Posttraumatic reconstruction of the elbow in the pediatric patient

Radial nerve lesion after medial epicondyle osteosynthesis in a pediatric patient: A rare complication of surgery

Fractures of the medial epicondyle are relatively common in children and may be associated with nerve lesion, especially in case of displacement. Incarceration of the ulnar nerve in the fracture site is feared in Watson-Jones stage II, rarely directly related to osteosynthesis. Depending on the degree of fracture displacement, various osteosynthesis techniques may be used; nerve injuries are a rare but known complication of these procedures. We report a case of radial nerve injury related to pinning osteosynthesis of a medial epicondyle fracture.

Closed reduction by trans-physealantegrade elastic stable intramedullary nailing in acute pediatric Monteggia fractures: a report of 22 cases

Treatment of acute pediatric Monteggia fractures is still debated. The aim of this study was to assess the efficacy of strategy based on closed reduction by trans-physeal antegrade elastic stable intramedullary nailing (ESIN) of the ulnar fracture. Retrospective analysis of 22 patients (13 boys and nine girls) treated for acute Monteggia fractures between May 2008 and August 2018 was performed. Mean age at injury was 6.6 years. Mean follow-up was 4.5 years. On the basis of the Bado classification, 15 lesions were of type I, three types III and four types IV. All the patients were managed with closed reduction and ESIN of the ulna fracture within 2-19 h of arrival. Intraoperative stability of reduction of the radial head was checked under fluoroscopic control in pronation and supination. Outcomes were assessed with the Bruce et al. scoring system. Closed alignment of the ulnar fracture by ESIN had simultaneously reduced and stabilized the radial head dislocation in all patients. At the final follow-up, all the patients had excellent results. Complete healing of the fracture occurred in 6 weeks and the elastic nail removed at 3-6 months postoperatively. There was no case of instability or subluxation or re-dislocation of the radial head. No olecranon epiphysiodesis or growth disorders were noticed. Early diagnosis and management of acute pediatric Monteggia fractures by closed reduction and ESIN achieve excellent clinical and radiographic outcomes.

Midterm Outcomes After Open Arthrolysis for Posttraumatic Elbow Stiffness in Children and Adolescents

BACKGROUND

Open arthrolysis is used for treating elbow stiffness in adults. This study evaluated the midterm outcomes after open arthrolysis in children and adolescents with posttraumatic elbow stiffness.

METHODS

Data of 31 children and adolescents with posttraumatic elbow stiffness following open arthrolysis with or without hinged external fixation from 2010 to 2014 were retrospectively analyzed. Their mean age was 15 (range: 6 to 19) years. At baseline and the follow-up (>4 y), we evaluated the outcomes (range of motion and Mayo Elbow Performance Index) and postoperative complications (pain, ulnar nerve symptoms, infections, and instability) and analyzed the association between outcomes and clinical variables.

RESULTS

The Mayo Elbow Performance Index improved from 67.9 (range: 35 to 95 points) to 93.7 points (range: 65 to 100 points; P<0.001). The elbow active flexion/extension arc increased significantly from 49 degrees (range: 0 to 120 degrees) to 108 degrees (range: 0 to 120 degrees; P<0.001), with a mean flexion of 123 degrees (range: 70 to 140 degrees; P<0.001) and mean extension of 15 degrees (range: 0 to 85 degrees; P<0.001) postoperatively. The increasing age at surgery was associated with improved elbow motions (P=0.004). Patients with increased preoperative serum alkaline phosphatase level demonstrated decreased arc of motion (P=0.015). Patients with extra-articular fractures had better outcomes than the other patients. At the final follow-up, 8 patients experienced recurrent contracture in the flexion arc with heterotopic ossification. Two patients had postoperative pain, 1 elbow instability, and 1 ulnar neuropathy.

CONCLUSIONS

Most patients showed satisfactory functional outcomes after arthrolysis, indicating that open release with or without hinged external fixation is an effective and maintained technique for children and adolescents with posttraumatic elbow stiffness. The age at surgery, preoperative alkaline phosphatase level, and injury type should be considered to achieve good outcomes.

LEVEL OF EVIDENCE

Therapeutic level III.

