Triple management of cubitus valgus deformity complicating neglected nonunion of fractures of lateral humeral condyle in children: a case series

Long standing nonunion of the lateral humeral condyle (LHC) usually results in elbow pain and instability with progressive cubitus valgus and tardy ulnar neuritis. Surgical treatment of long standing nonunion is still a controversial issue due to the reported complications, such as stiffness, loss of elbow motion, and avascular necrosis of the LHC fragment. In this study, we reported the outcomes of treatment of cubitus valgus deformity in long standing nonunion of the LHC in children treated with combined triple management (fixation of the nonunion site, dome corrective osteotomy, and anterior transposition of ulnar nerve) through a modified para-triceptal approach.

We evaluated ten patients with cubitus valgus deformity more than 20 degrees after neglected nonunion of the lateral humeral condyle more than 24 months. Only childern with post-operative follow up more than 24 months were included in this study. All patients were evaluated clinically, radio logically, and by pre- and post-operative functional evaluation using Mayo elbow performance score. For evaluation of ulnar nerve affection, the Akahori’s system was used.

There were six females and four males with the average age of 7.7 years at operation. The left elbow was affected in six patients and the right elbow was affected in four patients. The average time between fracture of the LHC and operation was 40.3 months with average post-operative follow up of 44.3 months. The average carrying angle of the healthy side was 5.5 degrees and pre-operative carrying angle of the affected side was 33.5 degrees. The average post-operative carrying angle of the affected side was 6.1 degrees. The improvement of the carrying angle at the last follow up was found statistically significant (p < 0.05). All six patients that had pre-operative various degrees of ulnar nerve affection had completely improved at last follow up. The osteotomy site united in an average time of 43 days, whereas the LHC nonunion site united in an average time of 77.2 days. The osteotomy site united in significantly less time than the LHC non-union site (p < 0.05). The correlation between time since injury and time of union of LHC non-union site was significant (p < 0.05). Post-operative elbow range of motion was not changed in five patients, slightly decreased in four patients, and increased in one patient. Three patients had an average 6.7 degrees (range; 5–10) loss of the last degrees of flexion. One patient developed extension lag of 10 degrees. The mean elbow range of motion (ROM) pre-operatively was 139 ± 4.6 degrees while the mean post-operative ROM was 138 ± 5.3 degrees. The difference was found to be statistically insignificant (p > 0.05). The mean pre-operative Mayo elbow performance score was poor 55 ± 9.7, four patients had fair score, and six had poor score. The mean post-operative Mayo elbow performance score was excellent 92.5 ± 10, six patients had excellent score, and four had good score. The improvement of the Mayo score at the last follow up was found to be statistically significant (p < 0.05). No intra-operative complications were recorded during any of the procedures and no patient developed a wound or pin track infection post-operatively. At the last follow up, none of the patients had developed avascular necrosis of the LHC.

Preservation of the blood supply of the nonunited fragment is the key to successful management. This combined technique successfully addresses different aspects of the problem simultaneously and provides a durable solution without deterioration of the results over time. The para-triceptal approach provided excellent exposure of both sides of the elbow with minimal disruption of the triceps muscle.