Radial neck fractures commonly occur in children and tend to be more prevalent at ages 9 to 10 years; they represent up to 10% of all pediatric elbow fractures. The mechanism of injury is usually a fall on an outstretched hand with a valgus compressive force across the elbow joint. The initial assessment should include an examination of the elbow joint, followed by plain radiographs of the elbow. Obtaining orthogonal projection with anteroposterior (AP) and lateral views of the elbow joint is key, and an oblique-lateral view known as the ‘Greenspan’ or radiocapitellar view may also be obtained to allow easier visualization of the radial head.
Classification of radial neck injuries is based on angulation between the radial head and neck. The Judet classification and O’Brien classification systems are most commonly used. Undisplaced fractures may be difficult to visualize on plain radiographs; an additional sign to look for is the posterior fat pad, which is sometimes present and is indicative of an occult fracture.
Long bones can be divided into three sections:
Ossification centers are parts of the bone involved in osteogenesis and can be divided into primary and secondary. The primary ossification center is where the bone first forms, for example, the diaphysis in long bones. Secondary ossification centers are usually found in the epiphysis, and there may be multiple centers present. There are six ossification centers around the elbow joint, which may be remembered using the mnemonic ‘CRITOE.’ The location and years at which these ossification centers appear around the elbow are:
The radial head fuses with the shaft between 16 to 18 years of age. Fractures of the radial neck usually involve the proximal radial physis; hence can be usually classified as Salter-Harris type-2 injury.
Operative radial neck fracture repair is usually indicated when the fracture angulation is greater than 30 degrees following attempts at closed reduction, translation of greater than 3 mm, and reduced range of supination and pronation of under 45 degrees. For cases in which angulation is close to thirty degrees, closed reduction with immobilization in a long-arm cast is acceptable. Closed percutaneous reduction using a K-wire or the Metaizeau technique using an elastic retrograde intramedullary (IM) nail can be trialed if closed reduction maneuvers fail and an angulation deformity of greater than 30 degrees persists. If an angulation deformity of greater than 45 degrees persists despite attempts at a closed percutaneous reduction, then open reduction should be undertaken with caution.
Operative repair of radial neck fractures is contraindicated if the fracture is minimally angulated (less than 30 degrees) and translated (less than 3 mm translation). Fractures that have more than 30 degrees of angulation may be managed with a closed reduction if an adequate reduction is achieved.
This procedure should be carried out by surgeons with appropriate training and experience; this may be a registrar (resident) or consultant (attending). The theatre team will include an anesthetic team, operating department practitioners, a scrub nurse, and a radiographer.
In preparation for this procedure, a theatre team brief should take place where team members are introduced, roles established, cases briefly discussed, including the list order, equipment required, and patient position. Prior to the procedure starts, the surgical team should complete the World Health Organisation (WHO) surgical safety checklist. The patient is positioned supine with the affected arm on an arm board. The patient should then be prepped and draped to above the elbow.
Closed Reduction- K-wire Joystick Technique
Closed Reduction and Internal Fixation - Elastic Stable Intramedullary Nailing (ESIN)-(Métaizeau technique)
Open Reduction Techniques- K-wire Fixation
Avascular necrosis (AVN) is one of the most significant complications from radial neck fractures. AVN can occur in 10% to 20% of radial neck fractures. Since the radial head relies on blood supply from the periosteum, the risk of AVN is even higher, up to 70%, in cases requiring open reduction due to damage to the periosteum. Elbow stiffness and decreased range of motion can be difficult to treat; therefore, prevention with an early active-assisted range of motion is crucial. In children, a safe and easy way to achieve this is by teaching children how to use their other arm to carry out movements on the affected side. Another cause of reduced function and range of movement can be due to malunion and non-union, highlighting the need for accurate reduction. Management of both malunion and non-union should be considered on a case by case basis depending on the patient’s signs, symptoms, and function.
Radioulnar synostosis is the fusion of the radius to the ulna, which may be due to reflected periosteum. The condition can hinder pronation, supination, and result in shortening of the arm. It is more common in cases that have delayed treatment or open reduction cases in which extensive dissection has been undertaken. Osteotomy procedures can be used to treat synostosis with the aim of improving function. Finally, compartment syndrome is a possible postoperative complication that presents early and can be challenging to diagnose in children. Compartment syndrome should be suspected in children with increasing pain or pain that is not responsive to opioids. If a definitive diagnosis of compartment syndrome is made, then a fasciotomy will need to be performed without delay.
Attempts should be made to manage radial neck fractures with closed reduction and manipulative closed reduction. If unsuccessful, gentle open reduction techniques can be used, but care must be taken to avoid damage to the periosteal hinge and preserve the blood supply. Open reduction is associated with greater rates of loss of function, AVN, and synostosis. Additionally, not all fractures will require reduction, and conservative management is a valid treatment option for fractures that are minimally displaced.
Management of radial neck fractures in children should be undertaken by an interprofessional team. Following surgery, support from allied healthcare professionals, in particular physiotherapists and occupational therapists, will further enhance the patient experience. These professionals should be routinely available to deliver a therapy plan that children will be able to follow at home. The child should be encouraged to start early range of movement to avoid stiffness. Patients are usually followed up in a fracture clinic, which is conducted with support from plater technicians and radiographs. This improves clinic flow, ensures patient safety, and enables high-quality care. Open communication with parents and thorough reviews in the fracture clinic will ensure holistic care is provided to these pediatric patients, and potential complications are flagged up early.
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