External Fixator-assisted Ulnar Osteotomy: A Novel Technique to Treat Missed Monteggia Fracture in Children

Objective

The treatment of missed Monteggia fracture remains a challenge, despite the various surgical methods described. The purpose of this study was to explore a new surgical technique utilizing external fixator‐assisted ulnar osteotomy and to assess the surgical results in a case series.

Methods

Thirteen patients with missed Monteggia fractures were treated at our institution using this new surgical technique from August 2012 to January 2016. Our series included 11 boys and 2 girls. The left elbow was involved in 6 patients and the right elbow was involved in 7 patients. According to the Bado classification, 10 fractures were classified as Bado type I with anterior radial head dislocation and 3 were classified as Bado type III with anterolateral dislocation. The average age at the time of surgery was 5 years 8 months (range, 2 years 2 months–10 years). The mean trauma‐to‐surgery interval was 12 months (range, 2–36 months). All patients underwent ulnar osteotomy with angulation and lengthening using a temporary external fixator, plate fixation of the osteotomy, and open reduction of the radial head dislocation without annular ligament reconstruction.

Results

The average follow‐up was 27 months (range, 16–44 months). The average operation time was 175 min (range, 140–215 min). The average length of distraction was 0.7 cm (range, 0.5–1.2 cm) and the average angulation was 28° (range, 20°–30°) at the ulnar osteotomy site intraoperatively. The elbow performance score (Kim's) was excellent in 10 cases and good in 3 cases. No neurovascular complications, compartment syndrome or implant breakage occurred. No pain in the distal radioulnar joint or limited range of motion of the wrist occurred in any patient. The radial head remained reduced in all patients with no subluxation or redislocation. However, delayed ulnar union occurred in 3 cases, all of which were successfully treated with plaster cast immobilization within approximately 6 months postoperatively. One patient presented with cubitus valgus postoperatively with a carrying angle of 30°, which was 10° greater than the contralateral carrying angle.

Conclusions

External fixator‐assisted ulnar osteotomy offers substantial flexibility for achieving the optimal positioning of the transected ulna to reduce the radial head prior to the final ulnar osteotomy fixation with a plate, thereby facilitating an effective operative performance. Our procedure is a safe and effective method to treat missed pediatric Monteggia fractures.

Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents

BACKGROUND

Posttraumatic elbow contractures in children and adolescents are challenging to manage, and studies investigating surgical treatment are limited by the rarity of this condition. Small case series have shown variable gains in immediate and long-term elbow arc of motion after open surgical release. We reviewed our experience with open surgical release of posttraumatic elbow contracture in patients <21 years old at 2 institutions.

METHODS

A retrospective chart review identified patients who underwent posttraumatic open elbow contracture release by 2 surgeons at 2 institutions between 2006 and 2013. Nontraumatic contractures and arthroscopic releases were excluded. Twenty-six patients were included in this study. Mean age at the time of injury was 12 years (5 to 19 y) and at the time of surgery was 14 years (7 to 20 y). Capsulotomy, osteoplasty, removal of hardware, ulnar nerve release or transposition, and ligament reconstruction were performed through medial and lateral approaches as indicated by the pathology. Ten patients had ligament repair or stabilization, and 16 patients used a continuous passive motion (CPM) postoperatively. Outcomes included active range of motion and complications.

RESULTS

Mean time from injury to surgical release was 29 months. Mean postoperative follow-up was 42 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 49 and 70 degrees, respectively, at final follow-up. A mean 85% of intraoperative flexion-extension arc was maintained at final follow-up. Ligament repair or reconstruction and the use of a postoperative CPM did not significantly change these outcomes. Outcomes were not significantly different if our contracture release was performed within a year from injury. Patients who had surgery before our contracture release had decreased restoration of forearm rotation after release. Complications included 2 recurrent contractures (1 used a CPM and 1 did not), and 2 postoperative ulnar neuropathies (1 used a CPM and 1 did not).

CONCLUSIONS

Open contracture release for posttraumatic elbow contracture in an adolescent population can significantly improve active range of motion.

LEVEL OF EVIDENCE

Level 3-therapeutic.

In vivo 3-dimensional Kinematics of Cubitus Valgus after Non-united Lateral Humeral Condyle Fracture

Background

Nonunion of lateral humeral condyle fracture causes cubitus valgus deformity. Although corrective osteotomy or osteosynthesis can be considered, there are controversies regarding its treatment. To evaluate elbow joint biomechanics in non-united lateral humeral condyle fractures, we analyzed the motion of elbow joint and pseudo-joint via in vivo three-dimensional (3D) kinematics, using 3D images obtained by computed tomography (CT) scan.

