEINE) in pediatric patients, simultaneously comparing with medial to lateral injury of the elbow (MELAINE).

Methods

Eighteen males and 10 females were diagnosed with LAMEINE. The average age at the time of injury was 3.8 ± 2.3 years (range, 1–9). Out of the 28 fractures, 19 (67.9%) occurred on the left side and nine (32.1%) on the right side. The OC fractures were classified according to the Weiss system, 2 being type I, 17 type II, and 9 type III fractures. Based on the specific case characteristics, the OC fractures were further subdivided into five types corresponding to 2 types of AO classification: 24 (85.7%) cases of AO 21u-M/2. 1 incomplete fractures [(3 type I (10.7%), 16 type II (57.1%), and 5 type III fractures (17.9%)], and 4 (14.3%) cases of AO 21u-M/3.1 complete simple fractures [(2 type IV (7.1%), and 2 type V fractures (7.1%)]. All patients underwent surgical intervention. Their clinical and functional outcomes were evaluated using the carrying angle (CA) and EPS. These results were then compared with those of our MELAINE patients.

Results

All patients were followed up for 42.9 ± 23.5 months (range, 15–88). Radiographs indicated that all fractures healed in 5.9 ± 1.4 weeks (range, 4–10). At the last follow-up, the CA and EPS of the injured side were 11.3° ± 2.8° and 97.7 ± 3.7, respectively. All patients had favorable outcomes: 27 patients (96.4%) had excellent EPS, and only 1 patient (3.6%) had good EPS. The LAMEINE group displayed lower age, displacement, incidence of elbow dislocation, and CA than the MELAINE group (P < 0.05).

Conclusions

Although relatively rare, LAMEINE should not be neglected. Surgical treatment aims to stabilize the elbow and avoid varus deformity. With appropriate diagnosis and treatment, good clinical and radiographic outcomes can be achieved for both patterns of "diagonal lesions" of the pediatric elbow.

Level of evidence: III

Children

Lateral condyle

Olecranon

Diagonal lesion

LAMEINE

MELAINE

Fractures of the lateral condyle (LC) and olecranon (OC) are common injuries in children, accounting for 12%-20% and 5%-7% of pediatric fractures, respectively^1,2.

There is limited literature available on the simultaneous ipsilateral occurrence of these two injuries. The few publications reporting on combined LC and OC fractures in children mostly consist of case reports of high-energy trauma^3,4,5.

Li et al. introduced the term "diagonal lesion" to describe the link between an anteromedial tibial plateau compression fracture and a posterolateral complex or posterior cruciate ligament tensile disruption when varus stress is applied to an overextended knee joint in adults⁶.

A similar pathogenetic mechanism, known as medial to lateral diagonal injury of the elbow (MELAINE), has recently been described in children with concomitant medial epicondyle (MEP) and radial neck (RN) fractures⁷. A combined LC and OC injury may be caused by a forced varus mechanism during hyperextension of the elbow due to the spatial relationship of the lateral condyle and olecranon, similar to the diagonal relationship of the MEP and RN. Forced varus causes lateral condyle rotation due to lateral ligament and extensor traction, with concomitant olecranon injury due to impact on the lateral wall of the olecranon fossa⁸^,9. This results in a lateral to medial oblique injury of the elbow, abbreviated as LAMEINE.

The study aimed to evaluate the radiological, clinical, and functional outcomes of pediatric patients with LAMEINE by utilizing the elbow performance score (EPS) introduced by Kim et al.¹⁰. In addition, the study aimed to differentiate these injuries from MELAINE and to make comparisons between the two patterns of “diagonal lesion” of the elbow.

This research was approved by our institutional review board (No. 2022216). After obtaining approval, we conducted a retrospective review of medical records to identify cases of LAMEINE among children and adolescents who presented to our institution's emergency department (ED) between February 1, 2015, and August 31, 2021.

The inclusion criteria were as follows: 1) age <14 years; 2) acute injury of the elbow; 3) ipsilateral LC and OC fractures (LAMEINE lesion) diagnosed on plain radiographs or computed tomography (CT) scans; 4) follow-up >1 year; and 5) complete clinical and radiographic data. The term “acute” is used to indicate that the injury responsible for the ipsilateral LC and OC occurs suddenly and differs from chronic lesions that develop over time.

The exclusion criteria were pathological or open fracture, follow-up shorter than 1 year, and incomplete clinical and radiographic data.

