Surgical management of pediatric radial neck fractures

Corrective Osteotomy and Ligamentous Reconstruction in a Neglected Elbow Dislocation with Radial Neck Malunion: A Case Report

CASE

Neglected elbow dislocation and radial neck malunion frequently result in chronic pain, instability, and early arthrosis. These complications are best prevented by early treatment with open reduction, corrective osteotomy, and ligament reconstruction, followed by early supervised physiotherapy. We present a peculiar case with neglected complex elbow dislocation and radial head malunion. In this case, we performed an open reduction of the elbow joint and radial neck corrective osteotomy, medial collateral ligament, annular ligament reconstruction, and lateral collateral ligament repair.

CONCLUSION

Neglected complex elbow dislocations require reconstruction of both ligamentous and osseous structures to achieve a good functional outcome.

Predictive factors for open reduction of operatively treated radial neck fractures in children

INTRODUCTION

Open reduction is a therapeutic option for displaced radial neck fracture in children, which once was considered the last resort because of its potential risk for functional outcomes. This study aimed to identify risk factors for open reduction in operatively treated radial neck fractures in children.

PATIENTS AND METHODS

One hundred and thirty-seven patients with displaced radial neck fractures, treated surgically at our department from January 2010 to December 2021 were retrospectively enrolled. Patients' data of age, sex, injury side, obesity, type of fractures, combined fractures, nerve injury, reduction methods, and delay from injury to surgery were reviewed. Univariate analysis and multivariate logistic regression were used to identify independent risk factors and odds ratios of open reduction.

RESULTS

Overall, 137 patients (62 females and 75 males) with an average of 8.0 ± 2.2 years were analyzed. There were 62 cases of type III fractures and 75 cases of type IV based on the Judet classification. Thirty-two cases had combined fractures and 19 cases presented with nerve injury. The open reduction rate was 24.1 % (33/137). Univariate analysis indicated obesity, fracture type, and combined fractures were significantly associated with open reduction. (P = 0.039, P = 0.000 and P = 0.000, respectively). While multivariate logistic regression analysis showed that only fracture type (OR, 5.18; CI, 1.63-16.46, p = 0.005) and combined fractures (OR, 7.79; CI, 2.97-20.41, p = 0.000) were independent risk factors for open reduction.

CONCLUSIONS

Judet type IV fracture and combined fractures are two significant risk factors for open reduction in operatively treated radial neck fractures in children. These findings will facilitate preoperative decision making, remind surgeons of the risk of failure in closed reduction and the use of new surgical techniques to decrease the open reduction poor outcome rate.

Judet type-IV fracture of the proximal end of the radius in a 7-year-old child. A surgical case report of open reduction and percutaneous pinning

INTRODUCTION

Fractures of the proximal end of the radius are rare and account for 1 % of all childhood fractures. The treatment of the proximal end of the radius in children depends on age, the degree of angular displacement, and the presence of additional injuries.

CASE PRESENTATION

This is a case of a 7-year-old child with a 90-degree angular displaced radial neck Judet type-IV fracture treated with open reduction and intramedullary stabilization with Kirschner wire. Follow-up examinations performed 4 and 12 weeks after the operative treatment revealed very good functional and radiological results.

DISCUSSION

In fractures of the radial neck with head displacement reaching 90an open reduction is the method of choice. An undoubted advantage of this method is the possibility of achieving a satisfactory reduction and fixation on the fragments. Although other operative treatment techniques including percutaneous K-wire leverage, Metaizeau technique, may be taken into consideration.

CONCLUSION

The method of open reduction and pinning is safe and gives good early outcomes as well as long-term results without leading to impairment of function or deformation of the elbow joint.

Recurrent Infections After Percutaneous Pinning of a Proximal Radius and Ulna Fracture

Elbow fractures in the pediatric population are an exceedingly common injury, comprising 5% to 10% of all pediatric fractures, with supracondylar fractures being the most common of the subset. Radial neck fractures are less frequent, comprising only 1% of all pediatric fractures. We provide a case report of a 7-year-old girl with a left radial neck and proximal ulna fracture. A 7-year-old girl presented to the emergency department after falling off a rock wall the day before. Imaging showed a left proximal ulna and proximal radial neck fracture. The patient underwent percutaneous reduction and fixation, complicated by subsequent infection requiring surgical débridement. The patient then developed a recurrent infection 1 year later, requiring repeat irrigation and débridement. The patient has since made a full recovery, returned to activities of daily living, and regained a full range of motion. Radial neck fractures have a low incidence and have been frequently associated with poor outcomes. The main mechanism by which these fractures occur is due to falling on an outstretched arm. Percutaneous pinning is often recommended after unsuccessful attempts at closed reduction because open reduction is often complicated by postoperative stiffness. As with any procedure that involves breaking the skin, there is a risk of infection. However, there is unclear evidence regarding ideal perioperative management to prevent postoperative infection.

Corrective Osteotomy for Symptomatic Radial Head and Neck Malunions in the Skeletally Immature

BACKGROUND

Radial head and neck fracture malunion can lead to pain, stiffness, deformity, and functional limitations. This study analyzed the early radiographic and functional outcomes of corrective osteotomy for symptomatic radial head and/or neck malunion in skeletally immature patients.

METHODS

Thirteen pediatric patients treated with corrective osteotomy for symptomatic radial head and/or neck malunion from 2004 to 2018 were identified. Radiographic union, range of motion, pain, and complications were recorded. Functional outcomes were assessed using the Broberg and Morrey Elbow Scale.

RESULTS

The average age at the time of surgery was 12.3 years (range: 8.6 to 16.3). The mean time from injury to osteotomy was 7.5 months (range: 2 to 24.1 mo). Before osteotomy, mean radial head-shaft angulation was 23 degrees (range: 5 to 57 degrees), mean displacement was 76% (range: 0 to 55), average elbow flexion contracture was 18 degrees (range: 0 to 60 degrees), and average elbow flexion was 112 degrees (range: 95 to 135 degrees). After a mean follow-up of 14.3 months, 12 of 13 osteotomies (92%) healed; 1 patient had a painless nonunion. The number of patients reporting pain decreased from 9 to 2 ( P =0.012). Radiographic alignment and range of motion improved in all patients. Mean angulation and displacement improved to 8 degrees (range: 2 to 15 degrees, P =0.001) and 3% (range: 0 to 18 degrees, P =0.001), respectively. Mean elbow flexion contracture was reduced to 5 degrees (range: 0 to 30 degrees, P =0.008), and the average elbow flexion increased to 128 degrees (range: 100 to 135 degrees, P <0.001). Three patients underwent implant removal for complications, including heterotopic ossification and avascular necrosis. Physeal arrest did not lead to any adverse sequelae. The sole case of avascular necrosis had a reduced range of motion but no pain. The mean postoperative Broberg and Morrey score was 91.1; 7 patients had excellent postoperative scores, 4 good, and 2 fair.

CONCLUSIONS

Corrective osteotomy for symptomatic malunion of the radial head and/or neck in skeletally immature patients can improve elbow alignment, motion, pain, and function. Preservation of the soft-tissue attachments to the proximal epiphysis and rigid internal fixation are critical components of this surgical technique.

LEVEL OF EVIDENCE

Therapeutic Level IV.

A retrospective review of 101 operatively treated radial neck fractures in children and analysis of risk factors for functional outcomes

INTRODUCTION

Radial neck fracture is a less common injury in childhood and many factors are associated with the final functional outcomes. This study aimed to describe the clinical and radiological results of the patients with radial neck fractures treated surgically and assess the potential risk factors for poor functional outcomes.

