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Scientific Articles   |    
Surgical Management of Pediatric Radial Neck Fractures
Ryan M. Zimmerman, MD1; Leslie A. Kalish, ScD2; M. Timothy Hresko, MD3; Peter M. Waters, MD3; Donald S. Bae, MD4
1 Massachusetts General Hospital, 55 Fruit Street, WHT 535, Boston, MA 02114
2 Clinical Research Center, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA 02115
3 Boston Children’s Hospital, Orthopedic Center, 300 Longwood Avenue, Fegan 2, Boston, MA 02115
4 Boston Children’s Hospital, Orthopedic Center, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: Donald.Bae@childrens.harvard.edu
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Investigation performed at the Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts

A commentary by Roger Cornwall, MD, is linked to the online version of this article at jbjs.org.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 16;95(20):1825-1832. doi: 10.2106/JBJS.L.01130
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Abstract

Background: 

Management of pediatric radial neck fractures is controversial regarding acceptable alignment, variable reduction techniques, and suboptimal outcomes. The purpose of this study was to assess the characteristics, management, and results in a surgical cohort, in efforts to identify prognostic factors and offer treatment suggestions. It was hypothesized that less invasive reduction maneuvers would precede open reduction and that worse results would correlate with fracture severity, open reduction, and the presence of associated injuries.

Methods: 

Retrospective analysis of 151 children in whom a radial neck fracture had been surgically treated from 2001 to 2011 was performed. The mean age (and standard deviation) and duration of follow-up were 8.4 ± 2.9 years and 13.3 ± 20.0 months, respectively; 40% of the patients were male. A successful clinical result was defined as elbow flexion of ≥120°, flexion contracture of <20°, forearm rotation of ≥90° with ≥45° of supination and pronation, and no complications.

Results: 

An isolated radial neck fracture occurred in 54% of the children. The mean angulation and displacement improved from 43° ± 19° and 37% ± 35%, respectively, before treatment to 13° ± 7° and 0.9% ± 4% after treatment (p < 0.001). Twenty-two procedural combinations were used to treat these patients, and 67% of the open reductions were not preceded by percutaneous or closed reduction attempts. Among 131 patients with adequate follow-up, 31% had an unsuccessful outcome. An age of ten years or more (odds ratio [OR] = 5.85, p = 0.001), a time to surgery of two days or less (OR = 4.73, p = 0.02), and greater fracture displacement (OR = 1.25 per 10%, p = 0.001) were independent predictors of unsuccessful outcomes. Increased fracture severity and open reduction were associated with poor results, although the presence of concomitant injuries was not. It is predicted that closed manipulation will fail for half of fractures angulated ≥36°, and that half of fractures displaced ≥65% will require open reduction. The predicted frequency of unsuccessful outcomes is 50% with 76% displacement.

Conclusions: 

There continues to be great variation in the approach to treatment of displaced radial neck fractures in children. Suboptimal results occurred in 31% of the patients in this series, with worse results in patients older than ten years, who had increased fracture severity, and who underwent open reduction. Less invasive reduction methods should precede open reduction whenever possible.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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