Is Improper Surgical Alignment the Cause of My Child's Hip Issue?

Is it a case of improper surgical reduction?

Hello! My son is currently 10 years old.
Two years ago, he suffered a complete fracture of the left hip joint and had a steel pin inserted, which was removed three weeks later.
After the cast was removed, I noticed that his hand appeared to be misaligned.
When I reported this to the doctor, he jokingly said it was like Chen Shui-bian and that he could become president in the future! However, he also mentioned that it would gradually correct itself due to the "sunflower" principle, as the growth plates in children are still developing.
Yet, three years later, when he extends his arm straight out, it still appears to point downward.

When I first noticed the issue, I consulted pediatric orthopedic specialists at both National Taiwan University Hospital and Veterans General Hospital.
The doctors indicated that he would need corrective surgery.
I then went back to ask the original surgeon, who still insisted that the growth plates would continue to grow and that doing surgery now might lead to further complications later on, suggesting that it might require another operation.

My question is: this should not be considered a highly intricate cardiovascular surgery in medical terms.
Shouldn't the initial surgery have been accurately positioned using imaging technology to avoid such significant discrepancies? Is it possible for the growth plates to have deviated so quickly within just a few weeks? Moreover, if the condition continues to worsen, will it truly self-correct? Is it typical in orthopedic practice for such fractures to require multiple corrective surgeries?

Yihuo de mama, 40~49 year old female. Ask Date: 2005/11/28

Dr. Li Wenlin reply Orthopedics

Hello,
In response to your inquiry, based on your description, your son likely has a supracondylar humeral fracture that underwent reduction surgery followed by percutaneous pin fixation.
After the removal of the pins three weeks later, it was noted that there is either valgus or varus deformity.
Generally, supracondylar humeral fractures can indeed lead to complications, which is why surgical intervention is necessary.
Postoperatively, there may still be some degree of valgus or varus deformity visible.

Typically, even if the fracture reduction is not ideal and there is significant deformity, with limitations in full extension or excessive hyperextension, it is advisable to monitor the situation until skeletal maturity is reached (females around 13 to 15 years, males around 15 to 17 years).
At that point, if there is limited potential for remodeling, corrective surgery may be considered, except in rare cases where there is nerve or vascular compression.
Therefore, I recommend regular outpatient follow-ups and consulting a pediatric orthopedic specialist for surgical treatment at the appropriate time.
Orthopedic advancements have significantly progressed in recent decades, but fracture treatment involves considerations of nerves and blood vessels.
Although it may not be as precise as cardiovascular or neurosurgery, it is certainly not a simple procedure.
Orthopedic surgeons undergo five years of training to comprehensively assess each fracture case, including the mechanism of injury, the degree of comminution, and the extent of damage to nearby nerves and vessels, in order to determine the safest treatment approach with the least complications.
Currently, computer navigation has been introduced in joint reconstruction and spinal surgeries, but it is not yet widely used in fracture surgeries.
However, intraoperative fluoroscopy is routinely employed during pin fixation surgeries to confirm the reduction and monitor the position of the pins.
Supracondylar humeral fractures are inherently challenging, and even with expert intervention, there is still about a 10% chance of complications (such as valgus or varus deformity, nerve, or vascular injury).

Moreover, children's bones have a high remodeling capacity, and some fractures require close monitoring to ascertain the final outcome.
Until skeletal maturity is reached, no expert can definitively predict the results.
I encourage you to maintain close follow-up appointments, as some cases may worsen over time while others may self-correct.
Please try not to be overly pessimistic during this monitoring phase.

Reply Date: 2005/11/28

More Info

Improper surgical alignment can indeed be a significant factor in the development of hip issues, particularly in children who are still growing. In your child's case, the history of a complete hip fracture followed by surgical intervention raises several important considerations regarding the alignment and healing of the hip joint.

When a child undergoes surgery for a fracture, especially in a critical area like the hip, the alignment of the bones is crucial for proper healing and function. If the bones are not aligned correctly during the surgical procedure, it can lead to malunion or nonunion, where the bones heal in an incorrect position. This misalignment can result in functional issues, such as difficulty in movement, pain, and in some cases, deformity, as you have observed with your child's arm appearing to be "twisted" or misaligned.

The concept of the growth plate (physis) is essential in pediatric orthopedics. The growth plate is the area of growing tissue near the ends of the long bones in children and adolescents. As the child grows, the growth plates gradually harden into solid bone. If a fracture occurs near or through the growth plate, it can affect the future growth of the bone. In some cases, if the alignment is off, the bone may continue to grow in a misaligned position, leading to further deformity. This is particularly concerning in your child's situation, where the arm appears to be deviating further from the normal alignment over time.

The notion that the growth plate will "self-correct" is sometimes true, but it heavily depends on the degree of misalignment and the specific circumstances of the injury. Minor misalignments may indeed correct themselves as the child grows, but significant deviations often require surgical intervention to realign the bones properly.
Regarding your concerns about the surgical technique and the potential for further corrective surgeries, it is important to understand that while orthopedic surgeons strive for precision, the complexities of human anatomy, especially in growing children, can lead to unexpected outcomes. The healing process can be unpredictable, and sometimes, despite the best surgical techniques, complications can arise.

In terms of whether multiple corrective surgeries are common, it varies by case. Some children may require only one surgery to correct a significant issue, while others may need additional procedures if the initial surgery does not yield the desired results. It is not uncommon for children with complex fractures or deformities to undergo more than one surgery, especially if the initial alignment was not optimal.

In conclusion, it is essential to have a thorough discussion with your child's orthopedic surgeon regarding the specific nature of the misalignment, the potential for self-correction, and the risks and benefits of any proposed corrective surgery. A second opinion from a pediatric orthopedic specialist may also provide additional insights and options for treatment. Early intervention is often key in preventing further complications, so timely and informed decisions are crucial in managing your child's hip issue effectively.

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