During the study period, 857 children with LC fractures (81.3%) and 197 children with OC fractures (18.7%) were admitted to the ED of our institution. All patients were consecutive and treated by the same surgical team at a single facility.

Twenty-eight out of those 1054 patients (2.7%; 18 males and 10 females) were diagnosed with a LAMEINE (Figures 1-5) and were included in the study. The average age at injury was 3.8 ± 2.3 years (range, 1-9). Nineteen fractures were observed on the left side (67.9%), 9 on the right side (32.1%).

The LC fractures were classified according to the Weiss classification¹¹, which distinguishes three types of fractures: type I, where there is <2 mm displacement with articular surface congruency; type II, where there is >2 mm displacement with articular surface congruency; and type III, where there is >2 mm displacement with incongruent articular surface or rotation of the fracture fragment. Of the fractures, 2 (7.1%) were type I, 17 (60.7%) were type II, and 9 (32.1%) were type III LC fractures.

All OC fractures occurred in the metaphyseal region and involved the humero-ulnar joint. According to the characteristics of our cases, the OC fractures were divided into five categories: type I, greenstick fractures (Figure 1); type II, radial distraction uncomplete fractures (Figure 2); type III, ulnar compression uncomplete fractures (Figure 3); type IV, transverse complete fractures (Figure 4); and type V, oblique complete fractures (Figure 5). There were 3 type I (10.7%), 16 type II (57.1%), 5 type III (17.9%), 2 type IV (7.1%), and 2 type V fractures (7.1%). According to the AO classification of OC fractures¹², types I, II, and III of the classification system developed for this study correspond to AO 21u-M/2.1 incomplete fractures, while types IV and V correspond to AO 21u-M/3.1 complete simple fractures.

Four patients (14.3%) had avulsion fractures of the tip of the coronoid process visible on lateral radiographs (Figures 2 and 4). One patient (3.6%) also had simultaneous ipsilateral fractures of the distal radius and ulna.

Table 1 displays patient demographics and fracture characteristics (Table 1).

Treatment

Ten type II LC fractures underwent closed reduction and percutaneous pinning (CRPP), while 9 type II and 9 type III LC fractures underwent open reduction and percutaneous pinning (ORPP).

All OC fractures were treated surgically, except that 2 AO 21u-M/2.1 (or type III) fractures with small displacement underwent conservative treatment with a long-arm cast in extension. Open reduction and internal fixation (ORIF) with plates was used for 2 AO 21u-M/3.1(or type V) OC fractures, while other patients were treated with CRPP.

Among the patients with associated lesions, the patient with a fracture of distal radius and ulna (n=1) underwent closed reduction and fixation with plate and titanium elastic nails, while the patients with an avulsion fracture of the tip of the coronoid process (n=4) underwent conservative treatment. Table 2 shows the treatment modality and outcomes (Table 2).

Clinical and radiographic follow-up

All patients had full-length AP and lateral radiographs of the injured upper extremity and underwent regular radiographic evaluation for at least 12 months after the index surgery (range, 15-88) to assess fracture consolidation and to detect complications such as secondary displacement, refracture, hardware migration, nonunion and malunion. Specifically, radiographs were taken monthly for the first 3 months after treatment and every 3 months thereafter.

After surgery, the upper extremity was immobilized in a cast for 3 to 6 weeks, after which progressive limb mobilization was allowed.

The carrying angle (CA) and the function (EPS) of both elbows were measured at the last clinical and radiographic follow-up visit at least 12 months after the index surgery.

The CA is the angle between the longitudinal axes of the arm and forearm with the elbow extended, as described by Chang et al.¹³. The EPS, used to assess elbow function as proposed by Kim et al., is a composite score out of 100, with higher scores reflecting better outcomes (pain: 45; motor function: 20; stability: 10; activities of daily living: 25)¹⁰. The functional outcome of the elbow was classified as excellent (score ≥90), good (score 75 to 89), fair (score 60-74), or poor (score <60) according to the EPS.

Statistical analysis

Data were analyzed using the IBM SPSS statistical package version 22.0 (IBM Corporation, Armonk, NY, USA). The Shapiro‒Wilk test was first used to determine whether the data followed a normal distribution. Age, follow-up, healing time, CA, and EPS score were normally distributed, so their data are expressed as the mean, range, and standard deviation. The t test for two independent samples was used for comparisons between the two types of lesions (MELAINE and LAMEINE). Categorical parameters are expressed as frequencies and percentages. Categorical variables were compared using the chi-square test or Fisher’s exact test. Statistical significance was defined as P<0.05.