PATIENTS AND METHODS

This study enrolled 101 children with radial neck fracture and treated surgically at our department. Patients were followed up at least three years and assessed clinically and radiographically. The primary outcome of this study was the functional outcome assessed by using Metaizeau criteria and the secondary outcome was complications of radial head necrosis, postoperative radial nerve palsy, bone union, infection, and skin irritation. Related risk factors for unsatisfactory functional outcomes were recorded and analyzed by multivariable logistic regression.

RESULTS

In total, 101 patients with 101 elbows (44 on the left side, 57 on the right side) were evaluated in our study, including 55 females (54.5%) and 46 males (45.5%), with a mean age of 7.5±2.7 years old (range, 3 to 14 years). There were 65.3% excellent (66 cases), 18.8% good (19 cases), 11.9% fair (12 cases), and 4.0% bad (4 cases) results in these patients. The rate of satisfactory outcome was 65.3% (66/101) and the rate of "unsatisfactory outcome" was 34.7% (35/101). Complications included postoperative radial nerve palsies in 15 cases (14.9%), radial head necrosis in 4 cases (4.0%), skin irritation due to the nail-end in 5 cases (5.0%), infection in 2 cases (2.0%), and bone nonunion in 1 patient (1.0%). Only Judet type (OR, 5.78; CI, 1.72-19.39, p=0.005) and surgical method (OR, 12.68; CI, 2.55-63.06, p=0.002) were independent risk factors for the unsatisfactory functional outcomes.

CONCLUSIONS

Closed reduction with intramedullary fixation is a primary treatment for type III and IV radial neck fractures in children. Fracture severity classified as Judet type IV and open surgical method were independent predictors for unsatisfactory functional outcomes.

Pediatric Radial Neck Fractures: A Systematic Review Regarding the Influence of Fracture Treatment on Elbow Function

Background: This review aims to identify what angulation may be accepted for the conservative treatment of pediatric radial neck fractures and how the range of motion (ROM) at follow-up is influenced by the type of fracture treatment. Patients and Methods: A PRISMA-guided systematic search was performed for studies that reported on fracture angulation, treatment details, and ROM on a minimum of five children with radial neck fractures that were followed for at least one year. Data on fracture classification, treatment, and ROM were analyzed. Results: In total, 52 studies (2420 children) were included. Sufficient patient data could be extracted from 26 publications (551 children), of which 352 children had at least one year of follow-up. ROM following the closed reduction (CR) of fractures with <30 degrees angulation was impaired in only one case. In fractures angulated over 60 degrees, K-wire fixation (Kw) resulted in a significantly better ROM than intramedullary fixation (CIMP; Kw 9.7% impaired vs. CIMP 32.6% impaired, p = 0.01). In more than 50% of cases that required open reduction (OR), a loss of motion occurred. Conclusions: CR is effective in fractures angulated up to 30 degrees. There may be an advantage of Kw compared to CIMP fixation in fractures angulated over 60 degrees. OR should only be attempted if CR and CRIF have failed.

Radial Head Incarceration After Closed Reduction of a Pediatric Elbow Dislocation With a Radial Neck Fracture: A Case Report

Case:

A 10-year-old girl sustained a radial neck fracture with a posterior elbow dislocation. She was treated with closed reduction of the elbow with subsequent intra-articular displacement of the radial head, which necessitated open reduction and pinning of the radial neck fracture.

Conclusion:

Displacement of the radial neck fracture from impingement of the capitellum on the anterior radial head during closed reduction of the elbow dislocation is a rare injury pattern. It is important to examine the radial neck in high-energy posterior elbow dislocations before attempted reduction. We present a case with imaging depicting the injury mechanism and successful management with subsequent open reduction and fixation of the radial neck fracture.

Diagnosis, treatment and complications of radial head and neck fractures in the pediatric patient

Radial head and neck fractures represent up to 14% of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient. In up to 39% of proximal radius fractures, there is a concomitant fracture, which can easily be overlooked on the initial standard radiographs. The treatment options for proximal radius fractures in children range from non-surgical treatment, such as immobilization alone and closed reduction followed by immobilization, to more invasive options, including closed reduction with percutaneous pinning and open reduction with internal fixation. The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient; an angulation of less than 30 degrees and translation of less than 50% is generally accepted, whereas a higher degree of displacement is considered an indication for surgical intervention. Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures, range of motion and complications compared to severely displaced fractures requiring surgical intervention. With proper management, good to excellent results are achieved in most cases, and long-term sequelae are rare. However, severe complications do occur, including radio-ulnar synostosis, osteonecrosis, rotational impairment, and premature physeal closure with a malformation of the radial head as a result, especially after more invasive procedures. Adequate follow-up is therefore warranted.

Fractures of the proximal radius in children: management and results of 100 consecutive cases

INTRODUCTION

Pediatric radial neck and head fractures are rare, accounting for only 1% of all fractures in children. The aim of this study is to describe the management and results of the respective fracture types and different injury characteristics.

MATERIALS AND METHODS

This study performs a retrospective data analysis of 100 consecutive patients with a fracture of the proximal radius treated in a single high-volume pediatric trauma center.

RESULTS

One hundred patients [mean age 7.5 years (1-15)] were documented with a fracture of the proximal radius between 3/2011 and 12/2019. The gender distribution was 62 girls and 38 boys. Twenty-seven patients had concomitant injuries. Conservative treatment was performed in 63 patients (Judet I = 27; II = 30; III = 6; Mason I = 2) using an above-the-elbow cast for 21 days (6-35). Surgical treatment was performed in 37 patients (Judet II = 3; III = 22; IV = 5; V = 7) using elastic stable intramedullary nailing (ESIN). Open reduction was necessary in five cases, and additional immobilization was performed in 32 cases. Six complications occurred: loss of implant stability (n = 2), healing in malalignment, pseudarthrosis, radioulnar synostosis, and a persisting hypoesthesia at the thumb. As a result, two ESIN osteosynthesis were revised, and one radial head resection was performed. Loss of movement was seen in 11% of cases, overall Mayo elbow performance index (MEPI) was 99.8 (90-100), and none of the patients experienced negative impacts on activities of daily life.

CONCLUSIONS

Proximal radial fractures occur predominately without dislocation. Good results are obtained with conservative treatment throughout. In cases with displacement exceeding growth-related correction, ESIN is the undisputed treatment of choice. Open surgery and long immobilization periods should be avoided whenever possible.

Comparison of different treatments for children with radial neck fracture and analysis of prognostic factors

INTRODUCTION

The aim of this was to analyze the effect of different treatment options on radial neck fractures in children and to explore the factors affecting the prognosis of fractures.

METHODS

The clinical data of 131 children with radial neck fractures admitted to our hospital from 2010 to 2018 were retrospectively analyzed, and the patients were divided into 6 groups according to treatment methods [manual reduction with Kirschner wires (K-wires) for internal fixation (group A); manual reduction with elastic stable intramedullary nails (ESINs) for internal fixation (group B); leverage reduction with K-wires for internal fixation (group C); leverage reduction with ESINs for internal fixation (group D); manual and leverage reduction with K-wires/ESINs for internal fixation (group E); and open reduction with K-wires/ESINs for internal fixation (group F)]. Postoperative elbow function and complications were analyzed.

