Introduction
Radial neck fracture accounts for 4.5 to 21% of pediatric elbow fractures. Most radial neck fractures are minimally displaced or nondisplaced [
1‐
3]. Elbow fractures often occur as a result of falling onto an outstretched hand with elbow in extension [
4]. The vast majority of radial neck fractures which are undisplaced or minimally displaced, can be treated nonoperatively with good outcomes, especially for young patients with an angulation less than 30° [
2]. Most authors have advocated for closed reduction for fractures with an angulation greater than 30°, although there have been recommendations for closed reduction for angulations ranging from 20° to 45° of the initial angulation [
5]. These fractures are classified according to the O’Brien [
6] and Judet [
7] classification, which have been suggested to be the both effective guides in both treatment and prognosis. Severely angulated fractures (O’Brien type II, III and Judet type III, IV) are rare and require closed or open reduction and internal fixation, which can include several techniques [
8,
9]. Percutaneous leverage reduction and internal fixation techniques for severely displaced radial neck fractures have been further developed since the first description by Feray in 1969 and provide a minimally invasive procedure than other techniques [
10]. Since 1993, closed extracapsular reduction by the Metaizeau technique has gained excellent results but can result in complications such as proximal radial physeal injury, damage of extensor pollicis longus and injury of sensory radial nerve at the insertion site of the pin tail [
4,
11‐
13].. This article is a retrospective study of our experience treating radial neck fractures (O’Brien type II, III and Judet type III, IV) using a modified percutaneous leverage technique and radial intramedullary fixation.
Discussion
The management of obviously displaced radial neck fractures in children remains a challenge in pediatric orthopedics. There is a general agreement that conservatively treated moderate and severe displaced radial neck fractures with an angulation > 30° can result in a decreased range of motion (ROM) and increase the risk of avascular necrosis [
10,
14‐
16]. A series of surgical procedures have been reported, including percutaneous or intramedullary fixation and open or closed reduction. Open procedure has been conventionally recommended for unsuccessful closed manipulation in this kind of fractures but leads to bad outcomes [
1,
14,
17]. Close reduction achieves better clinical results than open procedure. In severely angulated radial neck fractures, closed reduction alone without fixation has unpredictable results ranging from inability to achieve complete reduction to even loss of reduction inside the plaster [
18,
19].
In 1993, Metaizeau et al. reported intramedullary nailing as a surgical option for the treatment of displaced radial neck fractures [
4]. The main superiority of intramedullary fixation is that it simultaneously allows for accurate and stable reduction without disturbing the blood supply [
20]. However, this treatment must be performed carefully to protect the superficial branch of the radial nerve and the radial physis [
21]. Intramedullary nailing has acceptable indirect reduction and preserves the lateral periosteum and the epiphyseal vascular supply; both of these are associated with internal fixation, which prevents displacement before fracture healing [
22]. Moreover, several authors have reported excellent results with percutaneous K-wire manipulation; however, they still recommended that this technique may not be used for radial neck fractures with major translocation [
10,
17,
23‐
26].
A research compared the results in patients with severely displaced radial neck fractures treated with ESIN and percutaneous pinning techniques. Both methods achieved excellent results. However, the ESIN technique seems to be the better approach [
22]. In our study, there was no complications such as nonunion, growth arrest in the proximal radial epiphysis, radioulnar synostosis, iatrogenic nerve injury and periarticular ossification and asymptomatic enlargements of the radial head. The minor complication of inadvertent radial head inversion during closed reduction reported by Sirois [
27] wasn’t represented in our cases.
From our cases, one 1.5 years old child with a displaced fracture of radial neck (O’Brien type II and Judet type III) may be difficult to monitor the reduction for the unossified radial neck, the only clue was irregularity in the smoothness of proximal metaphyseal margin. During closed reduction, the metaphyseal margin leads the leverage under fluoroscopy. The use of arthrogram and ultrasonography to assess the extent of displacement and the accuracy of reduction would be good choices in children with unossified radial head [
28,
29]. According to Salter-Harris (SH) classification two groups were composed as follow: group A 15(62.5%) SH- type I or II and group B 9 (375%) total metaphyseal fracture [
30]. The different type of fractures did not affect the duration time of reduction procedures significantly (group A mean 0.24 min vs group B mean 0.30 min,
p > 0.05).
