Courtesy: Dr PN Gupta, Govt Medical College, Chandigarh

 

Radial Neck Fractures in Children

Treatment Options

• Closed reduction.
• Percutaneous reduction and fixation.
• Intramedullary reduction and fixation (Metaizeau technique).
• Open reduction as the final option.

Principles of Closed Reduction

• Most radial neck fractures are displaced posterolaterally.
• Apply varus stress at the elbow.
• Apply thumb pressure over the radial head.
• Successful reduction depends on preservation of the periosteal hinge.

Intramedullary Pinning (Metaizeau Technique)

Principle

• Flexible intramedullary nail is inserted through the distal radius.
• Nail is advanced to the radial head fragment.
• Rotation of the nail reduces the fracture.
• Considered the gold standard technique.

Limitation

• Fractures angulated more than 40 to 45 degrees may not allow the nail to engage the radial head fragment.
• Reduction should be achieved before advancing the intramedullary nail.

Techniques to Facilitate Reduction

Joystick technique

• Insert a blunt K wire into the radial head fragment.
• Manipulate the fragment using the K wire as a joystick.
• Perform intramedullary fixation after satisfactory reduction.

Leverage technique

• Insert a K wire into the fracture site.
• Use the wire as a lever to elevate the radial head onto the shaft.
• Stabilize with an intramedullary nail or K wire.

Modified intramedullary K wire technique

• Useful in small children with a narrow radial canal.
• Use a K wire with a 15 degree bend at the tip.
• Create the canal using a blunt wire.
• Advance the bent sharp K wire into the radial head fragment.

Pitfalls

• Avoid repeated attempts at closed reduction when the radial head is completely displaced.
• Fractures without a periosteal hinge are unlikely to reduce closed.
• These injuries usually require open reduction.

Procedures to Avoid

• Avoid transcapitellar pinning.
• It increases the risk of physeal injury.
• It may damage the articular cartilage.
• It is associated with postoperative elbow stiffness.

Additional Fixation

• Supplementary K wires may be required if instability persists after intramedullary fixation.
• Additional fixation is particularly useful when the radial head fragment is small or lacks metaphyseal support.

Key Takeaways

• Most pediatric radial neck fractures displace posterolaterally.
• Achieve fracture reduction before intramedullary pinning whenever possible.
• Metaizeau intramedullary pinning remains the gold standard technique.
• Joystick and leverage techniques are valuable when reduction is difficult.
• Avoid transcapitellar pinning because of the high complication rate.
• Reserve open reduction for fractures that cannot be managed by closed or percutaneous techniques.