RESULTS

Among the 131 patients with fractures, the median age was 8 years, the median preoperative angulation was 52°, the follow-up rate was 86.3% (113/131), the average follow-up time was 58.3 months, and the postoperative complication rate was 17.7% (20/113). The comparison among the different treatment groups showed that group B had the best recovery of elbow function, postoperatively, and the lowest postoperative complication rate. Age, duration of hospitalization, and preoperative angulation were independent factors affecting postoperative complications. Older age, longer duration of hospitalization, and higher angulation increase the postoperative complications.

CONCLUSION

Different treatment options have different efficacies for radial neck fractures in children, of which manipulative reduction with internal fixation using ESINs can achieve good efficacy and a low postoperative complication rate. Age, duration of hospitalization, and preoperative angulation are independent factors for postoperative complications.

Monteggia type-I equivalent fracture in a fourteen-month-old child: A case report

BACKGROUND

Monteggia and equivalent lesions are relatively rare but result in severe injuries in childhood, typically affecting children between 4 and 10 years old. The diagnosis and treatment of an equivalent Monteggia lesion is more complicated than those of a typical Monteggia fracture. This type of lesion may be challenging and may lead to serious complications if not treated properly. Pediatric Monteggia equivalent type I lesions have been reported in a few reports, all of which the patients were all over 4 years old.

CASE SUMMARY

A 14-mo-old boy was referred to our clinic after falling from his bed 10 d prior. With regard to the clinical examination, an obvious swollen and angular deformity was noted on his right forearm. Plain radiographs and reconstructed computed tomography scans showed a Monteggia type I fracture and dislocation. Magnetic resonance imaging (MRI) confirmed a type I Monteggia equivalent lesion consisting of ulnar fracture and Salter-Harris type I injury in the proximal radius. The radial head was still in the joint, and only the radial metaphysis was displaced anteriorly. Open reduction and pinning of both displaced radial and ulnar fractures achieved an excellent result with full function.

CONCLUSION

We recommend MRI examination or arthrography during reduction, especially if the secondary ossification center has not appeared.

Open reduction of radial neck fractures in children: injury severity predicts the radiographic and clinical outcomes

BACKGROUND

Radial neck fractures are the third most common elbow fracture in children. Open reduction may be required if closed or mini-open techniques are not successful in reducing the fracture. Previous reports on open reduction have noted poor outcomes and complications with this treatment approach. However, it is unknown whether it is the open procedure itself or the severity of the initial injury that leads to the poor results. The purpose of this study was to evaluate the correlation between intraoperative findings at the time of open reduction of radial neck fractures and the clinical and radiographic outcomes.

METHODS

Data from patients who underwent open reduction for an acute radial neck fracture between January 2009 and December 2018 were abstracted and reviewed. Patients undergoing open treatment for a nonunion or malunion and those with inadequate follow-up were excluded. Demographic data, injury characteristics, treatment strategies, intraoperative findings, and clinical and radiographic outcomes were assessed.

RESULTS

Twenty-two patients met the inclusion criteria. Of these patients, 14 were girls. The mean age was 9.7 ± 3 years, and the mean follow-up period was 15.8 months. Fifteen patients had a Judet grade IV displacement. Fair or poor outcomes were observed in 12 patients (55%). Ten reoperations were recorded during the study period. Age, weight, and associated injuries were not predictive of poor outcomes. Intraoperative findings of soft-tissue stripping and radial head comminution were the only significant predictors of fair or poor clinical outcomes (P < .001) and subsequent radiographic changes including fragmentation and collapse of the radial head and arthritic changes (P < .001). The quality of reduction and the choice of hardware were not significantly associated with either clinical or radiographic outcomes.

CONCLUSION

Our findings support the notion that the outcomes of open reduction of radial neck fractures are most closely correlated with the injury severity, with the intraoperative findings of complete soft-tissue stripping or comminution of the radial head fragment being significant predictors of poor clinical and radiographic outcomes. The choice of hardware and the quality of reduction achieved at the time of surgery have less significance than injury severity.

[Surgical treatment strategies and their radiological potential for correction of proximal radius fractures in children and adolescents]

BACKGROUND AND OBJECTIVE

The isolated proximal radius fracture in children is a quite rare injury. In difference to adults a conservative treatment is often possible. But in case of increasing dislocation the indication for surgery is given. Options for an operative treatment are "closed reduction", "percutaneous reduction", "intramedullary nailing", "open reduction" with and without fixation. Aim of this study is to compare these procedures with each other.

STUDY DESIGN AND METHODS

This was a retrospective investigation and 82 patients who underwent surgery after an isolated proximal radius fracture were included. Fracture types were classified according to the AO (working group for osteosynthesis questions)/OTA (Orthopedic Trauma Association) classification. The preoperative and postoperative degrees of axis deviation were compared and were considered to be a measure of the quality of treatment.

RESULTS

The lowest degree of axis deviation resulted by open reduction and implantation of K‑wires (15,8°) and implantation of headless compression screws (HCS, 16°). Closed reduction without any fixation resulted in 19°, with implantation of an TEN (titan elastic nail) in 20° and the open reduction without any fixation resulted in 21° of axis deviation. No correlation was observed concerning the fracture type and the postoperative axis deviation.

CONCLUSION

The study shows that the postoperative result does not depend on the fracture type (according to the AO/OTA classification) but on the surgical procedure. Despite the good radiological results in open reduction and internal fixation this procedure should be reserved for difficult situations in which less invasive surgical procedures fail, to avoid aseptic bone necrosis.

Radiological and functional outcomes of modified Metaizeau technique in displaced radial neck fractures

The management of displaced radial neck fractures in children is still a controversial topic. The objective of this study is to examine the outcomes of modified Metaizeau technique in the children with displaced radius neck fractures. The retrospective study included 15 children with displaced radial neck fracture with an angulation of more than 30° who were managed with the use of leverage technique by mosquito clamps and internal fixation with elastic stable intramedullary nailing (ESIN). Radiological and functional assessments were performed during follow-up. Additionally, the patients were evaluated using Mayo Elbow Per- formance Score (MEPS). All the children could be managed with clamp-assisted closed reduction. The average duration of follow up was 25.5 ± 6.1 months (15-36 months). An excellent elbow function was achieved in all but one patient. Based on Metaizeau classification, excellent, good, fair, and poor outcomes were achieved in 11, 1, 2, and 1 patients, respectively. The average postoperative MEPS score was 98.7 ± 5.1 (80-100). Clamp-assisted closed reduction and fixation with ESIN is a good choice in the children with displaced radial neck fractures. This technique is associated with good functional and radiologic outcomes in the medium-term. Further studies are warranted with larger sample sizes.

Nonunion of the radial neck in children: a rare but severe complication after fractures of the radial neck

PURPOSE

Nonunion of the radial neck poses an enormous challenge for treating surgeons. It is a very rare complication of the radial neck with limited experiences. In this current major study, the authors report of their own experiences concerning this problem.

METHODS

11 patients with severe displaced radial neck fracture Metaizeau type IV with elbow dislocation and 2 ongoing fractures. 9 fractures had to be treated with open reduction, six with intramedullary nailing, two with K-wires and one with periosteal suture fixation. In two children, aged 4 and 5, the fracture was not diagnosed initially. The patients showed a successful reduction intraoperatively.

RESULTS

All patients developed nonunion of the radial neck. 9 out of 11 children presented with pain and 5 out of 11 with valgus deformity. All children underwent surgical management of the complications. 3 children received a debridement of the elbow joint with resection of the fragmented radial head. 7 cases needed a following reduction, spongiosa-plasty and periosteal flap reconstruction and plate osteosynthesis. One patient received radial intramedullary pinning. All nonunions showed reunion. All patients with obtained radial head showed significant improvement concerning complaints and range of motion. Only one child showed a slight deterioration in range of motion. Children with resected radial head showed good range of motion but complaints and instability in loaded joint needing further surgical treatment.

