Keywords
pediatric - elbow - arthroscopy - osteochondritis dissecans - lateral condyle
Introduction
Arthroscopy provides a minimally-invasive method to treat both acute and chronic conditions,
but has historically been a challenge in the elbow due to the complex articular anatomy,
confined joint space, and proximity of neurovascular structures. Historically, fear
of complications with arthroscopy has limited its appeal and application to pediatric
elbows.[1] However, recent studies[2]
[3]
[4]
[5] have demonstrated low complication rates in pediatric elbow arthroscopy, ranging
from 0% to 8% and comparable to the 5% to 11% complication rate reported in adult
elbow arthroscopic procedures. Examining complication rates after elbow arthroscopy
in a large cohort of adult and pediatric patients, Intravia et al.[6] reported no significant difference in the incidence of nerve palsy, heterotopic
ossification, or infection between adult and pediatric arthroscopic procedures.
Advancements in instrumentation and technique have significantly expanded the pathologies
treatable via arthroscopy, with pediatric elbows as one of the greatest beneficiaries.
As with any procedure, surgical success depends on achieving good exposure and minimizing
collateral damage. Arthroscopy is our preferred approach where possible, as it can
increase surgical precision due to magnification; decrease the risk of peripheral
damage, pain, and scar-tissue formation; and is amenable to staged procedures. One
issue, however, is that, while pediatric orthopedists are experienced in the treatment
of children and adolescents, they may lack proficiency in arthroscopy. This provides
an opportunity for collaboration among orthopedists.
Though initial interest in pediatric elbow arthroscopy focused largely on the treatment
of osteochondritis dissecans (OCD) lesions, the role of arthroscopy has expanded to
include contracture release, arthroscopic-assisted fracture fixation, debridement
of bony and soft tissue pathologies, correction of bony deformity, and release of
synostosis.[2]
[7]
[8]
[9]
[10] While its complication profile appears to be improved from that of open elbow surgery,
elbow arthroscopy is a challenging procedure with a steep learning curve.[5]
[11] The minimally-invasive nature of arthroscopy is of particular utility in the pediatric
population, given the ability to avoid the morbidity of large open incisions. The
present update article aims to address the current state of pediatric elbow arthroscopy
and demonstrate several innovative cases highlighting the versatility of arthroscopy
in treating pathologies of the pediatric elbow.
Patient Set-up and Arthroscopy Portals
Patient Set-up and Arthroscopy Portals
In general, our preference is for regional anesthesia, with a preoperative motor and
sensory block via an indwelling catheter, which allows for immediate control of the
post-operative pain and rehabilitation as needed. If there is concern for compartment
syndrome, a regional block should be avoided. While elbow arthroscopy can be performed
in the prone, lateral decubitus, or supine positions, our preference is supine, with
the operative arm draped freely and a tourniquet placed high on the upper brachium.
The utilization of an Articulated Sterile Intraoperative Positioning System (ASIP,
McConnell Orthopedic Manufacturing Co., Greenville, TX, US) enables ample shoulder
and elbow positioning without obstructing operative maneuvers. In cases in which the
patient's arm is too small for a secure fit within the ASIP, a surgical assistant
is required to hold the limb.
In adolescent and larger children, a standard 30°, 4.5-mm shoulder arthroscope and
associated electrocautery wand, shaver, and burr can be utilized; however, younger
children (∼ 5 years of age or younger) may require a 2.5-mm wrist arthroscopy set-up.
Distension of the joint with saline will displace the capsule and neurovascular structures
anteriorly to aid in safe portal creation. In the setting of trauma, an effusion may
already be present and sufficient. Pump pressure should be set to a maximum of 25 mmHg,
and inflow should run solely through the tip of the trocar sheath, as opposed to more
standard side-fenestrated trocars. Outflow is managed through the use of an arthroscopic
shaver. Fluid management is of utmost importance to avoid extravasation and subsequent
swelling, which can alter landmarks for portal placement.
Portal placement is similar to that used in adults, and knowledge of the surgical
anatomy is necessary to avoid the multiple nearby neurovascular structures. Bony landmarks,
including the medial and lateral epicondyle, the tip of the olecranon, the radial
head, and the posterior radiocapitellar joint are reliable and reproducible for portal
localization, although some may be cartilaginous depending on the age of the child.
