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http://upload.orthobullets.com/topic/4011/images/11_moved.jpg
http://upload.orthobullets.com/topic/4011/images/epiphysis of elbow.jpg
http://upload.orthobullets.com/topic/4011/images/displaced radial neck fracture.jpg
http://upload.orthobullets.com/topic/4011/images/illustration classification.jpg
http://upload.orthobullets.com/topic/4011/images/monteggia variant ii.jpg
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
      • 1-5% of all pediatric elbow fractures
  • Pathophysiology
    • 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
    • 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
        • 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) to radiocapitellar joint
      • avoid deep branch of radial nerve
    • 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
 

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Technique Guides (1)
Questions (5)

(OBQ13.266) A 9-year-old girl falls onto her left elbow while swinging from the monkey bars and sustains a radial neck fracture. Closed reduction with adequate sedation under mini-C arm guidance is performed in the emergency room. Radiographs following this attempt are shown in Figures A and B. Residual angulation is 62°. What is the next best step in treatment? Review Topic

QID:4901
FIGURES:
1

Early range of motion

4%

(133/3627)

2

Percutaneous reduction with pin fixation as needed

89%

(3236/3627)

3

Immobilize in 90º of elbow flexion and neutral forearm rotation

3%

(105/3627)

4

Open reduction and plate fixation

3%

(112/3627)

5

Open reduction and epiphysiodesis

1%

(29/3627)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

This child has a displaced, angulated radial neck fracture. Residual angulation after reduction is >30º. The next step is percutaneous reduction and pinning. Direct reduction (inserting a pin into the head or shaft fragment as a joystick) and indirect reduction (Metaizeau method using a retrograde intramedullary pin) are possible options. Hardware is removed at 8 weeks.

Radial neck fractures are Salter Harris II fractures and generally occur after a valgus load in 9-10 year olds. One treatment algorithm suggests the following: (1) <30º angulation, immobilize without reduction. (2) >30º angulation, perform closed reduction. (3) >30º residual angulation, perform percutaneous reduction and pinning. (4) Unsuccessful closed or percutaneous reduction, perform open reduction.

Ursei et al. performed Metaizeau intramedullary pinning in 20 patients with severely displaced radial neck fractures. In 4 cases, the procedure was converted to open reduction. They achieved 85% excellent or good results, 5% fair and 10% poor results with limited ROM. In 2 cases, pin reduction of the fracture was unsuccessful either because of elbow dislocation and radial head entrapment in the joint, or soft tissue interposed between the radial head and neck.

Metaizeau et al. described the original technique. They cautioned that when angulation >80°, the wire may not reach the epiphysis. They recommend (1) first trying closed reduction before introducing the wire, or (2) using an external pin to directly push against the outer aspect of the epiphysis.

Figures A and B show a displaced and angulated pediatric radial neck fracture. Illustration A shows the Metaizeau technique. The technique is as follows: (1) drill the cortex 2 cm proximal to the physis, (2) introduce the pin into the medullary canal and drive it to the inferior aspect of the fracture, where the tilt is the greatest, (3) fix the point of the pin into the epiphysis and elevate it until it is under the lateral condyle, (4) rotate the pin around its long axis through 180° to shift the radial head medially and reduce it. The tension produced in the lateral intact periosteum prevents medial overcorrection.

Incorrect Answers:
Answer 1: Closed reduction with adequate sedation and fluoroscopic guidance has already been attempted unsuccessfully. The next step is percutaneous reduction.
Answer 3: Immobilization with 62° of residual angulation may not remodel completely and may result in permanent angular deformity.
Answes 4, 5: Open reduction is only indicated if both closed and percutaneous reduction fail. Only pin fixation is required after open reduction. Epiphysiodesis is not indicated.

ILLUSTRATIONS:

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Question COMMENTS (11)

(OBQ11.198) A 10-year-old boy sustains an injury to his dominant elbow and presents with the injury shown in Figures A and B. What is the next best step in management? Review Topic

QID:3621
FIGURES:
1

Immobilization in full pronation

1%

(12/1563)

2

Open reduction

2%

(37/1563)

3

Closed reduction

58%

(909/1563)

4

Closed reduction and percutaneous pinning

29%

(455/1563)

5

Open reduction and internal fixation

9%

(147/1563)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The scenario and image depict a patient with an isolated radial neck fracture. The next best step is an attempted closed reduction as the images demonstrate angulation >30.