CONCLUSION

Treatment of radial neck nonunion in children should not be delayed until pain, deformity and limited function occurs because this goes along with severe transition of the radial head right up to bone atrophy.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND

The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED).

METHODS

A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories.

RESULTS

CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED.

CONCLUSIONS

Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED.

LEVEL OF EVIDENCE

Level III-prognostic.

Prognostic factors for intramedullary nailing in radial neck fracture in children

INTRODUCTION

Radial fracture accounts for 1% of fractures in children. It is potentially serious, and treatment is controversial. Several studies assessed prognostic factors, only one of which used exclusive intramedullary nailing, despite this being the gold standard.

HYPOTHESIS

Open surgery provides poor functional results in radial neck fracture.

MATERIAL AND METHOD

All patients undergoing reduction and internal fixation of radial neck fracture between 2005 and 2015 were analysed. Inclusion criteria comprised Jeffery type 1 fracture with open growth plate, complete file, and ≥1 year's follow-up. Treatment systematically comprised Métaizeau intramedullary nailing, with crossover to open reduction only in case of failure. Good results were defined as full range of motion and pain-free elbow.

RESULTS

Fifty-six patients were included: 33 girls, 23 boys; mean age, 9 years. On the Judet classification modified by Métaizeau, 4 fractures were grade 2, 29 grade 3, 15 grade 4A and 8 grade 4B. Closed reduction was performed in 48 cases, including 8 with the help of percutaneous leverage effect. Eight required a surgical approach. Twenty-three showed postoperative reduction defect. At a mean 74 months' follow-up, at a mean age of 15 years, 37 patients had reached full skeletal maturity. Sixteen had poor results. Open reduction was associated with poor outcome (p<0.01). Age, initial epiphyseal tilt, associated lesions, immobilisation time, time to nail removal and residual tilt after reduction did not significantly affect outcome (p-values>0.05). Percutaneous leverage effect had no impact on the quality of results (p=1).

DISCUSSION

Open reduction is to be avoided in radial neck fracture. A prospective study is needed to assess remodelling potential according to age.

LEVEL OF EVIDENCE

IV, retrospective study.

Radial neck fracture in children: anatomic and functional results of Metaizeau technique

Fractures of the radial neck accounts for 1% of all childhood fractures and 5% to 10% of childhood traumatic lesions involving the elbow. Intramedullary percutaneous nail reduction (Metaizeau technique) is considered the most effective surgical technique. The purpose of this study was to identify the main clinical features of radial neck fracture in children and to evaluate the anatomical and functional results of the Metaizeau technique. In this retrospective study, we evaluated 22 patients under the age of 16 who were treated for radial neck fracture at the orthopedic and trauma surgery department of Sahloul University Hospital in Sousse over a period of 16 years from January 2001 to April 2017. Authors used Metaizeau classification. Functional results were evaluated by Mayo elbow performance score (MEPS) and the radiological evaluation was based on standard images with measurement of the residual rocker. The average age was 8.6 years (5-13 years). Seven fracture were grade III injuries and three grade IV. In the immediate postoperative period, radiological measurements showed a residual rocker less than 20° in 86.3% and more than 20° in 13.7% of cases. At an average follow-up of 13 months and a half, the MEPS score was excellent and good for 17 patients. Four types of complications were found: necrosis of the radial head in 1 case, pseudarthrosis in 1 case, periarticular calcification in 2 cases and stiff-ness of the elbow in 3 cases. Despite the small number of patients in our series, we believe that the elastic stable intramedullary pinning according to the Metaizeau technique is the treatment of choice for displaced radial neck fractures in children.

Treatment principles, prognostic factors and controversies in radial neck fractures in children: A systematic review

INTRODUCTION

Radial Neck fractures are rare injuries in children. There is controversy surrounding their prognosis and management.

AIMS

This review aims to produce an up-to-date summary to clarify prognostic factors and management principles, in the light of recent, better-quality evidence.

METHODS

A systematic review was undertaken in accordance to PRISMA guidelines, applying pre-defined selection criteria. 6 papers were found suitable after quality assessment. All were observational cohort studies, one prospective and the rest retrospective. A semi-qualitative review was undertaken as heterogeneity, especially in the fracture classification and outcome assessment tools used, prevented quantitative synthesis.

RESULTS

Majority of these fractures occur at the metaphysis. Consistently good results are seen with simple immobilization in fractures angulated<30° with translation<50%, with nearly all achieving a good outcome. In more displaced fractures, results are poorer and only about 70% patients achieve a good outcome. Both higher fracture displacement and more invasive treatment are associated with worse outcomes, but also with each other. Associated injuries are common, with Proximal Ulna fractures being commonest (71%), but their effect on outcomes is unclear. Age more than 10 years is associated with worse displacement, more invasive treatment and worse results. There is much confounding among all these factors which remains to be convincingly addressed. An algorithmic approach is advisable for these fractures, with stepwise application of more invasive treatment only if less invasive methods fail. Percutaneous fixation with either K-wires or retrograde intramedullary elastic nails is acceptable. Fractures reduced closed in theatre fare better if fixed percutaneously to prevent re-displacement. Open treatment should be considered only if the fracture can't be reduced to within the displacement limits of angulation<30° and translation<50%. Incidence of serious complications is generally low (3-5%), but their effect on outcomes is unclear.

CONCLUSIONS

The treatment of higher-grade radial neck fractures is still controversial, needing further research, possibly through multi-center prospective data collection in pediatric fracture registries using validated outcome measures.

Arthroscopically-assisted reduction and pinning of a radial neck fracture in a child: a case report and review of the literature

Background

Displaced radial neck fractures in children are challenging to treat. The age of the patient and the degree of angulation are the main criteria to consider when managing these fractures in children. Various surgical techniques have been described in the literature for both indirect and direct reduction and for fixation. However, the best treatment is still debated.

Case presentation

The case presented is of a 6-year-old Caucasian boy with an impacted and displaced radial neck fracture. With the patient in lateral position, under general anesthesia, elbow arthroscopy was performed to better visualize the articular surface and to assist with reduction and fixation. The fracture was reduced and fixed with a single K-wire under direct arthroscopic visualization. No associated lesions were found. An above-elbow cast was applied after surgery. The cast and K-wire were removed 3 weeks later. At the 3-month follow-up, the patient showed a full recovery with complete range of movement without any postoperative and radiographic complications.

Conclusion

Traditionally, surgery for displaced radial neck fractures in children is performed by closed reduction with percutaneous pinning or elastic intramedullary nail fixation under fluoroscopic guidance. Direct visualization of the articular surface via an open approach allows better reduction in complex fracture patterns but is related to a higher risk of complications: elbow stiffness, instability, or avascular necrosis. Elbow arthroscopy in children could be a valid alternative to open fixation surgery for displaced radial neck fractures without the complications associated with articular exposure, allowing the direct visualization of the fracture and reducing radiation exposure. Although technically demanding, we believe elbow arthroscopy should be considered an alternative option because it is effective in assisting reduction and fixation and enables the detection of associated joint lesions.

Percutaneous leverage technique for reduction of radial neck fractures in children: technical tips

PURPOSE

Paediatric radial neck fractures are challenging to treat. Multiple strategies exist for reduction and fixation; there is no clear consensus on the best surgical technique to achieve reduction. The percutaneous leverage technique is a method for reduction of radial neck fractures that has previously been described by Wallace, though there is a lack of published literature on this technique. We present a technical note and a modest case series on our modification to the percutaneous leverage technique accompanied by intramedullary fixation.