Tables 1 and 2 show the patient demographics and treatment outcomes, respectively. All patients were followed up for a mean of 42.9 ± 23.5 months (range, 15-88). Radiographs showed that all fractures healed in a mean of 5.9 ± 1.4 weeks (range, 4-10). At the last follow-up visit, the CA of the injured side was 11.3° ± 2.8°, and the EPS of the injured side was 97.7 ± 3.7. The results were good to excellent in all patients: the EPS was excellent in 27 patients (96.4%) and good in 1 patient (3.6%) (Tables 1 and 2).

One case of pin tract infection was reported, which healed without complications after removal of the pin. One case of loss of CA (0°) was noted, although it did not require any further treatment. None of the patients developed complications such as secondary displacement, hardware migration, nonunion, malunion, elbow stiffness or instability.

Comparison between MELAINE and LAMEINE injury

Table 3 shows the demographics and operative characteristics of a group of patients (n=12) with MELAINE lesions (simultaneous ipsilateral fractures of the MEP and RN) treated by the same surgical team and published in a previous paper⁷ (Table 3). Table 4 compares the characteristics and outcomes of patients in the LAMEINE (n=28) and MELAINE (n=12) groups and provides comparisons between the two types of lesions (Table 4). There was no significant difference in sex, side, follow-up, healing time, EPS score or complications between the two groups (P>0.05).

The age in the LAMEINE lesion group (3.8 ± 2.3 years; range, 1-9) was significantly lower than that in the MELAINE lesion group (11.1 ± 2.5 years; range, 6-14) (P<0.05). There was no associated elbow dislocation in the LAMEINE lesion group (0/28; 0%), while there was in the MELAINE lesion group (3/12; 25%) (P <0.05).

Similarly, the CA was lower in the LAMEINE lesion group (11.3° ± 2.8°; range, 0-15) than in the MELAINE lesion group (15.5° ± 2.6°; range, 12-20) (P <0.05) (Table 4).

Our study has revealed a possible correlation between LC and OC fractures caused by varus trauma on a hyperextended elbow. LAMEINE constituted 2.7% of elbow injuries in our series. Li et al. first proposed the concept of “diagonal lesions” based on the correlation between a compression fracture of the anteromedial tibial plateau and a tensile disruption of the posterior cruciate ligament or posterolateral complex caused by varus stress on an extended knee joint in adults⁶. However, the combined lesion that bears Segond's name, characterized by a fracture of the anterolateral tibial plateau with associated tensile disruption of the anterior cruciate ligament, was first described more than a century ago¹⁴. In the past, poor comprehension of these oblique injuries caused inaccuracies in diagnosis and treatment, ultimately resulting in varus/valgus deformities of the knee or instability of joints¹⁵.

Recently, Lu et al. described a similar pathogenetic mechanism involving the elbow in a medial to lateral direction (MELAINE) in children with concomitant MEP and RN fractures⁷. In our study, we found that LAMEINE was caused by a forced varus of the hyperextended elbow due to the repositioning of the LC and OC from proximal and lateral to distal and medial of the elbow joint, respectively, similar to the diagonal relationship between the MEP and RN described as MELAINE. As a result of the traction of the lateral collateral ligament and extensor muscles, the forced varus produces a pulling force on the lateral condyle. At the same time, the olecranon and the lateral wall of the olecranon fossa are impacted, resulting in compression of the olecranon, particularly on its ulnar side. Conversely, the radial side of the olecranon can be considered the tension side (radial distraction), as opposed to the ulnar side (ulnar compression) (Figure 6). OC fractures generally have minimal or no displacement because the olecranon is the center of rotation of the forced varus. Therefore, most OC fractures in a LAMEINE lesion are incomplete (24/28, 85.7%) and consist of Type I (Figure 1), Type II (Figure 2), or Type III (Figure 3) fractures, corresponding to AO 21u-M/2.1 incomplete fractures. Complete fractures are relatively rare (4/28, 14.3%) and consist of Type IV (Figure 4) or Type V (Figure 5) fractures, corresponding to AO 21u-M/3.1 complete fractures. These results support the hypothesis of a varus stress-type injury. Avulsion fractures of the tip of the coronoid process induced by elbow over-extension also occurred in four cases (Figures 2 and 4), while a fall on an hyper-extended upper extremity was responsible for a distal metaphyseal fracture of both forearms in one case. The fragments were relatively small, and all of these patients underwent conservative treatment with immobilization in a long arm cast for 3 to 6 weeks. They had no need for surgical intervention.

