Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction

The posterior approach for open reduction of supracondylar fractures of the humerus has been condemned for causing decreased elbow movement. This study investigates this by comparing the range of movement in children treated by posterior open reduction and Kirschner wiring with those treated by closed reduction and immobilization. A total of 65 children with severely displaced supracondylar humeral fractures have been reviewed.

There was some loss of movement in 66 per cent of the open reduction group and 42 per cent of the closed reduction group. The proportion losing more than 10 ° of movement was the same in both groups. The difference between the two groups was due to the increased numbers in the open reduction group who lost less than 10 ° of motion. Posterior open reduction of childhood supracondylar fractures is not associated with an important loss of elbow movement and need not be avoided on this account.     

The Significance of Associated Lesions Including Dislocation in Fractures of the Neck of the Radius in Children

A series consisting of 29 children with markedly dislocated fractures of the neck of the radius has been analysed. The method of measuring the angular dislocation is discussed. A true dislocation not exceeding 30° may be left unreduced. Associated skeletal lesions of the elbow imply a less favourable prognosis.     

Reconstruction after resection of the proximal ulna: Report of a case of chondrosarcoma

After resection of the proximal ulna for chondrosarcoma, the elbow was reconstructed by dislocating the radius posteriorly until the radial neck articulated with the trochlea. The triceps tendon was sutured to the radial head. At 9 months' follow-up, the elbow was painless and stable with 35-135° of flexion.     

Varus deformity in supracondylar fractures of the humerus in children

Eighty cases of supracondylar fracture of the humerus at the elbow in children have been analysed. The post-reduction radiograph of the fracture was classified depending on the residual deformity present and related to the loss of carrying angle and cubitus varus deformity at the time of follow-up. Fifty-four per cent of the displaced fractures showed a loss of carrying angle greater than 5 °, and of these, 23 per cent developed cubitus varus deformity. Eighty-five per cent of those cases with a loss of carrying angle greater than 10 ° showed either residual tilt or medial rotation on the post-reduction radiograph. All cases in which there was residual medial tilt after manipulation and 40 per cent of those with medial rotation on the post-reduction radiograph developed cubitus varus.

In our series, there was no evidence of epiphyseal injury causing the deformity and in none of the cases was the deformity progressive. It is suggested that, in order to reduce the incidence of varus deformity in supracondylar fractures, open reduction and internal fixation is indicated in those fractures in which tilt or medial rotation cannot be reduced by conservative means.     

Regression of femoral anteversion: A prospective study of intoeing children

To study the spontaneous regression of femoral anteversion, 30 children referred to the outpatient clinic for intoeing were followed until at least 15 years of age. The mean observation time was 9 (7-12) years, and all the children were examined three times during the growth period.

The mean radiographic angle at the first examination was 42°, at the second examination 36°, and at the last examination 28°. The mean decrease of the AV angle per year was 1.5°, with a considerable range (0.2-3.1°). The mean internal rotation of the hip decreased from 74° to 53° during the observation period, and the external rotation increased from 19° to 37°.

While all 30 children had an intoeing gait at the first examination, this disappeared in all but 5 children.     

Overgrowth and correction of rotational deformity in 12 femoral shaft fractures in 3-6-year-old children treated with an external fixator

We treated 11 young children (3-6 years old) who had uncomplicated femoral shaft fractures primarily with an external fixator. 9 children were available for follow-up and were evaluated for the amount of overgrowth and rotational deformity. All underwent a clinical examination and an MRI after mean 21 (13-25) months. The mean overgrowth was 0.4 (-0.3 - -1.1) cm and the anteversion angle showed a mean increase of 12°, as compared to the contralateral femur. In 5 children with an anteversion angle difference of 10° or more, a second MRI was done 4 years after the trauma. The mean anteversion angle difference of the femora in these 5 children had diminished from 15° on the first MRI to 7.4° on the second. 3 of the 5 children had a full correction of their rotational deformity. Growth did not correct the rotational deformity in the oldest child in this group.     

Late results of the Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis 6/19 implants loose after 5 years

We performed total elbow replacement, using the Souter-Strathclyde prosthesis in 19 elbows of 18 patients with rheumatoid arthritis and followed the patients for 5 (1-11) years. Pain relief was achieved initially in all patients. The average range of flexion-extension was increased by 12° and pronation-supination by 40°. There were no infections. 1 patient sustained an intraoperative fracture of the medial epicondyle, 3 patients developed neuropathies and 1 patient had an immediate postoperative dislocation of the joint.