Methods

Eight non-united lateral humeral condyle fractures with cubitus valgus and 8 normal elbows were evaluated in this study. CT scan was performed at 3 different elbow positions (full flexion, 90° flexion and full extension). With bone surface model, 3D elbow motion was reconstructed. We calculated the axis of rotation in both the normal and non-united joints, as well as the rotational movement of the ulno-humeral joint and pseudo-joint of non-united lateral condyle in 3D space from full extension to full flexion.

Results

Ulno-humeral joint moved to the varus on the coronal plane during flexion, 25.45° in the non-united cubitus valgus group and -2.03° in normal group, with statistically significant difference. Moreover, it moved to rotate externally on the axial plane -26.75° in the non-united cubitus valgus group and -3.09° in the normal group, with statistical significance. Movement of the pseudo-joint of fragment of lateral condyle showed irregular pattern.

Conclusions

The non-united cubitus valgus group moved to the varus with external rotation during elbow flexion. The pseudo-joint showed a diverse and irregular motion. In vivo 3D motion analysis for the non-united cubitus valgus could be helpful to evaluate its kinematics.

Delayed treatment of a neonatal type-I Monteggia fracture-dislocation: a case report

Delayed diagnosis of a Monteggia fracture-dislocation changes a straightforward, treatable injury into a complex problem. Acute neonatal injuries may be missed because of the inability to visualize the unossified skeleton on radiography, interpreted later as 'congenital' dislocations. We report the case of a 14-month-old with a neonatal Monteggia type-I fracture-dislocation secondary to birth trauma, with anterior radial head dislocation and plastic deformation of the ulna. Uniplanar external fixation was used to restore ulnar length and correct angulation, with subsequent radiocapitellar joint closed reduction. Joint congruity was maintained at the 2-year follow-up, with articular remodeling shown on serial arthrogram.

Fixation of Displaced Medial Epicondyle Fractures in Adolescents

BACKGROUND

Open reduction and internal fixation of displaced medial epicondyle fracture dislocations in adolescents is recommended for incarceration of the epicondyle in the joint and for athletes who need a stable elbow for their sport. A screw placed across the epicondyle into the medial column avoiding the olecranon fossa is a common fixation method. One author has recommended adding a metal washer to the screw fixation because of the perceived risk of epicondyle fragmentation or penetration when using a screw alone. The purpose of this study was to determine whether the use of a screw and washer for the fixation of pediatric medial epicondyle fractures results in less fragmentation of the epicondyle at the time of surgery and more complaints of hardware prominence leading to a second surgery to remove a deep implant.

METHODS

A retrospective review was performed of patients treated surgically for displaced medial epicondyle fracture dislocations between 2008 and 2014.

RESULTS

Sixteen patients with a total of 17 fracture dislocations were included in the study. The average follow-up was 11.5 months. Twelve fractures were treated with a screw and washer and 5 fractures were treated with a screw alone. All fractures healed. No fracture treated with a screw alone resulted in fragmentation or penetration of the epicondyle fragment. Seven of 12 patients treated with a screw and washer requested deep metal removal due to prominence and irritation at the medial epicondyle. No patient treated with a screw alone requested metal removal (58% vs. 0%; P=0.04).

CONCLUSIONS

One author suggested that adding a washer to the screw for fixation of medial epicondyle fractures improved the ability to safely compress the fragment. However, the results of the present study report no case of fragmentation or penetration of the epicondyle when a washer was not used. In addition, the use of a screw and washer significantly increased the likelihood of a second surgery for removal of prominent hardware.

LEVEL OF EVIDENCE

Level IV.

Repositioning of the Annular Ligament in the Management of Missed Monteggia Fracture

BACKGROUND

Successful treatment of missed Monteggia fractures usually requires ulnar osteotomy and open reduction of the radial head with reconstruction of the annular ligament. We have observed cases in which the annular ligament was displaced into the joint but remained intact. Here we report our experience with repositioning of the annular ligament at the time of the open reduction rather than reconstruction in the management of missed Monteggia fractures.