Based on our results and our understanding of the potential pathogenetic mechanism of LAMEINE-type injuries, valgus stress applied to the extended elbow joint allows both LC and OC fractures to be reduced because the reduction maneuver acts in the opposite direction from the forced varus responsible for the injury. We treated the majority of OC fractures (26/28; 92.9%) with K-wire or plate fixation, and the overall function was good. However, one patient with a combined radial and ulnar fracture exhibited CA loss (0°). In this case, we hypothesized that the simultaneous fracture of both bones in the forearm limited our ability to apply sufficient valgus force at the elbow to reduce the LAMEINE lesion. In a case report by Cattle and Hemmadi, an 8-year-old with a combined LC and OC fracture presented with a residual cubitus varus deformity of 5 degrees, and a single screw was used to fix the unstable AO 21u-M/3.1 (or type V) OC fracture¹⁶.

When comparing LAMEINE and MELAINE lesions⁷, it was discovered that the CA in the LAMEINE group was smaller than that in the MELAINE group (11.3° ± 2.8° vs. 15.5° ± 2.6°; p<0.05)⁷. This is an additional indication that the pathogenetic mechanism we favor is plausible. This is the first time this theory has been proposed (Figure 7).

There was a significant age difference between the LAMEINE and MELAINE groups (3.8 ± 2.3 years vs. 11.1 ± 2.5 years, P<0.05), highlighting the importance of careful recognition of this combined injury pattern across different age groups. It is noteworthy that MELAINE lesions show a higher frequency of association with elbow dislocation, possibly due to age-related susceptibility to severe trauma^{6, 7}. Although both groups achieved good functional outcomes, attention should be focused on these two injury patterns, particularly with regard to diagnosis and treatment.

Our analysis had some limitations, including the study's retrospective design and the assessment of only surgically treated patients. Furthermore, we defined LAMEINE lesions solely based on pathogenetic mechanisms and radiographic findings since no biomechanical studies were conducted. However, this study identified the LAMEINE-type injury pattern, and we put forth a plausible pathogenetic mechanism. In addition, the study evaluated the clinical and radiographic outcomes of LAMEINE lesions in a series of pediatric patients and compared them with previously described MELAINE lesions⁷. The patients received were enrolled consecutively and given similar treatment according to a set of predefined principles. Future prospective studies with larger sample sizes and biomechanical studies are essential to validate our preliminary findings.

In conclusion, although "diagonal lesions" of the elbow are relatively rare in pediatric patients, they should not be neglected. The goal of surgical treatment of LAMEINE is to stabilize the elbow and prevent varus and malalignment. With proper diagnosis and treatment, good clinical and radiographic results can be achieved for both patterns of "diagonal lesions" (LAMEINE and MELAINE⁷) of the pediatric elbow.

- Ethical Approval

All procedures in studies involving human participants were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This was a retrospective study, and IRB approval was obtained (approval No. 2022216).

- Clinical trial number

Not applicable

- Availability of data andmaterials

Not applicable

- Competing interests

Yunan Lu, Chentao Xue, Federico Canavese, Yongjie Xia, An Yan, Yuchen Pan and Shunyou Chen declare that they have no competing interests.

- Funding

The authors gratefully acknowledge the financial support of Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma (2020Y2014)and the Key Clinical Specialty of Fujian Province and Fuzhou City (20220104).

- Authors' Contributions

Yunan Lu and Chentao Xue: design of the study, manuscript preparation, statistical analysis, revision.

Federico Canavese: design of the study, manuscript preparation, statistical analysis, revision.

Yongjie Xia, An Yan and Yuchen Pan: drafted the manuscript, statistical analysis and revision of the manuscript.

Shunyou Chen: design of the study, surgery and general supervision of the research group.

All authors read and approved the final manuscript.

