Intra-articular corrective osteotomy of humeral lateral condyle malunions in children: early clinical and radiographic results

Andrea S Bauer, Donald S Bae, Katherine A Brustowicz, Peter M Waters
Journal of Pediatric Orthopedics 2013, 33 (1): 20-5

BACKGROUND: Intra-articular malunions of pediatric humeral lateral condyle fractures may lead to pain, loss of motion and function, deformity, and elbow arthritis. Little information is available, however, regarding the treatment of symptomatic articular malunions. The purpose of this investigation is to report early results of intra-articular osteotomy of lateral condyle malunions in children.

METHODS: Seven patients who underwent intra-articular osteotomies for lateral condyle malunions were evaluated. Clinical records and radiographs were reviewed for demographics, fracture characteristics, initial fracture care, surgical technique, and early clinical and radiographic results. Outcomes were classified according to the Dhillon score.

RESULTS: Mean age at time of injury was 8.1 years (range, 4.3 to 11.4 y). Three patients had Milch type I fractures; 4 had Milch type II fractures. The mean interval from injury to osteotomy was 10 months. Two patients were initially treated with cast immobilization, and 5 underwent surgical treatment with either percutaneous pin fixation (n=2) or open reduction internal fixation (n=3). Before osteotomy, mean arc of elbow motion was 60 degrees (range, 40 to 100 degrees), average Dhillon score was 4 (range, 3 to 6), and average Baumann angle was 75 degrees. Postoperatively, mean elbow arc of motion improved to 105 degrees (range, 60 to 140 degrees) (P=0.028), and mean Dhillon score improved to 5.6 (range, 3 to 7) (P=0.02). There was a trend toward better postoperative Dhillon scores in patients with Milch type I (mean 7) versus Milch type II injuries (mean 4.5) (P=0.12). Average Baumann angle postoperatively was 85 degrees. Two patients had persistent radiographic evidence of osteonecrosis of the capitellum or trochlea at most recent follow-up, consistent with preoperative imaging.

CONCLUSIONS: Intra-articular corrective osteotomy may improve range of motion in patients with functionally limiting elbow stiffness due to lateral condyle malunion. Milch I fracture malunions may be more amenable to surgical correction than fractures extending into the trochlea. Preservation of soft tissue attachments to the lateral condylar fragment is recommended to minimize the risk of subsequent osteonecrosis.

LEVEL OF EVIDENCE: IV (retrospective case series).

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