METHODS

We retrospectively reviewed 23 patients with missed Monteggia fractures treated by repositioning of the annular. There were 16 males and 7 females with an average age of 6 years (range, 4 to 9 y). The average time from injury to definitive treatment was 7 months (range, 6 wk to 16 mo). The average follow-up was 18 months (range, 8 to 36 mo). We evaluated the patients by clinical examination, Kim score, and radiographs.

RESULTS

All patients had no pain and full elbow function at the latest follow-up. There were no significant differences between the preoperative and postoperative Kim scores. Radiographs at the latest follow-up demonstrated maintenance of radial head reduction in all cases.

CONCLUSIONS

Repositioning of an intact annular ligament in cases of missed Monteggia fractures is a viable alternative to reconstruction of the ligament and provides long-term stability.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Complications of Pediatric Elbow Fractures

Fractures about the elbow in children are common and varied. Both diagnosis and treatment can be challenging, and optimal treatment protocols continue to evolve with new research data. This article reviews common complications related to pediatric elbow fractures and presents recent literature to help guide treatment.

Osteosynthesis in situ for lateral condyle nonunion in children

BACKGROUND

This study investigated the efficacy of osteosynthesis in situ by evaluating the functional and cosmetic results in children with nonunion of lateral condyle fractures.

METHODS

Sixteen consecutive patients were treated with in situ fixation consisting of minimal curettage of fracture gap and screw compression of metaphyseal fragments without bone grafting. The mean age at the time of surgery was 5.6 years (range, 1 to 10 y). The mean interval between the initial lateral condylar fracture and surgery was 4.8 months (range, 3 to 12 mo). The average amount of displacement measured on radiographs was 6.6 mm medially and 7.4 mm laterally. Outcome was assessed by clinical and radiologic evaluation at the latest follow-up.

RESULTS

All patients achieved bony union. The mean duration of follow-up was 45.4 months (range, 24 to 67 mo). The range of motion and flexion contracture improved postoperatively in all patients. There was no evidence of premature growth arrest, osteonecrosis, or fishtail deformity until last follow-up. The overall result was excellent in 5, good in 10, and fair in 1 patient. However, 3 patients developed valgus or varus deformities of >10 degrees.

CONCLUSIONS

Osteosynthesis in situ can be an effective and safe treatment for achieving bone union and improved elbow motion and preventing avascular necrosis. However, valgus or varus deformities may occur after this procedure and corrective osteotomy may be necessary.

LEVEL OF EVIDENCE

Level IV - case series.

Arthroscopic Correction of a Supracondylar Malunion in a Child

Malunions are a well-recognized complication of pediatric supracondylar humeral fractures. Results of corrective osteotomies vary, and complication rates have been reported to be as high as 40%. Considering the high rate of complications for malunion correction, we investigated the feasibility of arthroscopy. We present a technique for arthroscopic supracondylar osteotomy and percutaneous pinning. There are many advantages of an arthroscopic approach to malunion correction, including extension-type deformity correction, safe access to the anterior humerus, and minimal dissection and scarring; any intracapsular contracture can be addressed as well. Elbow arthroscopy appears to be a viable option in the pediatric orthopaedic surgeon's armamentarium.

Chronic anterior monteggia lesions in children: report of 4 cases treated with closed reduction by ulnar osteotomy and external fixation

BACKGROUND

Chronic, subacute, and chronic Monteggia fracture dislocations of the elbow are challenging problems. The literature generally recommends complex open reconstructive procedures. We present an alternative, minimally invasive, percutaneous method with external fixation.

METHODS

This was a retrospective review of 4 cases presenting with chronic Monteggia lesions with anterior dislocation of the radial head.

RESULTS

Reduction of the radiocapitellar joint was successfully achieved in all patients after ulnar osteotomy and gradual correction using the Ilizarov external fixation. Open reduction or reconstruction of the radio-ulnar-capitellar joint and/or ligament was not undertaken. The patients were between 9 and 11 years of age at the time of injury. The time from injury to treatment was between 3 and 56 months. At follow-up of an average of 3.5 years (range, 2 to 6 y), all patients had full movement of the elbow and normal function of the forearm. Radiographically, all radial heads were well reduced and the ulnar osteotomy showed remodeling.

