HOW TO MINIMIZE COMPLICATIONS IN THE TREATMENT OF PEDIATRIC RADIAL NECK FRACTURES

Abstract

Introduction: Pediatric radial neck fractures account for 5 to 10 % of all elbow fractures. Depending on the degree of radial head displacement either operative intervention or conservative treatment is recommended. Open reduction offers anatomic fracture fixation but compromises the vulnerable blood supply. Intramedullary nailing combines the advantages of closed reduction and stable internal fracture fixation. The purpose of the presented study was to evaluate the outcome of treatment of a series of pediatric radial neck fractures. Special contributions in our algorithm were made to the age dependant capacity for spontaneous fracture remodelling.

Materials and Methods: The medical data of all children with fractures of the radial head between 1999 and 2008 were retrospectively analyzed. Fractures were classified according to the classification system described by Judet et al. Depending on the angulation of the fracture and on the age of the patient the treatment algorithm was defined. Type I fractures were treated conservatively and Type IV fractures operatively independent of age. Type III fractures in patients younger than 6 years of age were treated conservatively without reduction and Type II fractures were reduced in children older than 12 years of age. The functional outcome was graduated from excellent to poor according to the score of Linscheid and Wheeler.

Results: In our study 168 patients, 88 male and 80 female, were included. The average age of the patients was 9 years (range 3 to 16 years). There were 103 Type I injuries, 21 Type II, 30 Type III and 14 Type IV injuries. Conservative treatment was possible in 124 (73.8%) patients (103 Type I, 12 Type II, 9 Type III injuries). Operative intervention was performed in 44 (26.2%) patients (9 Type II, 21 Type III, 14 Type IV injuries). In 10 patients a K-wire was used to leverage the radial head percutaneous. Open fracture reduction was required in 4 patients. Necrosis of the radial head was found in 2 patients with open reduction. One child presented with hypoesthesia in the area of the superficial radial nerve. The latest follow up examination was performed after 26 months mean (range 11 months to 7 years). We found excellent results in 158 patients, good results in 5, fair in 3 and poor in 2 patients.

Discussion: An intact vascular supply to the radial head is essential to avoid complications. The iatrogenic impact to the nutritive vessels should be kept to a minimum. Closed fracture reduction and intramedullary nailing has improved the prognosis. Spontaneous fracture remodeling might successfully replace unnecessary maneuvers for fracture reduction. However, the proximal physis of the radius is responsible for only 20–30% of the growth of the radius and therefore spontaneous fracture remodeling is restricted. Following our treatment algorithm we found excellent results in the majority of cases.