METHODS

We describe a retrospective series of patients who underwent the modified percutaneous leverage technique for paediatric radial neck fracture reduction followed by flexible intramedullary nail fixation at a single Level I trauma centre from 2008 to 2016. This technique involves making a small incision over the dorsal border of the ulna and using a blunt curved surgical forceps to dissect towards the ulnar border of the radius just distal to the radial neck fracture site. The curved forceps is then used to push the radial shaft away from the ulnar shaft which reduces the radial neck fracture. Intramedullary fixation is then utilized to stabilize the reduction. Pre- and postoperative radiographs and clinical data from the medical record were reviewed, and patient, injury and treatment characteristics as well as complication rates are summarized.

RESULTS

We successfully treated a series of eight radial neck fractures with the modified percutaneous leverage technique. This technique allows for a small incision and a minimally invasive method for the reduction of paediatric radial neck fractures. This allowed for subsequent intramedullary fixation and early postoperative elbow mobilization. In our series, no patients developed synostoses or sustained peripheral nerve injuries using this technique.

CONCLUSION

The modified percutaneous leverage technique followed by intramedullary fixation is a safe and effective technique for fixation of displaced paediatric radial neck fractures.

LEVEL OF EVIDENCE

Level IV.

Closed manipulation under anesthesia for pediatric post-traumatic elbow arthrofibrosis

BACKGROUND

Post-traumatic elbow arthrofibrosis (PEA) and its associated limitations to elbow range of motion (ROM) are a recognized consequence of trauma to the pediatric elbow. Closed manipulation under anesthesia (CMUA) of the elbow can be performed in pediatric patients as a nonoperative attempt to improve dysfunctional ROM. Minimal outcome data to support CMUA exist. The study evaluates the efficacy of CMUA for PEA in pediatric patients.

METHODS

Patients younger than 18 years who underwent CMUA (Current Procedural Terminology code 24300) for PEA between 2005 and 2015 at 3 institutions were included. A retrospective chart review was performed to collect demographic data and ROM premanipulation and at last follow-up. Paired 2-tailed t tests were used to compare pre- and postmanipulation elbow ROM.

RESULTS

Thirteen patients with a mean age of 12.2 ± 2.6 years (range 6.7-15.6 years) met the inclusion criteria. Median time to CMUA from initial surgery was 4.2 months (interquartile range [IQR] 3.6-8.4, range 1.4-19.7 months). Median follow-up time was 6 months with an IQR of 3.3-10.0 months. At last follow-up, there was significant improvement in elbow flexion of 22° ± 17° (P < .001) and extension of 29° ± 21° (P < .001). The average premanipulation motion arc of 60° ± 24° significantly increased to 110° ± 22° at final assessment (P < .001).

CONCLUSION

CMUA appears to be a valuable alternative and reliable procedure for improving PEA in pediatric patients who exhaust nonoperative interventions.

Management of Severely Displaced Radial Neck Fractures in Children: A Systematic Review and Meta-analysis of Outcomes

BACKGROUND

This systematic review is an attempt to provide an evidence-based analysis of literature on management of severely displaced radial neck fractures (with > 60° displacement) in children.

MATERIAL AND METHODS

A systematic literature search was conducted to identify all original articles published between 01/01/1999 and 20/01/17 on surgical treatment of radial neck fractures in children in the following databases: MEDLINE, EMBASE, and CINAHL PLUS. Studies reporting pre-operative fracture displacement and post-operative outcomes according to standard outcome measures were included.

RESULTS

Out of 887 studies identified on initial search, 48 were eligible for full-text review and 14 studies with a total of 173 patients were included in the final review. The overall success rate after severely displaced radial neck fractures in skeletally immature patients was 87% (95% CI, 82%, 92%). Closed reduction methods reported higher success rate of 90% (95% CI, 85%, 95%) compared to open reduction methods 77% (95% CI, 63%, 89%).

CONCLUSION

The average rate of patients achieving excellent/good outcomes following surgical management after severely displaced radial neck fractures in this review is better than reports from previous reviews. Considering the limitations in current evidence base including lack of direct comparison of techniques and small study samples, large comparative studies controlling for possible confounders are merited.

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.

The Emergency Evaluation and Management of Pediatric Extremity Fractures

Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.

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.

Percutaneous leverage reduction with two Kirschner wires combined with the Métaizeau technique versus open reduction plus internal fixation with a single Kirschner-wire for treating Judet IV radial neck fractures in children

Objective

To compare the clinical effectiveness of a novel approach, percutaneous leverage reduction using two Kirschner-wires (k-wires) combined with the Métaizeau technique, versus open reduction plus internal fixation with k-wire for the treatment of Judet IV radial neck fractures in children.

Methods

Thirty-four patients with Judet IV radial neck fractures were treated either with percutaneous leverage reduction using two k-wires and the Métaizeau technique (n = 16) or open reduction plus internal fixation with k-wire (n = 18). Patient data including sex, age, time from trauma to surgery, fracture type, follow up, postoperative healing time, X-ray studies, elbow function, and complications were collected.

Results

There were no significant differences in patient characteristics between the two treatment groups. In postoperative elbow function assessment, 93.8% of patients in the group that underwent the novel treatment approach had a score of excellent or good, compared with 83.3% of patients in the open reduction and internal fixation with k-wire group. Furthermore, no postoperative complications were reported in patients in the novel treatment group, compared with 5 patients in the open reduction and internal fixation with k-wire group. All patients in both groups were classified as excellent or good according to Métaizeau criteria in postoperative X-ray assessment.

Conclusions

Compared with the open reduction and internal fixation with k-wire approach, percutaneous leverage reduction using two k-wires combined with the Métaizeau technique can significantly increase the minimally invasive reduction rate, and represents an attractive strategy for the treatment of Judet IV radial neck fractures in children.

The Community Orthopaedic Surgeon Taking Trauma Call: Radial Neck Fracture Pearls and Pitfalls

Pediatric radial neck fractures will inevitably be encountered by the general orthopaedist, and they carry great potential for poor outcomes. Acceptable displacement varies by age, and unlike adults, most of these injuries can be managed by closed means. If they are taken to the operating room, the mainstays of treatment are percutaneous techniques. Increasing patient age, inadequate reduction, unnecessary open reductions, and prolonged immobilization are all associated with worse outcomes, most commonly manifesting as significant elbow stiffness. Knowledge of the age-specific acceptable displacement criteria, a stepwise approach to closed and percutaneous techniques, and safe strategies for open reduction when needed as a last resort will greatly improve treatment success.

Radial neck fractures in children: A surgical tip using the Metaizeau technique to improve stability of the reduction

Aim

To evaluate early results of management of radial neck fractures with Métaizeau technique in the paediatric age group and to elaborate on a surgical tip to improve stability of the fixation.

Method

A retrospective analysis of 21 patients, with fracture radial neck, who underwent closed reduction and internal fixation with elastic intramedullary nailing (Métaizeau technique), was performed. Mean age at injury was eight years, and the average follow-up was 4.5 months (range: 3-6 months). Follow up Clinical and radiological evaluation was performed at first and sixth postoperative weeks. At six weeks following removal of the nail, a clinical assessment was conducted to record the outcomes, and any later follow-up was arranged based on pain and range of motion.