Techniques of closed reduction include applying extension, varus stress, and manual pressure; elbow flexion with forearm pronation and manual pressure(Israeli method), and the Esmarch method. Open reduction commonly causes iatrogenic stiffness and should be avoided unless an acceptable closed reduction restoring motion is unsuccessful. While acceptable tolerances are controversial, anatomic reduction is not required. Once reduced, the fractures are commonly stable and do not require fixation.


Incorrect Answers
Answer 1: The presenting alignment is not acceptable.
Answer 2: Open reduction may cause iatrogenic stiffness and should be avoided if possible.
Answer 4: Percutaneous pinning is not required if the reduction is stable.
Answer 5: Open reduction may cause iatrogenic stiffness and should be avoided if possible.


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Question COMMENTS (6)

(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 performed under sedation in the ER. A post-reduction radiograph is provided in Figure A revealing residual angulation measuring in excess of 45. Which of the following actions should be taken? Review Topic

QID:3200
FIGURES:
1

Immobilization in a sling until pain subsides

3%

(77/2800)

2

Immobilization in a long arm cast for 6 weeks to allow for callus formation and subsequent bony remodeling

2%

(49/2800)

3

CT scan to further evaluate the fracture and physis

2%

(68/2800)

4

Hinged external fixation of the elbow

0%

(7/2800)

5

further reduction and fixation in the operating room with ESIN

93%

(2591/2800)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The radiograph demonstrates a radial neck fracture with greater than 45 degrees of residual angulation following closed reduction. The majority of pediatric radial neck fractures can be treated with closed reduction. Up to 30 degrees of angulation is considered acceptable.

it is generally agreed that residual angulation greater than 30 is not well tolerated. Tarallo et al compares 2 methods of surgical management: elastic intramedullary versus percutaneous pinning. Both methods in this study reveal outcomes superior to those found in the literature for open reduction. ESIN (elastic stable intramedullary nailing) resulted in improved range of motion.

Dormans et al summarizes the evaluation and treatment of radial head and olecranon fractures in pediatric patients stating that most radial head fractures can be treated with closed reduction. As the age of the child increases, the necessity for open reduction also increases.


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Question COMMENTS (4)

(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? Review Topic

QID:540
FIGURES:
1

Short arm cast without reduction

1%

(4/702)

2

Long arm cast without reduction

4%

(30/702)

3

Attempt closed reduction

73%

(510/702)

4

K-wire percutaneous reduction in the operating room

12%

(84/702)

5

Open reduction with a lateral approach

10%

(67/702)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The radiograph demonstrates a physeal radial neck fracture with 45 degrees angulation. An attempt of closed reduction should be performed with a goal of less than 30 degrees residual angulation. Most pediatric radial neck fractures can be treated with closed reduction and immobilization followed by early range of motion at three to seven days. Percutaneous reduction and open reduction should be reserved for failure of closed treatment.

Tibone et al reviewed 33 cases of pediatric radial head and neck fractures. Inferior outcomes were associated with fractures that were treated open, increasing age of children, and those with other associated upper extremity fractures. Many patients with deformity on radiograph reported a good clinical outcome. Steinberg et al reports 31% poor results in 42 pediatric patients with radial neck fracture. Primary angulation was the most important prognostic factor.


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Question COMMENTS (22)

(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 is most likely developing in this scenario? Review Topic

QID:1276
FIGURES:
1

Extensor pollicis longus rupture

0%

(3/955)

2

Posterior interosseous nerve neurapraxia

10%

(95/955)

3

Forearm compartment syndrome

85%

(810/955)

4

Common extensor origin avulsion

2%

(23/955)

5

Medial collateral ligament rupture

2%

(18/955)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Figure A demonstrates a non-displaced pediatric radial neck fractures as evidenced by a mildly abnormal angular configuration of the lateral aspect of the proximal radial metaphysis.

Peters et al reports on 3 patients who developed volar compartment syndrome with a radial neck fracture. Important clinical information is that they all fell from standing height on an outstretched hand, and the compartment syndrome developed 12-24 hours after the injury. All had severe pain that was exacerbated by passive flexion and extension of the fingers. All were treated with fasciotomies with good clinical results. The study illustrates the need for a high suspicion of compartment syndrome even in skeletally immature patients with a minimally displaced fracture of the radial neck.


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Question COMMENTS (8)
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