Management of Malunions and Nonunions Following Elbow Trauma

Abstract

Fractures in children are common in pediatric orthopaedic practice with the majority having positive outcomes with standard treatment. However, complications can develop and clinicians should be aware of common sequelae of pediatric elbow trauma and understand their prevention and treatment. The focus of this article is to provide an overview of common sequelae following pediatric elbow trauma including malunions of supracondylar humerus fractures and nonunion of lateral condyle, radial neck, and medial epicondyle fractures. Key Concepts • Coronal malunions of supracondylar humerus fracture have been largely recognized as cosmetic deformities but do demonstrate a propensity for late lateral condyle fracture and ulnar nerve dysfunction. Corrective osteotomy is the preferred surgical treatment, taking care to orient the osteotomy obliquely to the distal humerus to prevent excessive lateral prominence. • Sagittal plane malunions of supracondylar humerus fractures have the capacity to remodel in patients 5 years and younger but are nearly nonexistent in patients over 8 years. • Lateral condyle nonunion is best prevented by initial treatment based on initial fracture displacement. Established nonunions can be successfully treated with surgical intervention based upon the patient's skeletal maturity, size and location of osseous fragment, and associated deformity. • Radial neck nonunion is a rare complication but one that is particularly challenging for surgical treatment. Non-surgical treatment measures are the preferred treatment approach with surgical treatment reserved for severe cases. • Nonunion of the medial epicondyle is a frequent occurrence following nonsurgical treatment of medial epicondyle fracture but is symptomatic in only 21% of cases. For large osseous fragments, open reduction with nonunion repair and screw fixation is preferred while fragment excision and suture anchor repair are reserved for small fragments or revision cases with deficit bone.