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Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus
Technical Note
Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus Luis Perez Carro, M.D., Ph.D., Pau Golano, M.D., and Jordi Vega, M.D.
Abstract: Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (⬎2 mm) lateral condyle fractures is open reduction–internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopicassisted reduction. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries. Key Words: Elbow—Pediatric—Reduction.
F
ractures of the lateral condyle in children are not rare. Anatomic reduction obtained by direct visualization through an arthrotomy or intraoperative arthrography, followed by closed reduction and percu-
From the Hospital Universitario Marqués de Valdecilla (L.P.C.), Santander; Servicio Cirugia Ortopedica y Traumatologia, Centro Medico Lealtad (L.P.C.), Santander; Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona (P.G.), Barcelona; and Servicio Cirugia Ortopedica y Traumatologia, “La Mutua” Granollers (J.V.), Barcelona, Spain. The authors report no conflict of interest. Address correspondence and reprint requests to Luis Perez Carro, M.D., Ph.D., Avda Estadio 17D 3°IZ Santander 39005, Spain. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Perez Carro L, Golano P, Vega J. Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus. Arthroscopy 2007;23: 1131.e1-1131.e4 [doi:10.1016/j.arthro.2006.11.030]. 0749-8063/07/2310-6460$32.00/0 doi:10.1016/j.arthro.2006.11.030
taneous pinning, is the traditional treatment method for displaced fractures. Open surgical exposure increases the morbidity and introduces additional potential for complications. We describe in this report the accurate reduction of displaced intra-articular lateral condyle fractures through arthroscopic control. The advantages of this alternative treatment are excellent intra-articular visualization, decreased soft-tissue dissection, less radiation time, and shortened postoperative recovery. The cosmetic and functional results were excellent. Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intraarticular lateral condyle fracture have never been reported. OPERATIVE TECHNIQUE AND CASE REPORT An 11-year-old girl was involved in a bicycle accident, injuring her left elbow. Swelling and tenderness
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 10 (October), 2007: pp 1131.e1-1131.e4
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in the lateral region of the elbow and plain radiographs suggested a Milch type II1 and Rutherford type II2 fracture of the lateral condyle (Fig 1). The patient’s neurovascular status was normal. Five days after the injury, she was admitted for arthroscopy. After induction of general anesthesia, she was placed in the supine position. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal antero-
FIGURE 2. Arthroscopic view of left elbow showing fracture line. The arthroscope is in the proximal anteromedial portal, and a proximal anterolateral portal was created for instrumentation. (arrows, fracture site.)
FIGURE 1. Anteroposterior radiograph of left elbow showing Milch type II and Rutherford type II fracture of lateral condyle.
medial portal with no pump, and a proximal anterolateral portal was created for instrumentation. Blood, fibrin, and loose articular debris were irrigated from the joint. The fracture line and minimal changes consistent with cartilaginous contusion were easily visualized (Fig 2). No other associated injuries were found. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and by rotation until there was no step in the articular cartilage. The elbow was flexed and pronated to lock the reduction, and then 2 lateral Kirschner wires were placed percutaneously, which resulted in firm fixation of the fracture. During the procedure, we carefully checked for fluid extravasation. Arthroscopic observation confirmed that the wires had not violated the articular surface. Intraoperative radiographs (Figs 3 and 4) were taken to confirm satisfactory reduction and pin placement. The pins were cut short but were left protruding through the skin for subsequent removal. The skin incisions were closed with nylon suture, and a sterile bulky dressing and posterior splint were applied. The patient’s vasculonervous status was checked, and she was discharged as an outpatient. She was seen at 1 week after primary treatment, at which time the splint was removed, the pin sites were examined, and radiographs showed that the pins were in a satisfactory
LATERAL CONDYLE FRACTURES AND ARTHROSCOPY
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DISCUSSION Lateral condyle fractures of the distal humerus represent approximately 12% of childhood elbow fractures. Anatomic reduction of intra-articular displacement is considered a priority. Rutherford2 advocated treatment of lateral condyle fractures based on the stability of the fracture pattern and classified type I fractures as incomplete and nondisplaced, type II as complete with mild displacement, and type III as displaced laterally and rotated. He recognized that type II fractures are prone to progressive displacement and should be monitored carefully. A shortcoming of this classification system is that it may be difficult to judge articular surface continuity on a plain radiograph. Failure to recognize displacement or rotation in fractures treated in a closed manner or with percutaneous pinning and failure to visualize the intra-articular component of the fracture and obtain an anatomic reduction are important pitfalls, because of the possibility of late displacement and development of a non-
FIGURE 3. Anteroposterior radiograph showing satisfactory reduction and pin placement.
