ASSESSMENT OF FRACTURES OF THE

PROXIMAL RADIUS IN CHILDREN By :- Dr OPENDER SINGH KAJLA RNT MEDICAL COLLEGE, UDAIPUR

INTRODUCTION• Fractures of the proximal radius in skeletally immature patients usually involve the metaphysis

or physis.

• True isolated radial head fractures are rare.

• Fractures of the radial neck account for slightly more than 1% of all children’s fractures.Radial

neck fractures make up approximately 5% of elbow fractures in children.

• Radial head fractures are uncommon, and when they occur usually are Salter–Harris type IV

injuries.

• The median age at injury is 9 to 10 years in the pediatric population.

• There is little difference in the occurrence rates between males and females 22,40,68; however, this injury

seems to occur on an average approximately 2 years earlier in girls than in boys.

MECHANISM OF INJURY

• Fractures of the proximal radius most commonly occur after a fall on an outstretched arm

with elbow extended and valgus stress at the elbow.

• The cartilaginous head absorbs the force and transmits it to the weaker physis or metaphysis

of the neck.

• These fractures characteristically produce an angular deformity of the head with the neck.

• Vostal showed that in neutral, the pressure is concentrated on the lateral portion of the head

and neck. In supination, the pressure is concentrated anteriorly, and in pronation it is con-

centrated posteriorly.

• Proximal radial fractures also may occur in association with elbow.

FIGURE SHOWS TYPE OF INJURY IN ELBOW DISLOCATION

Associated Injuries with Fractures

of the Proximal Radius • Can occur concomitantly with distal humerus, ulna, radial shaft, or distal radius

fractures.

• Fractures in combination with ulnar fractures often are part of the Monteggia fracture

pattern.

• Portends a poor prognosis for patients with proximal radius fractures with higher rates

of persistent stiffness and pain compared to those with isolated proximal radius

fractures.

• The posterior interosseous nerve (PIN) wraps around the proximal radius and

occasionally can be injured in association with proximal radius fractures.

Signs and Symptoms of Fractures

of the Proximal Radius • The pain is usually increased with forearm supination

and pronation more so than with elbow flexion and

extension.

• Displaced fractures frequently result in visible bruising

or ecchymosis on the lateral aspect of the elbow with

significant soft tissue swelling.

• Neurologic examination should in particu- lar evaluate

the PIN, which can be affected by fractures of the

proximal radius.

• In a young child, the primary complaint may be wrist

pain, and pressure over the proximal radius may

accentuate this referred wrist pain.2 The wrist pain may

be secondary to radial shortening and subsequent distal

radioulnar joint dysfunction.

Imaging and Other Diagnostic Studies for Fractures of the Proximal Radius

• Displaced fractures are easy to evaluate on AP and Lateral views of elbow X-rays.

• Some variants in the ossification process can resemble a fracture. Most of these involve the radial head, although a step-off also can develop as a normal variant of the metaphysis.

• There may be a persistence of the secondary ossification centers of the epiphysis. Comparison views of the contralateral elbow are useful for evaluation of unusual ossification centers after an acute elbow injury.

• If elbow cannot be extended due to pain then one view is taken with the beam perpendicular to the distal humerus, and the other with the beam perpendicular to the proximal radius.

Oblique view/ Radio-capitellar view

• For minimally displaced fractures.

• Suggested by Greenspan et al and Hall- Craggs et al.

• This view projects the radial head anterior to the coronoid process and is especially helpful if full supination and pronation views are difficult to obtain because of acute injury.

• The diagnosis of a partially or completely

displaced fracture of the radial neck may be

difficult in children whose radial head remains

unossified.88

• The only clue may be a little irregularity in the

smoothness of the proximal metaphyseal

margin.

• Displacement of supinator fat or anterior/posterior

humeral fat pad may indicate fracture but not

always.

• MRI is best in these cases.

• Arthrogram, ultrasound, or MRI are helpful to

assess the extent of the displacement and the

accuracy of reduction in children with an

unossified radial epiphysis.

• In the preossification stage, on the AP radiograph, the edge of the metaphysis of

the proximal radius slopes distally on its lateral border.

• This angulation is normal and not a fracture.

• In the AP view, the lateral angulation varies from 0 to 15 degrees, with the average

being 12.5 degrees.

• In the lateral view, the angulation can vary from 10 degrees anterior to 5 degrees

posterior, with the average being 3.5 degrees anterior .

• Radial head fractures can be associated with ligament injuries so MRI should be

considered if displacement occurs in serial radiographs.

xray showing lateral angulation ofproximal radius Arthrogram of same patient showing

displaced radial head

Chambers Classification of Proximal Radial Fractures

Group I: Primary Displacement of the Radial Head

A. Valgus fractures

1. Type A—Salter–Harris type I and II injuries of the proxi-

mal radial physis

2. Type B—Salter–Harris type IV injuries of the proximal

radial physis

3. Type C—Fractures involving only the proximal radial

metaphysis

B. Fractures associate with elbow dislocation

1. Type D—Reduction injuries

2. 2. Type E—Dislocation injuries

Group II: Primary Displacement of the Radial Neck

A. Angular injuries(Monteggia typeIII variant)

B. Torsional injuries

Group III: Stress Injuries

A. Osteochondritis dissecans or osteochondrosis of the radial head

B. Physeal injuries with neck angulation

A: Acute injury films revealing small

displacement of radial head fracture on the

flexed elbow anteroposterior (AP) view and

subtle posterior subluxation not originally

appreciated on the lateral view.

