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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?
Early range of motion
Percutaneous reduction with pin fixation as needed
Immobilize in 90º of elbow flexion and neutral forearm rotation
Open reduction and plate fixation
Open reduction and epiphysiodesis
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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.
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.
Ursei M, Sales de Gauzy J, Knorr J, Abid A, Darodes P, Cahuzac JP
Acta Orthop Belg. 2006 Apr;72(2):131-7. PMID: 16768254 (Link to Abstract)
Injury. 2005 Feb;36 Suppl 1:A75-7. PMID: 15652940 (Link to Abstract)
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Average 4.0 of 10 Ratings
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?
Immobilization in full pronation
Closed reduction and percutaneous pinning
Open reduction and internal fixation
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.
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.
Average 2.0 of 26 Ratings
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?
Immobilization in a sling until pain subsides
Immobilization in a long arm cast for 6 weeks to allow for callus formation and subsequent bony remodeling
CT scan to further evaluate the fracture and physis
Hinged external fixation of the elbow
further reduction and fixation in the operating room with ESIN
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.
Tarallo L, Mugnai R, Fiacchi F, Capra F, Catani F.
J Orthop Traumatol. 2013 Dec;14(4):291-7. Epub 2013 Jul 11. PMID: 23843093 (Link to Abstract)
Dormans JP, Rang M.
Orthop Clin North Am. 1990 Apr;21(2):257-68. PMID: 2326052 (Link to Abstract)
Average 3.0 of 22 Ratings
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?
Short arm cast without reduction
Long arm cast without reduction
Attempt closed reduction
K-wire percutaneous reduction in the operating room
Open reduction with a lateral approach
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.
Steinberg EL, Golomb D, Salama R, Wientroub S.
J Pediatr Orthop. 1988 Jan-Feb;8(1):35-40. PMID: 3335620 (Link to Abstract)
Tibone JE, Stoltz M.
J Bone Joint Surg Am. 1981 Jan;63(1):100-6. PMID: 7451512 (Link to Abstract)
Average 3.0 of 19 Ratings
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?
Extensor pollicis longus rupture
Posterior interosseous nerve neurapraxia
Forearm compartment syndrome
Common extensor origin avulsion
Medial collateral ligament rupture
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.
Peters CL, Scott SM.
J Bone Joint Surg Am. 1995 Jul;77(7):1070-4. PMID: 7608230 (Link to Abstract)
Average 3.0 of 40 Ratings
HPI - falling down
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HPI - Fall from the chair 1 day back
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HPI - Fall on hand
How would you treat this injury?