The incidence of radial neck fracture is around 1% of all pediatric fractures and between 5% and 10% of all pediatric elbow fractures.1–3 The mechanism of injury is usually a fall over an extended and outstretched arm associated with a valgus force.1,4 Most of the fractures are closed and 30 % to 50% are associated with other injuries such as olecranon fracture, elbow dislocations, and rupture of the collateral ligaments.5–8 Treatment recommendation varies according to the amount of displacement, angulation, age of the child, and the presence of associated injuries. Treatment options include cast immobilization with or without closed reduction, percutaneous (PC) reduction with or without fixation, and open reduction and fixation.5,7,9 The aims of the treatment are to achieve primary healing and restore elbow motion, while minimizing the risks of complications. Several classification systems have been described, most based on the severity of the fracture, mechanism of injury, and associated injuries (Fig. 1).
Potential complications include elbow stiffness, pain, heterotopic ossification, avascular necrosis, nonunion, radioulnar synostosis, posterior interosseous nerve (PIN) injury, compartment syndrome, and radial head overgrowth.5,10,11 The reported rate of complication approaches 40%, with stiffness/decreased range of motion (ROM) being the most frequent. Factors contributing to stiffness include the severity of initial injury, presence of associated fractures, multiple attempts of closed reduction, and need for open reduction.5,9,11 It is often reported that open reduction is associated with worse outcomes.5,6,11,12 Through this review, we identify and discuss the prognostic factors for radial neck fractures in children.
PRINCIPLES OF MANAGEMENT
The treatment of radial neck fractures follows the following algorithm: fractures with <30 degrees of angulation and minimal displacement/translation (<3 mm) do not require reduction in skeletally immature children who present with full pronation and supination.2,5,6,13 Fractures with angulation >30 degrees and displacement >50% (or >4 mm) should undergo attempt of closed reduction under sedation or anesthesia.12,14,15 When closed reduction is unsuccessful, the next step is a PC-assisted reduction, through direct manipulation of the fragment with a Kirschner wire or Freer elevator, or alternatively utilizing the Metaizeau technique.16
Open treatment of radial neck fractures in children is best avoided and should be used only when the other methods have failed to obtain adequate reduction.5,6,11,12 Treatment outcome depends on several factors, most of which are outside the surgeon’s control, including the amount of displacement and angulation, the age of the child, presence of associated injuries, and treatment method (open vs. close).
Older children have lower potential of remodeling compared with younger children; therefore less displacement should be accepted. Basmajian et al5 reported 74% of excellent and good outcomes in patients younger than 10 years old compared with 54% of patients aged 10 years and older. The outcome was graded according to the Tibone and Stoltz17 outcome elbow system that is based on elbow ROM, pain, and deformity. De Mattos et al9 reported correlation between older children and severely displaced radial neck fractures. This reflects the need of open reduction surgery and the higher rate of poor to fair outcomes.
The role of the amount of the initial angulation and displacement has also shown conflicting results. Zimmerman et al7 found that the greater initial angulation and displacement were associated with less favorable patient outcomes, whereas De Mattos et al,9 did not find any correlation. The presence of associated injuries is usually associated to higher energy traumas, and often associated to more significant soft tissue compromise, displaced fracture, and need for more invasive treatment.18
Closed Reduction Techniques
Fractures with <30 degrees of angulation and minimal translation are amenable to conservative treatment without the need of closed reduction. Fractures angulated>30 degrees and >50% of translation (>4 mm) may block forearm rotation by a cam effect and closed reduction is indicated. Monson et al15 described a technique in which the elbow is flexed to 90 degrees with full supination of the forearm. In that position applying pressure on the proximal radial shaft may reduces the shaft to the radial head. Neher and Torch14 described a technique in which the elbow is in full extension and requires assistant. The assistant presses on the proximal part of the radius shaft with his thumbs while the surgeon applies varus stress on the fracture in one hand and reduces the radial head to the shaft with his thumb.
PC-assisted Reduction Techniques
If closed reduction is unsuccessful, PC-assisted reduction should be performed (Fig. 2). One option is the leverage method (direct manipulation of the fragment)12,19 using small PC incision, followed by placement of the blunt side of a large Steinman pin, or Freer elevator. The wire should come from the posterior distal and the forearm should be held in pronation to increase the distance and protect the PIN. Once the fragment is levered up, closed reduction maneuvers are performed. Reduction is usually stable, but PC fixation can also be performed if needed. Similar to that it is the joystick method20 in which the surgeon insert Steinman pin or Kirschner wire directly to the radial head to maneuver the head to the shaft. The forearm in this technique should also be pronated to increase the distance to PIN. In our experience the leverage maneuver is easier as there is no difficulty removing the “joystick” pin. Another often used option for PC-assisted technique is the Metaizeau16 in which a flexible intramedullary nail with a curved tip is inserted from the distal radius throughout the radial shaft into the radial head. Once the nail engages the radial head the T handle is rotated to realign the proximal radius. The nail is retained for added stability. In more severely angulated and displaced fractures a combination of these 2 techniques can be performed.
Many factors have been described as poor prognosticator in radial neck fractures in children, most pertain to the personality of the fracture (angulation and translation), patients demographics (aged 10 y and older) and energy of the trauma, and are beyond the surgeon’s control. Treatment has also been directly related to the development of complications, especially stiffness and decreased ROM.5,7 Unfortunately treatment is directly related to the fracture personality, worse fractures needing more invasive treatment, resulting in additional damage to the soft tissue and blood supply, ultimately leading to poor outcomes.
It is well described that open reduction is one of the most contributing factors for postoperative poor outcomes,5,6,11,12 therefore most authors would agree that open reduction should be avoided if at all possible. PC-assisted techniques have gained into popularity, as the outcome is better than with formal open surgery. In a series presented by Zimmerman et al7 24% of the patients underwent open reduction without any prior attempt of closed or PC reduction. There was no correlation between poor outcomes and number of intervention. The author recommends attempts of closed/PC reduction before switching to an open reduction. Tan and Mahadev21 reported poor outcomes in patients treated in more invasive methods. Among patients with grades 3 and 4, better outcomes were achieved in patients treated by closed or PC reduction than by open reduction. Schmittenbecher et al6 treated 25/30 (83%) of fracture grades 3 and 4 by closed/PC reduction and reported excellent result in 74% of these patients. Basmajian et al,5 in a multicenter study reported better outcomes for patients who underwent PC reduction than patients who underwent open reduction. Only 6/17 (35%) of patient treated by open reduction had good to excellent result compared with 19/26 (73%) of those who went PC reduction.
Different authors demonstrate good to excellent results when using closed reduction methods. Song et al22 presented a series of 12 patients with severely displaced radial neck fracture. All patients were treated with PC leverage reduction and had good to excellent result. One patient developed transient PIN palsy which spontaneously recovered after 2 weeks from surgery. Wang et al20 treated 23 patients, of which 15/23 had preoperative angulation >30 degrees and 8 patient with angulation >60 degrees. All were treated with PC leverage technique and intramedullary fixation with Kirschner wires. All had good to excellent outcome. González-Herranz et al23 report the result of 17 displaced radial neck fracture treated with the Metaizeau technique. After average follow-up of 4 years all patient except 1 had excellent result.
In summary, we follow a treatment algorithm based on ours and different studies2,5–7,13 and believe that most radial neck fractures in children can be treated by closed reduction or PC-assisted techniques, while open reduction should be used only as a last resort for cases in which all closed techniques failed.
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