At follow-up, 6 prostheses had radiographic loosening, with sagittal tilting and migration of 4 humeral components. 2 patients had clinical symptoms of loosening.     

Trunk rotation in scoliosis the influence of curve type and direction in 150 children

We compared the angle of trunk rotation (ATR) from scoliometer readings with Cobb angle measurements of the lateral deviation of the spine in 150 children referred to hospital for evaluation of scoliosis. the mean Cobb angle in thoracic curves was 16 °, in thoracolumbar curves 17° and in lumbar curves 20°. in thoracic curves and in right convex curves no patient with a Cobb angle of 25° or more had an ATR below 9°. in thoracolumbar and lumbar and in left convex curves, 7° ATR was occasionally associated with scoliosis of 25° or more. the correlation coefficient between the ATR and Cobb angle in right convex curves was 0.65 compared to 0.57 in left convex curves. We conclude that a criterion of 7° ATR for thoracic or right convex curves and one of 6° ATR for thoracolumbar and lumbar or left convex curves seem adequate for identification of patients with Cobb angles of 25° or more, which reduces the need for spinal radiography and follow-up outside the school screening programs.     

Posterior dislocation of the ulna at the elbow with associated fracture of the radial shaft

An exceptional case of posterior dislocation of the ulna at the elbow, associated with fracture of the radial shaft, is reported. Diagnosis was established with anteroposterior and lateral radiographs of the forearm, elbow and wrist. Treatment consisted of closed reduction of the ulnar dislocation and open reduction and internal fixation of the radius with an AO plate. A long arm cast was applied for 3 weeks with the elbow held at 90 °. Six months later full function of the limb had been achieved.     

Femoral anteversion related to side differences in hip rotation: Passive rotation in 1, 140 children aged 8-9 years

We assessed whether the range of passive hip motion is reliable for predicting abnormal femoral ante-version. We measured the passive medial and lateral rotation in extension in both hips of 1, 140 children between 8 and 9 years of age. The children were divided into 3 groups: group 1: difference between lateral and medial rotation less than 10° group 2: medial rotation more than 10° greater than the lateral; group 3: lateral rotation more than 10° greater than the medial. Group 1 comprised 90% of the children, whereas 8% belonged to group 2 and 2% to group 3.

The angle of femoral neck anteversion was measured in 57 children from the first group, in 67 from the second and in 24 children from the third group, using biplane radiography. The mean anteversion angles in the 3 groups were 24°, 36° and 14°, respectively. To predict an abnormally high anteversion angle (above mean +2SD), the difference between medial and lateral rotation must be 45° or more, whereas an abnormally low anteversion angle (lower than mean -2SD) could be predicted when the lateral rotation was at least 50° higher than the medial rotation.     

Osteotomy for femoral anteversion: Complications in 95 children

Totally, 95 children with increased femoral anteversion had derotational subtrochanteric osteotomy with plate fixation. The mean anteversion angle was reduced from 48° to 4°, internal hip rotation from 81° to 42°, and external rotation increased from 9° to 48°.

All the osteotomies healed, but serious complications occurred in 13 of the 95 patients. Because of the risk for complications and the trend towards spontaneous regression of femoral anteversion with age, we recommend a much more conservative attitude with regard to operative treatment.     

Elbow arthroplasty in rheumatoid arthritis: Function after 1-2 years in 20 cases

The function of the hand and arm was studied after total elbow arthroplasty in a consecutive series of 18 rheumatoid patients with a total of 20 primary arthroplasties and one revision. Extensive clinical evaluation with locomotion score and Sollerman's hand function test was undertaken preoperatively and at 6 months postoperatively. The mean flexion range increased 25° and extension lag decreased 5°. Pain relief was achieved in all the cases, and 16 of 20 primary operated on elbows became fully painfree. Hand function score (max. 80) improved from 52 to 64, upper extremity score (max. 100) from 57 to 68 and subjective score (max. 100) from 46 to 58. Complications were 2 cases of ulnar nerve paresthesia and 1 epicondylar fissure.     

