RADIAL HEAD AND NECK FRACTURES -PEDIATRIC

RADIAL HEAD AND NECK FRACTURES -PEDIATRIC

Prepared by Dr. Muhammed Furkan DARILMAZ

1. Definition & Key Points

• Fractures of the proximal radius in skeletally immature patients, most often involving the radial neck (metaphysis) rather than the articular surface.
• Considered pediatric elbow trauma; majority are extra-articular, with true intra-articular radial head fractures being rare before physeal closure.
• Management choice (nonoperative vs operative) is primarily based on angulation, translation, rotation, patient age, and associated injuries.

2. Epidemiology

• Account for 5–10% of all pediatric elbow fractures and about 1% of all pediatric fractures.
• Peak age: 9–10 years; no consistent sex predominance.
• In many series, radial neck fractures constitute the majority of proximal radius injuries in children.

3. Relevant Anatomy & Biomechanics

• Elbow ossification centers (CRITOE): Capitellum, Radius, Internal (medial epicondyle), Trochlea, Olecranon, External (lateral epicondyle).
• Radial head ossification:
  • Appears around 3–5 years, may be bipartite.
  • Fuses with radial shaft at 16–18 years.
• Annular ligament:
  • Continuation of joint capsule, drapes over epiphysis and physis.
  • Protects physis but creates a stress riser at the metaphysis, so fractures preferentially occur at the neck.
• Blood supply: largely from the metaphysis → aggressive dissection & open reduction risk osteonecrosis.

4. Mechanism & Associated Injuries

• Mechanism:
  • Extension + valgus load on an outstretched elbow is classic.
  • Less commonly associated with elbow dislocation or Monteggia variants.
• Associated injuries (must be actively excluded):
  • Elbow dislocation.
  • Olecranon fracture.
  • Medial epicondyle fracture.
  • Forearm compartment syndrome (rare but serious).

5. Clinical Presentation

• Symptoms:
  • Lateral elbow pain and tenderness over radial head/neck.
  • Refusal to move the elbow; pain with forearm rotation (pronation–supination) is very typical.
• Physical exam:
  • Lateral swelling, sometimes minimal deformity.
  • Pain increased by passive rotation; flexion/extension may be less painful.
  • Neurovascular exam: specifically assess radial, median, ulnar nerves; check compartments (especially if high-energy trauma).

6. Imaging

• Standard radiographs:
  • AP and lateral of the elbow.
  • Assess:
    • Radiocapitellar line: line along radial shaft axis should intersect capitellum on all views (not fully reliable in very young children).
    • Lateral humeral line: tangent to lateral condyle, lies lateral to radial neck in normal elbows; may be more reliable in younger children to assess alignment.
  • Look for:
    • Subtle metaphyseal fracture lines at neck.
    • Radial head tilt / translation, rotation.
    • Posterior or anterior fat pad sign (note: partial extra-articular location of radial neck → effusion may be absent).
• Special view:
  • Radiocapitellar (Greenspan) view: oblique lateral with beam angled 45° proximally to better visualize radial head.
• CT:
  • Reserved for older children with comminuted intra-articular head fractures and for preoperative planning.
• MRI:
  • Rarely needed; may help in a pre-ossified elbow or for occult compression fractures and ligamentous injury; cost vs benefit must be considered.

7. Classification

• O’Brien classification (angulation of radial neck)
  • Type I: <30° angulation.
  • Type II: 30–60°.
  • Type III: >60°.
• Judet classification
  • I: Undisplaced.
  • II: <30° angulation.
  • III: 30–60°.
  • IVa: 60–80°.
  • IVb: >80°.
• Chambers classification (by primary displacement & mechanism – less used clinically).
• Treatment algorithms and prognostic studies generally use angulation + translation + age rather than pure fracture type.

8. Treatment Principles

• Aim: restore radiocapitellar alignment, preserve motion, avoid iatrogenic damage (especially osteonecrosis and synostosis).
• General rules:
  • Less invasive first (closed reduction, percutaneous techniques) whenever acceptable reduction can be obtained.
  • Avoid open reduction unless absolutely necessary; strongly associated with higher rates of stiffness, osteonecrosis, and synostosis.

9. Nonoperative Management

• Immobilization alone (no reduction)
  • Indications (commonly accepted):
    • Angulation <30°.
    • Translation <3 mm.
    • Satisfactory motion (no gross mechanical block).
    • Reliable follow-up and no significant associated injuries.
  • Technique:
    • Long arm cast or splint, elbow 90° flexion, forearm neutral or slight supination.
    • Immobilization 7–21 days, then early active ROM.
  • Outcomes:
    • Systematic review data show excellent ROM and function for fractures with post-treatment angulation ≤20–30° treated conservatively; greater angulation correlates with loss of motion.
• Closed reduction + immobilization (no internal fixation)
  • Indications:
    • Initial angulation >30° where acceptable reduction (<30° and <3 mm translation) can be achieved by manipulation alone.
  • Maneuvers:
    • Patterson maneuver (traction, varus, direct pressure on radial head).
    • Israeli (Kaufman) technique (flexion 90°, pronation with pressure on head).
    • Neher–Torch technique (traction, varus, radial head manipulation)
    • Elastic bandage (Esmarch) method (application wrist to elbow, spontaneous reduction)
  • Key point: reassess with fluoroscopy; avoid repeated forceful manipulations that risk AVN.

