The effect of staged surgical treatment for cubitus valgus after non-union of lateral condylar fracture of distal humerus in older children

Abstract

Background: The purpose of this study was to investigate the effect of staged surgery (open reduction/internal fixation and osteotomy) for cubitus valgus after non-union of lateral condylar fractures of the distal humerus in older children.Methods: From January 2010 to January 2013, 9 patients were treated with two-staged surgery (open reduction/internal fixation and osteotomy). The study included 5 males and 4 females, with a mean age of 12.7 years. The interval from fracture to the first surgery was 8.2 years on average. All patients had symptoms of injury of the ulnar nerve and instability of the elbow. The first surgery included internal reduction, internal fixation, and bone grafting, exposing the elbow through a lateral approach. The procedure included clearing the peripheric callus and proximal distal fracture end cicatrix with rongeur until cancellous bone was exposed, and fixation of the lateral condylar fragment with a hollow screw 4.0 mm in diameter and smooth Kirschner wire. The limb was immobilized in a long arm cast with the elbow at 90 degrees of flexion and the forearm in neutral rotation for 3 weeks, and active exercises were begun after removal. The second surgery, osteotomy of the supracondylar humerus, was completed after 6 months to correct cubitus valgus. Internal fixation from the osteotomy was removed 6 months later.Results: Six months after the second surgery, follow-up revealed that in all patients the lateral condylar fractures attained clinical union and cubitus valgus was corrected. Elbow function recovered well without arthrochalasis or humeral condylar avascular necrosis. All patients’ ulnar nerve injury symptoms disappeared.Conclusion: Staged surgery to treat cubitus valgus secondary to lateral condylar fracture non-union in older children serves to first provide elbow stability, then to correct cubitus valgus. Staged treatment may make up for the deficiencies of conventional treatment. However, due to our relatively short follow-up time, the long term effects are unknown.

Long-standing Nonunited Fracture Lateral Humeral Condyle in Children. Evaluating a Two-stage Surgical Treatment Strategy With Critical Review

“…[3][4][5]9,12,19,23 Others did not do it and reported spontaneous recovery, where they owed this improvement to the gained laxity of the ulnar nerve after doing the corrective osteotomy. 11,18 In this study, we did not do any ATUN for the included cases, and we reported gradual spontaneous clinical improvement in all the cases presented with preoperative UND.…”

“…Lately, in the last 30 years a plethora of studies published urging for osteosynthesis of the nonunited LHC, corrective osteotomy, and ATUN as a 1-stage surgery. [2][3][4][5][6][7]9,10,[16][17][18] This treatment strategy may not be convenient nor reproducible for long-standing cases of LHC nonunion with distorted elbow anatomy that requires special surgical tracts.…”

“…We came across only one literature article by LiuLi et al (preprint) 18 which described a similar 2-stage strategy and reported satisfactory results of their 9 cases. The authors postulated that this strategy avoids possible stiffness or AVN of the fragment.…”

“…This will cut off the way on the pathologic remodeling and give the chance for the LHC to regain its participation in the remaining potential growth of the distal humerus. 2,3,5,6,18,19 Good refreshment of the pseudoarthrosis gap until reaching the "Paprika sign" (bleeding raw bone) while avoiding extensive soft tissue dissection of the common extensor origin or stripping of its posterior soft tissue to avoid AVN of LHC is very important. [3][4][5][6][7]15,20,21 Functional reduction is defined as fixing the mobilized LCH fragment with its intact soft tissue vascular pedicle in a position that allows the greatest elbow ROM.…”