Abstract
We reviewed the results of osteosynthesis for the treatment of an established non-union of the lateral humeral condyle in sixteen children whose average age was nine years (range, four to thirteen years) at the time of the operation. The average interval between the injury and the operation was five years (range, five months to ten years). The presenting symptoms were pain in the elbow in seven patients, apprehension in nine, a cubitus valgus deformity in six, limitation of motion in three, and dysfunction of the ulnar nerve in four. The average duration of follow-up was eleven years (range, four to thirty-two years).Osseous union was achieved after the initial operation in thirteen patients. Of the three patients who had a persistent non-union, two had a second operation and the third, who was asymptomatic, refused additional operative intervention. The result was rated excellent in eight patients, good in seven, and poor in one, with use of a modification of the functional rating index of Broberg and Morrey. The patient who had a poor result had evidence of avascular necrosis of the fragment.
Patients who have a non-union of the lateral humeral condyle often have pain, instability, or a progressive cubitus valgus deformity, prompting them to seek treatment15. Several authors have recommended operative treatment for selected patients, but there have been few reports of such treatment in children4,11-13. Other authors have not recommended operative intervention because the range of motion of the elbow may be decreased and the vascularity of the fragment may be jeopardized5-7,10,14.
In an earlier study of osteosynthesis for the treatment of a non-union of the lateral humeral condyle in seventeen patients, the results were not the same in adults and children9. In the current study, we retrospectively reviewed the results of such treatment in sixteen children to determine whether it is a viable option.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedic Surgery, Osaka Koseinenkin Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka 553, Japan.
‡Department of Physical Therapy, Osaka Prefectural College of Health Sciences, 3-7-30 Habikino, Habikino-c., Osaka 583, Japan.
§Department of Orthopaedic Surgery, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki-c., Hyogo 660, Japan.
We performed osteosynthesis in sixteen patients (thirteen boys and three girls) who had a non-union of the lateral humeral condyle, before closure of the epiphysis, between 1962 and 1991. The left side was affected in seven patients and the right side, in nine. At the time of the first visit, pain was a major symptom in seven patients; apprehension with use of the elbow, in nine; limitation of motion, in three; and a cubitus valgus deformity, in six. Four patients also reported paresthesias along the distribution of the ulnar nerve in the forearm and the hand, and we found clinical evidence of dysfunction of the ulnar nerve in seven patients.
The average age at the time of the operation was nine years (range, four to thirteen years). The average interval between the injury and the operation was five years (range, five months to ten years). The average duration of follow-up was eleven years (range, four to thirty-two years). The average age at the latest follow-up evaluation was twenty years (range, nine to forty-three years). Bone graft was used in eleven patients at the first operation for osteosynthesis. Osteosynthesis was repeated with bone-grafting in two patients who did not have a solid union after the initial operation.
Operative Procedure
The osteosynthesis was performed with use of a posterolateral approach; a medial incision, parallel to the ulnar nerve, was used when anterior transposition of the ulnar nerve was necessary. The details of the procedure were described in an earlier study9. Two, three, or four Kirschner wires usually were used for fixation to minimize the damage to the physis, especially in younger patients. Failure to achieve union in one patient (Case 3) has led us to use either tension-band wiring or fixation with screws in children more than ten years old. Anterior transposition of the ulnar nerve was performed in the seven patients who had preoperative evidence of dysfunction of the ulnar nerve, and it was performed three years later in one patient (Case 15) in whom a late ulnar-nerve palsy had developed.
A supracondylar osteotomy was performed in six patients who had a cubitus valgus deformity that was more than 20 degrees. Of these six patients, three (Cases 8, 10, and 11), who were thirteen years old, had the osteotomy at the time of the osteosynthesis and three (Cases 5, 6, and 16), who were less than ten years old, had it one to three years later to avoid a second procedure to correct recurrence of the deformity secondary to growth.
An above-the-elbow cast was worn for an average of six weeks (range, four to nine weeks) postoperatively, until there was radiographic evidence of union. Two patients (Cases 9 and 13) wore a molded plaster splint for an additional period until union was complete. The splint was removed each day in order to permit active range-of-motion exercises. The Kirschner wires and the screws were removed after there was evidence of union; in three patients (Cases 4, 5, and 11), the elbow was manipulated at the same time.
