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Commentary and Perspective   |    
The Controversy ContinuesCommentary on an article by Ryan M. Zimmerman, MD, et al.: “Surgical Management of Pediatric Radial Neck Fractures”
Roger Cornwall, MD1
1 Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
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Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 16;95(20):e157 1-2. doi: 10.2106/JBJS.M.01063
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Contemporary pediatric fracture textbooks are replete with conflicting recommendations regarding the management of displaced radial neck fractures in children, with the controversy fueled largely by the poor results that often follow open treatment of these fractures. While most authors have recommended using an algorithm progressing from closed to percutaneous to open reduction techniques, the details of management vary widely. Quoting all of the same retrospective studies, different experts have offered different summaries of what to do and when. While 30° of angulation is widely considered an indication for reduction1, some argue that residual angulation of 45° after closed reduction is acceptable2, citing the risks of open reduction. Others, however, urge surgeons to “not hesitate to operate on the displaced fracture and reduce it into an anatomic position” if closed treatment fails3. The definitions of open surgery vary as well, with some authors warning that “open reduction should be avoided if at all possible,”4 and others stating that “whenever possible, internal fixation should be avoided.”2 Is it the open reduction, the internal fixation, or the severity of the fracture that predisposes the patient to a poor result? We are all afraid of radial neck fractures that need surgery, but why? And what should we do with them? These are the questions that Zimmerman et al. attempted to answer in the present study. Do they succeed? Yes and no. This study is an exemplary retrospective review of an injury and its treatments, but it is also an excellent example of the many limitations of this type of research, on which much orthopaedic trauma knowledge is based.
Zimmerman et al. present the results of a retrospective review of 151 pediatric cases treated in the operating room for a displaced radial neck fracture. While this series is the largest of its kind, the patients were treated by twenty-one different surgeons and without a standardized algorithm or approach, as evidenced by the twenty-two different procedural combinations used once the patients reached the operating room. This variety in treatment strategies does not take into account the variation in indications for treating a child in the operating room, a limitation of any retrospective evaluation of a series of operative procedures performed by multiple different surgeons determining the indications for surgical treatment. The fractures were ultimately reduced by one of nine different techniques. The authors correctly point out that this variation in care is the most striking finding of their study.
Modifiable predictors of poor outcome following radial neck fractures also remain unclear. The authors found that an age of ten years or more, greater initial fracture displacement, and a time to surgery of two days or less were predictors of a poor outcome. Readers who do not venture past the abstract might be tempted to delay surgery past two days, modifying the only one of those three variables that they can alter. However, the authors correctly point out in the discussion that the timing of surgery was likely affected by selection bias, as the most severe fractures probably were evaluated sooner, and that “delaying surgery is not advocated.” This reasoning, however, is precisely what prevents any retrospective study from demonstrating a link between open reduction of radial neck fractures and poor outcome. Only the worst fractures undergo open reduction so, once again, is it the fracture or the treatment that leads to a poor outcome? The question is still not clearly answered by even this large series.
Another question that remains unanswered is the effect of final fracture alignment on outcome. Nearly all fractures had osseous union with angulation of ≤30° and translation of ≤25%, making it difficult to stratify functional results on the basis of final fracture alignment. Nonetheless, the authors still reported a 31% rate of unsatisfactory results. Thus, if successful union with acceptable alignment in 98% of patients leads to a satisfactory outcome in only 69%, what other variables are leading to the poor results? Also, the authors developed their own stringent criteria for satisfactory results, based on prior studies outlining definitions for a functional range of motion of the elbow and forearm. However, this system, like radiographic measurements, does not take into account patient-reported functional outcomes, a limitation that the authors highlight. Thus, the relationship between provider-based parameters and the child’s functional outcome remains unclear.
Nonetheless, several important points are demonstrated by this study. First, the maximum initial displacement was more predictive of outcome than the displacement in any one radiographic projection. Radiographic examination of the proximal part of the radius is affected by forearm rotation, and the true angular deformity of a radial neck fracture is not reliably visualized in any particular radiographic plane. True appreciation of the displacement often requires examination under fluoroscopy4. Second, in a large series in which many different techniques were used, the authors did not observe any harmful effect of multiple attempts at closed or percutaneous reduction. This finding allows a high threshold for conversion to an open approach to the radiocapitellar joint. There are a variety of techniques for minimally invasive reduction of radial neck fractures, including “lever” and “push” techniques with a pin at the elbow or intramedullary reduction with use of a retrograde flexible nail. Although the indications for and comfort with these techniques will vary among surgeons, the data reported by Zimmerman et al. suggest that there is little harm in trying them prior to open reduction. Third, although good results of these percutaneous techniques have been reported in cohort studies, in the current study only nine of thirty-one patients definitively treated with either percutaneous pins or retrograde intramedullary nailing had a successful clinical outcome. This finding highlights the important difference between efficacy and effectiveness. The developer of a technique may use the technique very successfully, whereas such success may not be realized when it is applied by a larger number of surgeons. Finally, although the article is entitled “Surgical Management of Pediatric Radial Neck Fractures,” it should be noted that nearly half (42%) of the patients had only closed reduction as their definitive treatment in the operating room. The authors point out that closed reduction in the controlled environment of the operating room may still be successful despite failed attempts at closed reduction in an emergency department setting.
In summary, the authors should be commended for taking a rigorous and candid look at a large number of patients with a problematic fracture. Despite the many questions that remain unanswered, the study adds weight to a growing consensus about progressing from closed to percutaneous to open reduction for radial neck fractures. Indeed, the authors propose an algorithm with just such a reduction ladder, as others have before them. Even though we still do not have all of the answers and many children still have less than optimal outcomes following this type of fracture, it looks as though we are approaching the problem in the right way.
Tibone  JE;  Stoltz  M. Fractures of the radial head and neck in children. J Bone Joint Surg Am.  1981 Jan;63(  1):100-6.
 
Erickson  M;  Frick  S.  Fractures of the proximal radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins' fractures in children. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p 405-45.
 
Green  NE;  Van Zeeland  NL.  Fractures and dislocations about the elbow. In: Green NE, Swiontkowski MF, editors. Skeletal trauma in children. 4th ed. Philadelphia: Saunders; 2009. p 207-82.
 
Frances  JM;  Cornwall  R.  Closed, percutaneous, and open reduction of radial head and neck fractures. In: Wiesel SW, editor. Operative techniques in orthopaedic surgery. Philadelphia: Lippincott Williams & Wilkins; 2011. p 1058-65.
 

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References

Tibone  JE;  Stoltz  M. Fractures of the radial head and neck in children. J Bone Joint Surg Am.  1981 Jan;63(  1):100-6.
 
Erickson  M;  Frick  S.  Fractures of the proximal radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins' fractures in children. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p 405-45.
 
Green  NE;  Van Zeeland  NL.  Fractures and dislocations about the elbow. In: Green NE, Swiontkowski MF, editors. Skeletal trauma in children. 4th ed. Philadelphia: Saunders; 2009. p 207-82.
 
Frances  JM;  Cornwall  R.  Closed, percutaneous, and open reduction of radial head and neck fractures. In: Wiesel SW, editor. Operative techniques in orthopaedic surgery. Philadelphia: Lippincott Williams & Wilkins; 2011. p 1058-65.
 
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