Radial Head & Neck Fractures In Children

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

GENERAL OVERVIEW

• Radial head and radial neck fractures in children are uncommon injuries.

• These fractures typically occur around 9 years of age.

• The usual mechanism of injury is a valgus force applied to the elbow.

• Fractures may involve:

  • The physis (growth plate) of the radial head

  • The metaphysis of the radial neck

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TYPES OF FRACTURES

Radial head and neck fractures may be:

• Non-displaced

• Displaced

• Tilted

• Translocated

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OSSIFICATION CENTERS OF THE ELBOW (CRITOE)

Knowledge of ossification centers is essential to avoid misdiagnosis.

• 1 year: Capitellum

• 3 years: Radial head

• 5 years: Internal (medial) epicondyle

• 7 years: Trochlea

• 9 years: Olecranon

• 11 years: External (lateral) epicondyle

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RADIOLOGICAL EVALUATION

Plain Radiographs

• Anteroposterior view

• Lateral view

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Radiocapitellar (Greenspan) View

• An oblique lateral view

• Elbow flexed to 90 degrees

• Thumb pointing upward

• X-ray beam directed at 45 degrees

• Useful for visualizing subtle radial head and neck injuries

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Computed Tomography

• Used selectively

• Helpful in complex or unclear fractures

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IMPORTANT RADIOLOGICAL SIGNS

Fat Pad Sign

• Non-displaced radial head fractures may not be visible on initial radiographs.

• Presence of a posterior fat pad is abnormal and indicates an occult fracture.

Radial Neck Fractures

• Partially extra-articular.

• Fat pad sign may be absent, even in the presence of a fracture.

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TREATMENT PRINCIPLES

Non-Displaced Fractures

• Managed with immobilization.

• Immobilization is acceptable when angulation is less than 30 degrees.

• Angulation up to 30 degrees is generally well tolerated in children.

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Displaced Fractures

Closed Reduction

• Indicated when angulation is greater than 30 degrees.

• Reduction techniques include:

  • Elastic bandage wrapped around the forearm and elbow

  • Elbow extension with traction

  • Supination and varus force

  • Direct pressure over the radial head to push it medially

  • Lateral displacement of the radial shaft

• After reduction, the radial head often remains stable due to the intact periosteum.

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Percutaneous Reduction

• A Kirschner wire may be used as a joystick for manipulation.

• Useful when closed manipulation alone is insufficient.

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Open Reduction

• Reserved for cases where:

  • Closed and percutaneous reduction fail

  • Residual angulation remains greater than 45 degrees

• Should be avoided when possible due to higher complication rates.

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COMPLICATIONS

• Radioulnar synostosis

• Loss of elbow motion, particularly forearm rotation

• Osteonecrosis of the radial head

• Non-union or malunion

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KEY POINTS

• Most pediatric radial neck fractures can be managed non-operatively.

• Accurate assessment of angulation is critical.

• Gentle reduction techniques reduce the risk of complications.

• Open reduction should be the last resort.

• Early mobilization after healing helps restore motion.