position and the reduction maintained. A long arm cast was applied. At 4 weeks, the pins were removed. At 6 weeks, gentle active motion was allowed. At 8 weeks, radiographs showed excellent bone healing. Between February 2003 and February 2006, we successfully performed 4 cases of arthroscopeassisted reduction and percutaneous external fixation of Rutherford type II2 fractures of the lateral condyle, in 3 boys and 1 girl, with a mean age of 10 years, that yielded excellent results with no complications. No associated injuries were found. Radiographic union was evident at a mean of 8 weeks (range, 6 to 11 weeks). To date, there have been no complications, and all patients have full motion compared with the nonoperative side.
FIGURE 4. Lateral radiograph showing satisfactory reduction and pin placement.
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union, which may lead to valgus instability, pain, or tardy ulnar nerve palsy. Until now, the technique has been described only to judge articular surface continuity via open surgery and direct visualization or confirmed with arthrography in case of closed reduction and percutaneous pinning.3 Magnetic resonance imaging may be helpful in patients with minimally displaced fractures, but younger children will probably not have the discipline to sit still during imaging. Closed reduction with percutaneous pin fixation has been advocated by several authors to treat minimally displaced lateral condyle fractures because it avoids the significant rates of complications of open reduction: deep infection, scar, pain, nonunion, and avascular necrosis. Most of them performed arthrography and used an image intensifier in different planes before performing reduction and confirmed reduction of the articular segment before fixation. In recent years the treatment of fractures has evolved from extensive open reduction to minimally invasive surgery. Arthroscopy is increasingly being recognized as an important adjunct in the management of displaced intra-articular fractures. Adjunctive use of the arthroscope for accurate reduction of intra-articular fractures has been successful in the management of the distal radius,4,5 tibial plateau,6,7 ankle,8-10 distal femoral condyle,11 elbow,12 and shoulder.13 Elbow arthroscopy has provided a reliable means of visualizing the articular surface. Visual inspection, lavage, reduction of fracture fragments with an appropriate periosteal elevator, and pin fixation conducted under arthroscopic control can restore the articular surfaces of lateral condyle fractures with the advantages of more accurate fracture reduction, reduced surgical trauma, decreased soft-tissue dissection, shortened postoperative recovery, better cosmetic, and less radiation time. This technique also allows a diagnostic and treatment alternative for associated injuries and loose fragments, and conversion to arthrotomy can be done if needed. As in other arthroscopic-assisted fracture reduction procedures, we must check carefully for compartment syndrome during the procedure with prevention of fluid extravasation. A delay of 5 to 7 days reduces the risk of this complication and allows the bleeding to subside. Elbow arthroscopy is a technically challenging procedure, and attention to the neurovascular anat-
omy about the elbow is essential for the prevention of complications. Methods to avoid these complications are as follows: define anatomic landmarks before joint distension, use joint distension to increase the boneto-nerve distance, use proximally placed portals, keep the elbow flexed to increase the distance between the nerves and capsule, and always visualize the tip of the instruments. The surgical trauma associated with open operative treatment of lateral condyle fractures can be minimized via minimally invasive techniques. Arthroscope-assisted reduction and percutaneous external fixation of lateral condyle fractures should be considered in the treatment of this type of fracture. To our knowledge, this is the first report of this alternative approach. REFERENCES 1. Milch H. Fractures of the external humeral condyle. JAMA 1956;160:641-646. 2. Rutherford A. Fractures of the lateral condyle in children. J Bone Joint Surg Am 1985;67:851-856. 3. Skaggs D. Elbow fractures in children: Diagnosis and management. J Am Acad Orthop Surg 1997;5:303-312. 