Radial neck fractures account for 5% to 10% of elbow injuries in children1,2 and 1% of all pediatric fractures.3 They are usually sustained by a valgus force that occurs when a child falls from a height onto an extended and outstretched arm.1,4,5 There can also be a torsional component to the injury. The direction of radial head displacement is thought to be influenced by the position of the forearm at impact.6 Fractures into the joint are rare in children, when the physis is open, fractures tend to occur through the physis [Salter-Harris (SH) I or II] or through the radial neck. The proximal radial physis closes at age 14 to 15 in boys, and age 12 to 14 in girls.2
In children, angulated radial neck fractures can remodel. Vocke and Von Laer7 showed that fractures treated conservatively with an angulation up to 50 degrees in children under age 10 corrected themselves spontaneously. Bernstein et al8 also showed that in a 6-year-old child 60 degrees of angulation will remodel, but if the child is 12 years old, angulation >30 degrees will not remodel. Most agree that maximum angulation <30 degrees and translation <2 mm, is acceptable at any age. Greater than 60 degrees of angulation is not acceptable at any age. Between 30 and 60 degrees, there is no clear agreement in the literature regarding what is acceptable in terms of final reduction, but it is clear that younger patients have more chance to remodel than older patients. Angulation tends to be better tolerated than translation as translation of the radial head related to the shaft will cause a cam effect, and rotation of the forearm may be disrupted.
Patients typically present with a swollen and painful elbow with loss of rotation and pain with pronation and supination. A good clinical examination helps to localize the area most likely to be fractured before an x-ray. Neurological examination is important as the posterior interosseous nerve (PIN) is at risk due to its proximity to the radial neck; hand function must be documented before and after reduction.
To best evaluate a radial neck fracture, the x-ray beam should be directed perpendicular to the proximal forearm. Multiple radiographic views should be obtained or live fluoroscopy can be used to visualize the maximum displacement and angulation that is often underestimated with just 2 x-rays of the elbow.
The radial head does not start to ossify until around age 5 years; if the radial head is still mostly cartilaginous, it may be very difficult to visualize on an x-ray. Tenderness over the radial neck and a fat pad sign on an x-ray indicate a fracture; sometimes a small fleck of metaphyseal bone can be seen indicating a SH II fracture. When the radial head is unossified and cannot be well visualized, a magnetic resonance imaging (MRI) or arthrogram9 may be needed to determine the location of the radial head.
Also, if there is concern about ligamentous or articular cartilage injury, MRI may be useful to better understand the full extent of the injury.
Associated injuries occur in 30% to 50% of patients with radial neck fracture.2,5,7,10,11 These additional injuries include fractures of the olecranon, proximal ulna, medial and lateral epicondyle, ruptures of the medial collateral ligament, and sheer injuries to the articular cartilage. If the fracture is significantly displaced, the patient should be examined both clinically and radiographically for other concomitant injuries. As mentioned previously, if there is concern about ligamentous or articular cartilage injury, MRI may be useful to better understand the full extent of the injury.
In the literature, up to half of children with radial neck fractures have subsequent limited forearm rotation.11–13 Stiffness is a common complication after radial neck fracture. Some of this is undoubtedly due to the trauma to the elbow joint and capsule at the time of injury; this can be worsened by multiple attempts at closed or percutaneous reduction or less than meticulous open reduction.7,8 Heterotopic ossification around the elbow14 and radioulnar synostosis can also limit motion.8,15
Deformity may result from avascular necrosis of the radial head,16 nonunion of the fracture, and radial head overgrowth.7 Physeal injury can lead to partial or complete physeal arrest, which can affect the length and alignment of the radius in the future.1,7,14,17 The most common deformity that results is cubitus valgus.
A completely displaced radial head may appear reduced but be upside down (with the articular surface facing the shaft instead of the capitellum)8,18 (see case 2). If not identified and corrected, this will lead to nonunion and destruction of the cartilage both on the capitellum and radial head.
The PIN can be injured by the fracture, by reduction attempts, or during an open reduction. Compartment syndrome can also be associated with radial neck fractures and their treatment.19 Pin-tract infections and/or a septic joint can follow pin fixation of fractures of the radial neck.
