Is hardware removal advised for a 3-year-old with a right distal humerus lateral condyle fracture union repair?

Hardware Removal for Right Distal Humerus Lateral Condyle Union Repair in a 3-Year-Old

There is no clear evidence to recommend for or against routine hardware removal for a right distal humerus lateral condyle union repair in a 3-year-old child, as the decision should be based on specific clinical circumstances such as symptomatic hardware or growth concerns.

Current Evidence on Hardware Removal

• The American Academy of Orthopaedic Surgeons (AAOS) guidelines are unable to provide specific recommendations regarding the optimal time for hardware removal in pediatric supracondylar humerus fractures, stating that the evidence is inconclusive 1.

• Prolonged pinning and immobilization might cause pin tract infection or elbow stiffness, while early removal of pins may increase the risk of redisplacement or refracture 1.

• There were no studies identified in the AAOS guidelines that explicitly linked the duration of pinning or immobilization to any outcome of interest 1.

Considerations for Lateral Condyle Fractures

• Lateral condyle fractures constitute 12-20% of all pediatric distal humerus fractures and require careful management to avoid complications such as nonunion and deformity 2.

• For lateral condyle fractures that have been surgically fixed, the following factors should be considered when deciding on hardware removal:

  • Symptomatic hardware: Hardware that causes pain, skin irritation, or limitation of motion may warrant removal 3.

  • Growth considerations: In young children (3 years old), there are concerns about potential growth disturbance if hardware crosses the physis 3, 4.

  • Type of fixation: Different fixation methods (K-wires vs. screws) may have different removal protocols 3, 4.

Complications to Consider

• Potential complications of retained hardware include:

  • Hardware prominence causing skin irritation or pain 3
  • Restriction of elbow motion 3
  • Theoretical risk of growth disturbance if hardware crosses the physis 4

• Potential complications of hardware removal include:

  • Risk of refracture or redisplacement if removed too early 1, 5
  • Infection at the surgical site 5
  • Anesthesia-related risks for a young child 6

Decision-Making Algorithm

1. Assess for symptoms related to hardware:

   • If the hardware is symptomatic (causing pain, skin irritation, or limiting motion), removal may be indicated 3.
   • If asymptomatic, consider other factors.

2. Evaluate fracture healing:

   • Complete radiographic union should be confirmed before hardware removal 5.
   • For lateral condyle fractures, union typically takes 6-8 weeks but may vary 4.

3. Consider the type of hardware:

   • K-wires: Often removed in the outpatient setting once healing is confirmed 4.
   • Screws: May be left in place unless symptomatic or crossing the growth plate in a way that might affect growth 3.

4. Assess growth potential:

   • In a 3-year-old child with significant growth remaining, hardware crossing the physis may warrant removal to prevent growth disturbance 4.

Common Pitfalls and Caveats

• Removing hardware too early before complete union can lead to redisplacement or refracture 1, 5.

• Delaying hardware removal when it's symptomatic can lead to decreased range of motion or discomfort 3.

• Hardware removal requires another anesthetic exposure for a young child, which carries its own risks 6.

• In cases of delayed union or nonunion, hardware should be retained until complete healing is achieved 5.