The Pediatric Elbow: Congenital and Reconstructive
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IC 02: The Pediatric Elbow: Congenital and Reconstructive Moderator(s): Ann E. Van Heest, MD Faculty: Ann E. Van Heest, MD, Michelle A. James, MD, Lisa L. Lattanza, MD, Charles A. Goldfarb, MD Session Handouts Thursday, September 05, 2019 74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 – 7, 2019 LAS VEGAS, NV 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. Instructional Course: IC02: The Pediatric Elbow: Congenital and Reconstructive Handout Date: 9/5/2019 Session Time: 4:45 - 6:00 PM Moderator: Ann E. Van Heest, MD 1. To describe normal pediatric elbow anatomy, and congenital conditions such as radial-ulnar synostosis and congenital radial head dislocations (Dr. Ann Van Heest) 2. To describe the pathoanatomy and treatment options for congenital elbow joint contractures (arthrogryposis) (Dr. Michelle James) 3. To describe the pathoanatomy and treatment options for post-traumatic elbow deformity (Cubitus varus, cubitus valgus, missed Monteggia) (Dr. Lisa Lattanza) 4. To describe the pathoanatomy and treatment options for elbow osteochondritis dissecans (Dr. Charles Goldfarb) 6/29/2019 Radio-Ulnar Synostosis and Growth Plates Radial Head Dislocation Ann E. Van Heest MD • Capitellum University of MN • Radial Head • Internal Gillette Childrens Specialtycare Epicondyle Shriner’s Clinic- Twin Cities •Trochlea • Olecranon • External C-R-I-T-O-E 1-3-5-7-9-11 Epicondyls OUTLINE Biomechanics of Load Share VALGUS/90°F •Anatomy ULNA • Radio-Ulnar Synostosis humerus RADIUS • Radial Head Dislocations Shepard M, Markolf K, Dunbar A. Effects of Radial Head Excision and Distal Radial Shortening Anatomy Growth Plates on Load-Sharing in Cadaver Forearm, JBJS 83A, 2001 VALGUS • Capitellum ULNA • Radial Head • Internal humerus RADIUS Epicondyle •Trochlea • Olecranon VALGUS • External ULNA Epicondyls humerus RADIUSRADIUS 60° 1 6/29/2019 CRUS: Embryologic Origin Clinical Management I. Failure of formation • Functional Adaptation Congenital Radial-Ulnar Synostosis II. Failure of differentiation • Ogino: Compensatory Wrist III. Duplication Rotation with R/U Synstosis IV. Overgrowth V. Undergrowth JHandSurg 1987 VI. Congenital band syndrome • 76 degrees Pronation VII. Generalized skeletal abnormalities • 43 degrees Supination Failure of longitudinal segmentation between the radius and ulna Left Side Affected anlage at seven weeks gestation Proximal Radial Congenital Radial Ulnar Synostosis (CRUS) Classification: Cleary and Omer Ulnar Synostosis Type Description • First described by Sandifort (1793) • Most frequesnt congenital elbow anomaly I Normal radiographs (fibrous synostosis with reduced radial head) • Incidence: Unknown (undiagnosed) II Bone synostosis only, reduced radial head • <500 reported cases III Bone synostosis with posteriorly dislocated radial head IV Bone synostosis with anteriorly dislocated radial head JBJS 1985 CRUS Cleary J, Omer G: Congenital proximal Surgical Managment radio-ulnar synostosis. Natural history and functional assessment. JBJS 1985 • Difficulty in 1. Hyper-extreme position accepting items • n=23 patients • Occupation, Pain, • 13 unilat, 10 bilat into the hand Jebsen Hand Fx 2. Ulnar overgrowth • Age 22 (3-50) • No significant • Average position impairment 3. Omer Type IV with symptomatic 30 degrees • No indication for radial head dislocation pronation intervention 2 6/29/2019 8 yo Unilateral PRUS- Elbow F/E Post Op Surgical Managment Hyperpronation 1. Hyper-extreme position 2. Ulnar overgrowth 3. Omer Type IV with symptomatic radial head dislocation s/p 90 ◌۫ Rotational Osteotomy Surgical Managment Anterior Radial Head Dislocation with Mechanical Symptoms 1. Hyper-extreme position 2. Ulnar overgrowth 3. Omer Type IV with symptomatic radial head dislocation Forearm Pron/Sup Post Op PRUS with ulnar + overgrowth Anterior Radial Head Dislocation with Mechanical Symptoms 3 6/29/2019 Anterior Radial Head Dislocation with Clinical Presentation: Congenital Radiographic Presentation: Congenital Mechanical Symptoms • “Elbow bump” • Flat or domed shaped radial head • Present in youth or • Underdeveloped adolescence capitellum • Longer radius than normal • Subluxation/dislocation Conclusions: Congenital R-U Synostos Clinical Presentation Radiographic Presentation • Failure of • “double elbow • Posterior-lateral bump” Differentation • 2/3 of cases • 4 types • Significant Adaptation • Surgical Intervention Rare Oto-palatal digital syndrome Pathogenesis Radiographic Presentation • Most common congenital elbow • Anterior deformity Pediatric Radial Head Dislocation • 1/3 of cases • “Congenital” • 60%: Bilateral, familial, non- 