4. Cooney WP, Berger RA. Treatment of complex fractures of the distal radius. Combined use of internal and external fixation and arthroscopic reduction. Hand Clin 1993;9:603-612. 5. Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular distal radial fractures. Clin Orthop Relat Res 1996;327:125-134. 6. Caspari R, Hutton P, Whipple T, Meyers J. The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1984;1:76-82. 7. Jennings J. Arthroscopic management of tibial plateau fractures. Arthroscopy 1985;1:160-168. 8. Whipple TL, Martin DR, McIntyre LF, Meyers JF. Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy 1993;9:456-463. 9. Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy 1997;13: 117-119. 10. Kim HS, Jahng JS, Kim SS, Chun CH, Han HJ. Treatment of tibial pilon fractures using ring fixators and arthroscopy. Clin Orthop Relat Res 1997;334:244-250. 11. McCarthy JJ, Parker RD. Arthroscopic reduction and internal fixation of a displaced intraarticular lateral femoral condyle fracture of the knee. Arthroscopy 1996;12:224-227. 12. Rolla PR, Surace MF, Bini A, Pilato G. Arthroscopic treatment of fractures of the radial head. Arthroscopy 2006;22:233.e1233.e6. Available online at www.arthroscopyjournal.org. 13. Perez Carro L, Perez Nuñez M, Echevarria JL. Arthroscopicassisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture. Arthroscopy 1999; 15:211-214.
Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus Luis Perez Carro, M.D., Ph.D., Pau Golano, M.D., and Jordi Vega, M.D.
Abstract: Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (⬎2 mm) lateral condyle fractures is open reduction–internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopicassisted reduction. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries. Key Words: Elbow—Pediatric—Reduction.
F
ractures of the lateral condyle in children are not rare. Anatomic reduction obtained by direct visualization through an arthrotomy or intraoperative arthrography, followed by closed reduction and percu-
From the Hospital Universitario Marqués de Valdecilla (L.P.C.), Santander; Servicio Cirugia Ortopedica y Traumatologia, Centro Medico Lealtad (L.P.C.), Santander; Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona (P.G.), Barcelona; and Servicio Cirugia Ortopedica y Traumatologia, “La Mutua” Granollers (J.V.), Barcelona, Spain. The authors report no conflict of interest. Address correspondence and reprint requests to Luis Perez Carro, M.D., Ph.D., Avda Estadio 17D 3°IZ Santander 39005, Spain. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Perez Carro L, Golano P, Vega J. Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus. Arthroscopy 2007;23: 1131.e1-1131.e4 [doi:10.1016/j.arthro.2006.11.030]. 0749-8063/07/2310-6460$32.00/0 doi:10.1016/j.arthro.2006.11.030
taneous pinning, is the traditional treatment method for displaced fractures. Open surgical exposure increases the morbidity and introduces additional potential for complications. We describe in this report the accurate reduction of displaced intra-articular lateral condyle fractures through arthroscopic control. The advantages of this alternative treatment are excellent intra-articular visualization, decreased soft-tissue dissection, less radiation time, and shortened postoperative recovery. The cosmetic and functional results were excellent. Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intraarticular lateral condyle fracture have never been reported. OPERATIVE TECHNIQUE AND CASE REPORT An 11-year-old girl was involved in a bicycle accident, injuring her left elbow. Swelling and tenderness
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 10 (October), 2007: pp 1131.e1-1131.e4
1131.e1
1131.e2
L. PEREZ CARRO ET AL.
in the lateral region of the elbow and plain radiographs suggested a Milch type II1 and Rutherford type II2 fracture of the lateral condyle (Fig 1). The patient’s neurovascular status was normal. Five days after the injury, she was admitted for arthroscopy. After induction of general anesthesia, she was placed in the supine position. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal antero-
FIGURE 2. Arthroscopic view of left elbow showing fracture line. The arthroscope is in the proximal anteromedial portal, and a proximal anterolateral portal was created for instrumentation. (arrows, fracture site.)
