Radial Head & Neck Fractures in Children

 

Fractures of the radial head and neck in children are not common. The fracture can be non-displaced, displaced, tilted, or translocated. These types of fractures are rare. They usually occur around 9 years of age, usually due to valgus force. The fracture may involve the physis (growth plate). It is a Salter-Harris Type II fracture, or the fracture may involve the radial neck at the metaphysis. There is a mnemonic statement that can be used to remember the names and order of the elbow ossification centers: CRITOE. 1, 3, 5, 7, 9, 11 are the approximate ages when the ossification centers appear around the elbow. Capitellum 1 year, Radial head 3 years, Internal epicondyle (medial) 5 years, Trochlea 7 years, Olecranon 9 years, External epicondyle (lateral) 11 years. An AP and lateral view of the elbow including the forearm should be taken. The radial head should align with the capitellum in all views. Radiocapitellar view may be helpful to view the radial head. The radiocapitellar view is an oblique lateral view; the elbow will be flexed to 90-degrees with the thumb pointing upwards, and the beam is directed 45 degrees proximally. Nondisplaced fractures of the radial head may not be seen on x-ray and then you are going to look for the fat pad sign. If you find the posterior fat pad, this is not normal and means that there is a fracture. In radial neck fractures, part of it is extra-articular, so if there is a fracture there, the fat pad sign may not be present even if there is a fracture. Treatment for a non-displaced fracture is immobilization. Immobilization is used if angulation is less than 30 degrees; up to 30 degrees of angulation is acceptable. Closed reduction is used if angulation is greater than 30 degrees. Reduction of the radial neck fracture is done with elastic bandage around the forearm and elbow or with extension of the elbow, traction, supination, and direct varus pressure over the radial head. Push the radial head medially and push the radial shaft laterally. If the reduction is acceptable, treat with immobilization. After reduction, the radial head usually stays in its position by the periosteum. K-wire joystick may be used for reduction in some cases. You will attempt closed reduction first before you use K-wire percutaneous reduction. Use the k-wire percutaneous reduction if the closed reduction failed. Open reduction can be done if more than 45 degrees or residual angulation after failure of reduction, either closed or by percutaneous methods. Complications include synostosis, loss of motion, osteonecrosis, and nonunion. Synostosis is fusion of the radius to the ulna; reflected periosteum is a possible cause of the synostosis. Osteonecrosis occurs due to interruption of the blood supply. Nonunion is rare. Interposition of the periosteum is a possible cause of nonunion. Risks and complications increase with open reduction. Open reduction should be the last resort in radial head and neck fractures in children. The worst outcomes are seen in children older than 10 years. With fracture of the radial head in children, repeat neurovascular examination should be done. Compartment syndrome of the forearm should be suspected in case of increased pain or increased analgesia requirements.