CONCLUSIONS

The technique is relatively simple and avoids the risks and technical challenges of open osteotomies, open reduction, and ligament reconstruction. Gradual reduction of the radial head with the aid of an external fixation is a safe and effective method of treatment for chronic Monteggia lesions.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion

INTRODUCTION

The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children.

MATERIAL AND METHODS

This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling.

RESULTS

Twenty-eight patients were reviewed, at a mean 6 years' follow-up (range, 2-34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation.

DISCUSSION

Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful.

LEVEL OF EVIDENCE

IV (retrospective).

[Posttraumatic complications on children's elbows]

Most fractures during growth affect the upper extremities. Severe fractures with an increased number of complications are mainly localized beyond the elbow joint. Displaced fractures of the elbow joint have limited potential for spontaneous correction as the bones near the elbow joint account for only 20% of growth in length and the possibility of spontaneous correction is already exhausted at the age of 7. The consequences of inadequately reduced elbow fractures, therefore, may adversely affect a patient for his lifetime. Cubitus varus and valgus are the most common deformities following insufficiently treated supracondylar humerus fractures, fractures of the radial or dislocations of the radial head. Posttraumatic deformities of the elbow are usually the result of an insufficient primary therapy and rarely the result of growth disturbances. For the attending surgeon, posttraumatic deformities on a child's elbow are challenging.

The problem of post-traumatic varization of the distal end of the humerus remaining after the recovery of a supracondylar fracture

We aimed to determine whether the distal end of the humerus had the capacity of spontaneous realignment of the remaining deformity following an inadequate reposition of the supracondylar fracture. The results in 56 children with a supracondylar humerus fracture were analysed. In 45 patients (80%), manual repositioning was performed along with transcutaneous fixation, whereas in 11 patients (20%), only manual repositioning and immobilization in plaster cast was applied. Immobilization was removed and physical therapy was started in all patients on the 21st day following the intervention. Anteroposterior and left-lateral radiography was performed and Baumann's angle was determined. Follow-up radiograph of the elbow of the traumatized and healthy extremity was performed at an interval of 5-15 years (median 9.4). There was no statistically significant difference between the relationship of Baumann's angle of the injured arm measured on the 21st day after the reduction of fragments on the one hand and the carrying angle of the injured and healthy arm measured at the long-term follow-up on the other (t=0.48, P=0.63). Similarly, there was no statistically significant difference between the relationship of Baumann's angle of the injured arm measured at the long-term follow-up and the findings of the carrying angle of both the injured and the healthy arm obtained on the same examination (t=0.78, P=0.44). On the basis of our experience, we conclude that there is no biological capacity to rectify a possible remaining postreduction varus deformity by spontaneous remodelling.

Management of missed Monteggia fractures with ulnar osteotomy, open reduction, and dual-socket external fixation

BACKGROUND

Open reduction of the radial head is usually necessary in the treatment of a missed Monteggia fracture. However, the best way to stabilize the reduction remains controversial. The purpose of this study is to present our experience using the dual-socket external fixator to stabilize the ulna osteotomy and capture the reduction of the radial head.

METHODS

We reviewed 33 patients with missed Monteggia fracture who underwent open reduction, ulnar osteotomy, and dual-socket external fixation from 2004 to 2010. The average age of this group was 7 years and the average time to surgical treatment after the fracture was 15 months. We treated all patients with open reduction of the radial head, fully releasing the capsular contracture, removing the fibrous scar tissue within the joint, performing ulnar osteotomy, and fixing the osteotomy with dual-socket external fixation. The clinical and radiographic follow-up averaged 38 months. Descriptive statistics utilized the Student test to compare the preoperative and postoperative functional movement of elbow and forearm.

RESULTS

All patients had excellent clinical and radiographic outcomes without losing motion of the elbow and forearm, and all patients maintained reduction of the radial head at the final follow-up. There were no significant differences in the motion of the elbow and forearm between preoperative and postoperative examinations. Delayed union of the ulna occurred in 2 cases, both successfully treated with autologous iliac crest bone graft at 7 months after the operation. Three cases had early redislocation of the radial head, and these were treated successfully by changing the position of the ulnar osteotomy and readjusting the external fixators.