Yoo et al.[12] demonstrated that condylar width and body mass index were correlated with proximal
anterior capsule location. Prior trauma, heterotopic ossification, or other distortions
of normal anatomy are relative contraindications to elbow arthroscopy. The ulnar nerve
should be palpated through flexion and extension to ensure there is no subluxation
that would place it at risk during the creation of the anteromedial portal. Although
uncommon in children, a prior ulnar nerve transposition is a contraindication to elbow
arthroscopy if it cannot be clearly palpated. In the case of long-standing contracture,
an in-situ ulnar nerve release is warranted before starting the procedure.
Commonly used portals include the transtricipital, posterolateral, midlateral (soft-spot),
anteromedial, and anterolateral portals. Accessory portals are utilized as required
by the pathology or surgical procedure. In our experience, placement of the posterior
portal should begin with the transtricipital portal and anteriorly with the anteromedial
portal to enable direct visualization of the anterolateral portal.[7]
[13]
[Fig. 1] shows the common elbow arthroscopy portals.
Fig. 1 Common Portals for Elbow Arthroscopy. (A) Lateral portals: proximal anterolateral, anterior radiocapitellar, posterior radiocapitellar.
(B) Medial portals: proximal anteromedial and accessory anteromedial. (C) Posterior portals: transtricipital, proximal posterolateral, distal posterolateral,
and accessory posterolateral. (Reprinted with permission from Koehler et al.[21])
Release of Elbow Contracture
Release of Elbow Contracture
Historically, the results of open elbow contracture release in pediatric patients
are not as favorable as those achieved in adults.[14]
[15] While the reasons are not entirely clear, one frequent observation is that the child's
nerves never reached adult length due to the contracture, and injury during periods
of rapid growth will quickly result in the nerve being excessively tensioned with
extension. Thus, earlier intervention may minimize this problem by preventing nerve
contracture. This is rarely, if ever, encountered in adults whose contracture-causing
injury occurred after skeletal maturity. While we lack sufficient evidence to fully
support this hypothesis, our early experience is suggestive. Arthroscopic release
or even staged arthroscopic release are more acceptable and tolerated by parents and
children, thus allowing earlier and, if necessary, repeated intervention to prevent
traction on the nerves and thus improve the outcomes for contracture release.
As with adult arthroscopic contracture releases, special care must be taken to avoid
the neurovascular structures, which can easily be accidentally injured if the arthroscopic
shaver is directed toward the elbow capsule during debridement. Our preferred technique
can be found in the October 2018 issue of the Journal of Pediatric Orthopedics.[19]
The common causes of pediatric elbow contractures are similar to those of the adult
population, and include posttraumatic sequelae, muscular imbalance, congenital dislocations,
burns, inflammatory arthropathies, hemophilia, and sepsis. The variety of etiologies
and small patient cohorts make direct comparisons difficult, and few studies exist
in the pediatric literature regarding arthroscopic release of elbow contracture. A
2013 systematic review of 798 predominantly adult subjects by Ködde et al.[16] found that arthroscopic contracture releases demonstrated results similar to those
of open procedures with less morbidity and lower complication rates. The published
literature on the release of pediatric arthroscopic elbow contracture, by comparison,
comprises less than 50 patients in total, but does report similar findings.[2]
[3]
[17]
[18]
[19]
The first article to describe the use of elbow arthroscopy for contracture in a pediatric
population was the one by Micheli et al.[2] (2001). In their series of 49 pediatric elbow arthroscopies, the authors performed
9 arthroscopic releases for arthrofibrosis and decreased range of motion. The majority
of patients achieved good to excellent results based on the modified Andrews elbow
score, with an average increase of 32° of extension and 21° of flexion at a minimum
follow-up of 2 years. No statistical analysis was performed to accompany their results.
They reported no complications, but cautioned that elbow arthroscopy is an acquired
skill, with significant risk even in the hands of experienced arthroscopists.
The largest series to date was published by our senior author in the Journal of Pediatric Orthopedics in 2018, which comprised 29 contracture releases in 25 patients with an average follow-up
of 15 months.[19] The most common etiology of contracture was following radial head fractures (n = 9), which has been described[20] to occur more frequently in intra-articular fractures. The average preoperative
flexion-extension arc measured 93° and improved to 128° (p = 0.00002) following release. The modest improvement in pronosupination of 12.2° ± 35.2°
(p = 0.097) can be explained by the majority of cases presenting primarily with pure
flexion-extension contractures. In a subgroup analysis of 10 patients with significant
limitations in pronosupination, a net improvement of 41° was observed. Seven patients
experienced a postoperative complication, including five minor complications (surgical
site infection, two transient neuropraxias, persistent wound drainage, and recurrence
of a prior physeal bar) and two major complications (supracondylar stress fracture
through a distal humeral osteoplasty, and a recurrent contracture secondary to patient
non-compliance). This study demonstrated an important equivalence to open pediatric
elbow contracture releases as a less invasive alternative, which is susceptible to
staging of complex pathologies.