FIGURE 1. Anteroposterior radiograph of left elbow showing Milch type II and Rutherford type II fracture of lateral condyle.
medial portal with no pump, and a proximal anterolateral portal was created for instrumentation. Blood, fibrin, and loose articular debris were irrigated from the joint. The fracture line and minimal changes consistent with cartilaginous contusion were easily visualized (Fig 2). No other associated injuries were found. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and by rotation until there was no step in the articular cartilage. The elbow was flexed and pronated to lock the reduction, and then 2 lateral Kirschner wires were placed percutaneously, which resulted in firm fixation of the fracture. During the procedure, we carefully checked for fluid extravasation. Arthroscopic observation confirmed that the wires had not violated the articular surface. Intraoperative radiographs (Figs 3 and 4) were taken to confirm satisfactory reduction and pin placement. The pins were cut short but were left protruding through the skin for subsequent removal. The skin incisions were closed with nylon suture, and a sterile bulky dressing and posterior splint were applied. The patient’s vasculonervous status was checked, and she was discharged as an outpatient. She was seen at 1 week after primary treatment, at which time the splint was removed, the pin sites were examined, and radiographs showed that the pins were in a satisfactory
LATERAL CONDYLE FRACTURES AND ARTHROSCOPY
1131.e3
DISCUSSION Lateral condyle fractures of the distal humerus represent approximately 12% of childhood elbow fractures. Anatomic reduction of intra-articular displacement is considered a priority. Rutherford2 advocated treatment of lateral condyle fractures based on the stability of the fracture pattern and classified type I fractures as incomplete and nondisplaced, type II as complete with mild displacement, and type III as displaced laterally and rotated. He recognized that type II fractures are prone to progressive displacement and should be monitored carefully. A shortcoming of this classification system is that it may be difficult to judge articular surface continuity on a plain radiograph. Failure to recognize displacement or rotation in fractures treated in a closed manner or with percutaneous pinning and failure to visualize the intra-articular component of the fracture and obtain an anatomic reduction are important pitfalls, because of the possibility of late displacement and development of a non-
FIGURE 3. Anteroposterior radiograph showing satisfactory reduction and pin placement.
position and the reduction maintained. A long arm cast was applied. At 4 weeks, the pins were removed. At 6 weeks, gentle active motion was allowed. At 8 weeks, radiographs showed excellent bone healing. Between February 2003 and February 2006, we successfully performed 4 cases of arthroscopeassisted reduction and percutaneous external fixation of Rutherford type II2 fractures of the lateral condyle, in 3 boys and 1 girl, with a mean age of 10 years, that yielded excellent results with no complications. No associated injuries were found. Radiographic union was evident at a mean of 8 weeks (range, 6 to 11 weeks). To date, there have been no complications, and all patients have full motion compared with the nonoperative side.
FIGURE 4. Lateral radiograph showing satisfactory reduction and pin placement.