Radial neck fractures can be angulated, translated, or completely displaced with dislocation of the radial head. The displacement is measured as the maximum angulation and maximum translation. Flouroscopy is the best way to determine maximum displacement as it is often not in a perfect saggital or coronal plane; multiple views or quick live flouroscopy will help identify the plane and amount of maximum displacement.
In 1965, O’Brien20 originally classified these fractures based on angulation and recommended treatment:
- Type I: angulated <30 degrees (immobilize).
- Type II: angulated 30 to 60 degrees (closed reduction).
- Type III: angulated >60 degrees (open reduction).
Chambers21 suggested a more comprehensive classification of radial head and neck injuries in children:
Most agree that radial neck fractures in skeletally immature patients that are angulated <30 degrees and are translated <2 mm and have full pronation and supination do not need reduction or operative treatment. Two to 3 weeks in a cast followed by early motion gives excellent results with few complications. As discussed previously, younger patients with angulation up to 60 degrees have been shown to do well with simple immobilization followed by early motion, but as they get closer to skeletal maturity, less remodeling is expected and reduction to <30 degrees and translation <2 mm is recommended. The presence of full pronation and supination may be more important to the patient’s clinical outcome than the degree of angulation and translation seen radiographically.
If there is angulation or translation beyond what is typically accepted, or a block to rotation, there are several techniques of closed reduction that can be used. However, we would caution that multiple attempts at closed reduction can lead to increased injury, bleeding and later stiffness; these techniques are very valuable and may prevent the need for open surgery, but if the fracture does not reduce into acceptable position with a few attempts, one should consider open reduction, which may in the long run be less traumatic.7
- Esmarch bandage: wrap forearm distal to proximal while holding elbow in varus, use soft tissue to push the fragment back into place. Rotation (pronation/supination) will also help the radial head to reduce (Fig. 1).
- With elbow at 90-degree flexion and full supination, apply anterior pressure on proximal radial shaft to reduce shaft to head23 (Fig. 2).
- With elbow at 90-degree flexion and full supination, apply pressure to lateral epiphysis while forearm rotated into full pronation.24
- Use flouroscopy to determine rotation of forearm where maximum angular displacement occurs. Then with elbow in extension and position of maximum displacement, 2 thumbs push prox radial shaft laterally, a second set of hands holds elbow in varus with 1 hand and other thumb puts medial force on radial head (presented by Neher and Torch,25 but first described by Reidy and Vangorder26) (Fig. 3).
PERCUTANEOUS-REDUCTION AND FIXATION TECHNIQUES
If the fracture cannot be reduced into an acceptable position after a limited number of closed reduction attempts, then surgery should be considered. Decreased forearm rotation is a good indication that the reduction is not acceptable. Surgery sometimes can be done percutaneously, however, if the radial head has displaced out of the capsule, or there is interposed soft tissue, closed and percutaneous reduction attempts are usually unsuccessful.
- Steinman Pin Joystick (leverage method)15,16,27,28 (see case 1): percutaneously insert a Steinman pin or Kirschner wire (K-wire) into the radial head and use it as a joystick to maneuver the head onto the shaft. Or insert a pin or periosteal elevator into the fracture site, lever the radial head up, then use your thumb or a second pin to slide the head over the pin onto the radial shaft (Fig. 4). When using Steinman pins percutaneously to reduce a radial neck fracture, the location of the PIN should be kept in mind and avoided.
- A Joker can be inserted between the radius and ulna from posteriorly along the olecranon and is used to push the shaft of the radius back underneath the radial head, whereas pressure on the head prevents further lateralization (Presented at The Pediatric Orthopedic Society of North America annual meeting Jacksonvillle, May 2003; Fig. 5).
- Metaizeau technique: a thin flexible nail or smooth wire with a curved tip is inserted from the distal radius into the intramedullary canal of the radius. The tip of the flexible nail is advanced to the fracture site and into the radial head. The nail is then rotated to rotate the radial head onto the shaft3,29–32 (Fig. 6).
If there is a gap at the fracture site after reduction or if the radial head is not able to be reduced into an acceptable position using the above techniques, there is likely a soft tissue interposition that is preventing reduction (periosteum, annular ligament, or capsule). Open reduction is then recommended through a lateral approach: with the arm in pronation (to protect the PIN), incision starts at the lateral epicondyle and extends distally and obliquely to the proximal ulna. Fascia over the anconeus and extensor carpi ulnaris is opened. The fibers are split in line with the extensor carpi ulnaris down to the joint capsule. Usually the injury has opened the capsule; if not, the capsule can be opened anterior to radial humeral ligamentous complex. The radial head, radial shaft, and annular ligament should now be visible. Be careful not to devascularize the radial head more than has already occurred; stripping of the soft tissue attachments will increase the risk of avascular necrosis (AVN). If necessary, the annular ligament can be cut to allow reduction, but this must be repaired after reduction.
