Arthroscopic Correction of a Supracondylar Malunion in a Child

Abstract

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. S upracondylar humeral fractures are common in children aged younger than 10 years.1 Angular deformities of the distal humerus are common after supracondylar fractures. 2 The results of corrective osteotomies vary widely, and complication rates have been reported at 33%.2 Considering the high rate of complications for supracondylar humeral malunions, we investigated the feasibility of using arthroscopy. In addition, the complex bony anatomy of the elbow and close proximity of vital neurovascular structures make exposure challenging and, often, limited. Further complicating exposure is the need to avoid damaging the ligaments, which could potentially exacerbate the injury. We present a technique for arthroscopic supracondylar osteotomy and percutaneous pinning. IndicationsThe principal surgical indication for this technique is a supracondylar humeral malunion that results in loss of functional motion (Table 1). In addition to addressing bony malunion, this approach affords the surgeon the opportunity to address any intracapsular contracture concomitantly. ContraindicationsContraindications for this technique revolve around exposure. If arthroscopy does not improve exposure, the procedure should be abandoned in favor of a traditional open osteotomy. In addition, this approach demands an experienced elbow arthroscopist comfortable with pediatric elbow arthroscopy. Lastly, if there has been prior ulnar nerve transposition, we find that elbow arthroscopy is generally contraindicated. Preoperative PlanningPreoperative planning is necessary to determine the requisite dimensions of the osteotomy and degree of correction. Therefore it is important to obtain goodquality preoperative radiographs. The radiographs must comprise true lateral and true anteroposterior views. Then, using elementary trigonometry and compensating for the magnification factor of the radiographs, we select our osteotomy site and plan for the amount of correction necessary to provide the patient with a functional range of motion. We use the techniques detailed by Kim et al. 3 to determine the preoperative angles and degree of malrotation. The humerus-elbow-wrist angle is measured on the anteroposterior radiograph as described previously to assess the varus and valgus angles.

Is Supine Position Superior to Prone Position in the Surgical Pinning of Supracondylar Humerus Fracture in Children?

“…At the same time, several methods have been described. The cross-wired and lateral wires configurations are the most examined [ 3 , 24 , 25 , 26 , 27 , 28 ]: cross-wired is more biomechanically stable [ 26 , 27 ], lateral reduces nerve injury risk [ 25 ].…”

Surgical Treatment of Displaced Supracondylar Pediatric Humerus Fractures: Comparison of Two Pinning Techniques

“…Malunion is a complication of SCHF treatment that occurs during an arthroscopic approach. Koehler et al [21] showed that arthroscopy is useful and favorable and offers deformity correction and safe access of the anterior humerus as well as minimal dissection, scarring and intracapsular contractures.…”

Arthroscopy of the Pediatric Elbow: Review of the Current Concepts

“…Though lateral condyle fractures (LCFs) are the most common fracture addressed arthroscopically in the pediatric population, the orthopedic literature also describes techniques for fixation of coronoid, supracondylar, medial epicondyle, radial head or neck fractures. 8,11,13,17,[21][22][23] Fractures of the lateral condyle are the second most common pediatric elbow fracture, and represent a diagnostic and treatment challenge with a relatively high rate of severe complications, including avascular necrosis (AVN), non-union, growth arrest, subsequent deformity, and loss of motion. 24,25 The limited ossification makes it difficult to correctly assess the type of fracture or level of displacement with radiographs alone.…”

“…Arthroscopic-assisted fracture management may be beneficial in other fractures about the elbow (coronoid, radial head/neck, capitellum, supracondylar), and recent small case series and reports have demonstrated good results with regard to fracture union, range of motion and complications. 7,21,28 There is also the potential for arthroscopic corrective osteotomies following supracondylar malunion, in which the current complication rates for open procedures is reported at upwards of 40%. 29 Larger studies and trials are needed, however, to compare these minimally-invasive procedures to their open counterparts.…”