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Table 1. Patient demographics and fracture characteristics of LAMEINE lesion (n=28)

Case	Sex	Age (years)	Side	Lateral Condyle fracture (Weiss classification¹¹)	Olecranon fracture according to AO classification¹² (corresponding subtype from current study)	Associated injury
1	M	2	L	II	AO 21u-M/2.1 (III)
2	M	1	L	III	AO 21u-M/3.1 (IV)
3	M	2	L	II	AO 21u-M/2.1 (III)
4	M	2	L	II	AO 21u-M/2.1 (II)	Fracture of the tip of the coronoid process
5	M	5	L	III	AO 21u-M/2.1 (II)
6	F	6	R	II	AO 21u-M/2.1 (II)
7	M	5	L	II	AO 21u-M/2.1 (II)
8	M	2	L	III	AO 21u-M/2.1 (II)
9	F	2	L	II	AO 21u-M/3.1 (V)
10	M	2	L	III	AO 21u-M/2.1 (II)	Fracture of the tip of the coronoid process
11	F	5	L	II	AO 21u-M/2.1 (II)
12	M	2	R	II	AO 21u-M/2.1 (III)
13	M	4	R	III	AO 21u-M/2.1 (III)
14	M	2	L	II	AO 21u-M/2.1 (III)
15	F	5	L	II	AO 21u-M/2.1 (II)
16	F	8	L	II	AO 21u-M/2.1 (I)	Fracture of the tip of the coronoid process
17	F	3	R	II	AO 21u-M/2.1 (II)
18	M	1	L	III	AO 21u-M/2.1 (I)
19	M	9	R	II	AO 21u-M/2.1 (II)
20	F	2	R	III	AO 21u-M/3.1 (IV)	Fracture of the tip of the coronoid process
21	F	3	R	III	AO 21u-M/2.1 (II)
22	M	5	R	II	AO 21u-M/3.1 (V)
23	M	8	R	II	AO 21u-M/2.1 (II)	Fracture of radius and ulna
24	F	4	L	III	AO 21u-M/2.1 (II)
25	M	3	L	II	AO 21u-M/2.1 (II)
26	M	8	L	II	AO 21u-M/2.1 (II)
27	M	3	L	II	AO 21u-M/2.1 (I)
28	F	1	L	II	AO 21u-M/2.1 (II)

M: male; F: female; L: left; R: right.

Table 2. Treatment and outcomes of LAMEINE lesion (n=28)

Case	Treatment	Follow-up (weeks)	Healing time (weeks)	Carrying angle (degree)	ROM of elbow	Complications	Elbow performance score
1	CRPP for LC	66	4	13	Full		Excellent
2	ORPP for LC; CRPP for OC	76	6	12	Full		Excellent
3	ORPP for LC; CRPP for OC	72	6	14	Full		Excellent
4	ORPP for LC; CRPP for OC	86	7	13	Full		Excellent
5	ORPP for LC; CRPP for OC	62	8	12	Full		Excellent
6	CRPP for LC; CRPP for OC	37	5	11	Full		Excellent
7	ORPP for LC; CRPP for OC	20	6	10	Full		Excellent
8	ORPP for LC; CRPP for OC	21	7	12	Full		Excellent
9	CRPP for LC; ORIF, Plate for OC	62	10	8	Full		Excellent
10	ORPP for LC; CRPP for OC	68	7	12	Full		Excellent
11	CRPP for LC; CRPP for OC	71	5	15	Full		Excellent
12	CRPP for LC; CRPP for OC	64	5	12	Full		Excellent
13	ORPP for LC; CRPP for OC	15	7	14	Full		Excellent
14	ORPP for LC	45	6	10	Full		Excellent
15	ORPP for LC; CRPP for OC	16	6	12	Full		Excellent
16	ORPP for LC; CRPP for OC	88	4	12	Full		Excellent
17	ORPP for LC; CRPP for OC	28	5	15	Full		Excellent
18	ORPP for LC; CRPP for OC	21	8	12	Full	Pin tract infection	Excellent
19	ORPP for LC; CRPP for OC	15	6	10	Full		Excellent
20	ORPP for LC; CRPP for OC	39	6	10	Full		Excellent
21	ORPP for LC; CRPP for OC	35	4	14	Full		Excellent
22	CRPP for LC; ORIF, Plate for OC	28	6	9	Full		Excellent
23	ORPP for LC; CRPP for OC; Plate and TEN for radius and ulna	42	4	0	Full	Loss of Carrying Angle	Good
24	ORPP for LC; CRPP for OC	23	6	12	Full		Excellent
25	CRPP for LC; CRPP for OC	27	5	10	Full		Excellent
26	CRPP for LC; CRPP for OC	31	6	11	Full		Excellent
27	CRPP for LC; CRPP for OC	20	5	10	Full		Excellent
28	CRPP for LC; CRPP for OC	24	4	10	Full		Excellent

CRPP: closed reduction and percutaneous pinning; ORPP: open reduction and percutaneous pinning; ORIF: open reduction and internal fixation; TEN: titanium elastic nail; ROM: range of motion.

