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Elbow arc of motion may take up to 1 year to return following pediatric elbow fracture
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Children who sustain a lateral condyle fracture of the humerus can expect an early rapid recovery in their relative arc of motion, along with progressive improvements for up to 1 year, according to a study of 141 such fractures, which are the second most prevalent injury of the elbow in children after supracondylar humerus fractures.
“One of the most common questions asked by parents is ‘When will my child’s elbow be normal again?’” said lead author Nicholas M. Bernthal, MD, a senior resident in orthopedic surgery at the David Geffen School of Medicine at UCLA.
The study was conducted at Los Angeles Orthopaedic Hospital in downtown Los Angeles. The mean age of patients was 5.2 years, and mean follow-up was 29 weeks.
“We were surprised that range of motion continues to improve out to a full year,” Bernthal told Orthopedics Today. “One of the misconceptions in orthopedic surgery, especially in orthopedic trauma, is that after you break a bone it heals and you regain your motion fairly quickly.”
One aspect of the study, which was presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons, compared surgical vs. nonsurgical intervention. For both groups, “the regaining of motion is relatively rapid initially, but does continue to improve out to 1 year,” Bernthal said. “However, surgical elbows take a bit longer to improve. Out to about 18 weeks there was a difference in the relative arc of motion (RAM). But then the surgical elbow sort of catches up by 18 weeks and beyond.”
Treatment decisions
Generally, elbow fractures displaced less than 2 mm were treated nonoperatively with casting, whereas displacement in the range of roughly 2 mm to 5 mm was treated with closed reduction and percutaneous pinning. More than 5 mm of displacement was managed with open reduction and pinning.
For all three treatment groups, the mean RAM was 44% at cast removal and reached 84% by week 12 and 97% by week 48 following injury. Nonsurgical treatment, though, resulted in a significantly lower RAM from the time of cast removal and up to 18 weeks after injury.
There was no significant difference in RAM observed at any time interval between patients treated with closed or open reduction, Bernthal reported.
Predictors of recovery
Two definite independent predictors of recovery of range of motion were older age with older children taking longer to regain motion, and duration of immobilization as the longer the child was in the cast, the longer to regain motion.
There were also five cases of osteonecrosis. “Despite these patients having radiographic signs of osteonecrosis, the range of motion was equivalent to children who did not have osteonecrosis,” Bernthal said. “But we don’t know if long-term this osteonecrosis leads to arthritis. Unfortunately, most institutions do not have the luxury to follow these children past 1 or 2 months. Still, osteonecrosis is something we feel people should keep their eye on.” – by Bob Kronemyer
Reference:
- Bernthal NM, Hoshino CM, Dichter D. Prospective longitudinal evaluation of elbow motion following pediatric lateral condyle fractures. Paper 176. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19. San Diego.
- Nicholas M. Bernthal, MD, can be reached at Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, CHS, Box 956902, Los Angeles, CA 90095-6902; 301-518-7147; e-mail: nbernthal@mednet.ucla.edu.