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L. PEREZ CARRO ET AL.
union, which may lead to valgus instability, pain, or tardy ulnar nerve palsy. Until now, the technique has been described only to judge articular surface continuity via open surgery and direct visualization or confirmed with arthrography in case of closed reduction and percutaneous pinning.3 Magnetic resonance imaging may be helpful in patients with minimally displaced fractures, but younger children will probably not have the discipline to sit still during imaging. Closed reduction with percutaneous pin fixation has been advocated by several authors to treat minimally displaced lateral condyle fractures because it avoids the significant rates of complications of open reduction: deep infection, scar, pain, nonunion, and avascular necrosis. Most of them performed arthrography and used an image intensifier in different planes before performing reduction and confirmed reduction of the articular segment before fixation. In recent years the treatment of fractures has evolved from extensive open reduction to minimally invasive surgery. Arthroscopy is increasingly being recognized as an important adjunct in the management of displaced intra-articular fractures. Adjunctive use of the arthroscope for accurate reduction of intra-articular fractures has been successful in the management of the distal radius,4,5 tibial plateau,6,7 ankle,8-10 distal femoral condyle,11 elbow,12 and shoulder.13 Elbow arthroscopy has provided a reliable means of visualizing the articular surface. Visual inspection, lavage, reduction of fracture fragments with an appropriate periosteal elevator, and pin fixation conducted under arthroscopic control can restore the articular surfaces of lateral condyle fractures with the advantages of more accurate fracture reduction, reduced surgical trauma, decreased soft-tissue dissection, shortened postoperative recovery, better cosmetic, and less radiation time. This technique also allows a diagnostic and treatment alternative for associated injuries and loose fragments, and conversion to arthrotomy can be done if needed. As in other arthroscopic-assisted fracture reduction procedures, we must check carefully for compartment syndrome during the procedure with prevention of fluid extravasation. A delay of 5 to 7 days reduces the risk of this complication and allows the bleeding to subside. Elbow arthroscopy is a technically challenging procedure, and attention to the neurovascular anat-
omy about the elbow is essential for the prevention of complications. Methods to avoid these complications are as follows: define anatomic landmarks before joint distension, use joint distension to increase the boneto-nerve distance, use proximally placed portals, keep the elbow flexed to increase the distance between the nerves and capsule, and always visualize the tip of the instruments. The surgical trauma associated with open operative treatment of lateral condyle fractures can be minimized via minimally invasive techniques. Arthroscope-assisted reduction and percutaneous external fixation of lateral condyle fractures should be considered in the treatment of this type of fracture. To our knowledge, this is the first report of this alternative approach. REFERENCES 1. Milch H. Fractures of the external humeral condyle. JAMA 1956;160:641-646. 2. Rutherford A. Fractures of the lateral condyle in children. J Bone Joint Surg Am 1985;67:851-856. 3. Skaggs D. Elbow fractures in children: Diagnosis and management. J Am Acad Orthop Surg 1997;5:303-312. 4. Cooney WP, Berger RA. Treatment of complex fractures of the distal radius. Combined use of internal and external fixation and arthroscopic reduction. Hand Clin 1993;9:603-612. 5. Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular distal radial fractures. Clin Orthop Relat Res 1996;327:125-134. 6. Caspari R, Hutton P, Whipple T, Meyers J. The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1984;1:76-82. 7. Jennings J. Arthroscopic management of tibial plateau fractures. Arthroscopy 1985;1:160-168. 8. Whipple TL, Martin DR, McIntyre LF, Meyers JF. Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy 1993;9:456-463. 9. Miller MD. Arthroscopically assisted reduction and fixation of an adult Tillaux fracture of the ankle. Arthroscopy 1997;13: 117-119. 10. Kim HS, Jahng JS, Kim SS, Chun CH, Han HJ. Treatment of tibial pilon fractures using ring fixators and arthroscopy. Clin Orthop Relat Res 1997;334:244-250. 11. McCarthy JJ, Parker RD. Arthroscopic reduction and internal fixation of a displaced intraarticular lateral femoral condyle fracture of the knee. Arthroscopy 1996;12:224-227. 12. Rolla PR, Surace MF, Bini A, Pilato G. Arthroscopic treatment of fractures of the radial head. Arthroscopy 2006;22:233.e1233.e6. Available online at www.arthroscopyjournal.org. 13. Perez Carro L, Perez Nuñez M, Echevarria JL. Arthroscopicassisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture. Arthroscopy 1999; 15:211-214.