Orthobullets.com
back next
questions
4

Radial Head and Neck Fractures - Pediatric

Author:
Topic updated on 04/20/13 3:02pm
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
    • median age is 9-10 years
    • no difference in incidence between sexes
    • 1-5% of all pediatric elbow fractures
  • Mechanism
    • usually associated with a valgus loading injury of the elbow 
  • Associated Conditions
    • elbow dislocation 
    • medial epicondyle fracture 
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
 
Chambers Classification
Group 1: Primary displacement of radial head (most common) Valgus Injury
A: Salter-Harris I or II
B: Salter-Harris IV
C: metaphyseal

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
    • lateral swelling and 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 with forearm in neutral rotation and beam directed 45 degrees proximally
    • findings
      • nondisplaced fractures may be difficult to visualize 
      • look for fat pads signs
        • a portion of the radial neck is extra-articular and therefore an effusion and fat pads signs may be absent.
Treatment
  • Nonoperative
    • immobilization +/- closed reduction
      • indications
        • most fractures can be treated closed
        • if < 30° angulation immobilize without closed reduction
        • if >30° angulation perform closed reduction and immobilize if angulation reduced to < 30° 
      • followup
        • begin early ROM at 3-7 days to prevent stiffness
  • Operative
    • operative percutaneous reduction 
      • indications
        • > 30° of residual angulation
        • 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 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 technique 
        • pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the 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 
      • 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)
    • 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
    • up to 70% of cases occur with open reduction
  • Synostosis
    • most serious complication
    • occurs in cases of open reduction with extensive dissection or delayed treatment

 

Please Rate Educational Value!
4.0
Average 4.0 of 13 Ratings

Qbank (4 Questions)

TAG
(OBQ11.198) A 10-year-old boy sustains an injury to his dominant elbow and presents to the emergency department with the injury shown in Figures A and B. Following closed reduction and casting, the fracture remains angulated 20 degrees and translated 2mm. What is the next best step in management? Topic Review Topic
FIGURES: A   B        

1. Immobilization in full pronation
2. Immobilization in full supination
3. Immobilization in neutral rotation
4. Closed reduction and percutaneous pinning
5. Open reduction and internal fixation

PREFERRED RESPONSE ▶
TAG
(OBQ10.106) A 12-year-old boy falls 8 feet from a tree limb and lands on his outstretched hand. He complains of elbow pain and a displaced radial neck fracture is noted on radiographs. Closed reduction is attempted with sedation. A post-reduction radiograph is provided in Figure A. Which of the following actions should be taken? Topic Review Topic
FIGURES: A          

1. Immobilization in a sling until pain subsides
2. Immobilization in a long arm cast for 6 weeks to allow for callus formation and subsequent bony remodeling
3. CT scan to further evaluate the fracture and physis
4. Hinged external fixation of the elbow
5. Operative reduction and fixation

PREFERRED RESPONSE ▶
TAG
(OBQ08.154) A 10-year-old female falls from the swing and lands on her left arm. She complains of left elbow pain. On physical exam she has pain exacerbated by motion, especially supination and pronation. She is neurovascularly intact. A radiograph is provided in Figure A. Which of the following is the most appropriate first step in management? Topic Review Topic
FIGURES: A   B        

1. Short arm cast without reduction
2. Long arm cast without reduction
3. Attempt closed reduction
4. K-wire percutaneous reduction in the operating room
5. Open reduction with a lateral approach

PREFERRED RESPONSE ▶
TAG
(OBQ04.171) A 6-year-old boy has right elbow pain after falling onto an outstretched hand eight hours ago. Radiographs are shown in Figure A. Overnight, he develops increasing pain and swelling in his right forearm. What associated condition can develop with the fracture sustained in figure A? Topic Review Topic
FIGURES: A          

1. Extensor pollicis longus rupture
2. Posterior interosseous nerve neuropraxia
3. Forearm compartment syndrome
4. Common extensor origin avulsion
5. Medial collateral ligament rupture

PREFERRED RESPONSE ▶




Evidence & References Show References




Topic Comments

Subscribe status:

Recent on Bottom  |  Recent on Top
Page:1