Fractures of the proximal radius in children: management and results of 100 consecutive cases

Abstract

Introduction: Pediatric radial neck and head fractures are rare, accounting for only 1% of all fractures in children. The aim of this study is to describe the management and results of the respective fracture types and different injury characteristics.

Materials and methods: This study performs a retrospective data analysis of 100 consecutive patients with a fracture of the proximal radius treated in a single high-volume pediatric trauma center.

Results: One hundred patients [mean age 7.5 years (1-15)] were documented with a fracture of the proximal radius between 3/2011 and 12/2019. The gender distribution was 62 girls and 38 boys. Twenty-seven patients had concomitant injuries. Conservative treatment was performed in 63 patients (Judet I = 27; II = 30; III = 6; Mason I = 2) using an above-the-elbow cast for 21 days (6-35). Surgical treatment was performed in 37 patients (Judet II = 3; III = 22; IV = 5; V = 7) using elastic stable intramedullary nailing (ESIN). Open reduction was necessary in five cases, and additional immobilization was performed in 32 cases. Six complications occurred: loss of implant stability (n = 2), healing in malalignment, pseudarthrosis, radioulnar synostosis, and a persisting hypoesthesia at the thumb. As a result, two ESIN osteosynthesis were revised, and one radial head resection was performed. Loss of movement was seen in 11% of cases, overall Mayo elbow performance index (MEPI) was 99.8 (90-100), and none of the patients experienced negative impacts on activities of daily life.

Conclusions: Proximal radial fractures occur predominately without dislocation. Good results are obtained with conservative treatment throughout. In cases with displacement exceeding growth-related correction, ESIN is the undisputed treatment of choice. Open surgery and long immobilization periods should be avoided whenever possible.

Keywords: ESIN; Elastic stable intramedullary nailing; Pediatric trauma; Proximal radius fracture; Pseudarthrosis; Radial neck fracture.

Fig. 1

Different types of proximal radius fractures representative for different dimensions of stability, courses and prognosis. Stable buckle fracture of the radial neck (→ arrow) in a 4-year-old girl (a). Salter–Harris II fracture of the radial neck with the risk of further dislocation (b). Complete dislocation of a metaphyseal radial neck fracture in a 12-year-old boy with elbow dislocation, presenting the worst prognosis due to the complete disruption of the nutritive vessels possibly resulting in total or partial necrosis or pseudarthrosis (c). Intraarticular fracture of the radial head representing an adulthood fracture in a 15-year-old adolescent boy with closed physis (d)

Fig. 2

Complete fracture of the metaphyseal radial neck and proximal ulna shaft fracture in a 5-year-old boy treated with ESIN (a). The postoperative control showed axial alignment of both fractures (b). Consolidation was documented after four weeks, but the radial implant showed evidently missing the radial head, which represents a technical complication that should not have been overlooked intraoperatively (c). Due to the consolidation process and to not further damage the blood supply, we refrained from a nail revision and the nail was removed consecutively (d). Following this, pseudarthrosis seemed to develop, but complete consolidation (e) and remodeling were observed after 11 months (f), and 2 years (g). In this age group, an enormous potential for growth-related correction exists, however, it should never be overestimated

Fig. 3

Completely displaced proximal radial fracture in a seven-year-old girl (a, b). Open reduction and stabilization were performed using two ESIN implants to provide maximal stability to the radial head, which healed even though having been totally deperiostized (c, d)

Fig. 4

ESIN osteosynthesis in an eight-year-old boy with a Salter–Harris II radial neck fracture (a, b). A sharpened 2.0 mm titanium nail was used for closed reduction and an additional intraarticular olecranon fracture was treated using a 4.0 mm lag screw to allow early elbow mobilization (c, d)