CONCLUSIONS

Dual-socket external fixation has the major advantage of permitting and capturing the optimal position of the ulna osteotomy to achieve the best possible reduction of the radial head. A further advantage is the possibility of easily changing the position of the ulnar osteotomy by adjustment of the fixator should the radial head subluxate or redislocate in the early postoperative period as had occurred in 3 of our cases. We conclude that our procedure of fully releasing the capsular contractures, removing scar tissue, ulnar osteotomy, reduction of the radial head, and fixation of the osteotomy with dual-socket external fixation is a safe and effective way to manage children with a missed Monteggia fracture.

LEVEL OF EVIDENCE

Therapeutic level IV.

[Functional outcome of posttraumatic elbow contractures]

INTRODUCTION

Posttraumatic elbow contractures can cause functional limitations and impairment of activities of daily living in children and adults. The aim of this study was to investigate the outcome and differences between posttraumatic elbow contractures in children and adults during rehabilitation.

MATERIAL AND METHODS

We analyzed 68 patients with posttraumatic elbow contractures, who had been admitted to the regional rehabilitation center and managed by procedures of physical therapy. All patients were divided into two groups: group A (34 children) and group B (34 adults). Mayo Clinic Performance Index for Elbow (MCPI) was measured at the beginning and at the end of the physical treatment for each patient.

RESULTS

Out of the study sample, 76.47% of children and 47.06% of adult patients had excellent score at the end of the therapy. The median of Performance index increased for both groups after the physical therapy and the differences were significantly high for both groups, children (t = 5.66, p < 0.001) and adults (t = 2.47, p < 0.001). MCPI at the discharge was significantly higher in the children than in the adults (t = 2.85, p < 0.05).

CONCLUSION

The results of our investigation have shown that the elbow function assessment in patients with posttraumatic elbow contractures (in regard to pain, motion, stability and sum of daily function) was better in children than in adults at discharge, after approximately 3 weeks of rehabilitation.

Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review

PURPOSE

There is ongoing debate about the management of medial epicondyle fractures in the pediatric population. This systematic review evaluated non-operative versus operative treatment of medial epicondyle fractures in pediatric and adolescent patients over the last six decades.

METHODS

A systematic review of the available literature was performed. Frequency-weighted mean union times were used to compare union rates for closed versus open treatments. Moreover, functional outcomes and range-of-motion variables were correlated with varying treatment modalities. Any complications, including ulnar nerve symptoms, pain, instability, infection, and residual deformity, were cataloged.

RESULTS

Fourteen studies, encompassing 498 patients, met the inclusion/exclusion criteria. There were 261 males and 132 female patients; the frequency-weighted average age was 11.93 years. The follow-up range was 6-216 months. Under the cumulative random effects model, the odds of union with operative fixation was 9.33 times the odds of union with non-operative treatment (P < 0.0001). There was no significant difference between operative and non-operative treatments in terms of pain at final follow-up (P = 0.73) or ulnar nerve symptoms (P = 0.412).

CONCLUSIONS

Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. There was no difference in pain at final follow-up between operative and non-operative treatments. As surgical indications evolve, and the functional demands of pediatric patients increase, surgical fixation should be strongly considered to achieve stable fixation and bony union.

WITHDRAWN: Missed Monteggia fracture in children: is annular ligament reconstruction always required?

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Open reduction of medial epicondyle fractures: operative tips for technical ease

In the pediatric population, medial humeral epicondylar fractures account for nearly 12% of all elbow fractures. There is ongoing debate about the surgical management of medial epicondyle fracture cases. Our technique in the operative management of medial epicondyle fractures uses the external application of an Esmarch bandage, as well as provisional fixation with needle rather than K-wire fixation. This technique decreases the need for soft-tissue release and, therefore, theoretically, maintains soft-tissue vascularity of the small fracture fragments. Moreover, it preserves the soft-tissue tension medially. It involves the use of a bandage that is universally available in orthopedic operating rooms, including those in developing nations. It is easy to apply by either the principal or assisting surgeon. With practice, it cuts down operative time and can help substitute for an assistant. This relatively simple operative technique makes for a more seamless operative process, improved reduction, and key preservation of soft-tissue vascularity.

Missed Monteggia fracture in children: Is annular ligament reconstruction always required?

BACKGROUND

Chronic (neglected) radiocapitellar joint dislocation is one of the feared complications of Monteggia fractures especially when associated with subtle fracture of the ulna bone. Many treatment strategies have been described to manage chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. The purpose of this study is to highlight the management of missed Monteggia fracture with particular emphasis on utility of annular ligament reconstruction by comparing the two groups of patients.

