Indications and Timing of Guided Growth Techniques for Pediatric Upper Extremity Deformities: A Literature Review

Abstract

Osseous deformities in children arise due to progressive angular growth or complete physeal arrest. Clinical and radiological alignment measurements help to provide an impression of the deformity, which can be corrected using guided growth techniques. However, little is known about timing and techniques for the upper extremity. Treatment options for deformity correction include monitoring of the deformity, (hemi-)epiphysiodesis, physeal bar resection, and correction osteotomy. Treatment is dependent on the extent and location of the deformity, physeal involvement, presence of a physeal bar, patient age, and predicted length inequality at skeletal maturity. An accurate estimation of the projected limb or bone length inequality is crucial for optimal timing of the intervention. The Paley multiplier method remains the most accurate and simple method for calculating limb growth. While the multiplier method is accurate for calculating growth prior to the growth spurt, measuring peak height velocity (PHV) is superior to chronological age after the onset of the growth spurt. PHV is closely related to skeletal age in children. The Sauvegrain method of skeletal age assessment using elbow radiographs is possibly a simpler and more reliable method than the method by Greulich and Pyle using hand radiographs. PHV-derived multipliers need to be developed for the Sauvegrain method for a more accurate calculation of limb growth during the growth spurt. This paper provides a review of the current literature on the clinical and radiological evaluation of normal upper extremity alignment and aims to provide state-of-the-art directions on deformity evaluation, treatment options, and optimal timing of these options during growth.

Keywords: alignment; children; growth correction; limb length discrepancy; timing.

Figure 1

(A) Visual inspection of the carrying angle of the elbow in a 10-year-old girl showing a unilateral cubitus varus on the right side. (B) Anteroposterior radiographic views of the elbow with the unaffected contralateral side for comparison.

Figure 2

Distal humerus radiographic reference lines. (A) Baumann angle (BA) on an anteroposterior elbow view. (B) The lateral capitellohumeral angle (LCHA) on a lateral elbow view. (C) Anterior humeral line (AHL) on a lateral view. This line should pass between the two dotted lines in the middle.

Figure 3

Distal radius radiographic reference lines. (A) Radial height (RH). (B) Volar tilt (VT). (C) Radial inclination (RI).

Figure 4

Distal ulna radiographic reference lines. (A) The Hafner method for measuring ulnar variance. (B) The method of perpendiculars for measuring ulnar variance, with ‘PRPR termed as the two most proximal points of the physis and ‘DIDI’ termed as the two most distal points of the physis.

Figure 5

(A) A 17-year-old boy with congenital anterior radial head dislocations of the right arm. (B) A 16-year-old girl with congenital posterior radial head dislocations of the left arm, accompanied by a symptomatic elbow contracture. The girl was treated conservatively with a static progressive elbow flexion brace.

Figure 6

Radiographic wrist measurements used for the assessment of Madelung deformity. (A) Palmar carpal displacement (PCD) on a lateral wrist view, measured as the distance between the longitudinal ulna axis and the most volar lunate aspect. (B) Lunate subsidence (LS) on a posterioanterior view, measured as the distance between a perpendicular line to the longitudinal ulna axis and the most proximal lunate point.

Figure 7

(A) Elbow radiographs of a 9-year-old girl with a posttraumatic cubitus varus, a flexion deficit of 60 degrees, and avascular necrosis of the medial condyle after a fall from height. (B) An epiphysiodesis using transphyseal screws was performed in addition to an arthrolysis with reduction of the coronoid fossa and release of the ulnar nerve.

Figure 8

(A) A 15-year-old boy with premature closure of the distal radial physis after a Salter–Harris type 2/4 fracture. Initially, the boy had an ulna minus wrist. (B) A closed radial physis, accompanied by an impending ulna plus. (C) Intraoperative radiographs during epiphysiodesis of the ulna. (D) Postoperative radiographs show a closed physis of both the radius and the ulna. Note that the ulna had been growing until the epiphysiodesis, leading to an ulna zero. (E) Radiographs after 1-year follow-up. Note the unaltered ulnar variance.

Figure 9

(A) A 17-year-old boy with a traumatic premature closure of the distal radial physis. (B) A closed radial physis, accompanied by an ulna plus. (C) Intraoperative radiographs during correction osteotomy of the radius combined with an epiphysiodesis of the ulna. (D) Radiographs six weeks postoperatively.