Fracture Fixation
Though lateral condyle fractures (LCFs) are the most common fracture addressed arthroscopically
in the pediatric population, the orthopedic literature also describes techniques for
fixation of coronoid, supracondylar, medial epicondyle, radial head or neck fractures.[8]
[11]
[13]
[17]
[21]
[22]
[23]
Fractures of the lateral condyle are the second most common pediatric elbow fracture,
and represent a diagnostic and treatment challenge with a relatively high rate of
severe complications, including avascular necrosis (AVN), non-union, growth arrest,
subsequent deformity, and loss of motion.[24]
[25] The limited ossification makes it difficult to correctly assess the type of fracture
or level of displacement with radiographs alone.[26] Even using intraoperative arthrography, one cannot be completely assured of either
an anatomic reduction, as hematoma can prevent dye extravasation behind the displaced
fragment, or fixation within the ossific nuclei.[27]
Arthroscopy is, essentially, a surgical approach ([Fig. 2]). In the setting of LCFs, it affords a degree of exposure unachievable by open means
without detaching critical ligaments and violating the precarious posterolateral blood
supply that could cause AVN. It can be used diagnostically to assess the degree of
fracture displacement as well as therapeutically to assist in debridement and achieving
a stable, anatomic reduction.
Fig. 2 5-year-old with a displaced lateral condyle fracture who underwent arthroscopic-assisted
reduction and internal fixation. (A) Injury radiographs of the lateral condyle fracture. (B) Initial inspection from the proximal anteromedial portal demonstrates the fragment
and fracture surface covered with hematoma. (C) The secondary ossification center is exposed, and a fixation pin is inserted under
direct vision to ensure accurate placement. (D) The fracture is anatomically reduced, again under direct arthroscopic visualization.
(EF) Kirschner wires are placed percutaneously to fix the fracture. The trajectory of
the Kirschner wire is confirmed via fluoroscopy, and the maintenance of reduction
is confirmed under arthroscopy.
Our preferred technique and results have been described in the October/November 2007
issue of the Journal of Pediatric Orthopedics,[8] as have subsequent techniques by Perez-Carro et al.,[22] Temporin et al.,[23] and Kang et al.[11] In our series of 6 patients, with an average age of 4 years and treated within 24 hours
of the injury, all went on to achieve full functional range of motion, with no statistical
difference in range of motion or carrying angle compared with the uninjured contralateral
elbow. One patient developed radiolucency of the capitellum without clinical significance.
In the recent series by Kang et al.,[11] one-third of the patients undergoing closed reduction and percutaneous pinning (CRPP)
required re-reduction after the arthroscopic assessment, despite an acceptable appearance
on fluoroscopy.[11] This may represent a patient at risk for complications if undergoing traditional
CRPP alone. The authors noted full range of motion in 27/30 of patients, with the
remaining 3 experiencing mild contractures (10° to 20° decrease regarding the opposite
side). Complications included two transient radial nerve palsies and no instances
of AVN or non-union.
Arthroscopic-assisted fracture management may be beneficial in other fractures about
the elbow (coronoid, radial head/neck, capitellum, supracondylar), and recent small
case series and reports have demonstrated good results with regard to fracture union,
range of motion and complications.[7]
[21]
[28] There is also the potential for arthroscopic corrective osteotomies following supracondylar
malunion, in which the current complication rates for open procedures is reported
at upwards of 40%.[29] Larger studies and trials are needed, however, to compare these minimally-invasive
procedures to their open counterparts.
Clinical case 1: ([Fig. 2])
Management of Osteochondritis Dissecans
Management of Osteochondritis Dissecans
Another condition benefitting from the improved exposure that can be obtained with
arthroscopy as well as the increased precision of performing the procedure under magnification
is OCD.
