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Introduction
  • In children, fractures of the proximal end of the radius typically involve the physis or radial neck (metaphysis)
    • most cases are Salter-Harris type II fractures
    • radial head involvement is rare
  • Epidemiology
    • demographics
      • median age is 9-10 years
      • no difference in incidence between sexes
      • 5-10% of all pediatric elbow fractures and 1% of pediatric fractures overall
  • Pathophysiology
    • mechanism
      • usually associated with an extension and valgus loading injury of the elbow 
      • elbow dislocation
  • Associated Conditions
    • elbow dislocation 
    • olcecranon fracture 
    • medial epicondyle fracture 
  • Outcomes
    • worse outcomes seen in patients >10 years of age 
Anatomy
  • There are 6 ossification centers around the elbow joint 
    • age of ossification is variable but occurs in the following order (C-R-I-T-O-E) at an average age of (years)
      • Capitellum (1 yr.)
      • Radius (3 yr.)
      • Internal or medial epicondyle (5 yr.)
      • Trochlea (7 yr.)
      • Olecranon (9 yr.)
      • External or lateral epicondyle (11 yr.)
  • Ossification center of radial head appears between and 3 and 5 years of age
    • may be bipartite
    • radial head fuses with radial shaft  between ages of 16 and 18 years
Classification
 
O'Brien Classification
Type I < 30 degrees   
Type II 30-60 degrees  
Type III > 60 degrees  
 
Judet Classification 
Type I Undisplaced  
Type II < 30 degrees
 
Type III 30-60 degrees   
Type IVa 60-80 degrees   
Type IVb More than 80 degrees
  
 
Chambers Classification
Group 1: Primary displacement of radial head (most common) Valgus Injury
A: Physeal injury - Salter-Harris I or II
B: Intra-articular -Salter-Harris III or IV
C: metaphyseal fracture

Elbow Dislocation
D: reduction injury
E: dislocation injury
 
Group 2:  Primary displacement of radial neck Monteggia variant

Group 3:  Stress injury Osteochondritis dissecans
 
Presentation
  • Symptoms
    • elbow pain
    • refusal to move
  • Physical exam
    • inspection
      • lateral swelling 
    • motion
      •  pain exacerbated by motion, especially supination and pronation.
    • must have high suspicion for forearm compartment syndrome 
    • pain may be referred to the wrist 
Imaging
  • Radiographs 
    • recommended views 
      • AP and lateral of the elbow 
      • radiocapitellar (Greenspan) view 
        • oblique lateral performed by placing the arm on the radiographic table with the elbow flexed 90 degrees and the thumb pointing upward
        • The beam is directed 45 degrees proximally
    • findings
      • nondisplaced fractures may be difficult to visualize 
      • look for fat pads signs
        • anterior fat pad may be normal, but a posterior fat pad sign should be treated as an occult fracture
        • a portion of the radial neck is extra-articular and therefore an effusion and fat pads signs may be absent.
Treatment
  • Nonoperative
    • immobilization alone
      • indications
        • rule of 3's: <30 degrees of angulation, <3mm translation, 1/3 of radial head
        • immobilize in long arm cast or splint without reduction
      • follow-up
        • 7 days of immobilization followed be early range of motion
    • closed reduction and immobilization
      • indications
        • >30 degrees of angulation
        • closed reduction followed by immobilization in long arm cast or splint
  • Operative 
    • closed percutaneous reduction 
      • indications
        • > 30° of residual angulation following closed reduction 
        • 3-4 mm of translation
        • < 45° of pronation and supination
      • outcomes
        • improved outcomes with younger patients, lesser degrees of angulation, and isolated radial neck fractures
    • open reduction
      • indications
        • fracture that cannot be adequately reduced to <45 degrees angulation with closed or percutaneous methods 
      • outcomes
        • open reduction has been associated with a greater loss of motion, increased rates of osteonecrosis and synostosis compared with closed reduction
Techniques
  • Closed reduction
    • reduction techniques
      • Patterson maneuver 
        • hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head
      • Israeli (Kaufman) technique 
        • pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head
      • Nehar and Torch technique 
        • elbow held in extension and supination with distral traction and varus force with assistant pushing laterally on radial shaft and surgeon pushing medially on radial head
      • elastic bandage technique
        • tight application of an elastic bandage beginning at the wrist continuing over the forearm and elbow may lead to spontaneous reduction
  • Closed Reduction and Percutaneous Pinning
    • reduction technique
      • K-wire joystick technique 
        • push technique 
          • blunt end of a large k-wire is pushed agins the posterolateral aspect of the proximal fragment and pushed into place
        • lever technique
          • k-wire is placed into the fracture site and levered proximally
        • if unstable after reduction a pin may be placed to maintain reduction
      • Metaizeau technique  
        • involves retrograde insertion of a pin/nail across the fracture site 
        • fracture is reduced by rotating the pin/nail 
  • Open reduction
    • approach
      • performed with lateral approach (Kocher interval) to radiocapitellar joint
      • pronate to avoid the posterior interosseous nerve (PIN)
    • fixation
      • avoid transcapitellar pins
      • internal fixation only used for fractures that are grossly unstable 
Complications
  • Decreased range of motion
    • loss of pronation more common than supination
  • Radial head overgrowth
    • 20-40% of fractures
    • usually does not affect function
  • Osteonecrosis 
    • 10-20% of fractures
    • radial head in children is entirely cartilage and blood supply is primarily from the metaphysis
    • up to 70% of cases occur with open reduction
  • Nerve injury
    • PIN may be injured
  • Physeal arrest
    • may lead to cubitus valgus deformity
  • Synostosis
    • most serious complication
    • occurs in cases of open reduction with extensive dissection or delayed treatment
 

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