MATERIALS AND METHODS

In a prospective study 12 patients with mean age of 7.4 years, who presented with neglected Monteggia fractures, were studied. All children underwent open reduction of the radiocapitellar joint. Five children (Group A) were treated with angulation-distraction osteotomy of ulna and annular ligament reconstruction and six cases (Group B) required only angulation-distraction osteotomy of ulna without ligament reconstruction. In one case an open reduction of the radiocapitellar joint was sufficient to reduce the radial head and this was included in Group B. The gap between injury and presentation was from 3 months to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III respectively. We used the Kim's criteria to score our results.

RESULT

The mean follow-up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15 degree in Group A and 10 degree in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. The elbow score was excellent in 10 cases, and good in two cases.

CONCLUSION

Distraction-angulation osteotomy of the ulna suffices in most cases of missed monteggia fracture and the need for annular ligament reconstruction is based on intraoperative findings of radial head instability.

Oblique closing wedge osteotomy and lateral plating for cubitus varus in adults

Corrective osteotomy around the elbow can require longer recovery time in adults than in children because of the longer healing period and the propensity for stiffness. We hypothesized a lateral oblique closing wedge osteotomy with a larger contact area and fixation with a lag screw plus early motion would provide stable fixation and early motion recovery in adults with cubitus varus deformity. Twelve consecutive patients who needed surgery were treated using this procedure. They were allowed active motion exercises 1 week postoperatively. The age of the patients at the time of surgery averaged 39 years (range, 31-48 years). The minimum followup was 15 months. All patients achieved healing of the osteotomy, and regained preoperative arcs of elbow motion at a mean of 7.3 weeks (range, 2-12 weeks) postoperatively. The average humerus-elbow-wrist angle improved from -23.3 degrees to 8 degrees (p < 0.002) by a mean gain of 29.6 degrees . The mean lateral prominence index did not increase postoperatively. The final MEPI and DASH score averaged 95.4 points and 5.5 points. No patient experienced nerve palsy. Oblique osteotomy and fixation with a lag screw and lateral plating is a reasonable alternative technique for cubitus varus in adults, with early recovery of elbow motion and satisfactory deformity correction.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

[Medial epicondyle fractures in children]

INTRODUCTION

Medial epicondylar fractures account for 11% of elbow injuries in children. It represents a Salter-Harris type I lesion. Diagnosis is difficult but on the whole, results are satisfactory. The treatment of this fracture is controversial.

PATIENTS AND METHODS

Our study looked at fifty-nine patients between 7 and 14 years old. The main mechanism of injury in our study was a fall (98%). The significance of the fracture displacement was judged according to the classification of Marion and Faysse. We noted 10 cases of stage II, 14 cases of stage III and 35 cases of stage IV according to their classification. Forty-one patients were treated by surgical fixation. Fifty patients were reviewed at an average of six years follow up and the results evaluated according to the criteria of Hardacre.

RESULTS

The result was good in 95% of those cases with conservative treatment and in 80% of those cases with operative treatment. Prominence of the medial epicondyle and limitation of elbow motion were the main complications.

DISCUSSION

According the literature, a sports accident is the most frequent cause of the injury. The results are better with conservative treatment because there is no relation between fracture displacement and final results. The excellent results of conservative treatment permit us to recommend this method except in those cases with a persistent intra-articular fragment or neurovascular complication.

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents. Surgical technique

BACKGROUND

Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

METHODS

Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees . Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

RESULTS

The mean preoperative arc of total elbow motion was 37 degrees . The mean pronation was 46 degrees , and the mean supination was 56 degrees . After a mean duration of follow-up of thirty-four months, all patients but two had achieved an arc of motion of 100 degrees . The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees ). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees ), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees ). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

CONCLUSIONS

Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents

BACKGROUND

Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

METHODS

Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

RESULTS

The mean preoperative arc of total elbow motion was 37 degrees. The mean pronation was 46 degrees, and the mean supination was 56 degrees. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100 degrees. The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

CONCLUSIONS

Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Pediatric humeral condyle fractures

Condylar and epicondylar fractures differ from other pediatric upper extremity fractures because of the anatomy and ossification of the distal humerus. These fractures are prone to nonunion,and initial deformities do not remodel well. Radiographic diagnosis and severity are difficult to determine, and adjunct studies, particularly arthrography and MRI, often are needed. The correlation of an intact cartilaginous hinge and subsequent fracture stability has helped identify fractures at risk for displacement and nonunion,prompting closer follow-up or more aggressive initial treatment. Although many humeral condylar fractures can be treated successfully with cast immobilization, operative treatment often is warranted. Specific treatment recommendations continue to evolve. The general trend is toward treating more fractures and nonunions with surgical fixation while using less invasive techniques.