Souter-Strathclyde arthroplasty of the rheumatoid elbow: 23 cases followed for 3 years

Twenty-three elbows in 17 rheumatoid arthritis patients have undergone unconstrained Souter-Strathclyde elbow replacements since March 1984. One patient developed a deep-wound infection, and 4 others had a temporary ulnar nerve paresis. At follow-up 3 (0.5-6) years postoperatively, there was a moderate improvement in the arc of movements: 25° in extension-flexion and 45° in forearm rotation. Pain relief was achieved in 20 cases. Three elbows required revision, two following recurrent dislocation and the other after a humeral fracture and component loosening.     

Surgical treatment of posttraumatic stiffness of the elbow: 2-year outcome in 21 patients after a column procedure

Background and purpose Posttraumatic stiffness is a common complication of elbow injury and can result in considerable impairment in daily life. We assessed the outcome in 21 patients treated by a column procedure.

Patients and methods We followed 21 patients (average age 40 (10-76) years, 11 women) for 2 years after surgery for a stiff elbow. Range of motion (ROM) and function (EFA score) were measured preoperatively and at 3,12, and 24 months postoperatively.

Results Before surgery, the mean ROM was 69° (SD 24) and the mean EFA score was 74 (SD 13), which improved significantly to 104° (17) and 91 (6), respectively, after release. There were no significant differences between the postoperative measurements at 3,12, and 24 months. No neurovascular complications were noted; 2 patients developed periarticular ossifications postoperatively.

Interpretation A column procedure results in an increase in motion and functional scores at 2-year follow-up. Outcome at 3 months after treatment is the same as after 2 years.     

A mechanical study of the moment-forces of the supinators and pronators of the forearm

We determined the torque generated by the muscles rotating the forearm at varying degrees of pronation and supination. We used 8 human cadaveric upper extremity specimens with the humerus and ulna rigidly fixed with the elbow in 90° of flexion, while free rotation of the radius around the ulna was allowed. The tendons of the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), supinator, biceps, pronator teres (PT), and the pronator quadratus' (PQ) superficial and deep heads were isolated. After locking the forearm at intervals of 10° from 90° of pronation to 90° of supination, we loaded each muscle/tendon with a ramp profile.

We found that the biceps and supinator are both active supinators, the biceps generating four times more torque with the forearm in a pronated position. As for pronation, the PT and both heads of the PQ are active throughout the whole rotation, being most efficient around the neutral position of the forearm. The ECU and FCU contribute significantly less to pronation and supination torque. However,they do generate potential pronating torque while the forearm is positioned maximally in supination and, to a lesser extent, potential supination torque while the forearm is positioned maximally in pronation.     

9 years’ follow-up of 168 pin-fixed supracondylar humerus fractures in children

Background and purpose — The long-term outcome of pin-fixed supracondylar humerus fractures (SCHF) in children is not well known. We assessed the 7- to 12-year outcome in 168 children.

Patients and methods — During 2002–2006, 210 domestic children (age 7 (1–14) years) with SCHF (Gartland III 79%, Gartland II 19%, and flexion type 2%) were pin fixed in Helsinki. 36 (17%) patients had a nerve palsy. Radiographic alignment was regarded as satisfactory in 81% of patients (Baumann angle (BA) within ±10? of normal range and whose anterior humeral line (AHL) crossed the capitulum). After a mean follow-up of 9 (7–12) years, 168 (80%) patients answered a questionnaire regarding elbow appearance (scale 0–10), function (scale 0–10), and pain (scale 0–10), and symmetry of range of motion (ROM) and carrying angle (CA). 65 (31%) patients also attended a clinical follow-up examination.

Results — Mean subjective score for appearance was 8.7 (2–10) and for function 9.0 (2–10) (n = 168). Elbow ROM asymmetry was experienced by 28% and elbow CA asymmetry by 17% of the patients. Elbow pain was reported by 14%, and was more common in children with nerve injuries. Long-term outcome was good or excellent in 60/65 and CA in 56/65 of the follow-up visit patients using Flynn’s criteria. BA exceeding normal values by 10? was associated with lower subjective outcome; AHL crossing point with the capitulum was not associated with outcome.

Interpretation — Long-term subjective outcome is satisfactory with few exceptions if elbow ROM and CA are restored within 10° of the uninjured elbow. Radiographs at fracture union have little prognostic value. Nerve injuries can cause long-term pain.     