Evaluation
The clinical result was evaluated in terms of pain, apprehension, grip strength, range of motion, deformity, and activities of daily living. The result was rated as excellent, good, fair, or poor, according to a modification of the functional rating index of Broberg and Morrey (Table I). A total score of 95 to 100 points indicated an excellent result; 80 to 94 points, a good result; 60 to 79 points, a fair result; and 0 to 59 points, a poor result. Function of the ulnar nerve was assessed with use of a modification of the staging system of Akahori et al., as described in our earlier study2,9.
The radiographs were evaluated for evidence of early closure of the epiphyseal line, hypertrophy of the lateral humeral condyle, fishtail deformity (a defect of the center of the distal end of the humerus), and congruity of the joint (to assess the extent of remodeling of the distal end of the humerus). Arthrograms were made for seven patients (Cases 3, 9, 10, and 13 through 16), and arthroscopy was performed in one (Case 16) to evaluate the congruity of the elbow joint.
Eight patients were rated as having an excellent result; seven, a good result; and one, a poor result, according to the modified functional-rating index of Broberg and Morrey. The average preoperative score was 81 points (range, 67 to 92 points), and the average postoperative score was 93 points (range, 59 to 100 points). Preoperatively, thirteen patients had pain or apprehension with motion that was reproduced by a varus or valgus stress maneuver with the elbow passively extended. Pain and apprehension with movement resolved postoperatively in all but four patients, and it decreased in three of the four. The remaining patient (Case 14), who had a poor result, had pain with use of the elbow, severe restriction of motion, and avascular necrosis of the fragment (Table II). The average postoperative grip strength, measured as a percentage of that of the contralateral hand, was 93 per cent (range, 75 to 140 per cent). Twelve patients participated in sports activities without any difficulty.
The arc of motion ranged from 65 to 145 degrees preoperatively and from 35 to 145 degrees postoperatively. In seven patients (Cases 7, 9 through 12, 15, and 16), a good range of motion was achieved soon after the operation. In five patients (Cases 3, 4, 5, 8, and 13), it was initially restricted but gradually improved. In three patients (Cases 10, 13, and 14), the range of motion at the latest follow-up evaluation had decreased more than 20 degrees. One of them (Case 14) had an arc of flexion of 35 degrees (55 to 90 degrees). The other two (Cases 10 and 13) were satisfied despite the limited range of motion, as it did not interfere with their activities of daily living.
Postoperatively, function of the ulnar nerve was excellent in thirteen patients, good in two, and poor in one. The patient (Case 15) in whom it was poor had not wanted a corrective osteotomy at the time of the osteosynthesis despite a 25-degree cubitus valgus deformity. Three years after the osteosynthesis, he reported hypoesthesia and paresthesia on the ulnar side of the hand. The symptoms resolved after an anterior transposition of the ulnar nerve was performed.
Radiographic Findings
The epiphysis closed early, compared with that of the contralateral elbow, in twelve patients. The lateral condyle was larger in six patients and smaller in four. There was hypertrophy of the radial head in seven patients and a fishtail deformity of the distal end of the humerus in fourteen. Despite these findings, the articulation between the humerus and the ulna or the radius was congruous in most patients. This was confirmed with arthrograms in six patients and arthroscopically in one.
The average carrying angle was 19 degrees preoperatively and 9 degrees postoperatively. The carrying angle improved after a corrective osteotomy in six patients (Cases 5, 6, 8, 10, 11, and 16) and without an osteotomy in five (Cases 1, 4, 9, 12, and 13), possibly because of reduction of the fragments and use of a wedge-shaped bone graft.
Complications
Three patients did not have a solid union after the initial operation. Bone graft had been used in one of the three (Case 13). In two patients (Cases 9 and 13), osteosynthesis was repeated with bone-grafting and union was achieved. The third patient (Case 3) was asymptomatic and did not want additional operative intervention. No patient had an infection. One patient (Case 14) had avascular necrosis of the lateral condyle; this patient had had two operations at another institution before coming to our hospital.