Table 3. Demographics, treatment and outcomes of patients with MELAINE lesion⁷ (n=12)

Case	Sex/Side	Age	Papavasiliou type	Judet type	Associated injury	Treatment	Healing time	Carrying angle	Follow-up	Complications	Elbow Performance Score
1	M/L	11 years	II	III	Cubitus valgus of 8° post supracondylar fracture	ORIF (screw) for MEP; PLR, CR TEN for RN	7 weeks	20°	17 months		Excellent
2	F/L	12 years	IV	II	Elbow dislocation	ORIF (screw) for MEP	8 weeks	18°	73 months	Loss of forearm rotation	Good
3	F/L	11 years	IV	II	Elbow dislocation	ORIF (screw) for MEP; PLR, CR TEN for RN; repair of MCL	6 weeks	16°	36 months		Excellent
4	M/L	13 years	II	I		ORIF (screw) for MEP	6 weeks	14°	20 months		Excellent
5	M/L	13 years	II	III		CRPP for MEP; PLR, CR TEN for RN	4 weeks	12°	16 months		Excellent
6	M/R	13 years	II	III		ORIF (screw) for MEP; PLR, CR TEN for RN	6 weeks	13°	83 months		Excellent
7	F/L	13 years	II	III		ORIF (screw) for MEP; PLR, CR TEN for RN	5 weeks	17°	90 months		Excellent
8	F/L	12 years	IV	II	Elbow dislocation; contusion of the capitellum (MRI)	ORIF (screw) for MEP; CR TEN for RN	9 weeks	15°	38 months		Excellent
9	M/R	6 years	III	I	Injury of ulnar nerve	ORIF (screw) for MEP; ulnar nerve release	6 weeks	12°	27 months		Excellent
10	F/L	7 years	II	II	Olecranon fracture	CRPP for MEP; CR TEN for RN; CRPP for olecranon fracture	7 weeks	18°	13 months		Excellent
11	F/L	8 years	II	III		CRPP for MEP; PLR, CR TEN for RN	6 weeks	17°	37 months		Excellent
12	M/L	14 years	III	I		ORIF (screw) for MEP	6 weeks	14°	41 months		Excellent

M: male; F: female; L: left; R: right; MEP: medial epicondyle; RN: radial neck; ORIF: open reduction and internal fixation; CR: closed reduction; CRPP: closed reduction and percutaneous pinning; PLR: percutaneous leverage reduction; MCL: medial collateral ligament; TEN: titanium elastic nail

Table 4. Comparative analysis of “diagonal lesions” of the elbow: LAMEINE and MELAINE⁷

Variables	LAMEINE (n=28)	MELAINE (n=12)	t/c²	P value
Fractures	LC + OC	MEC + RN
Mechanism of injury	Varus stress on hyperextended elbow	Valgus stress on hyperextended elbow
Age (years)	3.8 ± 2.3	11.1 ± 2.5	-8.751	<0.001
Sex
Male	18 (64.3%)	6 (50.0%)	0.714	0.398
Female	10 (35.7%)	6 (50.0%)
Side
Left	19 (67.9%)	10 (83.3%)	1.009	0.315
Right	9 (32.1%)	2 (16.7%)
Associated with elbow dislocation	0 (0.0%)	3 (25.0%)	7.568	0.006
Follow-up (months)	42.9 ± 23.5	40.0 ± 25.6	0.238	0.813
Healing time (weeks)	5.9 ± 1.4	6.3 ± 1.2	-1.002	0.323
Carrying Angle (degrees)	11.3 ± 2.8	15.5 ± 2.6	-4.472	<0.001
EPS score	97.7 ± 3.7	96.3 ± 5.3	0.979	0.334
Functional evaluations (EPS)
Excellent	27 (96.4%)	11 (91.7%)	0.401	0.532
Good	1 (3.6%)	1 (8.3%)
Poor	0 (0.0%)	0 (0.0%)
Complications	2 (7.1%)	1 (8.3%)	0.017	0.896

LC: lateral condyle; OC: olecranon; MEC: medial epicondyle; RN: radial neck

No competing interests reported.

Diagnosis and treatment of lateral to medial diagonal injury of the elbow in children: Concomitant lateral condyle and olecranon fractures

Status:

Version 1

Abstract

Figures

Introduction

Materials and Methods

Results

Discussion

Declarations

References

Tables

Additional Declarations

Status:

Version 1