Results

We recorded five excellent, eight good, one fair, results for type 3 fractures. For type 4 fractures, we had one excellent, five good and one fair, results. Altogether, we recorded 20 (90.5%) excellent or good results, and 2 (9.5%) fair results. Complications noted were superficial skin infection at the entry site in one patient that required a course of oral antibiotics. Prominent metal work was noticed in 14 cases, which didn't need any further intervention as it did not cause any functional discomfort.

Conclusion

With Metaizeau technique, there were reported poor results of about 10% in literature. In our study, with the modification of the shape of the nail tip, we have managed to achieve stable fixation of the reduction without any loss of position and consequently, better outcomes.

Inadvertent Radial Head Inversion During Closed Reduction of a Pediatric Radial Neck Fracture

Management of displaced pediatric radial neck fractures can be fraught with challenges. This unique case presents an 11-year-old female with a Salter-Harris type II radial neck fracture and how her radial head overturned 180° with the articular surface facing the radial shaft rather than the capitellum during closed manipulation under anesthesia. The malreduction subsequently required open reduction and highlights the importance of a careful stepwise approach to managing markedly displaced radial neck fractures. After closed reduction, meticulous assessment of intraoperative imaging when determining proper alignment is of the utmost importance as a result of the transverse nature of Salter-Harris type I and II fractures. LEVEL OF EVIDENCE:: Level IV.

Functional and radiological results of percutaneous K-wire aided Métaizeau technique in the treatment of displaced radial neck fractures in children

OBJECTIVES

The aim of the present study was to determine the radiological and functional results and the efficiency of paediatric radial neck fracture fixation following reduction with the Métaizeau technique together with percutaneous K-wire applied under fluoroscopy to ensure minimum soft tissue damage.

METHODS

The study included 20 patients with Judet Type 3, Type 4a and Type 4b fractures operated on with the Métaizeau technique aided by percutaneous K-wire between 2007 and 2014. The mean age of the patients was 9.75 years (range, 4-13 years). Mean preoperative angulation was measured as 52.4° (range, 35°-85°). The average postoperative follow-up time was 34.65 months (range, 13-84) months. Postoperative radiological evaluations were made according to the Ursei classification and functional assessment with the Tibone - Stoltz classification system.

RESULTS

Radiologically, the difference between preoperative and postoperative radius head angulation was found statistically significant (p0.001). In the clinical assessment of injured and uninjured arms, there was no statistically significant difference between flexion-extension (p = 0.330) and supination-pronation range of motion (p = 0.330) and carrying angles (p = 0.094). According to the radiological Ursei evaluation, 17 (85%) patients were in perfect condition and 3 (15%) were good. In the classification of Tibone - Stoltz, 16 (80%) patients were evaluated as perfect, 3 (15%) as good and 1 (5%) as fair.

CONCLUSION

From the results of this study and related literature, the use of the Métaizeau technique in displaced radial neck fractures requiring surgical treatment in children can be recommended since it creates minimum damage to the soft tissue, is easy to apply and the results are satisfactory.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Clinical and Radiographic Outcomes of Pediatric Radial Head Fractures

BACKGROUND

The treatment of pediatric radial head fracture (RHF) is controversial, and the outcome is unpredictable. We aimed to evaluate the long term clinical and radiographic outcomes of patients with pediatric RHF.

MATERIALS AND METHODS

24 patients with pediatric RHFs operated between January 2004 and 2012 were included in this retrospective study. 17 patients had extra articular radial head (EARH) fractures and 7 had intraarticular radial head (IARH) fractures. The Mayo Elbow Performance Score (MEPS), Tibone and Stoltz classification, range of motion (ROM), and carrying angle (CA) were evaluated. The radial head diameter (RHD) and radial head height (RHH), neck shaft angle (NSA), and distance from the radial head to the radial tuberosity (RHRT) were measured and compared with the other side in simple anteroposterior views of elbow radiographs.

RESULTS

At the last followup, the mean MEPS was 100 and 97.9 in groups EARH and IARH, respectively. There were no clinically and radiographically significant differences between the groups. The injured elbows showed smaller ROMs than the uninjured elbows in flexion, supination, and pronation with statistically significant differences. However, the injured elbows showed larger extension ranges than the uninjured elbows with a statistical significance (all P = 0.000). CA, RHD, and RHH were higher in the injured elbows than in the uninjured elbows with statistically significant differences (P = 0.006, 0.000, and 0.011) However, NSA and RHRT of both elbows were similar, with no statistically significant difference (P = 0.810 and 0.752).

CONCLUSION

All patients with pediatric RHF were satisfied with the long term clinical results. The injured elbows showed restricted ROMs compared with the uninjured elbows; however, the extension range increased.

Computer-Assisted Corrective Osteotomy of Malunited Pediatric Radial Neck Fractures-Three-Dimensional Postoperative Accuracy and Clinical Outcome

Neglected or incorrect treatment of pediatric radial neck fractures may lead to symptomatic malunions. Computer-assisted corrective osteotomies with patient-specific guides have been proposed as a promising technique for the reconstruction of malunited long bone deformities. The aim of this study was to evaluate the accuracy and clinical outcome of this technique in children with malunited fractures of the radial neck. Four children [2 boys, 2 girls; mean age 12 (10-16) years] underwent computer-assisted closing wedge osteotomy of the radial neck. The contralateral uninjured side was used as a reconstruction template. Computed tomography were performed 8 weeks postoperatively to confirm bony consolidation and to quantify residual 3D rotational and translational displacement error. Clinical outcome [pain, range of motion (ROM)] and overall satisfaction were documented. Preoperative subluxation of the radial head could be corrected in 2 of 3 patients. One patient had to be revised because of secondary traumatic loss of reduction. At the last follow-up [mean 16 (range, 12-24) months], all patients were pain free for activities of daily living (preoperative pain: visual analog scale 6). Pain during sport activities could be substantially reduced (visual analog scale 8→2). Although the procedure failed to improve ROM, none of the patients had limitations regarding work, daily, or sports activities. Yet, restricted ROM was considered as a cosmetic problem in 1 patient. Full consolidation of the osteotomy site, with no signs of avascular necrosis of the radial head, was achieved in all patients. The deformity could be substantially reduced, from a 3D angle of 13-40 degrees to 3-7 degrees (58%-89% deformity correction). Computer-assisted corrective osteotomy is a novel technique for the treatment of radial neck malunions that led to adequate pain reduction and 3D accuracy of deformity correction in our small case series. Despite the lack of improved ROM, all patients were satisfied and would undergo the same procedure again.

Surgical Techniques for Displaced Radial Neck Fractures: Predictive Factors of Functional Results

BACKGROUND

Fractures of the radial neck represent about 1% of all childhood fractures and 5% to 10% of childhood traumatic lesions involving the elbow. Management of these fractures in children is still controversial. Intramedullary percutaneous nail reduction (Métaizeau technique) is considered the most effective surgical technique because of its excellent results and easy learning curve. Complications may arise, however, especially in Böhler technique, in which a percutaneous pin is placed over the radial head. When this technique does not provide correct reduction, open reduction must be performed. Because open reduction is traditionally associated with a high risk of complications, however, its use is restricted to severely displaced fractures and only when the percutaneous techniques have failed or their application contraindicated because of associated injuries to the distal radius.

