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

Comparing outcomes in the treatment of pediatric and adolescent intraarticular radial head fractures

Intraarticular radial head (IARH) fractures are uncommon pediatric injuries with unpredictable yet poor outcomes. The aim of this study was to evaluate clinical outcomes of IARH fractures in pediatric and adolescent patients, by testing our hypothesis that surgically managed fractures would have less risk for an unplanned second surgery and better elbow range of motion at the final follow-up. A retrospective review of 53 IARH fractures was performed. Demographic and clinical data were recorded. Concomitant and associated injuries were documented. Initial management and any attempted reduction in the emergency room were documented. The primary outcome was the need for an unplanned second procedure. Motion at final follow-up, presence of pain and need for physical therapy were reviewed. Radiographs were carefully reviewed and analyzed for physeal status, displacement, angulation and percent of radial head involved. We rejected our hypothesis, however, because it was displaced fractures that tended to require an unplanned change in treatment at a higher rate than nondisplaced fractures, regardless of index management with or without surgery. Fracture displacement on the lateral radiograph was a significant risk factor compared to the anterior-posterior images, and younger patients, particularly those with open physis, were at higher risk of an unplanned second procedure. Moreover, 80% of displaced fractures had asymmetric elbow motion after healing was achieved. It is important to counsel patients and families regarding the potential for suboptimal outcomes and elbow stiffness regardless of treatment choice, in the setting of an initially displaced IARH fracture. Level of evidence: Level III.

Opening Wedge Osteotomy for the Treatment of Pediatric Radial Neck Malunion and Anterior Radiocapitellar Dislocation: A Case Report

Radial neck fractures are common injuries of the elbow in the pediatric patient. Surgical intervention is recommended for significant angulation and displacement or mechanical blocks to motion. Radial neck malunion is a rare complication and may result in altered joint mechanics and, if severe, joint incongruency. Dislocation of the radial head has yet to be reported in this population after radial neck malunion. Treatment for radial neck malunions with dislocation varies and can include radial head excision or radial neck osteotomy. Outcomes after radial neck osteotomy is limited to case reports and small cases series. We present a case report of pediatric patient with radial neck malunion and anterior radiocapitellar dislocation treated with joint realignment via opening wedge osteotomy. To our knowledge, this is the first report of a pediatric case with radial head dislocation secondary to neck malunion and the first described report using this technique.

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.

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.

[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.

Intra-articular Radial Head Fractures: A Deceptive Type of Injury

BACKGROUND

Isolated intra-articular radial head (IARH) fractures in skeletally immature patients represent a rare injury. Despite their initial benign radiologic appearance, these fractures are at risk for progressive radial head subluxation and may end with degenerative irreversible changes of the radiocapitellar joint. The aim of this study is to highlight the seriousness of these injuries and the importance of early diagnosis and a proper follow-up to achieve optimal outcomes.

METHODS

We retrospectively reviewed 6 patients with IARH fractures treated at our institution between 2011 and 2016. All patients presented with Salter-Harris types III or IV fracture. Five of 6 fractures were initially undisplaced. Treatment, clinical, and radiographic results were analyzed. Patients were divided into 2 groups according to treatment: patients included in group A were treated conservatively, whereas patients of group B were treated with early surgery. The final functional outcome was assessed using the Oxford Elbow Score (OES). The Broberg-Morrey classification was used for the radiographic results.

RESULTS

Group A included 3 patients (average age, 11±2 y). They developed an initially missed posterior subluxation of the radiocapitellar joint that caused to all of them a painful elbow and limited range of motion (ROM). Despite rescue surgery, they all presented with limited ROM at the final follow-up, although no functional limitations (OES, 46.3±2.9). The radiographs showed early degenerative changes. Group B included 3 patients (average age, 11±1 y) all treated surgically within 1 week from the injury. They showed no limitation of ROM and good functional (OES, 47.7) and radiologic outcomes.

CONCLUSIONS

IARH fractures in skeletally immature children are deceptive injuries which are often underestimated. Surgeons should be aware of these fractures, especially when a discrepancy between the clinical signs and symptoms, and the radiologic appearance exists, as this may be the only red flag that allows their identification in the acute setting. An early and accurate diagnosis followed by prompt and more aggressive treatment when necessary is mandatory for successful results.

LEVEL OF EVIDENCE

Level IV-case series.

Functional outcome of displaced radial head fractures in children treated by elastic stable intramedullary nailing

The objectives of this study were to retrospectively investigate the clinical and radiological outcomes of displaced radial head fractures in children treated by elastic stable intramedullary nailing (ESIN) and evaluate the functional outcome of these injuries using the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). A total of 24 patients (nine males and 15 females) fulfilled the inclusion criteria. The mean age at the time of injury was 10.7±2.8 years (range: 9.5-16.33 years). Before surgery, the mean angulation was 53.8°±18.4° (range: 28°-82°) differentiating fractures on the basis of Judet's classification. The mean Quick DASH score was a good 4 (range: 0-15.9). Functional outcomes were similar irrespective of the severity of fracture displacement (P>0.05), presence or absence of associated fracture (P>0.05), and time immobilized (P>0.05). The Quick DASH score was better in children younger than 9 years of age (1.62) than children older than 9 years of age (4.95), but without a statistically significant difference (P=0.058). Children with displaced radial head fractures treated with ESIN showed good functional outcomes. Associated fracture injuries were not a predictive factor of functional outcome. Open reduction must be avoided as it carries an increased risk of complications.

Closed reduction using the percutaneous leverage technique and internal fixation with K-wires to treat angulated radial neck fractures in children-case report

Pediatric radial neck fractures are uncommon. Severely displaced and angulated fractures usually require treatment. Our goals for treatment are to avoid incision, reduce the fracture adequately with no reduction loss, and achieve good postoperative function. We aimed to observe the clinical outcomes of closed reduction with the percutaneous leverage technique and internal fixation with Kirschner-wires (K-wires) to treat angulated radial neck fractures in children.From January 2011 to April 2013, we treated 16 cases of angulated radial neck fracture in 12 boys and 4 girls. Five fractures were type II and 11 fractures were type III using the O'Brien classification. One K-wire was percutaneously introduced into the fracture site using the leverage technique to attain good reduction. Two K-wires were introduced from the proximal to the distal areas of the fracture site. The elbow was immobilized by cast in 90° of flexion and the forearm in supination for 3 to 4 weeks. The K-wires were removed at 3 to 4 weeks postoperatively. All cases were followed up for a mean duration of 3 years 6 months.According to the Metaizeau reduction classification, 12 cases were excellent, and 4 cases were good. According to the Metaizeau clinical classification, 14 cases were excellent, and 2 cases were good. There was no necrosis of the radial head. There was no infection, radioulnar synostosis, and damage of the radial nerve deep branch. There was no limitation in the pronation and supination functions of the forearm.Closed reduction using the percutaneous leverage technique and internal fixation using K-wires is easy to perform. It is encouraged to use this approach as the clinical outcome is good.

LEVEL OF EVIDENCE

level IV-retrospective case, treatment study.