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Updated: Aug 24 2022

Radial Head and Neck Fractures - Pediatric

Images radial neck fracture.jpg variant ii.jpg head ocd.jpg
  • 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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