In our study, most of the duration time of reduction procedures were performed within 0.29 min by 2–3 attempts of leverage, but 2 cases (O’Brien type III and Judet type IVb, angulation = 90°) required an especially long time to manage the leverage reduction. The initial unsuccessful K-wire leverage occurred when the proximal fracture portion moved dorsally and ventrally after several manipulations. However, our additional maneuver provided a second chance for the initially unsuccessful K-wire leverage to avoid open reduction. The ratio of open reduction of severely displaced radial neck fractures was ranged from 6.2 to 38.5% reported before [
7,
11,
17], but in our cases we achieved 100% closed reduction. Even for the 2 initial leverage failed cases, with the introduction of our additional maneuver, closed reductions managed. Our experience will be the excellent supplement of closed reduction maneuver of this kind of fractures.
Generally, higher closed reduction rates are associated with more radiation exposure (RE). RE is associated with leukemia, solid organ and thyroid cancer [
31]. The risk of RE need to be understood and minimized in pediatric trauma theatres. Recent studies of RE in elbow fracture of children reported that the mean DAP (dose area product) were ranged from 22.3 to 87.41 mGy/cm2. The lower screening times and RE was found in procedures performed by consultant and senior register [
32,
33]. One study documented that the equivalent dose to the thyroid and gonads of patients was minimal and approximates daily background radiation with lead shield during operative fixation of pediatric supracondylar humerus [
34]. Ultrasonography (US) has also been reported using intraoperative guidance for the reduction of radial neck fractures in children. The use of US can identify the pin for reduction and constantly monitor the reduction in multiple planes. However, US can identify only the near cortex of bone [
28]. From our own experience, we recommend the limits to fluoroscopy time by several methods: (1) Avoiding repeated or redundant images; (2) These procedures should either be operated or be supervised by senior surgeons; (3) Surgeons should be familiar with the anatomic landmarks and palpation of fractures to minimize the using of C-arm intensifier.
In previous studies, most surgeons agreed that closed reduction might fail in severely displaced fractures [
1,
20,
21]. However, few of those authors analyzed why the closed reduction failed and how closed reduction can be achieved for the failed cases. Nitin Bither et al. recommended the presence of a periosteal hinge as an obvious marker of success in closed reduction [
24]. When we reviewed the unsuccessful procedures, we hypothesized that the integrity of the lateral periosteal hinge and elbow capsule is the anatomic basis of a successful closed reduction, especially in O’Brien type III and Judet type IVb fractures with angulation = 90°and severe edema for which the initial percutaneous leverage failed.
We preferred the percutaneous K-wire leverage to the Metaizeau method for two reasons. First, our reduction maneuver minimize iatrogenic insults to the fragile proximal radius. The potential insults are cumulative trauma from repeated failed manipulation reductions [
2,
9]. Higher fracture angulation and increased displacement (more severe O’Brien type and Judet type) were associated with more invasive interventions in the cases reported by Zimmerman et al. [
35]. Second, the radial neck is vascularized by the branches of the radial recurrent artery and the branch ulnaris of the ulnar artery [
36]. The protection of these two artery structures is critical to fracture healing. During the reduction procedure in the Metaizeau method, the rotation of the periosteal hinge may tear the residual proximal radius to damage the blood supply, which is critical to fracture healing. While passing the 2.0 mm K-wire through the fracture, the surgeon must be careful not to resist resistance to protect the annular ligament [
25]. Percutaneous K-wire manipulation may lead to damage to the physis. However, in our study, we did not observe any damage when the lever arm technique was used. We also performed the technique carefully to avoid injury to the sensory branch of the radial nerve and distal radial physis.
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