Chronic posttraumatic anterior dislocation of the radial head in children: thirteen cases treated by open reduction, ulnar osteotomy, and annular ligament reconstruction through a Boyd incision

OBJECTIVE

To report the results of open reduction, ulnar osteotomy, and annular ligament reconstruction all through a Boyd incision for chronic radial head dislocations in children.

DESIGN

Retrospective review.

SETTING

Tertiary pediatric orthopaedic care unit at a general hospital in Taichung, Taiwan.

PATIENTS/PARTICIPANTS

From 1986 to 2003, 13 children, aged 4 to 13 (mean, 8.3) years, who had a chronic traumatic anterior dislocation of the radial head were treated at our institute. These patients were seen at our hospital 2 to 36 (mean, 8.2) months after injury.

INTERVENTION

Open reduction of the radial head, ulnar osteotomy, then rigid fixation with plate/screws, and annular ligament reconstruction with forearm fascia, all performed through a Boyd incision.

MAIN OUTCOME MEASUREMENTS

Forearm radiographs for reduction and osteotomy site union, physical examinations for elbow mobility, and Kim's elbow performance scores for overall elbow function. Evaluations were done at a special follow-up clinic for this study by a pediatric orthopaedic surgeon who was not involved in the patients' previous care.

RESULTS

Patient follow-up averaged 7.8 (range, 1-16.9) years after surgery. Twelve of our cases had successful radial head reductions, satisfactory elbow mobility, and excellent functional outcome. One case had a redislocation, was retreated, and had a fair result. Other complications included 1 patient with transient posterior interosseous nerve palsy, and 1 delayed union of an ulnar osteotomy site, which healed without further intervention at 1 year with an excellent result.

CONCLUSION

This surgical procedure provides a high success rate with a low level of complications for chronic radial head dislocations in children.

Open reduction and annular ligament reconstruction with fascia of the forearm in chronic monteggia lesions in children

Fifteen children with chronic Monteggia lesions were treated with open reduction, annular ligament reconstruction with fascia of the forearm, and ulnar osteotomy. Mean age was 8 years 3 months (range 3-16 years). The chronicity of missed Monteggia was from 6 weeks to 2 years (mean 12 weeks). All patients were classified as Bado type I, except one with Bado type III. Mean follow-up was 4 years 3 months after surgery. There was a loss of pronation in six cases with the mean of 16 degrees. However, only four cases had rotational loss; the others had a mean rotational arch increase of 5 degrees. The flexion arches improved in all patients, with a mean of 27.7 degrees. The functional result was excellent in 11 patients, good in 3 patients, and poor in 1 patient. This one-incision approach is safe in treating chronic Monteggia lesions in children.

Compass elbow hinge: short-term results in five adolescents

The Compass Elbow Hinge (Smith and Nephew, Memphis, Tennessee, USA) was developed in the late 1990s as a mean of treating elbow contractures, utilizing Ilizarov's principles of distraction histeogenesis and a circular frame external fixator. Subsequent reports were published on its use for treating elbow ankylosis and instability in adults. Since 1999 five paediatric patients (aged from 12 to 15 years) have been treated by this device in our institute. The indications were post-traumatic elbow stiffness in four patients and elbow ankylosis following septic arthritis in one patient. Application of the elbow hinge was accompanied by open soft tissue contracture release, both anteriorly and posteriorly. Elbow mobilization and physiotherapy were commenced immediately postoperatively. The hinge was removed after 6-8 weeks. Follow-up ranged from 5 to 36 months. Complications were limited to simple pin track infection in three patients, and transient ulnar neuropraxia in one. The Compass Elbow Hinge (Smith & Nephew) application was successful in improving the arc of motion in three patients out of five.