Cubitus Valgus Deformity Research Articles

Supracondylar Dome Osteotomy for Cubitus Valgus Deformity Associated with a Lateral Condylar Nonunion in Children

Open reduction, autogenous bone-grafting, and internal fixation for the treatment of established nonunion of the lateral condyle associated with a cubitus valgus deformity has a high rate of complications. As a consequence, we developed a new technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision. Eight consecutive patients were treated with the new surgical technique between 1994 and 2000. The mean age at the time of surgery was 8.6 years. The mean interval between the lateral condylar fracture and surgery was 4.9 years. The mean preoperative radiographic humerus-ulna angle was 31 degrees of valgus. The postoperative results were classified with a modification of the scoring system described by Dhillon et al., which assesses pain, weakness, range of motion, the humerus-ulna angle, and prominence of the medial epicondyle on a 12-point scale. All eight lateral condylar nonunions achieved union within three months postoperatively. The mean postoperative humerus-ulna angle was 5.5 degrees of valgus. All of the supracondylar dome osteotomies healed uneventfully, and there was no loss of correction postoperatively. The mean duration of follow-up was 4.5 years. The overall results were excellent in two patients, good in four patients, and fair in two patients. With better exposure of the lateral condylar nonunion through a posterior approach, we can effectively stabilize the lateral condylar nonunion and avoid postoperative loss of motion and osteonecrosis of the condyle. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. With careful selection of patients, this new technique can be an effective method to treat this clinically challenging problem.

A Comparison of Closed Reduction and Open Reduction in Children with Fracture of Lateral Humeral Condyle

Purpose: The fracture of humeral lateral condyle in children was classified and the complications and results were analyzed according to the treatment modality and the types of fracture. Materials and Methods: 92 patients who could be followed upone year or more, and were treated for a humeral lateral condyle fracture from May 1995 to May 2001 were studied. 66 cases were male, 26 cases were female, and 79 cases were under 9 years of age. The Milch stage I encountered in 12 cases, and II in 80 cases. Jacob stage I were encountered in 15 cases, stage II in 59 and stage III in 18 cases. Conservative treatment was performed in 9 cases and surgery was performed in 83 cases. A closed reduction and internal fixation with K-wire was performed in 18 cases, and an open reduction and internal fixation as performed in 65 cases. Results: The change in the carrying angle was not clinically significant except for 7 cases, with a cubitus varus and cubitus valgus deformity. The change in the carrying angle showed an average -1.3 (from +7 to -18). The results according to the Hardacre criteria were 'excellent' in 46 cases, 'good' in 41 and 'poor' in 5. Regarding the complications, bony spur formation was encountered in 8 cases, overgrowth of the lateral condyle and cubitus varus in 4, cubitus valgus in 3, avascular osteonecrosis in 3, premature epiphyseal fusion in 2, nonunion in 2, delayed union in 1, fish-tail deformity in 1, local infection in 5, range of motion limitation in2 and transient radial nerve palsy in1 case. Conclusion: Humeral lateral condylar fractures have a high rate of complications and clincally significant complication appeared mainly in stage II and III. This suggests that more a careful dissection of the soft tissue and anatomical reduction in Jakob stage III is required in cases of an open reduction.

The short stature homeobox gene SHOX is involved in skeletal abnormalities in Turner syndrome.

Turner syndrome is characterized by short stature and is frequently associated with a variable spectrum of somatic features including ovarian failure, heart and renal abnormalities, micrognathia, cubitus valgus, high-arched palate, short metacarpals and Madelung deformity. Madelung deformity is also a key feature of Leri-Weill syndrome. Defects of the pseudoautosomal homeobox gene SHOX were previously shown to lead to short stature and Leri-Weill syndrome, and haploinsufficiency of SHOX was implicated to cause the short stature phenotype in Turner syndrome. Despite exhaustive searches, no direct murine orthologue of SHOX is evident. SHOX is, however, closely related to the SHOX2 homeobox gene on 3q, which has a murine counterpart, Og12x. We analysed SHOX and SHOX2 expression during human embryonic development, and referenced the expression patterns against those of Og12x. The SHOX expression pattern in the limb and first and second pharyngeal arches not only explains SHOX -related short stature phenotypes, but also for the first time provides evidence for the involvement of this gene in the development of additional Turner stigmata. This is strongly supported by the presence of Turner-characteristic dysmorphic skeletal features in patients with SHOX nonsense mutations.

