If closed reduction does not work, the arm is prepped and sterilely draped in the usual manner. Under fluoroscopic control, the position of maximal angulation and
displacement is determined. A small puncture wound is made distally and
posterolaterally to the radial head and neck. A firm Kirschner wire or small Steinmann pin is then inserted and directed to the fracture site. The surgeon should be aware of the local anatomy, especially the arcade of Frosch and the posterior interosseous nerve, which courses through this area (Fig. 3-3).
FIGURE 3-3 Arcade of Frosch—note proximity of radial nerve to Steinmann pin and fracture.
P.30 The pin is directed under fluoroscopic control to the neck or head of the radius. The sharp end of the pin is used, as it gives more stability to the reduction (Figs. 3-4, 3-5
and 3-6). The proximal pin end should be padded to prevent physician injury. Pressure is then utilized to disimpact the fracture and reduce the head and neck while partially rotating the forearm. If the reduction is satisfactory, a dressing is applied, followed by a long-arm cast with the elbow flexed to 90 degrees and neutral rotation of the
forearm. While a loss of significant reduction is uncommon the literature has noted loss of reduction and recommended pin fixation with flexible nail, leaving the nail in place until healing has occurred.4 It is advisable not to cross the elbow joint with pins, as pinning the radial head with a Kirschner wire or Steinmann pin through the
capitellum into the radial head and neck can result in fracture of the pin and difficulty in pin retrieval.
FIGURE 3-4 Markedly displaced fracture of the radial neck.
FIGURE 3-5 Reduction by percutan- eous Steinmann pin.
FIGURE 3-6 End result—healed fracture with excellent alignment.
It is strongly recommended that these fractures not be opened unless reduction cannot be obtained by semiclosed means or unless the radial head and neck fracture fragment is so widely displaced that open reduction is necessary.
P.31
POSTOPERATIVE MANAGEMENT
Postoperative immobilization with a long-arm cast or splint is used for 2 to 3 weeks following fracture reduction. Range-of-motion exercises for the elbow are initiated, as is forearm muscle rotation. Formal physical therapy is reserved for those patients who are slow to regain elbow motion following cast removal. Full activity is resumed after there is adequate elbow motion and pain-free upper extremity function.
COMPLICATIONS TO AVOID
The parents and the injured child should be warned prior to the treatment of the radial neck fracture that this is one of the more difficult pediatric fractures to treat, with approximately 15% to 35% of patients reported to have fair or poor final results.
The most common complication is loss of forearm rotation, which may occur from an incompletely reduced fracture or from later radial head hypertrophy, which can occur months after the original fracture has healed. Avascular necrosis, with or without proximal radial physeal arrest, occurs most commonly with radial neck fractures in which there has been wide displacement of the proximal fracture fragment at the time of injury. If open reduction is done on moderately displaced radial neck fractures, care is needed to avoid excessive soft-tissue stripping, which may interfere with the
vascular supply to the radial head. If there is a physeal arrest in the proximal radius as a result of this fracture, a valgus deformity of the elbow may occur.
PEARLS AND PITFALLS
If there is more than 30 degrees angulation and/or 5 mm displacement, fracture reduction is needed.
Advise the parents before the reduction is done that this fracture has a 15% to 35% rate of poor or fair results, even with adequate reduction.
Attempt to reduce the fracture with percutaneous pin reduction techniques before resorting to open reduction.
Save open reduction for irreducible fractures or for fractures with wide displacement of the proximal radial neck fracture fragment.
Avoid placing pins across the capitellar-radial head joint.
Limit postreduction immobilization for 2 or 3 weeks.
REFERENCES
1.Bernstein SM, McKeever P, Bernstein L. Percutaneous reduction of displaced radial neck fractures in children. J Pediatr Orthop. 1993;13:85–88.
2.Gaston SR, Smith FM, Baab O. Epiphyseal injuries of the radial head and neck.
Am J Surg. 1953;85:266–276.
3.Jeffery CC. Fractures of the head of the radius in children. J Bone Joint Surg Br.
1950;32:314–324.
4.Metaizeau JP, Lascombes P, Lemelle JL, et al. Reduction and fixation of
displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop.
1993;13:355–360.
5.Murray RC. Fractures of the head and neck of the radius. Br J Surg.
1940;48:106–118.
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6.Neher CG, Torch MA. New reduction technique for severely displaced pediatric radial neck fractures. J Pediatr Orthop. 2003;23:626–628.
7.Reidy JA, VanGorder GW. Treatment of displacement of the proximal radial epiphysis. J Bone Joint Surg Am. 1963;45:1355–1372.
8.Tachdjian MO. Pediatric Orthopedics. 2nd ed. Philadelphia: WB Saunders;
1990;3137–3143.
9.Waters PM, Stewart SL. Radial neck fracture nonunion in children. J Pediatr Orthop. 2001;21:570–576.
10.Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in Children. Philadelphia: JB Lippincott Co;
1984:363–576.
Editors: Tolo,, Vernon T.; Skaggs,, David L.
Title: Master Techniques in Orthopaedic Surgery: Pediatrics, 1st Edition
Copyright ©2008 Lippincott Williams & Wilkins
> Table of Contents > SECTION I - TRAUMA > 4 - Operative Treatment of Forearm Fractures Using Flexible IM Rods