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Radial Head and Neck Fractures - Pediatric

Topic updated on 09/27/15 10:12am
Introduction
  • In children, fractures of the proximal end of the radius typically involve the physis or radial neck (metaphysis)
    • most cases are Salter-Harris type II fractures
    • radial head involvement is rare
  • Epidemiology
    • demographics
      • median age is 9-10 years
      • no difference in incidence between sexes
      • 1-5% of all pediatric elbow fractures
  • Pathophysiology
    • mechanism
      • usually associated with a valgus loading injury of the elbow 
  • Associated Conditions
    • elbow dislocation 
    • medial epicondyle fracture 
Anatomy
  • There are 6 ossification centers around the elbow joint 
    • age of ossification is variable but occurs in the following order (C-R-I-T-O-E) at an average age of (years)
      • Capitellum (1 yr.)
      • Radius (3 yr.)
      • Internal or medial epicondyle (5 yr.)
      • Trochlea (7 yr.)
      • Olecranon (9 yr.)
      • External or lateral epicondyle (11 yr.)
  • Ossification center of radial head appears between and 3 and 5 years of age
    • may be bipartite
    • radial head fuses with radial shaft  between ages of 16 and 18 years
Classification
 
Chambers Classification
Group 1: Primary displacement of radial head (most common) Valgus Injury
A: Salter-Harris I or II
B: Salter-Harris IV
C: metaphyseal

Elbow Dislocation
D: reduction injury
E: dislocation injury
 
Group 2:  Primary displacement of radial neck Monteggia variant

Group 3:  Stress injury Osteochondritis dissecans
 
Presentation
  • Symptoms
    • elbow pain
    • refusal to move
  • Physical exam
    • inspection
      • lateral swelling 
    • motion
      •  pain exacerbated by motion, especially supination and pronation.
    • must have high suspicion for forearm compartment syndrome 
    • pain may be referred to the wrist 
Imaging
  • Radiographs 
    • recommended views 
      • AP and lateral of the elbow 
      • radiocapitellar (Greenspan) view 
        • oblique lateral performed with forearm in neutral rotation and beam directed 45 degrees proximally
    • findings
      • nondisplaced fractures may be difficult to visualize 
      • look for fat pads signs
        • a portion of the radial neck is extra-articular and therefore an effusion and fat pads signs may be absent.
Treatment
  • Nonoperative
    • immobilization +/- closed reduction
      • indications
        • most fractures can be treated closed
        • if < 30° angulation immobilize without closed reduction
        • if >30° angulation perform closed reduction and immobilize if angulation reduced to < 30° 
      • followup
        • begin early ROM at 3-7 days to prevent stiffness
  • Operative
    • operative percutaneous reduction 
      • indications
        • > 30° of residual angulation
        • 3-4 mm of translation
        • < 45° of pronation and supination
      • outcomes
        • improved outcomes with younger patients, lesser degrees of angulation, and isolated radial neck fractures
    • open reduction
      • indications
        • fracture that cannot be adequately reduced with closed or percutaneous methods 
      • outcomes
        • open reduction has been associated with a greater loss of motion, increased rates of osteonecrosis and synostosis compared with closed reduction.
Techniques
  • Closed reduction
    • reduction techniques
      • Patterson maneuver 
        • hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head
      • Israeli technique 
        • pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head
      • elastic bandage technique
        • tight application of an elastic bandage beginning at the wrist continuing over the forearm and elbow may lead to spontaneous reduction
  • Closed Reduction and Percutaneous Pinning
    • reduction technique
      • K-wire joystick technique 
      • Metaizeau technique  
        • involves retrograde insertion of a pin/nail across the fracture site 
        • fracture is reduced by rotating the pin/nail 
  • Open reduction
    • approach
      • performed with lateral approach (Kocher interval)
    • fixation
      • avoid transcapitellar pins
      • internal fixation only used for fractures that are grossly unstable 
Complications
  • Decreased range of motion
    • loss of pronation more common than supination
  • Radial head overgrowth
    • 20-40% of fractures
    • usually does not affect function
  • Osteonecrosis
    • 10-20% of fractures
    • up to 70% of cases occur with open reduction
  • Synostosis
    • most serious complication
    • occurs in cases of open reduction with extensive dissection or delayed treatment

 

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Qbank (5 Questions)

TAG
(OBQ13.266) A 9-year-old girl falls onto her left elbow while swinging from the monkey bars and sustains a radial neck fracture. Closed reduction with adequate sedation under mini-C arm guidance is performed in the emergency room. Radiographs following this attempt are shown in Figures A and B. Residual angulation is 62°. What is the next best step in treatment? Topic Review Topic
FIGURES: A   B        

1. Early range of motion
2. Percutaneous reduction with pin fixation as needed
3. Immobilize in 90º of elbow flexion and neutral forearm rotation
4. Open reduction and plate fixation
5. Open reduction and epiphysiodesis

PREFERRED RESPONSE ▶
TAG
(OBQ11.198) A 10-year-old boy sustains an injury to his dominant elbow and presents with the injury shown in Figures A and B. What is the next best step in management? Topic Review Topic
FIGURES: A   B        

1. Immobilization in full pronation
2. Open reduction
3. Closed reduction
4. Closed reduction and percutaneous pinning
5. Open reduction and internal fixation

PREFERRED RESPONSE ▶
TAG
(OBQ10.106) A 12-year-old boy falls 8 feet from a tree limb and lands on his outstretched hand. He complains of elbow pain and a displaced radial neck fracture is noted on radiographs. Closed reduction is performed under sedation in the ER. A post-reduction radiograph is provided in Figure A revealing residual angulation measuring in excess of 45. Which of the following actions should be taken? Topic Review Topic
FIGURES: A          

1. Immobilization in a sling until pain subsides
2. Immobilization in a long arm cast for 6 weeks to allow for callus formation and subsequent bony remodeling
3. CT scan to further evaluate the fracture and physis
4. Hinged external fixation of the elbow
5. further reduction and fixation in the operating room with ESIN

PREFERRED RESPONSE ▶
TAG
(OBQ08.154) A 10-year-old female falls from the swing and lands on her left arm. She complains of left elbow pain. On physical exam she has pain exacerbated by motion, especially supination and pronation. She is neurovascularly intact. A radiograph is provided in Figure A. Which of the following is the most appropriate first step in management? Topic Review Topic
FIGURES: A   B        

1. Short arm cast without reduction
2. Long arm cast without reduction
3. Attempt closed reduction
4. K-wire percutaneous reduction in the operating room
5. Open reduction with a lateral approach

PREFERRED RESPONSE ▶
TAG
(OBQ04.171) A 6-year-old boy has right elbow pain after falling onto an outstretched hand eight hours ago. Radiographs are shown in Figure A. Overnight, he develops increasing pain and swelling in his right forearm. What associated condition is most likely developing in this scenario? Topic Review Topic
FIGURES: A          

1. Extensor pollicis longus rupture
2. Posterior interosseous nerve neurapraxia
3. Forearm compartment syndrome
4. Common extensor origin avulsion
5. Medial collateral ligament rupture

PREFERRED RESPONSE ▶




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