The Result After Surgical Treatment on Lateral Condyle Fracture of Humenu in Children

Fracture of the lateral condyle of humerus in children are common injury next to supracondylar fracture in children, account for 10 to 15% about the elbow and 18 to 20% about distal humerus fractures. This is the one fracture that can be overlooked clinically and that has a high potential for nonunion and cubitus valgus deformity. Sixty children treated by closed or open reduction with internal fixation on the lateral condyle fracture of humerus from January 1994 to August 1997, were reviewed. Almost fractures were treated within 12 hours after injury for the purpose of prevention of further displacement and occurrence of complication. According to Hardacre et al’s criteria, most patients showed excellent and good results. We report the result after surgical treatment on the lateral condyle fracture of humerus in children.

Osteosynthesis for the Treatment of Non-Union of the Lateral Humeral Condyle in Children*

We reviewed the results of osteosynthesis for the treatment of an established non-union of the lateral humeral condyle in sixteen children whose average age was nine years (range, four to thirteen years) at the time of the operation. The average interval between the injury and the operation was five years (range, five months to ten years). The presenting symptoms were pain in the elbow in seven patients, apprehension in nine, a cubitus valgus deformity in six, limitation of motion in three, and dysfunction of the ulnar nerve in four. The average duration of follow-up was eleven years (range, four to thirty-two years). Osseous union was achieved after the initial operation in thirteen patients. Of the three patients who had a persistent non-union, two had a second operation and the third, who was asymptomatic, refused additional operative intervention. The result was rated excellent in eight patients, good in seven, and poor in one, with use of a modification of the functional rating index of Broberg and Morrey. The patient who had a poor result had evidence of avascular necrosis of the fragment.

FRACTURES OF THE LOWER END OF THE HUMERUS IN CHILDREN

Contrary to prevailing opinion, supracondylar fractures can produce serious growth disturbances if the fracture lines extend into the epiphyseal centers. Cubitus varus and cubitus valgus are not considered serious disabilities, if flexion and extension are complete. However, if the deformity is progressive and is caused by disturbances in the growth centers, disabilities and limitation of motion may occur years after the initial injury. A satisfactory reduction is one in which the alignment in both planes is good. An anterior or posterior displacement of the fragments, in which the articular surfaces are displaced to a corresponding degree, will produce permanent limitations of flexion and extension. Lateral displacement above the epiphyses will produce valgus and varus deformities, but a good functional elbow may still result. Supracondylar fractures in which the fracture line, or part of it, extends into the epiphyses may produce growth disturbances similar to those which result from fractures of the lateral and medial condyles. If the fragment is intra-articular and not attached to overlying bone and soft tissue, it will undergo avascular necrosis. Supracondylar fractures of this type should have an accurate anatomical reduction; and, if the fragments are displaced and rotated, an open reduction is probably the best method of obtaining accurate alignment. A series of lateral condylar fractures, in which there were poor results in 50 per cent, of the cases treated by closed reduction, speaks for the ineffectiveness of this method. Early open reduction with minimal trauma to soft tissues will give the best results. Avascular necrosis of the capitellum will occur if the fracture line separates the epiphysis from the overlying bone and soft tissues. Fractures of half of the capitellum occurred in two patients with lateral condylar fractures. One had poor apposition by open reduction, and avascular necrosis occurred in one year. In the other, the separation was not complete, the position was good, and healing was uneventful. Avascular necrosis of the trochlea may occur later, despite a good reduction of a supracondylar fracture. It can cause stiffness at the joint, due to thinning of the cartilage and distortion of the articular surface of the humerus. Delayed ulnar palsy may cause progressive growth disturbances, and was present in two cases of severe cubitus valgus deformity. Fracture of the medial epicondyle will not cause a serious disability unless the fragment enters the joint cavity. Non-union is difficult to avoid in closed reduction.