10. Operative Management

• Closed reduction and percutaneous fixation (CRPP / ESIN)
  • Indications:
    • Residual angulation >30° after closed reduction.
    • Translation >3–4 mm.
    • Pronation/supination arc <45° due to block.
  • Techniques:
    • K-wire “joystick” (push or lever technique) from proximal or distal metaphysis to correct tilt and translation; wires may be left as fixation.
    • Metaizeau technique (ESIN): retrograde flexible nail inserted from distal radius, advanced across fracture; rotation of nail used to lever head into alignment, nail left for internal fixation.
  • Evidence:
    • JPOSNA and systematic reviews emphasize CRPP/Metaizeau as preferred for significantly angulated yet reducible fractures, with good ROM and lower complication rates versus open reduction.
    • Recent series suggest faster ossification and earlier radiographic healing with Metaizeau vs K-wire fixation, though functional differences may be modest.
• Open reduction ± internal fixation (ORIF)
  • Indications (when all closed / percutaneous methods fail):
    • Residual angulation >45°.
    • Inability to obtain or maintain satisfactory alignment with closed/percutaneous techniques.
    • Irreducible fracture, often due to interposed tissue or severe displacement/comminution.
  • Principles:
    • Lateral approach to radiocapitellar joint.
    • Pronate forearm to move PIN away from surgical field.
    • Gentle handling, minimal periosteal stripping; avoid transcapitellar pins when possible.
  • Outcomes:
    • Consistently associated with higher rates of stiffness, osteonecrosis (up to ~70% of AVN cases), synostosis, and need for revision compared with closed techniques—partly reflecting more severe fracture patterns.

11. Complications

• Loss of motion / stiffness
  • Most common complication (reported ~10–30% in many series). Loss of pronation is more frequent than loss of supination.
• Radial head overgrowth
  • Radiographic enlargement or irregularity in 20–40% of cases; usually no functional consequence.
• Osteonecrosis (AVN) of radial head
  • Occurs in ~10–20% overall; majority associated with open reduction and severe displacement.
• Physeal arrest / growth disturbance
  • May lead to cubitus valgus deformity and elbow incongruity.
• Radioulnar synostosis
  • Serious but rare; associated with extensive dissection, delayed treatment, and open reduction with interosseous scarring.
• PIN palsy
  • May occur after surgical manipulation or pinning; up to ~15% transient deficits reported, usually neuropraxia.
• Malunion / chronic instability
  • Malunited intra-articular fractures can lead to radiocapitellar incongruity, chronic pain, mechanical symptoms, and degenerative change.

12. Prognostic Factors

• Worse prognosis associated with:
  • Age >10 years.
  • Higher Judet/O’Brien grade (greater angulation/displacement).
  • Intra-articular head involvement vs extra-articular neck fractures.
  • Associated injuries (olecranon, medial epicondyle, elbow dislocation, Monteggia).
  • Need for open reduction and extensive dissection.
• Key positive factors:
  • Successful closed or percutaneous reduction to ≤20–30° angulation and minimal translation.
  • Early motion after stable fixation, within safe window.

References

1. Langenberg LC, van den Ende KIM, Reijman M, Boersen GJJ, Colaris JW. Pediatric Radial Neck Fractures: A Systematic Review Regarding the Influence of Fracture Treatment on Elbow Function. Children (Basel). 2022;9(7):1049. Published 2022 Jul 14. doi:10.3390/children9071049
2. Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999;8(2):93-99.
3. Tan BH, Mahadev A. Radial neck fractures in children. J Orthop Surg (Hong Kong). 2011;19(2):209-212. doi:10.1177/230949901101900216
4. Kalbitz M, Lackner I, Perl M, Pressmar J. Radial head and neck fractures in children and adolescents. Front Pediatr. 2023;10:988372. Published 2023 Jan 20. doi:10.3389/fped.2022.988372
5. Meng H, Li M, Jie Q, Wu Y. Effect analysis of different methods on radial neck fracture in children. Sci Rep. 2023;13(1):1181. Published 2023 Jan 21. doi:10.1038/s41598-023-28294-9
6. Stöckell M, Lampio E, Sagstetter F, Sinikumpu J. Faster healing of radial neck fractures in children treated with the Metaizeau technique compared with percutaneous Kirschner wire fixation: a population-based study. BMC Musculoskelet Disord. 2025;26(1):624. Published 2025 Jul 4. doi:10.1186/s12891-025-08830-6