Aims. To propose a new method for evaluating paediatric radial neck fractures and improve the accuracy of fracture angulation measurement, particularly in younger children, and thereby facilitate planning treatment in this population. Methods. Clinical data of 117 children with radial neck fractures in our hospital from August 2014 to March 2023 were collected. A total of 50 children (26 males, 24 females, mean age 7.6 years (2 to 13)) met the inclusion criteria and were analyzed. Cases were excluded for the following reasons: Judet grade I and Judet grade IVb (> 85° angulation) classification; poor radiograph image quality; incomplete clinical information; sagittal plane angulation; severe displacement of the ulna fracture; and Monteggia fractures. For each patient, standard elbow anteroposterior (AP) view radiographs and corresponding CT images were acquired. On radiographs, Angle P (complementary to the angle between the long axis of the radial head and the line perpendicular to the physis), Angle S (complementary to the angle between the long axis of the radial head and the midline through the proximal radial shaft), and Angle U (between the long axis of the radial head and the straight line from the distal tip of the capitellum to the coronoid process) were identified as candidates approximating the true coronal plane angulation of radial neck fractures. On the coronal plane of the CT scan, the angulation of radial neck fractures (CTa) was measured and served as the reference standard for measurement. Inter- and intraobserver reliabilities were assessed by Kappa statistics and intraclass correlation coefficient (ICC). Results. Angle U showed the strongest correlation with CTa (p < 0.001). In the analysis of inter- and intraobserver reliability, Kappa values were significantly higher for Angles S and U compared with Angle P. ICC values were excellent among the three groups. Conclusion. Angle U on AP view was the best substitute for CTa when evaluating radial neck fractures in children. Further studies are required to validate this method. Cite this article: Bone Joint J 2024;106-B(9):964–969

Introduction – Elbow dislocation in children is a rare lesion and most of the times is associated with a fracture of the medial epicondyle. When there is a fracture of the radial neck it is even more rare and usually represents a major instability with large soft tissue disruption. Methods – Between 1984 and 2003, 56 patients with unilateral elbow dislocations were identified ranging from 4 to15 years of age. In 8 patients a radial neck fracture was associated and in two there was a radio ulnar translocation . All these patients were treated the same way: closed reduction of the fracture dislocation under general anesthesia, evaluation of the instability and fracture fixation by closed means (Metaizeau technique). No ligamentous reconstruction was performed even in the presence of severe instability after bone reconstruction. A plaster was applied for two weeks followed by active mobilization. Results – All fractures healed with no complications. All patients except one regained full range of motion. The patient with a loss of extension (20°) complaints of pain on the lateral side during sports activity and has a minor instability test positive for the lateral collateral ligament. Discussion – This is a rare lesion in children not well documented in the literature. In the adult population there is an emphasis on the necessity of a repair of the soft-tissue structures as an integral part of the surgical strategy for elbow dislocation that require operative treatment (Mckee et al. J Shoulder Elbow Surg. 2003 Jul–Aug;12(4):391–6). In this small series we found no major instability in a long follow-up study even without reconstruction of the soft-tissues. Conclusion – We concluded that in this particular type of lesion, a close anatomical reduction of the articular surfaces with restoration of the normal relationship around the elbow was fundamental to restore elbow stability with no need for soft-tissue reconstruction

Displaced fractures of the radial neck in children can lead to limitation of elbow and forearm movements if left untreated. Several management techniques are available for the treatment of radial neck fractures in children. Open reduction can disturb the blood supply of the soft tissue surrounding the radial head epiphysis and is associated with more complications. We report our experience of treating 14 children between the age of 4 and 13 years, who had severely displaced radial neck fractures (Judet type 111 and 1V). 12 patients were treated with indirect reduction and fixation using the Elastic Stable Intramedullary Nail (ESIN) technique, (3 with assisted percutaneous K-wire reduction) and 2 had open reduction followed by ESIN fixation of the radial head fragment. This method reduces the need for open reduction and thus the complication rate. Three patients had associated fractures of the same forearm which was also treated surgically at the same time. We routinely immobilised the forearm for two weeks and removed the nail in all cases in an average of 12 weeks. We had no complication with implant removal. All 14 patients have been followed up for average of 28 months. One patient (7%) developed asymptomatic avascular necrosis (AVN) of the head of radius. Thirteen patients (93%) had excellent result on final review. One patient had neuropraxia of the posterior interosseous nerve which recovered within 6 weeks. In conclusion we advocate ESIN for the closed reduction and fixation of severely displaced radial neck fractures in children. It remains a useful fixation method even if open reduction is required and allows early mobilisation

