Case of the Month
Seth Mathus Ganz, DVM, DACVS
Stitch is a now 6 month old intact male French Bulldog that presented to the Veterinary Specialty Hospital North County surgery service at 4 months of age for evaluation of left thoracic limb lameness after jumping out of his owner’s arms.
On exam, Stitch was BAR and hydrated. He exhibited a grade 4/4 (non weight-bearing) left thoracic limb lameness with pain, swelling and crepitus in the left elbow. Radiographs taken by the referring veterinarian demonstrated a mildly-displaced left lateral humeral condylar fracture. The treatment options were discussed with the owner. Fluoroscopic-guided closed reduction and internal fixation was elected.
Stitch was placed under general anesthesia and the left thoracic limb prepared for sterile surgery in the radiology suite. A point to point bone holding reduction forceps was used to reduce the humeral condylar fracture under fluoroscopic guidance. A self-compressing pin was driven lateromedially through the distal humeral epiphysis. A smooth Kirschner wire was then driven from the lateral epicondyle up the lateral epicondylar crest to exit the caudomedial aspect of the diaphysis to provide rotational stability. All of the implants were placed under fluoroscopic guidance. The implants were placed percutaneously without incisions and the skin entry points of the implants were not closed.
Immediate postoperative radiograph
Stitch made an uneventful recovery from anesthesia and was discharged the following day with instructions for exercise restriction and rechecks at 2 and 6 weeks (6 weeks for radiographs). At the 2 week recheck, Stitch was ambulating without lameness and had very good range of motion in the left elbow. At 4 weeks after surgery, Stitch re-presented for acute right thoracic limb lameness. A contralateral (right) lateral humeral condylar fracture was diagnosed with radiographs and repaired in a similar fashion to the left.
4 week postoperative radiograph, showing complete bony union with stable implants and no evidence of osteoarthritis
At this time, Stitch is fully healed from both surgeries and doing well. He did develop a seroma on the right elbow that was treated with explantation.
Humeral condylar fractures are typically seen in lateral (most common, see below), medial, and bicondylar configurations. Most of these fractures are appropriately categorized as Salter-Harris IV as they propagate from the articular surface, through the physis and into the metaphysis. There can be variable amounts of comminution present.
In our experience, humeral condylar fractures can be seen in any breed, but brachycephalic breeds and pit bull terriers seem to be over-represented. The radial head articulates chiefly with the capitulum (lateral aspect of the humeral condyle), so a jarring “jump-down” type of trauma drives the radius against the capitulum. The radial head is thought to produce a wedge effect on the intercondylar region, and the thinner lateral (compared to medial) epicondylar crest fails to produce a lateral condylar fracture. Spaniels are heavily over-represented for a condition called incomplete ossification of the humeral condyle, which can result in chronic elbow pain or can progress to fracture. In these cases advanced imaging (CT) of the elbows and interrogation of the contralateral elbow in unilaterally-affected cases is important. There is some clinical overlap, as spaniels can suffer true traumatic fracture and any adult dog with non-traumatic elbow-localized lameness may have IOHC. Stitch experienced minor trauma with both episodes of fracture, but his age and conformation may have contributed.
Open reduction and internal fixation has historically been recommended to perfectly restore the articular surface and provide rigid stabilization. This allows predictable and direct (without a callus) healing, avoiding osteoarthritis and impaired range of motion.
Minimally-invasive fixation is well-suited to many humeral condylar fractures because it allows excellent visualization of fracture fragments in multiple planes. This promotes accurate fracture reduction and implant placement. The other big advantage of this approach for this particular injury is that the traditional open surgical approach requires significant dissection. The closed method minimizes surgical time and trauma, allowing fast return to function.