Ulnar Epiphysiodesis: Success of the Index Procedure

Abstract

Introduction: Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting ulnar positive deformity leads to altered wrist mechanics and pain. Timely epiphysiodesis of the distal ulna with and without ulnar shortening osteotomy can address these issues, but continued ulnar overgrowth is a possible complication. We seek to evaluate the success rate of the primary epiphysiodesis of the ulna and associated clinical outcomes. Methods: A chart review was conducted at 2 children's hospitals from 2008 to 2019. Patients between the ages of 6 and 18 years old, with premature distal radius physeal closure, with or without positive ulnar variance, and > 2 months follow-up were included. We evaluated the following characteristics for each patient: demographics, initial cause of premature radial physeal closure, ulnar variance, additional procedures performed during epiphysiodesis, preoperative and postoperative pain, range of motion, instability. Summary statistics were conducted and expressed as proportions, medians and means. A paired t test evaluated change in ulnar variance for those who had an ulnar shortening osteotomy performed.Results: Thirty-one wrists among 30 patients were identified, and the median age at the time of surgery was 12.2 years (interquartile range: 3.4). Ulnar shortening osteotomies were performed in 53.1% of cases and distal radius osteotomy in 15.6%. Bone graft was utilized in 25.8% of the epiphysiodesis procedures. There were 2 failures of primary epiphysiodesis indicating an index success rate of 93.7%. The average ulnar variance correction was 3.1 mm (95% confidence interval: 1.9, 4.4). The mean physeal time to closure was 134 days. Preoperative symptoms were resolved for 90.6% cases at final follow-up. Conclusion: Ulnar epiphysiodesis successfully terminates ulnar physeal growth in 93.7% of cases. Preoperative symptoms were completely resolved with a median physeal closure of just over 4 months. Ulnar variance was corrected on average by 4.1 mm when a radial or ulnar shortening osteotomy was performed at the time of epiphysiodesis. Level of Evidence: Level IV-case series.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest

“…26 Identification earlier, closer to the time of injury, may allow for interventions before a resultant deformity, as was the case with patient ID 2 in Table 1. 1,26 Differences in treatment options available are based on the growth potential remaining and whether a symptomatic deformity has developed. Treatment decision-making is multifactorial and is similar to the indications described by Samora 26 for a distal radius growth arrest.…”

“…P remature growth arrest is a notable complication of physeal fractures and overuse injuries. 1,2 Distal radius and ulna fractures are among the most common pediatric fractures. [3][4][5] Studies on physeal fractures of the distal radius demonstrate growth arrest rates between 4% and 10%, a complication that often results in altered wrist mechanics and pain.…”

“…[3][4][5] Studies on physeal fractures of the distal radius demonstrate growth arrest rates between 4% and 10%, a complication that often results in altered wrist mechanics and pain. 1,2,6,7 Recognized risk factors for premature physeal closure include multiple fracture reduction attempts, late fracture reduction attempts, and intra-articular fracture patterns [Salter-Harris (SH) type III and IV injuries]. 2,8 Distal ulnar fractures are less common than distal radial fractures and usually occur in the setting of concomitant distal radius fractures.…”

Indications and Timing of Guided Growth Techniques for Pediatric Upper Extremity Deformities: A Literature Review

“…Campbell et al [63] followed 31 wrists in 30 patients with premature distal radius physeal closure. Patients had an average age of 13.8 years [SD 1.6] at the time of surgery and were followed for a median of 163 days (ICR 101-419).…”

“…In these cases, either a dome osteotomy or a closed lateral wedge osteotomy is a reliable and powerful method to achieve correction [25]. In isolated growth arrest of the radius, an ulnar shortening osteotomy may be needed to correct the ulnar overgrowth [63].…”