Pediatric radial neck fractures

  • Extra-articular fracture involving proximal humerus proximal to the bicipital tuberosity.
  • Usually a physeal injury either Salter-Harris I or II.
  • 1% of pediatric fractures and 5-10% of pediatric elbow injuries.
  • Major concerns are vascularity of proximal fragment, risk of growth arrest and proximal radioulnar and radiocapitellar malalignment.

Anatomy

  • Radial head has 150 lateral angulation on AP view and 50 angulation on lateral views.
  • Secondary centre for ossification appears at 4 years of age. Ultrasound, MRI or arthrography may be necessary in those younger than 4 years for diagnosis.
  • Stabilized by annular ligament and lateral ligament complex.
  • Radial nerve passes anteriorly and the posterior interosseous nerve enters the supinator muscle 2.5cm below the radial head.

Classification

Wilkin’s classification

Type I- Valgus injury

  • Salter Harris I or II
  • Salter Harris III or IV
  • Metaphyseal

Type II- With elbow dislocation

  • Occurred with initial injury (Radial head anterior)
  • Occurred during reduction (Radial head posterior)

O’Brien classification

I – <300 angulation

II- 30-600 angulation

III- >600 angulation

Judet classification

I- Undisplaced

II- Less than 300 angulated

III- 30-600 angulation

IV A- 60-800angulation

IV B- >800 angulation

Treatment

  • Ligament injury especially ulnar collateral ligament seen in 30-50%.
  • Prognosis depends on the age, amount of displacement, associated injury, body mass index and treatment method.
  • Poor prognosis factors
    • Age more than 10 years
    • Displacement more than 100%
    • Obesity
    • Open reduction
    • Associated dislocation of elbow
    • Delayed surgery
  • Closed treatment is recommended if the displacement is less than 3mm, angulation less than 450 if there is no block to forearm rotations and elbow movement.
  • Indications for surgery
    • Angulation is more than 300
    • Displacement more than 3mm
    • Age more than 9 years
  • Every effort should be made to reduce by closed or percutaneous methods as open reduction is associated with higher incidence of complications.
  • Reduction ladder
    • Closed reduction
    • Percutaneous reduction
    • Open reduction
  • Kaufman or Israeli technique
    • Done under C-arm.
    • Flex elbow to 900.
    • Supinate and pronate to identify the plane of maximum angulation.
    • With the thumb milk the head from distal to proximal to reduce the fracture.
  • Patterson technique
    • Done under C-arm.
    • Traction in extended position.
    • Supination and varus force.
    • Digital pressure over the radial head to reduce the fracture.
  • Metaizeau technique
    • Done under C-arm
    • Pass a titanium elastic nail proximal to the distal radius physis.
    • Drive the nail into the radial head under image guidance
    • Rotate the nail to reduce the fracture.
  • Immediate open reduction indications
    • Open fractures
    • Neurovascular compromise
    • >100% displacement
  • Transcapitellar pins associated with higher complications
  • Complications
    • Seen in 30%.
    • May go up to 50% in severely displaced fractures
    • Loss of pronation more than supination.
    • Osteonecrosis
    • Heterotopic ossification
    • Nonunion
    • Growth arrest
    • Radioulnar synostosis

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s