Updated: 8/24/2022

Radial Head and Neck Fractures - Pediatric

Review Topic
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  • summary
    • Radial Head and Neck Fractures in children are relatively common traumatic injuries that usually affect the radial neck (metaphysis) in children 9-10 years of age.
    • Diagnosis can be made with plain radiographs of the elbow.
    • Treatment can be nonoperative or operative depending on the degree of angulation, translation and displacement. 
  • Epidemiology
    • Incidence 
      • 5-10% of all pediatric elbow fractures and 1% of pediatric fractures overall
    • Demographics
      • median age is 9-10 years
      • no difference in incidence between sexes
  • Etiology
    • Pathophysiology
      • mechanism
        • usually associated with an extension and valgus loading injury of the elbow
        • elbow dislocation
    • Associated Conditions
      • elbow dislocation
      • olecranon fracture
      • medial epicondyle fracture
      • forearm compartment syndrome
  • 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 (rarely used)
      • 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
          • <30 degrees of angulation
          • <3mm translation
        • technique
          • immobilize in long arm cast or splint without reduction
        • follow-up
          • 7 days of immobilization followed by early range of motion
      • closed reduction and immobilization
        • indications
          • >30 degrees of angulation
          • closed reduction followed by immobilization in long arm cast or splint if an adequate reduction is achieved
    • 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 (though this is controversial as higher rates of open reduction are also seen with worse fractures)
  • 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 distal 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 (esmarch) 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 against 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
  • Prognosis
    • Worse outcomes seen in patients >10 years of age
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Questions (8)
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(OBQ13.266) A 9-year-old girl trips and falls onto an outstretched hand 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?

QID: 4901

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



L 2 B

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(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?

QID: 3621

Immobilization in full pronation



Open reduction



Closed reduction



Closed reduction and percutaneous pinning



Open reduction and internal fixation



L 3 C

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(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. Which of the following actions should be taken?

QID: 3200

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



Open reduction and internal fixation



Further reduction and percutaneous fixation in the operating room with elastic stable intramedullary nailing (ESIN)



L 1 C

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(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?

QID: 540

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



L 3 D

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(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?

QID: 1276

Extensor pollicis longus rupture



Posterior interosseous nerve neurapraxia



Forearm compartment syndrome



Common extensor origin avulsion



Medial collateral ligament rupture



L 2 D

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Evidence (25)
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