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Current Evaluation and Treatment of Radial Neck (Elbow) Fractures in Children
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Posted on: 07/18/2012
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There's more than one way to approach the treatment of pediatric radial neck fractures. In this report, Dr. M. E. Pring from the University of California's Department of Pediatric Orthopedic Surgery brings us up to date on what techniques can be used to treat this problem in children. Problems that can arise and what to do about them are also presented.
The radial head is a round, disc-shaped top to the radius bone (the smaller of two bones in the forearm). The radial head sits next to and articulates (moves) with the lower portion of the humerus (upper arm bone). The position of the radius is on the outside of the elbow (side away from the body).
The mechanism of injury is usually a fall on an outstretched arm. The force of the impact can be enough to snap the top of the radius right off. If the broken piece shifts away from the main bone, it is considered a displaced fracture. If the radial head moves off to the side and away from the shaft of the bone, it is a translation of the head in relation to the shaft.
If the radial head tips over and forms an angle with the radial shaft, it is considered both displaced and angulated. The amount of angulation will be an indication of severity of the fracture and also direct treatment. Angulation is easier to treat than translation. In younger children (up to age six), angulated radial neck fractures correct by themselves during the healing process.
General guidelines are: 1) less than 30 degrees of angulation can correct in children of all ages. 2) Displacement less than two millimeters does not require surgery. 3) More than 60 degrees of angulation must be treated surgically no matter how young the child is. 4) Angulation between 30 and 60 degrees is a gray area. There are no clear guidelines. In general, the younger the child, the greater the chances for healing and correction.
When selecting treatment options for radial neck fractures, there are other factors to consider. In one-third up to one-half of all children, there are other injuries that occur at the same time. For example, there can be other fractures in and around the elbow, torn ligaments, and damage to the joint surface. Sometimes the broken and displaced radial head flips over on itself and appears to be in the correct place but isn't. This situation must be identified and corrected or the joint will be destroyed.
In young children (up to age five), the radial head isn't even made of bone yet -- it is still mostly cartilage. X-rays won't always show damage to this area. With the possibility of additional soft tissue injuries, CT scans or MRIs may be needed to identify all potential problems make a complete diagnosis.
That's when the surgeon rolls up his or sleeves so-to-speak and gets to work on a treatment plan. The first question is always: conservative (nonoperative) care or surgery? For radial neck fractures with less than 30 degrees of angulation and less than two millimeters of separation, a cast for two to three weeks works just fine.
As a final test in this decision-making process, the surgeon will check forearm motion. If the child has full supination (palm up) and full pronation (palm down) motions, simple immobilization in a cast is acceptable. Any limitations or blocks to these rotational movements is a sign that reduction (correcting alignment) is needed.
The surgeon can attempt to perform what's called a closed reduction. There are several hands-on techniques to accomplish this type of manipulation. But if the radial head doesn't reduce (go back into place) with the first (or possibly second) attempt, the surgeon is advised not to keep trying. The risk of further damage is just too great.
Now the next set of decisions pop up. Should the surgeon use an open incision or percutaneous (through the skin) approach? What's the best way to line up the bones and hold them together? Fixation of the bones with pins or wires is most common.
The author provides drawings, X-rays, and written descriptions to explain various techniques for surgical reduction and fixation of these types of elbow fractures. Three case presentations are provided to illustrate what can happen and how treatment decisions are made. The author concludes these are not uncommon fractures and surgeons who understand the principles and pitfalls described in this article will better aid the patients in regaining elbow motion and function.
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References:
Maya E. Pring, MD. Pediatric Radial Neck Fractures: When and How to Fix. In Journal of Pediatric Orthopaedics. June 2012. Supplement. Vol. 32. No. 1. Pp. S14-S21.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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