1. Congenital traumatic, syndromic • 40%: Unilateral, isolated, 2. Traumatic non-traumatic • Traumatic? Developmental? Kelly JPO 1981 4 6/29/2019 16 year old female with painful subluxation with Mardem-Bey et al, JHand Surg 1979 Chronic Radial Head Dislocation in Children radial head overgrowth Kim et al (Korea) JPO 2002 • Elbow flexion 141° • Minimal functional • 2 bilateral congenital (14 children) (lack 9°) impairment • No pain, full function, limited ROM • Extension -17 ° • Shoulder/wrist • Radial shortening osteotomy, angular or • Pronation 45 ° compensation rotational correction, Bell-Tawse (triceps) annular ligament reconstruction • Supination 36 ° • 2 re-dislocations in the congenital group • + 11% F/E arc, -5% pron/sup arc Treatment Congenital Radial Head Dislocations Treatment: Radial Head Excision Sachar, Mih Hand Clinics 1998 • Observation • 12 elbows in 10 patients, • Excision- age? • Average age: 2 years old • Open Reduction • Open reduction with “annular ligament” re- suturing, K-wire 6-8 weeks • 10/12 reduced at 2 year follow-up • +pronation 25 °, +supination 18 °, F/E same Post-op Pain relief Open Reduction Excision of Radial Head 5 6/29/2019 Excision of the Radial Head for Congenital 16 YO isolated unilateral painful bump 11 yo Distal Arthrogryposis, elbow F 70 degrees Dislocation Campbell et al JBJS 1992 • 8 elbows in 6 patients • Ave age 13 years old (10-15 y.o.) • + flex/ext 11°, + pron/sup 53° • Improved elbow pain • Complication: mild wrist pain, one re-excision Goldfarb C, et al: Outcomes of Surgically and Nonsurgically Treated Painful bump 11 yo Distal Arthrogryposis, elbow F 70 degrees Congenital Isolated Radial Head Dislocations J Hand Surg Dec 2012 Limited ROM • Radial Head Surgical Non Surgical Resection N= 10 patients (5 bilateral) 6 patients (1 bilateral) • Intra-op Elbow Follow-up 10 yrs 16 yrs Flexion 100 degrees Pain (VAS) = 2 2 DASH = 23 13 Ulnar Varience +4.9 -0.2 Shepard M, Markolf K, Dunbar A. Effects of Radial Head Excision and Distal Radial Shortening Goldfarb C, et al: Outcomes of Surgically and Nonsurgically Treated Subluxation with Degenerative Changes on Load-Sharing in Cadaver Forearm, JBJS 83A, 2001 Congenital Isolated Radial Head Dislocations J Hand Surg Dec 2012 VALGUS ULNA • Surgically treated group humerus RADIUS • Age at surgery 15 (12- 18 yo) • Elbow Pre/Post F 137/135 Ext 27/23 VALGUS • Pre/Post Supination/Pronation 110/119* ULNA • Elbow Pain Pre/Post 8/2* humerus RADIUSRADIUS • 4 subsequent procedures: ulnar shortening 6 6/29/2019 Treatment: Observation 9 year old, cardiac surgery • Post operative Observation “bump” • No pain •No ROM limitation 4 year old Bilateral Anterior Dislocations 15 year old painfree elbow bump Anterior Radial Head Dislocations • Syndromic involvement • Oto-palatal digital syndrome • Hyperlaxity • Dentition 15 year old painfree elbow bump Anterior Radial Head Dislocations • Treatment: Observation 7 6/29/2019 Conclusions: Congenital RH dislocations OUTLINE • Treatment Options •Anatomy • Observation • Congenital Radio- Ulnar Synostosis • Excision • Congenital Radial • Open reduction Head Dislocations • Beware of other conditions OUTLINE OUTLINE •Anatomy •Anatomy • Congenital Radio-Ulnar • Congenital Radial Synostosis Head Dislocations • Congenital Radial Head • Traumatic Radial Dislocations Head Dislocations • Acute Monteggia • Chronic Monteggia OUTLINE •Anatomy • Congenital Radio-Ulnar Synostosis • Congenital Radial Head Dislocations 8 8/15/2019 Arthrogryposis Multiplex Congenita: Treatment of Elbow Contracture Michelle A. James, MD Shriners Hospital Northern California UC Davis School of Medicine Sacramento CA Upper Extremity in Arthrogryposis • Spectrum of involvement – Level, severity, bilaterality – Will the child ambulate? • Elbow in the context of other deformities – Shoulder, arm – Forearm, wrist – Thumb, fingers – Spine – Lower extremities – Contralateral elbow Elbow Extension Contracture • Flexibility & power are separate issues • Elbow must be flexible before muscle transfer • Operations to consider: – Posterior capsulotomy & triceps lengthening – Steindler flexorplasty – Long head of triceps transfer to biceps • Operations to avoid (poor long term results): – Pectoralis major transfer to biceps – Triceps transfer to biceps 1 8/15/2019 Elbow Extension Contracture • Family commitment – Ability to participate in stretching and splinting – Extent of disability may be overwhelming – Treatment of clubfeet may be burdensome • Occupational therapy support & consultation Elbow Extension Contracture • Shared goals – Flexibility alone may be sufficient • Independent performance of most ADL’s is possible • PC & TL may render long head of triceps transfer less