43 Complications of Pediatric Elbow Dislocations and Monteggia Fracture-Dislocations Scott H. Kozin, MD Joshua M. Abzug, MD Shannon Safi er, MD Martin J. Herman, MD Abstract management. This chapter discusses Pediatric elbow dislocations and Monteggia lesions are prone to acute and chronic compli- the acute and chronic complications of cations. A pediatric patient’s cartilaginous and unossifi ed distal humerus contributes to pediatric elbow dislocations and Mon- the risks of inaccurate diagnoses resulting from the misinterpretation of fi ndings on plain teggia fracture-dislocations. radiographs. The debate continues regarding the amount of acceptable displacement for medial epicondyle fractures. In contrast, the radial head should always point directly to Pediatric Elbow Dislocations the capitellum. Chronic complications include instability and arthritis. Instability, which Pediatric elbow dislocations are rel- can be subtle and diffi cult to diagnose, can occur in the medial or the posterolateral direc- atively uncommon; however, the ad- tion, depending on the injured stabilizer. Restoration of stability remains the mainstay vent of extreme sports has resulted in of treatment. Pediatric traumatic arthritis is extremely diffi cult to manage with surgery an increasing number of high-velocity because of the limited number of reliable treatment options. injuries in children. Similar to adults, Instr Course Lect 2015;64:493–498. posterior dislocations are the most common injury pattern.1,2 Children are Pediatric injuries about the elbow are additional imaging is warranted to bet- prone to apophyseal injuries instead common. Treatment requires accurate ter detail the anatomy. This chapter’s of ligamentous tears. After an elbow recognition and prompt management. authors prefer intraoperative arthrog- dislocation, the medial epicondyle with In children, the cartilaginous and un- raphy to delineate pathology and direct its attached collateral ligament is fre- ossifi ed distal humerus can confound treatment. Early treatment of pediatric quently displaced. the injury diagnosis. In equivocal cases, elbow injuries is more reliable than late Acute Complications When assessing radiographs of an el- Dr. Kozin or an immediate family member serves as a paid consultant to or is an employee of Checkpoint Surgical and serves as a board member, owner, offi cer, or committee member of the American Society for Surgery of the Hand. Dr. Abzug or bow dislocation, identifi cation of the an immediate family member serves as a paid consultant to or is an employee of Axogen. Dr. Safi er or an immediate family medial epicondyle is crucial. Specifi - member is a member of a speakers’ bureau or has made paid presentations on behalf of Orthopediatrics and serves as a paid cally, a diligent search is necessary to consultant to or is an employee of Orthopediatrics and Medicrea. Dr. Herman or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons and the Pediatric ensure that the medial epicondyle is Orthopaedic Society of North America. not residing within the ulnohumeral © 2015 AAOS Instructional Course Lectures, Volume 64 493 Pediatrics Figure 1 A, Lateral radiograph of the elbow of a 15-year-old, right hand–dominant adolescent boy with a posterior elbow dislocation and a displaced medial epicondyle fracture. B, A sagittal CT scan confi rms that the medial epicondyle is within the ulnohumeral joint. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.) (Figure 1, B). Prompt recognition of Chronic Complications the position of the epicondyle allows Chronic complications after elbow urgent surgical removal and fracture dislocations are typically related to in- fi xation. Failure to recognize the in- stability. Instability can occur in two carcerated medial epicondyle results in different scenarios: valgus instability pain and stiffness (Figure 2). or recurrent elbow dislocations.3,4 Val- When the elbow joint is not reduced, gus instability is related to nonunion secondary calcifi cations with resultant or malunion of the medial epicondyle stiffness in the elbow capsule are com- fracture and associated medial collateral mon. These calcifi cations may be mis- ligament insuffi ciency. The instability interpreted as an additional injury. After often presents years after an injury as the incarcerated medial epicondyle is the child increases his or her activity recognized, urgent removal is indi cated. level and valgus stress. The diagnosis Delayed extrication of the medial epi- requires a physical examination and Figure 2 A 12-year-old boy had condyle is diffi cult and often results imaging studies, such as intraoperative persistent stiffness after an elbow in suboptimal fi xation. Intraoperative fl uoroscopy. Examination