METHODS

In this retrospective study, we evaluated 51 children between the ages of 6 and 15 years who presented to our institution from 1996 to 2012 with Métaizeau-modified Judet grades 3, 4a, and 4b radial head fractures. The surgical techniques used were closed reduction and casting under general anesthesia (n=7), closed reduction and intramedullary nailing using Métaizeau technique (n=27), and Métaizeau technique and open reduction with intramedullary nailing (n=17). Functional results of the 3 surgical techniques were evaluated using the Mayo Elbow Performance Score (MEPS) and compared by modified Judet classification using χ analysis.

RESULTS

No statistic significant association was found between type of surgery and final MEPS was observed (P=0.110). However, a significant association was found between initial modified Judet grade and final MEPS.

CONCLUSIONS

In the present study, final functional outcome seems to be not affected by open reduction but was significantly associated with initial modified Judet grade.

LEVEL OF EVIDENCE

Level III-retrospective study comparing closed and open reduction techniques, performed at the same institution.

Stepwise Percutaneous Leverage Technique to Avoid Posterior Interosseous Nerve Injury in Pediatric Radial Neck Fracture

OBJECTIVES

To introduce a stepwise percutaneous leverage technique to avoid posterior interosseous nerve (PIN) injury in pediatric patients with radial neck fractures and to evaluate the clinical outcome and the predisposing factors affecting the outcome.

DESIGN

Retrospective case series study.

SETTING

University level 1 trauma center.

PATIENTS

Thirty-four children with a radial neck fracture, who were treated using a stepwise percutaneous leverage technique, were included in the study.

INTERVENTION

The radial head fragment was reduced by pulling the first Steinmann pin proximally as a lever. Then, the kinked soft tissue was released by removal of the Steinmann pin with buttressing the radial head by the operator's thumb. The second Steinmann pin was inserted into relaxed soft tissue for fixation of the radial head.

MAIN OUTCOME MEASUREMENTS

We used the Métaizeau classification as a radiologic result and Mayo Elbow Performance Score (MEPS) as a clinical outcome. Regression analysis was performed to identify the predisposing factors affecting the outcome.

RESULTS

There was no occurrence of PIN palsy. According to the Métaizeau classification, 23 cases were classified as excellent, 9 as good, 1 as fair, and 1 as poor. The average MEPS was 97.6 points. Based on the regression analysis, only the postoperative Métaizeau classification was confirmed as a risk factor of a relatively poor outcome.

CONCLUSIONS

The stepwise percutaneous leverage technique can be considered a good option in the treatment of pediatric radial neck fractures, because it ensures excellent results by avoiding injury to soft tissues including the PIN.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bioabsorbable Pin Fixation in Late Presenting Pediatric Radial Neck Fractures

BACKGROUND

Current treatment algorithms for pediatric radial neck fractures reserve open treatment for severe residual angulation. There is a paucity of literature guiding treatment for delayed presentation resulting in malunion. Bioabsorbable pins have been used successfully for many other fracture types in the upper extremity. The purpose of this study is to determine whether open reduction, bioabsorbable fixation with an osteotomy when necessary is a reasonable treatment option in delayed pediatric radial neck fractures by assessing pain, range of motion, functional, and radiographic outcomes.

METHODS

Radial neck fractures were evaluated in 7 children, 4 to 12 years old, with delayed initial presentation averaging 20 days. Patients presented with an average angular deformity of 63 degrees and translational deformity of 57% (6.1 mm) in the AP plane, all with painful and reduced range of motion. Patients underwent open reduction and fixation with Self-Reinforced Poly-L-Lactic Acid pins after failed closed reduction. Four patients required formal osteotomies. Postoperative follow-up averaged 9.2 months and consisted of radiographic and clinical evaluation with Wong-Baker FACES Visual Analog scale and the Mayo Elbow Performance (MEP) score.

RESULTS

Final radiographs demonstrate an improvement in angular deformity by 56 degrees and translational deformity by 51%. Final clinical outcomes demonstrated significantly improved pain-free range of motion with excellent MEP scores in 6 of the 7 patients. One patient developed a radioulnar synostosis, subsequently undergoing synostosis excision with a final MEP score of 80/100. There was no evidence of physeal closure or avascular necrosis and no cases requiring hardware removal or complicated by local inflammatory reactions.

CONCLUSIONS

This small series shows encouraging results in the treatment of pediatric radial neck fractures with delayed presentation using open reduction, bioabsorbable fixation, and when necessary an osteotomy. Bioabsorbable fixation may eliminate issues surrounding subsequent hardware removal and pin-site infections. Despite these encouraging results, radioulnar synostosis after open surgery is still a concern.

LEVEL OF EVIDENCE

Level IV-case series.

Outcomes after operative treatment of elbow contractures in the pediatric and adolescent population

BACKGROUND

The role of elbow contracture release in the very young is unclear, with existing studies reporting conflicting results. This study evaluated the long-term results after open elbow contracture release in patients aged younger than 18 years.

METHODS

Between 1994 and 2012, 32 patients underwent open elbow contracture release at a mean age of 13.8 years (range, 5-18 years), and their outcomes were reviewed. The primary cause was traumatic in 30 patients (4 radial head/neck fractures, 5 intra-articular distal humeral fractures, 11 extra-articular distal humeral fractures, 10 complex fracture-dislocations), and the mean time from the index injury to contracture release was 16.3 months (range, 3-82 months). The cause in 2 patients was nontraumatic (1 osteochondritis dessicans, 1 congenital). The mean follow-up period was 66 months (range, 7-202 months).

RESULTS

At the latest follow-up, total arc of motion improved from 69° to 123° (P <.0001), with a mean increase of 54° (P <.0001). The function arc was >100° in 28 patients (88%), and 29 patients (91%) achieved >20° of improvement in their arc. Twelve patients (38%) underwent a gentle manipulation under anesthesia at a mean of 2.7 weeks (range, 1-5 weeks) for early recurrence of stiffness. There were 3 complications (1 deep infection, 1 hematoma, 1 humeral fracture through the external fixator pin site). No patients lost motion after surgery.

CONCLUSION

Elbow contracture release in the pediatric and adolescent population can provide significant improvements in range of motion similar to that achieved in adults. The improvements in motion are durable.

Percutaneous Reduction of Displaced Radial Neck Fractures Achieves Better Results Compared With Fractures Treated by Open Reduction

There is uniform agreement in the literature that radial neck fracture with <30 degrees of angulation and minimal translation in younger children can be managed by casting alone, without the need for closed reduction. For more severe fractures, closed manipulation techniques followed by percutaneous reduction technique (in case closed reduction fails) should be performed before switching to an open reduction technique. Debate still exists regarding the best treatment protocol for severely displaced fractures. Although some surgeons favor open reduction with the argument that repeat manipulations may cause iatrogenic injuries, and stiffness, others believe that open reduction is one of the most contributing factors for poor outcome. On the basis of this paradigm, we present our treatment algorithm based on the data demonstrating that percutaneous reduction of displaced radial neck fractures achieve better results than open reduction.

Reduction and stabilization of radial neck fractures by intramedullary pinning: a technique not only for children

BACKGROUND

Isolated radial neck fractures occur only in rare cases. The majority of cases are non-displaced or minimally displaced and can be treated conservatively. Conservative treatment, however, might result in secondary displacement and/or malunion. On the other hand, open reduction and internal fixation (ORIF) as standard surgical approach in adults is associated with non-union, implant-related complications and reduced range of motion. For isolated radial neck fractures with an intact radial head, the procedure of centromedullary pinning--as widely used in the treatment of paediatric radial neck fractures--might be an alternative operative technique in adults as well. The purpose of this retrospective case series therefore was to evaluate the functional outcome of radial neck fractures treated by intramedullary pinning.