Illustrative Case Reports
CASE 4. A five-year-old boy sustained a fracture of the lateral humeral condyle (Fig. 1-A), which was initially treated with a cast. Eleven months later, he was seen by us, and an osteosynthesis with use of bone graft and Kirschner wires was performed (Fig. 1-B). The elbow was manipulated at the time of removal of the wires.
A radiograph made two years after the operation showed the lateral condyle articulating with the radial head and demonstrated a large defect in the trochlea (Fig. 1-C). Three years postoperatively, the patient had a range of motion of 5 to 140 degrees at the elbow, and the articular surface had remodeled.
Eleven years postoperatively, when he was seventeen years old, the patient had no limitation of activities of daily living or sports activities. He had a functional score of 100 points (an excellent result). Radiographs made at that time showed remodeling (Fig. 1-D). The range of motion was excellent (Fig. 1-E).
CASE 12. A four-year-old boy sustained a fracture of the lateral humeral condyle and was managed with an above-the-elbow cast for three weeks. He was seen six years later because of a feeling of apprehension when he used the elbow, weakness and paresthesias along the little finger, and atrophy of the hypothenar muscles. The ulnar nerve palsy was stage IV, according to the modified system of Akahori et al.2,9. The radiograph showed a non-union of the lateral humeral condyle (Fig. 2-A). Osteosynthesis with anterior transposition of the ulnar nerve was performed with use of bone graft from the iliac crest and screw fixation (Fig. 2-B). The function of the ulnar nerve improved to stage I. At the time of the latest follow-up, six years and five months postoperatively, the lateral humeral condyle appeared smaller than that on the contralateral side, but there was evidence of remodeling of the articular surface (Fig. 2-C). The patient played volleyball regularly. The functional score was 100 points (an excellent result) despite inadequate remodeling of the bone (Fig. 2-D).
Established non-unions of the lateral humeral condyle have been treated both non-operatively and operatively. Moorhead reported on a patient who had a non-union, noted seventeen years after the injury, that was not treated because the range of motion was acceptable and the patient had no pain. Smith reported on an eighty-five-year-old woman who had a long-standing non-union, with ulnar nerve palsy as the only symptom. Some authors5-7 did not recommend operative treatment of the non-union because they did not believe that the resulting impairment was a major functional problem unless there was evidence of dysfunction of the ulnar nerve or a progressive cubitus valgus deformity. Those authors5-7 reported complications after osteosynthesis that included a stiff elbow and necrosis of the condylar fragment. Other authors have reported favorable results after operative treatment1,8.
We reported the results of osteosynthesis in seventeen patients (eleven adults and six children) who had a non-union of the lateral condyle of the humerus9. Osteosynthesis yields better results in children than in adults, in whom osteosynthesis is indicated only if there is severe pain in the elbow or apprehension with use of the elbow secondary to lateral instability. Jakob et al. as well as Fontanetta et al. stated that open reduction should not be performed more than three weeks after the injury, as the blood supply of the fragment is easily disturbed, leading to avascular necrosis of the fragment. Flynn et al. advised early operative intervention for non-union only when the condylar fragment was minimally displaced. Shibata et al. reported the benefit of osteosynthesis in children and recommended fixation without realignment of the fragment. Authors of recent reports have recommended osteosynthesis after reduction of the fragment11,12. All of those studies showed that osteosynthesis for the treatment of a non-union is a technically demanding procedure. Wilkins et al. stated: "If we believe that we can obtain fracture union without loss of elbow motion and avoid avascular necrosis of the lateral condyle, then we recommend surgery for selected patients."
We believe that osteosynthesis is indicated for children, not only for those who have pain but also for those who are less symptomatic. In the current study, there was fairly good remodeling of the elbow joint and improvement in the range of motion over a several-year period in skeletally immature patients. Osteosynthesis prevents progression of a cubitus valgus deformity and subsequent dysfunction of the ulnar nerve. In children, union is easily achieved, the range of motion is maintained, the function of the ulnar nerve usually returns, and remodeling of the articular surface can be expected. Bone-grafting is essential, even in children, to bridge the defect, to obtain congruity of the joint, and to facilitate union. Damage to the blood supply of the fragment should be avoided to prevent avascular necrosis.
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