under anes- dislocation that occurred 3 months earlier. CT scan shows the medial fl uoroscopy is benefi cial in terms of thesia may be necessary to confi rm the epicondyle within the ulnohumeral identifying the fragment and guiding diagnosis. The initial treatments are ac- joint and periarticular calcifi cations. relocation of the epicondyle into the tivity modifi cation and fl exor-pronator (Courtesy of Shriners Hospital for Children, Philadelphia, PA.) optimal position. Fixation can be ac- strengthening. Failure to curtail the in- complished using a cannulated screw stability requires medial collateral liga- system or with tension wire fi xation. ment reconstruction4 (Figure 3). The The choice depends on the size and the procedure is complicated by malposi- joint1 (Figure 1, A). If there is any consistency of the fragment. The goal is tion of the epicondyle and distortion question about the location of the simply to obtain a stable ulnohumeral of the anatomy. Therefore, medial col- medial epicondyle, advanced imaging joint with adequate motion for activities lateral ligament reconstruction requires studies can accurately assess its position of daily living. ingenuity with regard to distal humeral 494 © 2015 AAOS Instructional Course Lectures, Volume 64 Complications of Pediatric Elbow Dislocations and Monteggia Fracture-Dislocations Chapter 43 Figure 3 A 13-year-old adolescent was unable to participate in gymnastics after a right elbow dislocation that occurred 2 years earlier. The elbow examination under anesthesia showed valgus instability. A, Radiograph shows a displaced medial epicondyle at the ulnohumeral joint (arrow). B, Intraoperative photograph of medial collateral ligament reconstruction using autograft tendon. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.) fi xation in this setting. The fragment undetermined reliability in children.6 consideration of biologic resurfacing may be left alone or excised depending The initial treatment for recurrent el- procedures, such as distraction inter- on its location with reference to the bow dislocation is activity modifi cation position arthroplasty or osteochondral ligament reconstruction. This recon- and fabrication of a hinged elbow brace autograft transplantation mosaicplasty. struction can restore stability and allow that blocks terminal extension and supi- Osteochondral autograft transplanta- a return to normal activity; however, nation. Because the local tissue is usu- tion mosaicplasty is indicated for de- activities requiring a high level of valgus ally inadequate for imbrication, lateral fi ned symptomatic defects, whereas elbow motion, such as gymnastics, may collateral ligament reconstruction is re- interposition arthroplasty is indicated not be possible. quired.7-9 The procedure is complicated for global loss of articular cartilage.10-12 Recurrent elbow dislocation is a by the open physis because docking into Interposition arthroplasty is designed rare problem.3 In contrast to valgus the distal humerus must avoid crossing to resurface the elbow joint to eliminate instability and medial insuffi ciency, re- the growth plate. Reconstruction can pain and enhance motion. In the gin- current dislocation is related to lateral restore stability and prevent further glymus, or elbow hinge joint, it appears collateral ligament defi ciency. The di- dislocations. Return to normal activity more suitable than in multiplanar joints. agnosis requires a physical examination is possible after recovery. Minimal resection of bone, careful re- and possible examination under anes- Osteonecrosis and/or arthritis can pair of the collateral ligaments, and dis- thesia. The posterolateral pivot shift occur after an elbow dislocation and traction of the joint surfaces (distraction test is unreliable in the awake child, and may be more likely in patients with a interposition arthroplasty) improves examination under anesthesia is often delayed diagnosis and open reduction. stability, decreases shear forces, and necessary to confi rm the posterolat- Loss of articular cartilage is a challeng- promotes healing of the graft. A hinged eral instability.5 Other tests, including ing problem in children. Asymptomatic external fi xator is helpful to distract the the chair sign, the fl oor push-up sign, arthritis does not merit extensive inter- articulating surfaces and permits imme- and the table-top relocation test, have vention. Symptomatic arthritis requires diate movement while protecting the © 2015 AAOS Instructional Course Lectures, Volume 64 495 Pediatrics interposition and soft-tissue repairs. ligament(s) and the common extensor Other treatment options include total and/or fl exor origins with transosseous elbow arthroplasty (contraindicated