ARTHROGRAPHY FOR REDUCTION OF A FRACTURE OF THE RADIAL NECK IN A CHILD WITH A NON-OSSIFIED RADIAL EPIPHYSIS

Arthrogram assisted reduction of radial neck fracture in a child with unossified radial head - A case report and review of literature

Radial neck fractures account for 1% of all paediatric fractures and constitute 5-10% of elbow injuries. Radial neck fractures rarely occur at age 2 or less. It is difficult to assess and reduce radial neck fractures in children with unossified radial head. We report a case of 2 years old female child presented to emergency with history of fall from stairs on an outstretched hand. Radiograph showed a metaphyseal spike in the proximal radius which prompted us to think of a radial neck fracture. Since the radial head was not ossified, the amount of displacement and angulation was not exactly quantifiable on radiographs only. Hence an arthrogram was planned. Intra operative use of radio opaque dye injection into elbow joint delineates the radial head and capitellum. It helps in identifying the fracture morphology and will also assist in reduction. We reduce radial head by K wire leverage technique and the intramedullary elastic titanium nail was added to assist in reduction and to improve fixation stability. We recommend arthrogram to be a safe and reliable option for proper assessment and reduction of radial neck fracture in an unossified radial head.

Closed reduction of severely displaced radial neck fractures in children

BACKGROUND

Severely displaced radial neck fractures in skeletally immature children are rare and can be difficult to reduce. The purpose of this study is to evaluate the results using our reduction maneuver.

METHODS

From October 2011 to December 2015, 26 children with radial neck fractures(O'Brien type II, III and Judet type III, IV) were treated at our institute. All patients underwent percutaneous K-wire leverage and radial intramedullary pinning in an average surgery time of 35 mins (15-80 min). The injured arm was immobilized at the functional position with plaster for 4-6 weeks, evaluated clinically and radiologically. The Metaizeau classification and Mayo elbow performance score were used to evaluate the radiological and clinical results, respectively. Percutaneous K-wire leverage and radial intramedullary pinning were performed for 26 patients. No patients were treated with open reduction. Twenty four patients were followed up for a mean of 33 (range 12-53 months) months.

RESULTS

There were 15 girls and 9 boys with ages ranging from 1.5 to 12 years and an average age of 7.2 years. Percutaneous K-wire leverage reduction and intramedullary pinning were successfully used in an average total surgery time of 35 mins (range 15-80 min). In total, 2 cases (O'Brien type III and Judet type IVb, angulation = 90°) needed the additional maneuver. Bone union was achieved in all patients within a mean time of 4.2 weeks. The clinical results were evaluated basing on the Mayo elbow performance score, and there were 23 excellent results and one good result. There were no refractures and no incidences of nonunion, suture infection, iatrogenic radial nerve injury, asymptomatic enlargements of the radial head or growth arrest in the proximal radial epiphysis.

CONCLUSION

Our modified percutaneous leverage technique with radial intramedullary fixation may be successfully used to avoid open reduction.

Proximal Radius Fractures in Children

Fractures of the proximal radius represent 5% to 10% of all elbow fractures in children. These fractures have many treatment options and have a high risk of complication, particularly loss of forearm rotation. Nonsurgical management of minimally displaced radial neck fractures produces excellent results in most patients. For displaced fractures, numerous methods of closed and percutaneous reduction have been proposed, whereas open reduction has been associated with particularly poor outcome. Many additional factors, including fracture angulation, patient age, associated injury, articular involvement, and internal fixation, may lead to worse outcomes. Because the literature is limited to retrospective case series, few studies provide high-level evidence to guide the treatment of pediatric proximal radius fractures; however, certain management principles have been established that are reviewed here.

Pediatric radial neck fractures: when and how to fix

This is a review of current evaluation and treatment recommendations for pediatric radial neck fractures, including a series of cases that were presented and reviewed by a panel at The Pediatric Orthopedic Society of North America annual meeting 2010. We summarize the different published techniques for closed, percutaneous, and open reduction, and review when these techniques are recommended. The potential complications that can arise from radial neck fractures and their treatment are discussed.

Elbow arthrography in children with an ulnar fracture and occult subluxation of the radial head

The purpose of this study was to investigate the use of elbow arthrography for detecting an occult subluxation of the radial head and for verifying the quality of reduction in children with ulnar fractures. The study involved 15 children who underwent closed reduction (with or without percutaneous pinning) based on arthrography for minimally displaced fractures with or without radial head subluxation. The mean age of the patient at the time of surgery was 6 years (range, 3-12 years). Initial diagnoses based on conventional radiographs were compared with arthrographically confirmed final diagnoses in groups of children with ulnar fractures of the olecranon, proximal, and diaphysis. Arthrography confirmed initial radiographic diagnoses in 10 and altered diagnoses in five patients. We conclude that arthrography can be useful for detecting an occult subluxation of the radial head and for evaluating adequate reduction in children of less than 6 years with ulnar fractures.