Open release and a hinged external fixator for the treatment of elbow stiffness in young patients

Elbow stiffness is a well-recognized complication following elbow trauma, but little information is available regarding the surgical treatment of elbow stiffness in children and adolescents. This article presents the results of open arthrolysis with twin incisions and a hinged external fixator to treat severe elbow contracture in children and adolescents.Twenty-one patients (mean age, 14.9 years; range, 7-19 years) were evaluated. All patients underwent surgery using a hinged external fixator and a combined mediolateral approach to address the elbow contracture. Mayo elbow score and range of motion (ROM) were measured preoperatively and at 3, 12, and 24 months postoperatively. All but 1 patient achieved a functional ROM of 100°. Preoperatively, mean flexion was 70.2° (range, 30°-100°), extension was 42.6° (range, 0°-80°), and total ROM was 28.5° (range, 0° to 80°); postoperatively, mean flexion improved to 122.8° (range, 90°-140°), extension to 10° (range, 0°-30°), and total ROM to 114.5° (range, 60°-140°). The Mayo elbow score improved from a mean of 48 points (range, 35-65 points) to 90 points (range, 75-100 points), and 9 patients had excellent results, 7 had good results, 4 had fair results, and 1 had a poor result. No significant differences existed between postoperative measurements at 3, 12, and 24 months. No pin-tract infections or deep infections occurred, and no vascular or neurological complications were noted.Surgical treatment of elbow stiffness using a hinged external fixator and open arthrolysis is an effective procedure in children and adolescents.     

Osteotomy for femoral anteversion: A prospective 9-year study of 52 children

Fifty-two children with increased femoral anteversion had bilateral derotational subtrochanteric osteotomies at a mean age of 7 years. They were followed prospectively until at least 15 years of age; the mean observation time was 9 years. They were a subset of 95 children whose 2-year results were reported in 1989. The mean increase of femoral anteversion after the osteotomy was 6° (0.7° per year) and of the neck-shaft angle 5°. The CE angle did not increase. Although we at present practice a more restrictive attitude towards operation of increased femoral anteversion, our study showed that a derotational osteotomy is effective in eliminating the intoeing gait and associated complaints, and the hip angles change only moderately during the remaining period of growth.     

The olecranon sled--a new device for fixation of fractures of the olecranon: a mechanical comparison of two fixation methods in cadaver elbows

Background Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems.

Material and methods Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45°, 90° and 135°, respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5 kg (50 N) for 20 cycles and the amount of fracture displacement measured.

Results Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23 mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques.

Interpretation The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures.     

The role of simple elbow dislocations in cubitus valgus development in children

Purpose

We investigated the functional and radiological outcomes of conservatively treated simple traumatic elbow dislocations and subsequent incidence of cubitus valgus development in children.

Methods

Eleven patients (one female, ten male; mean age 9.8 years, range seven to 12 years) who presented to our hospital with simple elbow dislocations and were conservatively treated between July 2008 and September 2010 were included in the study. All were posterolateral closed dislocations. None of the patients had accompanying elbow fractures. All patients had pre- and postoperative radiographic examinations. The carrying angle of the involved elbow was measured and compared to the contralateral non-injured elbow during follow-up. The incidence and severity of cubitus valgus development was assessed. The functional and clinical outcomes were evaluated using the Mayo Elbow Performance Scale. The mean monitoring period was 24.3 months (range 19–30 months).

Results

All patients had satisfactory good and excellent results (85–100 points; mean 96.8 points) according to the Mayo Elbow Performance Scale. The final average elbow flexion was 137° (range, 130–145°) and average extension was 8.6° (range 0–20°) with full supination and pronation in traumatic elbow. Four patients (36.4 %) had an average increase (cubitus valgus) of 14.5° (10–20°) in carrying angle compared to the other elbow.

Conclusions

While isolated traumatic dislocation of the elbow is uncommon among children, it can be successfully treated by urgent closed reduction, proper fixation of the elbow and appropriate timely rehabilitation. However, it should be considered that some patients may develop cubitus valgus deformity in a later period. Therefore, each patient with a simple traumatic elbow dislocation should be followed, and the parents should be informed of the potential for any deformity development.