Osteochondritis dissecans is currently the most common indication for pediatric elbow
arthroscopy. Multiple studies[2]
[30]
[31]
[32]
[33] in the orthopedic literature confirm its safety and efficacy. The majority of authors[2]
[30]
[31] present chondroplasty, debridement of unstable lesions, and/or microfracture to
address OCD lesions, though Tis et al.[33] and Takeba et al.[32] also report good short-term results after fixation of unstable OCD lesions with
bioabsorbable pins. Miyake and Masotomi[30] presented one of the largest series, including the surgical management of 106 OCD
lesions in pediatric patients, and demonstrated overall good results after arthroscopic
debridement and subchondral drilling; 99% of patients returned to sport at an average
of 2.4 months postprocedure, and 85% of patients returned to preinjury levels of sport.[30] However, the authors caution that a reconstructive procedure such as an osteochondral
autograft may better address large OCD lesions, given their poor outcomes in the subgroup
of patients with large OCD lesions and an open radial head physis; they reported that
all four such patients developed radial head enlargement, three went on to radiographic
osteoarthritis of the radiohumeral joint, and two required radial head resection.[30]
When we address OCD lesions, standard portals are employed, with the exception of
a distal “para-ulnar” portal ([Fig. 3]) just radial to the lateral border of the ulna. The distal “para-ulnar” portal facilitates
a trajectory that is perpendicular to the tangent to the capitellum at the site of
the lesion, thereby enabling proper alignment in the setting of a reconstructive procedure
like an osteochondral plug autograft or allograft.
Fig. 3 The distal “para-ulnar” portal (marked with an asterisk) is placed well distal to
the standard “soft-spot” portal.
The improved visualization facilitates more sophisticated repairs beyond simple drilling.
These include stabilization of loose but undetached fragments, actual replacement
and preservation of large fragments with subchondral drilling and bone grafting, cartilage
repair in skeletally-immature patients, mosaicplasty, and treatment of trochlear lesions.
All of these procedures are greatly facilitated by arthroscopy, which, without releasing
any ligaments, facilitates the exposure that is necessary not only to visualize the
pathology, but also to pass the mattress-type sutures that are needed to adequately
stabilize the fragments.
Our protocol also requires prolonged immobilization (usually 2 to 3 months) to allow
for healing of the fragment or graft, which is confirmed by magnetic resonance imaging
(MRI) or computed tomography (CT) scans. Initially, stiffness was a concern, but only
one patient has required a subsequent arthroscopic release to regain full motion.
Thus, performing these procedures with arthroscopic, rather than open, exposure may
improve healing by allowing for longer periods of immobilization and protection without
an increased risk of stiffness. Furthermore, if stiffness does occur, arthroscopic
release can be performed.
Clinical case 2: ([Fig. 4])
Fig. 4 13-year-old male patient with persistent elbow pain and failure of the conservative
treatment. Via arthroscopy, his capitellum lesion was secured with suture and bone
graft placed behind the OCD lesion. (A,B) Radiographs of an osteochondral lesion of the capitellum in a skeletally-immature
patient. (C,D) MRI correlation redemonstrating the capitellum lesion. The cartilaginous surface
remains intact, and this was confirmed on arthroscopy. (E) A cannulated drill was placed into the center of the lesion up to but not through
the subchondral bone, and placement was confirmed on fluoroscopy. A freer elevator
was used to ensure that the lesion did not get displaced during drilling. (F) PDS (Ethicon, Somerville, NJ, US) suture passed via a spinal needle through the
center of the OCD lesion. Medial and lateral holes are created to fashion a mattress
suture to secure the OCD lesion. Bone graft is used to backfill the cannulated drill
path. (G,H) 3-month postoperative MRI demonstrating healing of the OCD lesion with bone bridging
the formerly diseased capitellum. (I,J) Patient with almost complete elbow flexion and extension following the procedure.
Clinical case 3: ([Fig. 5])
Fig. 5 Adolescent male with a large, unstable OCD lesion. As previously noted in the literature[30], large and unstable OCD lesions often have poor results when debridement and chondroplasty
alone are performed. This patient underwent an arthroscopic-assisted osteochondral
autograft reconstruction, making use of the distal para-ulnar portal to obtain the
necessary trajectory to secure the autograft into the osteochondral deficit. (A,B) MRI and CT scans demonstrating a large OCD lesion in the capitellum. (C) Arthroscopic probe demonstrating a large, grossly loose flap of the OCD lesion.