METHODS

Between 02/2009 and 12/2014, a total of eight patients with isolated radial neck fractures (Mason type-III; Judet Type II and III) were treated with centromedullary pinning using titanium elastic nails (TEN). The mean age of the patients was 39 years (range 23-90 years) with a mean interval from injury to surgery of 2.9 days (range 1-7 days). Subjective and objective criteria included patient's satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey Elbow Score (MEPS), the QuickDASH and the Elbow Self Assessment Score (ESAS). Furthermore, follow-up radiographs were evaluated.

RESULTS

Seven of the eight patients were available for follow-up after a mean of 36 months (range 6-64 months). Patients' satisfaction was rated very good in four cases, good in two cases and sufficient in one case. An unrestricted active ROM compared to the contralateral side for extension-flexion arc and for pronation-supination-arc with full strength was rated in all cases. The Elbow Self Assessment Score was 98.52 ± 1.95 (range 96-100), the calculated Mayo elbow performance score was 95.71 ± 7.32 (range 85-100) and the QuickDASH score was 6.81 ± 10.42 (range 0-27). There were no complications as infection, non-union, heterotopic ossifications or secondary loss of reduction of the radial head. Only one patient complained about pain resulting from an affection of the superficial radial nerve.

CONCLUSION

In the present cohort, good to excellent results without relevant complications were seen. The technique of intramedullary pinning as described in the treatment of isolated radial neck fractures in children represents a suitable and reliable method in adults as well. In selected cases, this technique can be recommended as an alternative, minimal-invasive approach to the radial head plate osteosynthesis.

EVALUATION OF CHILDREN WITH RADIAL NECK FRACTURES TREATED WITH FLEXIBLE INTRAMEDULLARY NAIL

Objective

: To evaluate the results of displaced radial neck fractures in children trated surgically with flexible titanium intramedullary nails.

Method

: This is a retrospective study of five cases of radial neck fractures with displacement greater than 30° fixed with flexible intramedullary nails. Patients were evaluated regarding functional outcome through range of motion and the Mayo Elbow Performance Score (MEPS), as well as radiographic exams.

Results

: Five patients, with a mean age of 8.4 years were assessed, during a mean post-operative follow up of 12.2 months. Open reduction was necessary in three cases with major displacement. At the end of the follow up, 80% of the patients had excellent results, 20% good results, and all fractures healed. As complications we observed: heterotopic ossification, superficial infection and radial head necrosis.

Conclusions

: In spite of the small sample, our results with flexible titanium intramedullary nails were similar to the current literature, with good functional outcomes. Level of Evidence III, Retrospective Study.

Radial Neck Fractures in Children and Adolescents: An Examination of Operative and Nonoperative Treatment and Outcomes

BACKGROUND

Although most pediatric radial neck fractures can be treated with either immobilization alone or closed reduction and immobilization, a small subset result in permanent loss of motion despite surgical management. We sought to characterize the most problematic fractures and correlate final outcomes with both presenting fracture characteristics and the reduction achieved through surgical intervention.

METHODS

One hundred ninety-three consecutive children with a radial neck fracture, satisfactory initial treatment data, and follow-up range-of-motion (ROM) data presenting between 1999 and 2012 to our level 1 trauma center were evaluated. The O'Brien classification was used to evaluate angulation on radiographs. Final ROM outcomes were categorized into excellent, good, fair, and poor. ROM data were not used in the operative group if follow-up was <12 weeks (<6 wk in the nonoperative group) or if there was no follow-up after cast removal.

RESULTS

Thirteen percent of all patients presenting with radial neck fractures required operative treatment (average age 9.1 y). Of patients treated operatively with adequate ROM data, 26.4% healed with fair or poor outcomes. Patients requiring open management were of older average age (average 10 y old, P=0.02) and had a significantly greater risk of a fair or poor ROM outcome than those treated with closed operative techniques (P=0.02). Patients treated nonoperatively were of a younger average age than those in the operative cohort (8.2 vs. 9.1 y, P=0.03). Patients treated operatively were more likely to develop complications (P=0.004); however, presence of a complication was not predictive of fair or poor outcomes in either the operative (P=0.117) or nonoperative (P=0.264) groups.

CONCLUSIONS

Older children are more likely to have more severely displaced radial neck fractures requiring open surgical management, thus resulting in a greater risk of fair or poor outcomes. In the series as a whole, more complications were seen when operative management was required. Final outcomes were not shown to be significantly related to preoperative displacement, postoperative reduction, presence of associated injuries, energy of injury, or treatment complications.

LEVELS OF EVIDENCE

Level III—therapeutic.

Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients

PURPOSE

Isolated pediatric radial head and neck fractures are rare. In recent literature, their incidence is estimated to be around 1% of all fractures. High rates of complications are reported. Beside non-operative treatment, head fractures are treated with k-wires, mini-screws or polypins, whereas neck fractures are treated more and more with elastic stable intramedullary nailing (ESIN). Purpose of the study was to evaluate the operative management, complications and clinical outcomes of these injuries.

METHODS

Retrospective analysis between 2002 and 2014. 19 children with isolated radial head and neck fractures were treated in our institution. Age averaged 11 years (range 6-16). Operative treatment with elastic stable intramedullary nailing (ESIN) was performed in 13 patients, in one patient with an additional k-wire; two screw, two k-wire and one polypin fixation was performed in the others. One child was treated non-operatively.

RESULTS

Follow up averaged 19 months (2-89). Initial complications occurred in nine children such as fracture dislocation (1), nonunion (1), malunion (1), elbow ankylosis (1), infection (1), crossunion (2), intraarticular screw penetration (1) and radial nerve irritation (1). ESIN lead a complication rate of 36%, mini-screw fixation and k-wire fixation showed a complication rate of 100%. All children (100%) with an open reduction maneuver and 36% children with closed or percutaneous reduction developed a complication. Secondary surgeries included ESIN removal and k-wire fixation (1), open arthrolysis (1), debridement (1), removal of crossunion (1), radial head removal plus arthrolysis (3) and screw removal (1). Subsequently 74% (14) children showed a free or <20° limited range of motion on final follow up. Implant removal was performed after an average of 8 weeks (5-12). Three patients were transferred to our surgical department after a complication following initial treatment. Excluding these, an overall complication rate of 37.5% was noted.

CONCLUSIONS

Radial head injuries in children are rare. In this population, neck fractures occur more frequently. If conservative treatment is not possible, ESIN seems to be a simple and protective procedure for neck fractures; polypins or screws can be used for complicated radial head fractures. Complications occur frequently after open reduction. If closed reduction and internal fixation is possible, range of motion can be completely restored.

Radial Neck Osteotomy for Malunion of Radial Neck Fracture in Childhood

In a case of a neglected radial neck fracture in childhood, the management of initial fracture and its complications are subjected to discussion. In children, open reduction should be avoided but an angulation less than 30° must be obtained. Several techniques exist to manage symptomatic malunion in adults, including resection, prosthesis, and osteotomy. When performing an osteotomy, it is important first to preserve an intact osseous hinge to avoid avascular necrosis and second to align the edge of the radial head articular surface with the lateral edge of the coronoid process, in order to avoid overstuffing elbow joint.

Radial neck fractures in children: results when open reduction is indicated

BACKGROUND

Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed.

METHODS

Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus.

RESULTS

Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P = 0.001), reduction of elbow flexion-extension (P = 0.001), increase of elbow valgus angle (P = 0.002), necrosis of the radial head (P = 0.001), premature physeal closure (P = 0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P = 0.002).

DISCUSSION

In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.