The Pediatric Elbow: Congenital and Reconstructive

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 effective – Position of ipsilateral shoulder: ERO of humerus? – Position of contralateral elbow: fall recovery? • Anesthesia risk – Difficult airway & venous access – Stage interventions carefully (elbow, wrist, thumb, LE’s)

Passive Stretching

• Elbow must be flexible before muscle transfer • Good gains from passive stretching in infancy

2 8/15/2019

Posterior capsulotomy & triceps lengthening

• Reliably gains 40o flexion • “V-Y”, “W” or stepcut lengthening • Post-operative therapy and splinting is important – Alternating flexion and extension to avoid development of flexion contracture • Van Heest JBJS 2008

Steindler flexorplasty

• Advancement of the bony origin of the flexor/pronator mass proximal and lateral (from the medial epicondyle to the distal humerus) • Requires – Good strength in flexors – Stable wrist in neutral or extension (dorsal carpal wedge osteotomy) • Goldfarb JHS 2004

Long head of triceps transfer

• Functions as adductor of arm, independently of the remainder of the triceps • Requires – 90o passive flexion Triceps: – Requires 4/5 triceps strength Long, lateral & – Ability to cooperate with therapy medial post-op heads – Fascia lata interposition graft • Prior PC & TL may be a contraindication • Gogola THUES 2010: 121

3 8/15/2019

Other operations

• Staged or simultaneously with restoration of elbow flexibility or power, as indicated: – External rotation osteotomy of the humerus – Dorsal carpal wedge osteotomy – First web space deepening with index dorsal rotation flap

Elbow Extension Contracture Algorithm: Flexibility

Elbow Extension Vigorous passive stretching (< 1 year) Contracture

< 60o flexion: PC & TL

60-90o: continue stretching, splinting

> 90o flexion: nighttime splint

Elbow Extension Contracture Algorithm: Power

• Passive flexion maintained (≥ 90o) • Weak or absent active flexion that limits activities • Able to cooperate with therapy (> 3 years)

Steindler flexorplasty Long head of triceps transfer • Strong finger/wrist flexors • Strong triceps • Stable wrist (in neutral or • Possibly contraindicated after PC &TL extension)

Other UE reconstruction, staged or simultaneously, as indicated

4 7/7/19

IC#2 The Pediatric Elbow: Congenital and Reconstructive Capitellar Osteochondritis Dissecans

Charles A. Goldfarb, M.D. Charles A. Goldfarb, M.D.

Objectives Vascularity

• Background • Theory of compromised • Clinical Presentation/ vascularity Evaluation • Inability to heal repetitive trauma

Kobayashi K, et al J Am Acad • Treatment Algorithm • Subchondral damage and Orthop Surg 2004;12[4]:246-254 articular cartilage failure

Clinical Presentation AJSM, 2014 • Throwing athletes • Loading athletes (gymnasts) • 10-15 years of age • 2433 baseball players • US and clinical exam, then radiographs • 82 w OCDs • Started younger, played competitively for longer, had elbow pain

1 7/7/19

Clinical Presentation Clinical Presentation

• Symptoms • Exam Findings – Pain in the lateral elbow with loading (~98%) – Tenderness over the radiocapitellar joint – Decreased performance (~60%) – Effusion/ swelling – Swelling (~18%) – Decreased motion • Catching/ locking symptoms = – Mechanical symptoms w/ loose body loose body – May have crepitus with pronation/supination in extension

Radiographs

• Anterior-Posterior (AP) view JSES 2015 • 45 degree flexion view • Radial head view • Minami, Berndt and Harty, Ferkel and • Lateral view Sgaglione, Anderson • All fair or poor reliability- Minami best at 0.27

Takahara JBJS 2008 • My take away- MRI and arthroscopy key

MRI Treatment Algorithm

• Confirm the diagnosis Factors to consider • Lesion size and location • Patient age (physeal status) • Contained vs uncontained • Cartilage integrity • Stability of OCD • Loose bodies • Containment • Stable vs unstable – Waters, JPO 2012 – High signal line behind the fragment is most predictive of an unstable lesion.

2 7/7/19

Stability Non-operative Treatment

• Treatment depends on • Outcomes depend on stability and skeletal – stability, maturity • 25/30 with early stage defects healed – chronicity, • 1/9 advanced stage defects healed – age of patient • 16 /17 patients with an open growth plate healed • Stable lesion, open growth plate, benign • Average 4 months to heal exam- rest for 6 months • 11/22 patients (50%) with a closed growth plate healed • Average 8 months to heal Mihara et al. AJSM. 2009 Feb;37(2):298-304.

Surgical Treatment

• Stage III and Stage II (failed nonop) • Considerations – Loose bodies – Microfracture options • Antegrade or retrograde drilling JPO 2015 – Unstable fragment fixation – OATs

• 26 elbows, 24 patients Increased healing if: • Unstable, in situ • Age <15 years • 20/26 healed (77%) • Width <13mm • Improved function with 2/3 return to sports • Thickness <6mm

3 7/7/19

JPO 2015 • 21 patients reviewed • Younger patients (open physis) • 18 returned to any sport, 14 to • Smaller lesion primary sport • Contained • Av. 2 years to return • 4 required additional surgery

• 11 patients, 14.5 years of age • All returned to their sport, average 4.5mo • DASH and motion improved

Return to Sport Take Home Message

• Westermann, et al Ortho J Sports Med 2016 • Capitellar OCD is increasing prevalent – Systematic Review and Meta Analysis • Examination/ pathology understanding key – 24 studies, 492 patients • Treatment algorithm in evolution – 86% overall RTP after surgery – 94%, highest, with OATs

4 7/7/19

5

Speaker has not provided a handout for this presentation