Once the radial head is reduced under direct visualization, a single K-wire can be used to fix the radial head to the shaft. For very unstable reductions, 2 K-wires can be used. K-wires should enter the side of the radial head, cross the fracture and capture the metaphysis to prevent loss of reduction. The nonarticulating zone or safe zone of the radial head for insertion of K-wires or internal fixation is along a 90-degree arc determined by palpating the radial styloid and Lister’s tubercle distally33; these landmarks can also be used to confirm reduction as the cartilage in the safe zone appears much thinner than the articulating cartilage. K-wires should not go through the capitellum as they may break off in the joint.11 They should be removed 3 weeks postoperatively as intra-articular pins can lead to joint infection if left for too long.
There is controversy regarding how much angulation and translation can be tolerated in pediatric radial neck fractures. There is agreement that reduction to <30-degree angulation and 2 mm translation is acceptable, and >60 degrees or 3 mm of translation is not acceptable. Younger children have a higher potential to remodel, the closer they get to skeletal maturity, the less displacement one can accept.
Unlike adults, one should not excise or replace a child’s radial head. Every effort should be made to preserve the radial head.
Various recommendations have been described for the best position of immobilization of the forearm after radial neck fracture. Our recommendation is to immobilize for 3 to 4 weeks in a long arm cast/splint with the forearm in neutral rotation as this is the most functional position for the forearm if stiffness develops.
A 7-year-old boy sustained a displaced and angulated radial neck fracture (Fig. 7).
An initial attempt at reduction was made and was unsuccessful in the emergency department, therefore the patient was taken to the operating room for percutaneous reduction and casting (Fig. 8).
The patient was casted for 3 weeks and quickly regained full function of the elbow.
A 11-year-old boy sustained a significantly displaced and rotated radial neck fracture (Fig. 9).
The radial head was “reduced” such that the articular surface of the radial head was facing the shaft fragment (Fig. 10).
The reduction was revised through an open approach and K-wires were placed to stabilize the fracture (Fig. 11).
With this degree of displacement we would recommend that any attempt at reduction be done in the operating room and not by a junior resident in the emergency department. With increasing degrees of displacement, the risk of nonunion and AVN rises significantly, and great care needs to be taken to minimize additional trauma to the radial head.
A 3-year-old girl fell from the kitchen counter and presented with a significantly swollen elbow (Fig. 12).
This patient was treated with open reduction and K-wire fixation as the radial head was outside the capsule (Fig. 13).
In young patients, a halo or sliver of bone with an unossified epiphysis can easily be missed. A considerable amount of swelling about the elbow should raise suspicions for a significant injury that needs further investigation even with benign-appearing radiographs. MRI can be used to investigate these injuries further and allows evaluation of the unossified radial head and other soft tissue structures about the elbow that could be injured with an elbow dislocation. Another alternative is to evaluate the elbow intraoperatively with an arthrogram.
Radial neck fractures in the pediatric patient are not uncommon injuries. Although most patients do well, there are multiple complications that can occur that may lead to poor long term elbow function. There is debate in the literature regarding which patients can be treated just with immobilization and which need intervention with closed, percutaneous, or open reduction. It is important to know different techniques for reduction and to be able to minimize the risk of complications. Multiple techniques for reduction and fixation are reviewed in this paper with their associated risks. Three case examples are presented for clarification.
Summary of 3 most important points are as follows:
- Thirty degrees of angulation and 2 mm of translation of a radial neck fracture is acceptable in the pediatric patient, full pronation and supination after reduction is a good indication that reduction is adequate. More angulation may be acceptable in younger patients with more remodeling potential.
- There are multiple techniques for closed and percutatneous reduction of radial neck fractures that are reviewed in this paper.
- Multiple attempts at reduction may further traumatize the elbow and increase the risk of stiffness and AVN. If limited reduction attempts either closed or percutaneous do not give an acceptable reduction, the surgeon should convert to an open reduction of the radial neck fracture.
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