Pediatric radial neck fractures

The following case is a 11 y/o patient who presented with elbow pain after a fall. He presented with a radial head fracture that was angulated  45 degrees and had loss of forearm rotation. Due to the forearm rotation loss and degree of angulation operative fixation of the fracture was chosen. Injury films are shown below and xrays at one month after surgery.

Displacement and 45 deg of angulation on AP view

45 degrees of angulation at the radial neck (posterior)

2 weeks postop

One month postop

At 4 months post op there is significant remodeling and the patient lacks only 10 degrees of full pronation. Supination is full.

These injuries can be associated with:
MCL injury
Elbow dislocation
DRUJ dislocation
Capitellum fracture
Fracture of the olecranon or shaft of the ulna

Closed reduction should be attempted in the OR and if the reduction is not satisfactory then pinning of the fracture should be performed. If forearm rotation is less than 60 degrees then reduction is usually unsatisfactory

Accetable Reduction: 
    - age < 10 yrs: 
          - < 10 deg usually remodels with growth 
          - up to 30 deg of residual angulation can be accepted; 
          - angulation is > 30 deg 
                - closed manipulative reduction or percutaneous pinning to manipulate frx; 
    - age > than 10 yrs: 
          -if angulation > 30 deg, or translocation > 3 mm then poor results can be expected; 
          - inability to reduce angulation < 45 deg, requires ORIF 
          - inability to pronate and supinate the forearm more than 60 deg, is another sign that that the reduction is not adequate; 

It is important to educate patients and family that after this injury there is a change of loss of forearm rotation.

Possible complications are:

(1) Malunion may cause shortening of the radius and increased cubitus valgus, depending on pt's age & degree of cartilagenous damage.

(2) Non union 
This happens when there is severe fracture displacement at the time of injury or poor fixation technique. Nonunion can be treated with observation, radial head and neck excision (which should be avoided) . ORIF with bone graft has also been described. Healing of the nonunion is not always associated to improvement of clinical symptoms; 
                  
(3) Avascular necrosis

These complications are seen more often if extensive soft tissue damage is performed at the time of surgery or trauma that may cause premature fusion of upper radial epiphysis that occurs frequently after displaced fractures