A new ‘tripod’ technique using three crossed screws to stabilise radial neck fractures has been proposed and this technique was tested in vitro to evaluate whether it has at least equivalent stiffness and strength to fixation using a T-plate. Twenty composite sawbones with an axially stable simulated radial neck fracture were fixed either using the tripod technique (three crossed 2.3mm screws) or with a 2.3mm T-plate and screws. The specimens were tested for stiffness at 10 N load in three directions (antero-posterior (AP), ulnar-radial (UR) and eccentric axial (EA)) and load to yield and ultimate failure. The modes of failure of fixation were also evaluated. The tripod had significantly higher stiffness than the T-plate in AP loading (168 N/mm vs 95 N/mm, p=0.006) and trended to superior stiffness in UR loading (121 N/mm vs 77 N/mm, p=0.06). Both constructs were highly stiff in EA loading (513 N/mm vs 638 N/mm). The strength to yield and failure was significantly higher for the tripod in both AP loading (yield: 432 N vs 36 N, failure: 467 N vs 143 N, p< 0.001) and UR loading (yield: 444 N vs 36N, failure: 444N vs 76 N, p< 0.001). The T-plates failed by screw cut-out and subsequent plastic deformation of the plate. The tripod constructs did not fail at the load required to cause brittle fracture in the sawbone specimen, remote to the site of fixation. The tripod technique is a biomechanically sound construct for the fixation of axially stable radial neck fractures and thus further research to evaluate the clinical results of this technique is justified

Introduction: In the past, displaced radial neck fractures have been treated either by excision, prosthetic replacement or internal fixation with a plate and screws. More recent studies have investigated less invasive fixation constructs using two crossed obliquely orientated screws within the radial neck. A new ‘tripod’ technique using three crossed screws has been proposed and was tested to evaluate whether it has at least equivalent stiffness and strength to fixation with a T-plate. Methods: Twenty composite sawbones with an axially stable simulated radial neck fracture were fixed either with the tripod technique (three crossed 2.3mm screws) or with a 2.3mm T-plate. The specimens were tested for stiffness at 10 N load in three directions (anteroposterior (AP), ulnar-radial (UR) and eccentric axial (EA)) and load to yield and ultimate failure. The modes of failure of fixation were also evaluated. Results: The tripod had significantly higher stiffness than the T-plate in AP loading (168 N/mm vs 95 N/mm, p=0.006) and trended to superior stiffness in UR loading (121 N/mm vs 77 N/mm, p=0.06). Both constructs were highly stiff in EA compression (513 N/mm vs 638 N/mm). The strength to yield and failure was significantly higher for the tripod in both AP loading (yield: 432 N vs 36 N, failure: 467 N vs 143 N, p< 0.001) and UR loading (yield: 444 N vs 36N, failure: 444N vs 76 N, p< 0.001). The T-plates failed by screw cut-out and subsequent plastic deformation of the plate. The tripod constructs did not fail at the load required to cause brittle fracture in the sawbone specimen, remote to the site of fixation. Conclusions: The tripod technique is a biomechanically sound construct for the fixation of axially stable radial neck fractures and thus further clinical research to evaluate the clinical application of this technique is justified

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

The aim of this study is to discuss the results of intramedullary devices in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique. 30 patients with isolated Judet III and IV fractures were included in this retrospective study. The method of reduction was reviewed. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow score. Intramedullary K wires were used in 10 patients and blunt tipped TENS nails in 20 patients. The complications seen were radiocapitellar joint penetration-6 cases at mean 4.87 weeks, redisplacement − 6, radial epiphyseal sclerosis − 5 and heterotopic ossification − 1 case. The functional result was good to excellent in 24 of 30 cases(80%). The mean Oxford Elbow score was 44.32. The mean follow-up was 40.11 months. Intramedullary K wires may result in radiocapitellar joint penetration. Blunt tipped devices should not be used as purely fixation devices as they may not prevent redisplacement. Minimal redisplacement does not affect the functional outcome. Regular follow-up until atleast 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be closely followed up and given a guarded prognosis

