Secondary deformities of the elbow in children J Gil-Albarova J Bregante J De Pablos Abstract. – Secondary elbow deformities in children are usually due to trauma, infection or tumours, and much less frequently to osteochondritic and/or osteonecrotic processes, among other causes. The treatment of these deformities must be tailored to the individual patient. The potential functional and cosmetic results must be considered in the light of the remaining growth potential. The final object is to preserve or restore optimum function and appearance. © 2004 Elsevier SAS. All rights reserved. Keywords: Immature elbow, secondary deformities, surgical correction. Introduction The elbow is a complex joint consisting of three individual sections within a single capsule. During growth, the ossification nuclei appear in a known sequence which must not be disturbed if proper development is to occur. Interference with this may produce long term deformity. The capitellum ossifies at about one year in both boys and girls, the lateral condyle between 6 months and 2 years, the radial head between 2 and 4 years, and the medial epicondyle between 4 and 7. The olecranon ossifies at between 8 and 10 years of age, the trochlea between 7 and 9, and the lateral epicondyle between 10 and 12 [11, 16, 22] . Trauma is the most frequent cause of secondary deformities of the elbow in children, particularly with fractures of the distal end of the humerus and fractures and dislocations of the ulna and radius [2, 4, 32, 33, 34, 35, 38, 58, 59, 60, 61, 62, 63, 64] . Other causes are arthritis, neurological problems or osteochondritis dissecans [29, 45, 47, 52] . Clinical examination and appropriate imaging techniques will help to correctly assess the deformity and plan possible treatment. Table I shows an aetiological classification of the different causes of these deformities. Post-traumatic deformities Malunion. Angular deformities at the elbow resulting from supracondylar fractures are relatively infrequent since there has been more widespread use of methods of osteosynthesis based on the use of Kirschner wires. However, the most common cause of a varus deformity continues to be the inappropriate treatment of Gartland types I and II fractures, and not the result of a type III fracture [31] . Emphasis has been placed on the importance of reducing supracondylar fractures with impactation of the medial wall and percutaneous stabilisation with a Kirschner wire to prevent an eventual varus deformity [14] . Varus deformity may also result from healing of the distal fragment in rotation, which should be avoided [17] . Cubitus varus deformity is also the most frequent complication following displacement of the distal humeral epiphysis, although it appears less frequently than after a supracondylar fracture [1, 15, 46] . Although a varus deformity does not often result in functional loss, it is cosmetically damaging and a source of concern for parents and children (fig 1) [5, 13, 27, 41] . Correction of a varus deformity by lateral distal osteotomy of the humerus stabilised with Kirschner wires (fig 2), plates or external fixation has given satisfactory results if carried out when full movement has been regained and nor delayed until completion of growth [5, 13, 19, 27, 37, 41] . Fractures in children heal quickly, and their capacity for remodelling is high particularly in the younger the child and when adjacent to the most active physes such as the shoulder and wrist [16, 21, 22] . This should be taken into consideration when assessing a post-traumatic deformity of the elbow in children where there is less potential for remodelling than in the rest of the arm. Separate consideration should be given to fractures in the elbow in patients with osteogenesis imperfecta, where a sequence of injuries may produce significant problems in shape and function [53, 68] . PSEUDOARTHROSIS This is rarely seen in supracondylar fractures of the elbow in children, due to the good blood supply to the distal metaphysis [32] . However, it may be seen in displaced fractures of the lateral condyle of the Jorge Gil-Albarova, orthopaedic surgeon, hospital universitario Miguel Servet, avda Isabel La Católica 1-3, 50009 Zaragoza, España. J Bregante, orthopaedic surgeon (Director Pediatric orthopaedics Unit). hospital universitario Miguel Servet, avda Isabel La Católica 1-3, 50009 Zaragoza, España. Julio De Pablos, orthopaedic surgeon. hospital San Juan de Dios y Hospital de Navarra, Beloso Alto 3, 31006 Pamplona, España. Table I. – Aetiology of secondary deformities of the elbow. 1. Post-traumatic: - Malunion - Epiphysiodesis - Heterotopic calcification - Pseudoarthrosis - Avascular necrosis - Synostosis - Myositis ossificans - Chronic dislocations 2. Infection - Osteomyelitis - Infective arthritis 3. Tumours 4. Others - Osteochondrosis - Neuromuscular - Osteochondritis - Haemophilia - Iatrogenic Surgical Techniques in Orthopaedics and Traumatology 55-260-D-50 (2004) 55-260-D-50 All references to this article must include: Gil-Albarova J, Bregante J and De Pablos J. Secondary deformities of the elbow in children. Elsevier SAS (Paris). All rights reserved. Surgical Techniques in Orthopaedics and Traumatology, 55-260-D-50, 2004, 6 p.