(D,E) The center of the lesion was pinned, and a cannulated drill was passed over the
Kirschner wire. Position was confirmed on fluoroscopy and arthroscopy. (F) Following subsequent reaming to prepare the recipient site, a sizer was used to
measure and prepare the site for the autograft. (G) The osteochondral autograft nicely fills the prior defect. No articular incongruency
is noted.
Deformity Correction
Posttraumatic deformity correction may also be facilitated by arthroscopic techniques,
which may be less painful and better accepted. The risk of physeal injury and malunion
is a common complication following trauma to the pediatric elbow, including cubitus
varus deformity following supracondylar fracture, and cubitus valgus deformity following
lateral condyle non-union or malunion.[34]
[35] While the sequelae are often largely issues of cosmesis (which by themselves are
a common indication for a corrective procedure), we are becoming increasingly aware
of the pain and functional limitation that can arise from resultant nerve palsies,[36] stiffness, and posterolateral rotatory instability.[37] Additionally, malunion at the elbow may increase the risk of future fracture.[38]
[39]
Various osteotomies, including opening or closing wedge osteotomies, dome osteotomies,
and distraction osteogenesis have been described to correct elbow deformities.[40] However, open surgery for correction of pediatric elbow deformity is associated
with a high complication rate, from 14%[40] up to 40%[34] in one series, including risks of nerve injury, insufficient correction due to loss
of fixation, infection, growth arrest, stiffness, and unsightly scarring.[29]
[34]
[40]
[41] Despite the prevalence of open procedures, the orthopedic literature remains scarce
of arthroscopic techniques to address pediatric elbow deformity. Through an arthroscopic
approach, we believe we can minimize the morbidity of deformity correction surgery
while still achieving functional outcomes. Here, we present one case of correction
of lateral condyle avascular necrosis and one case of correction of supracondylar
malunion ([Figs. 6] and [7])
Fig. 6 8-year-old male with physeal fragmentation and deformity following a lateral condyle
fracture of the elbow. (A) MRI of normal lateral condyle for comparison. (B) MRI of lateral condyle deformity and physeal bar with anterior humeral articular
fragment. (C) MRI with improvement in the shape and contour of the lateral condyle following screw
removal and healing. (D) Intraoperative fluoroscopy demonstrating restoration of a spherical capitellum through
fixation of the anterior fragment with partially threaded posterior-to-anterior screws,
physeal bar resection, and restoration of the normal anterior-to-posterior width of
the lateral condyle. (E,F) Near-normal elbow flexion and extension following physeal correction. However, the
physeal bar has reformed, so close, longitudinal observation is necessary.
Fig. 7 7-year-old male with an extension malunion following a supracondylar elbow fracture.
He had limited elbow flexion and was indicated for a supracondylar osteotomy for correction
of his malunion. (A,B) Lateral and anteroposterior radiographs of this patient's extension malunion of
prior supracondylar fracture. (C) Incongruent radiocapitellar motion with the radial head swiping across the capitellum
during elbow flexion. (D) A needle is used to fluoroscopically confirm the location of the malunion so that
an anatomic osteotomy can be performed. (E,F) Following manual osteoclasis of the posterior cortex, the distal humerus is flexed
back into anatomic alignment and fixed with two lateral pins and one medial pin. The
fracture is pinned and casted until healed. (G,H) Patient's range of motion 2 weeks after pin removal with near-normal elbow flexion
and extension.
Clinical case 4: ([Fig. 6])
The patient's elbow motion is limited due to flattening of the fragmented humeral
physis and the reciprocal changes in the radial head, which continues to grow and
aggravate the deformity. Following failure of the non-operative management, he underwent
resection of the bony physeal bar and arthroscopic-assisted internal fixation of the
anterior articular fragment to the posterior humerus, similar to how we address adult
capitellum fractures. Continued monitoring is needed to prevent radial overgrowth,
but his condition and function were greatly improved following this procedure.
Clinical case 5: ([Fig. 7])
In this case, arthroscopic anteromedial and anterolateral portals were established.
The apex of the deformity was visualized, and the location, confirmed on intraoperative
fluoroscopy. The dimensions of the bony wedge resection were calculated preoperatively,
and a burr was used to cut the anterior cortex. Holding the elbow in his/her hands,
the surgeon used the thumbs to flex the distal fragment into the correct degree of
flexion and the osteotomy was secured with Steinmann pins. These pins were subsequently
removed following osteotomy healing.