The purpose of this prospective study was to determine the predictive factors and hence optimal management of closed uncomplicated proximal radial fractures. We examined all patients presenting to our unit over an 18-month period with isolated closed proximal radial fractures. 237 consecutive patients were included. Demographic data, physical examination, radiographs, treatment and complications were recorded. Patients were reviewed at 2, 6, 12, 26 and 52 weeks post injury. Outcome was determined via functional assessment and Mayo Elbow Score (MES). Data were analysed using SPSS. There were 156 (66%) radial head fractures and 81 (34%) radial neck fractures. 225 (95%) patients were treated non-operatively in a collar and cuff for one week followed by physiotherapy. 12 (5%) patients required primary surgical intervention due to either a mechanical block to forearm rotation (n=4) or a significant degree of radiographic comminution and/or displacement (n=8). Of the 201 patients who attended follow-up, 183 (91%) patients achieved excellent or good functional results measured on the MES. 155 (78%) patients achieved this by six weeks, with an average flexion arc of 125 degrees. Of the 12 patients treated operatively, the average MES at six weeks was fair (60). Regression analysis showed that increasing age, the AO-OTA fracture classification (B2.3, C2.3), radiographic displacement and operative treatment were significant predictors of a fair or poor outcome at six weeks. The majority of isolated proximal radial fractures can be treated non-operatively with early mobilization, achieving excellent or good results within 6 weeks. Age, fracture classification, radiographic displacement and treatment choice are important factors that determine speed of recovery

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail. METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months. RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications. CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging

For a long time treatment of all forarm fractures was coservatively in principle. Retrospective analysis of more than 1000 fractures showed that 97,8% were treated orthopedically, 22% finished consolidation with an axial malalignment of more than 10∞ and 6,9% showed bad functional results 3–13 years later. Most bad results were found in shaft fractures of both bones on the same level or in oblique fractures with convergent displacement. The introduction of elastic stable intramedullary nailing (ESIN) gave the opportunity to stabilize instable diaphy-seal fractures with less [Aufwand], with an implant adequate for children and with the possibility of immediate postoperative movement. Within three years, 161 diaphy-seal forearm fractures were managed by cast (27%), reduction (32%) or osteosynthesis (41%). In 14 cases (8,7%), secondary osteosynthesis took place because of secondary or re-displacement during orthopedic treatment. The functional results following ESIN are very good. In radial neck fractures with severe displacement of more than 60° an open reduction and fixation by K-wires was the preferred method for a long time. After open reduction, radial head necrosis was the result in a significant part of cases independent of the quality of reduction. Closed reduction with the tip of the nail without touching the fracture region improved the results extremely. Seldom a transcapsular reduction manoever is necessary. In a multicentric study of proximal radius fractures including 67 cases, 27 fractures with a relevant displacement were managed surgically (24 ESIN, 3 K-wire). 3 [Verplumpung] of the radial head, two of them combined with premature closure of epiphyseal plate, and one radial head necrosis took place, but only in one case with ESIN, whereas all cases with open reduction and K-wire use showed problems during the healing course

This paper presents the results of forearm fractures in twenty children treated with flexible intramedullary nailing, over a period of 3 yrs. Forearm fractures in children are an extremely common injury and excellent results are obtained in the majority of cases by closed reduction and plaster immobilisation. If adequate reduction cannot be achieved or maintained by conservative means or if it fails, some form of internal fixation will be required. Flexible nails are an extremely effective way for addressing this problem. Twenty children had flexible intramedullary nailing done following forearm fractures over a 3-year period from 1997–2000 [failed reduction (10), unstable post MUA(3), slipped in plaster(6) and open fractures(1)]. There were 15 male and 5 female patients, the mean age being 10. 9. The nature of the injury were radial neck (3); proximal radius (1), galeazzi (1) and both bone fractures (15). Nine patients had closed nailing, while 11 required a mini open approach of which, 5 needed exposure only on one side. Patients were protected post surgery until signs of union were seen. The patients had regular clinical and radiological assessment and nails were removed on an average of 6–8 months, though in patients with radial neck fractures it was removed much earlier [4–5 weeks]. All patients went on to full bony union in excellent position, the average time to union being 5. 8 weeks. All but one patient regained full prono-supination, elbow and wrist motion, though none had any functional disability. There were a few minor complications especially following implant removal, including superficial wound infections (3), transient hypoasthesia in the distribution of the superficial radial nerve (2) and one patient in whom one nail had to be left behind as it could not be removed. There were no long-term sequelae. Several methods of internal fixation are available, and the very diversity of choice demonstrates the lack of an ideal solution. K-wires are not applicable at all levels and plates have the disadvantage that they require extensive exposure of the fracture site. Removal of the plates is just as, if not more, fraught with complications. Flexible nails can often be inserted closed, leave cosmetically more acceptable scars, provide excellent alignment of the fracture and can be removed easily without requiring any postoperative immobilisation. In our opinion it should be considered as the method of choice in treating forearm fractures in children, when some form of internal fixation is required

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.