B: Follow-up radiographs at 1 week noted more

difficulty interpreting the AP view in cast, and

more radiocapitellar posterior displacement on

the lateral view.

An MRI scan (C) was ordered urgently

and revealed a marked effusion and intra-

articular displacement of radial head

fracture and posterior radiocapitellar

subluxation.

D: Open reduction internal fixation was

performed to anatomically align the radial

head fracture and reduce the joint.

Angular injuries

Stress Injuries (Group III)

Increasing grade has generally been associated with poorer outcomes with both nonoperative and operative care

PATHOANATOMY AND APPLIED ANATOMY RELATING TO FRACTURES OF

THE PROXIMAL RADIUS

• In the embryo, the proximal radius is well defined by 9 weeks of gestation.

• By 4 years of age, the radial head and neck have the same contours as in an

adult.

• Ossification of the proximal radius epiphysis begins at approximately 5 years of

age as a small, flat nucleus.

• This ossific nucleus can originate as a small sphere or it can be bipartite, which

is a normal variation and should not be misinterpreted as a fracture.

• No ligaments attach directly to the radial neck or head. The radial collateral

ligaments attach to the annular ligament, which originates from the radial side

of the ulna.

• The articular capsule attaches to the proximal third of the neck.

• Thus, only a small portion of the neck lies within the articular capsule.

• Because much of the neck is extracapsular, fractures involving only the neck

may not produce an intra-articular effusion, and the fat pad sign may be

negative with fracture of the radial neck.

TREATMENT• NON-OPERATIVE

• OPERATIVE

Nonoperative Treatment of Fractures of the Proximal Radius

Indications/Contraindications :-

• Nonoperative treatment is indicated for the majority of proximal radius fractures.

• Radial neck angulation of 30 to 45 degrees generally remodels and conservative

treatment will lead to good results.

• It is critical to assess forearm rotation, and if a block to full rotation is appreciated

operative treatment should be considered. Intra- articular aspiration of hematoma and

injection of local anesthetic can assist with pain relief and assessment of range of motion.

• Patients not requiring closed reduction should be immobilized for comfort for a short

period of time to allow for comfort and soft tissue healing.

• This is generally 1 to 3 weeks based on extent of injury and age.

• After fracture pain has subsided patients should work on progressively increasing range

of motion and resumption of activities as symptoms allow.

Closed Reduction Techniques

• Patterson’s manipulative technique.

• Kaufman et al. technique - elbow is manipulated in the flexed position.

• Neher and Torch reduction technique

• The Israeli technique.

• Esmarch bandage wrap technique - as an adjunct to all techniques. Helps in easy reduction.

• Monson technique - proximal fragment should be held by annular ligament. Radius shaft is

reduced.

• Radial neck angulation should be reduced to less than 45 degrees in children under 10 years

of age and less than 30 degrees in children greater than 10 years of age.

• The radiocapitellar joint should be congruent.

• The elbow joint must be stable to stress.

• Early range of motion should be encouraged once the acute pain has resolved, generally

within 1 to 3 weeks.

An assistant uses both thumbs to place a laterally directed force on the proximal radial shaft

while the surgeon applies a varus stress to the elbow. Simultaneously, the surgeon uses his

other thumb to apply a reduction force directly to the radial head

Operative Treatment of Fractures of the Proximal Radius

Indications/Contraindications :-

• Indicated in situations where acceptable alignment cannot be

achieved with closed means, or if there is persistent elbow

instability or restricted range of motion after closed treatment.

• Operative treatment should be considered when :-

A. Displacement remains over 2 mm,

B. angulation is greater than 45 degrees (age < 10) or greater than

30 degrees (age > 10), and for open injuries.

• Nerve palsy is generally not an indication for surgery because

most will recover function over time.

Instrument-Assisted Closed Reduction

Oblique pin insertion

Leverage techniqueLeverage technique of instrument-

assisted closed reduction of the

proximal radius

(A). Intraoperative AP

fluoroscopy image demonstrating

angulated radial neck fracture

(B). K-wire inserted at fracture

site and levering proximal

fragment into a reduced position

(C). Same wire driven through the

opposite cortex to hold reduced

position of the proximal fragment

(D).AP view of elbow following

pin removal in clinic showing

anatomic alignment of proximal

radius fracture.

Wallace technique

Intramedullary Nail Reduction/ Fixation of Proximal Radius Fractures

Mini screw fixation

Plate fixationOpen reduction internal fixation

of a proximal radius fracture

(A). AP radiograph of an 11-

year-old female with elbow

dislocation and radial neck

fracture

(B). Lateral radiograph of the

same patient.

C: Lateral radiograph in splint

after closed reduction showing

persistent radiocapitellar sublux-

ation. Examination under

anesthesia demonstrated very

unstable elbow joint and

therefore decision made to

proceed with open reduction

internal fixation

(D). Lateral radiograph after

open reduction internal fixation

with a fracture-specific plate.

Outcomes

Severity of initial displacement and angulation are the best

predictors of results after treatment. A higher incidence of good

outcomes is found in patients who do not require fracture

manipulation (closed or open) and present with fractures with

minimal angulation and displacement.68,108 For patients having

operative treatment, closed methods generally lead to improved

results compared to open treatments. This is again largely because

of increased severity of fractures requiring open reduction. In

certain cases, however, open treatment is pre- ferred and small

case series demonstrates improved results with open treatment in

appropriately selected patients.

THANKS