Groningen, The Netherlands
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Crooked Elbow After a Fracture
Complaint: the parents come with the complaint that their child’s elbow has become crooked after a fracture. The forearm points outwards or inwards with respect to the upper arm.
Assessment: there is a valgus or varus deformity at the elbow.
Diagnosis: posttraumatic cubitus valgus or varus
Explanatory note: posttraumatic cubitus valgus or varus. This usually occurs after a supracondylar humeral fracture. If it has insufficiently been reduced a valgus or varus deformity may occur (Fig. 6.1). In 90 % of cases of misalignment there is a varus deformity and in 10 % a valgus deformity. The valgus deformity in particular gives problems, in for instance eating. The child may have to abduct the shoulder 90° to get its hand up to its mouth.
Varus deformity of the right elbow after a supracondylar humeral fracture
After an inadequate reduction or redislocation of a lateral humeral condyle fracture a valgus deformity or a non-union resulting in a consequent valgus deformity and a tardy ulnar nerve palsy will develop (Fig. 6.2).
Anteroposterior (a) and lateral X-ray (b) of the right elbow. Non-union of the lateral humeral condyle with a valgus deformity of 40° and recurvation deformity of 50°. Situation 17 years after the injury. At time of injury the child was 4 years old
Supplementary assessment: an anteroposterior and lateral X-ray of the elbow.
Primary care treatment: a general practitioner can assess whether the deformity gives rise to functional problems.
When to refer: only in cases with functional problems.
Secondary care treatment: posttraumatic cubitus valgus or varus. If there are in case of a supracondylar humeral fracture severe functional problems a supracondylar correction osteotomy may be considered in order to correct the deformity.
A lateral humeral condyle fracture with a malunion less than 2 months and/or a non-union less than 6 months old may be revised for anatomic reduction. The complication rate of these procedures of joint stiffness, ischemic necrosis and premature physeal closure is very high. In the literature the consensus is a “hands-off” policy for a fracture 3 weeks old or more. The valgus deformity may be treated by a supracondylar closing wedge osteotomy. When the cubitus valgus is due to a non-union of the lateral condyle fracture both conditions require treatment. Besides the supracondylar closing wedge osteotomy an attempt should be made to fuse the metaphyseal fragment of the lateral condyle to the metaphysis.
At the earliest signs of an ulnar nerve entrapment the ulnar head is transferred anteriorly to the medial epicondyle.
Repeated Elbow Subluxation/Dislocation
Complaint: the child complains that the elbow keeps shifting out of its socket with or without a preceding trauma.
Assessment: the elbow subluxation/dislocation is usually reduced when the child goes to the general practitioner. In this case, no anomalies are found.
recurrent elbow subluxation/dislocation
voluntary elbow subluxation/dislocation
habitual elbow subluxation/dislocation
recurrent posttraumatic elbow subluxation/dislocation
Explanatory note: recurrent elbow subluxation/dislocation. There are three types of elbow subluxation/dislocation.
Voluntary elbow subluxation/dislocation
Habitual elbow subluxation/dislocation
A habitual elbow subluxation/dislocation refers to repeated subluxation/dislocation in a normal child with no ligamentous laxity or preceding significant elbow trauma.
This is a rare anomaly. In more than 90 % of cases it is a posterior or posterolateral dislocation. In 10 % of cases the anomaly is bilateral. This anomaly is more common among boys. Sometimes defects develop on the lateral side of the capitellum and radial head.
Recurrent posttraumatic elbow subluxation/dislocation
This type is a sequela from a nonunion of a medial epicondular fracture or due to residual instability from a previous dislocation. In contrast to a voluntary or habitual elbow subluxation/dislocation, the subluxations/dislocations are painful in this type.
Supplementary assessment: anteroposterior and lateral X-rays of the elbow.
Primary care treatment: in a voluntary or habitual dislocation there should be a wait-and-see policy at first, most of the time spontaneous cure occurs after 2 years after the initial subluxation/dislocation. There is also no indication for further treatment if a subluxation/dislocation occurs only once a year or even less frequently. The parents are encouraged to persuade the child to avoid dislocations.
When to refer: referral to an orthopedic surgeon after a recurrent posttraumatic subluxation/dislocation and 2 years after the initial voluntary subluxation/dislocation if this still leads to subluxation or dislocation.
An habitual elbow subluxation/dislocation does not need to be referred.
Secondary care treatment: recurrent posttraumatic and voluntary elbow subluxation/dislocation. Before operation one should try an elbow brace for a period of 6 months and wait-and-see if that’s enough to prevent subluxation/dislocation. In case of residual instability from a previous traumatic dislocation and in a voluntary subluxation/dislocation reefing and reatachment of the capsular ligament apparatus on the posterior side for a posterior or posterolateral dislocation or on the anterior side for an anterior dislocation. Operative correction is indicated in the case of a pseudarthrosis after a medial epicondylar fracture. In exceptional cases it may be necessary to place a bone block to limit motion and prevent subluxation/dislocation.
Elbow Swelling on the Back or Front or Outer Side
Complaint: there are usually no complaints. Sometimes the child complains about a “click” or stiffness. The anomaly, which is present at birth, usually goes unrecognized until the child is 3–5 years old, when the parents see a swelling around the elbow. In other cases there has been an injury.
Assessment: a swelling is visible on the posterior (Fig. 6.3), anterior (Fig. 6.4) or lateral side depending on the direction of the subluxation/dislocation. In anterior dislocations there is a limitation in flexion, whereas in a posterior subluxation/dislocation there is a limitation in extension.
Bilateral congenital posterolateral radial head dislocation
Congenital anterior dislocation of the radial head
congenital radial head subluxation/dislocationmissed posttraumatic radial head subluxation/dislocation
Explanatory note: congenital radial head subluxation/dislocation. The subluxation/dislocation is frequently posterior but sometimes anterior or lateral. An anterior congenital radial head subluxation/dislocation is usually associated with a syndrome such as acrocephalopolysyndactyly, acrocephalosyndactily (Apert syndrome2) or Cornelia de Lange syndrome2. Through the years the swelling increases, so the problem is easier to recognize. Sometimes movement of the forearm will not be possible as a consequence of a bony connection between the proximal part of the radius and the ulna, called a radioulnar synostosis (see p. 84).
Missed posttraumatic radial head subluxation/dislocation
A congenital radial head subluxation/dislocation should be distinguished from a missed traumatic subluxation/dislocation. A radial head subluxation/dislocation occurs especially after a fractured ulna (Monteggia fracture) which is missed in 20–50% of cases.
Supplementary assessment: an anteroposterior and lateral X-rays of the elbow. X-rays of the entire forearm are required to determine whether there is a posttraumatic dislocation with or without an old fracture of the ulna or a radioulnar synostosis.
Primary care treatment: the general practitioner can explain to the parents that there is no point in treating a congenital radial head dislocation until the child is around 10 years of age. Operative removal of the radial head may be considered. Physiotherapy will not help this problem.
When to refer: after the age of 10 if pain, functional and/or cosmetic problems are present, or if there has been an old Monteggia fracture.
Secondary care treatment: congenital radial head subluxation/dislocation. Operative reduction of a congenital radial head subluxation/dislocation and reconstruction of the annular ligament is not advisable for this anomaly. The nature of the deformation of the joint and the soft parts make this nearly impossible. Only in the case of pain and/or functional and/or cosmetic problems may one consider removal of the radial head after the age of 10. However, even after such an operation it is possible that the mobility of the elbow will not increase and the function will not improve. It is preferable not to remove the radial head before 10 years of age because that causes a progressive valgus deformation in the elbow.
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