In addition, the arthroscopic examination revealed an incongruent motion of the radial
head across the capitellum. This was unexpected, and presented another compelling
reason to correct the deformity and prevent future elbow pain and dysfunction. We
believe that many elbow problems treated in adults, like premature arthrosis, may
be the sequelae of childhood injuries that may be underrecognized on radiographic
and clinical examination alone.
Debridement of Soft Tissue and Osseous Impingement
Debridement of Soft Tissue and Osseous Impingement
Although it is less commonly indicated, elbow arthroscopy can be used for the treatment
of soft tissue and bony pathology that is not secondary to fracture or contracture.
Arthroscopy can be performed diagnostically, and the range of motion, assessed under
direct visualization to evaluate symptomatic bony or soft tissue pathology. Arthroscopic
soft tissue and bony debridement or resection in the pediatric population has limited
data, but studies[2]
[9]
[10]
[42]
[43] have shown successful outcomes in the treatment of synovitis, most commonly secondary
to hemarthrosis in hemophilic patients, as well as in the treatment of posteromedial
impingement.
In the earliest retrospective review of pediatric elbow arthroscopy, Micheli et al.[2] cited synovitis (10%) and impingement (5%) among the most common diagnoses and indications
for arthroscopic treatment. Those with synovitis underwent arthroscopic debridement
or biopsy of joint synovitis, and those with impingement underwent arthroscopic resection
of olecranon fossa spurs for treatment of posterior olecranon impingement syndrome.
There were no complications observed in either group, and they were among the 85%
of patients reported to have good or excellent results.
The majority of the remaining literature on the pediatric population focuses on arthroscopic
treatment of posteromedial impingement or valgus extension overload in throwing athletes.
In a recent study, Matsuura et al.[10] reported good results after arthroscopic debridement of posteromedial synovitis
and excision of olecranon spurs in 15 adolescent baseball players with posteromedial
elbow impingement. Though 2 patients demonstrated a recurrence of olecranon osteophytes
and subsequent mild discomfort with activity, all patients were able to return to
the previous level of play without complications.[10] Similarly, Park et al.[9] presented a series of 17 patients who underwent arthroscopic olecranon resection
with or without medial collateral ligament reconstruction with symptoms of posteromedial
impingement. They used MRI to evaluate the integrity of the ulnar collateral ligament
(UCL), and four patients underwent olecranon resection with staged UCL reconstruction.
Postoperatively, the mean range of motion with extension and supination was significantly
improved; flexion and pronation were unchanged. Patients reported less pain and 85%
of patients returned to play. While posteromedial impingement syndrome is less common
in this population, these studies[2]
[9]
[10] show that arthroscopic resection of olecranon osteophytes and removal of loose bodies
have favorable outcomes.
Additionally, arthroscopic synovectomy is proving to be an excellent alternative to
open synovectomy in children with recurrent hemarthrosis secondary to hemophilia.[42]
[43] Dunn et al.[43] reviewed 44 patients that underwent arthroscopic synovectomy of various joints after
failed medical management, and performed arthroscopic synovectomies on 21 elbows.
In those with more advanced arthritic disease, arthroscopic synovectomy was performed
in conjunction with chondral debridement and osteophyte resection. Despite the lack
of clinically significant improvement in elbow range of motion at 1 and 6 years of
follow up, arthroscopic synovectomy decreased the rate of hemarthrosis recurrence,
and there were no complications from the procedure.[43]
Conclusions
Arthroscopy can treat a wide range of pediatric elbow pathologies with equal, if not
better, efficacy and safety than open surgery. Arthroscopy can be considered another
surgical approach, and its utility can be applied to the treatment of various disorders,
including contracture releases, fracture fixation, OCD lesions, deformity corrections,
and debridement of soft tissue and bony impingements. In cases of elbow contracture
release, the morbidity of open surgery may preclude the ability to perform staged
procedures; in this situation, arthroscopy provides the unique advantage of enabling
multiple staged interventions with minimal morbidity to the patient. In trauma scenarios
such as the fixation of lateral condyle fractures, the direct visualization under
magnification provided by an arthroscopic approach facilitates a more anatomic reduction
of the fracture with minimal risk of avascular necrosis that can occur from open procedures.
As the instrumentation and techniques improve, arthroscopy should be considered a
valuable tool in the surgeon's armamentarium to treat pediatric elbows. Future research
is needed to address the expanding indications for pediatric elbow arthroscopy.
