MANAGEMENT OF RADIAL NECK FRACTURES IN CHILDREN AND ADOLESCENTS. A RETROSPECTIVE ANALYSIS OF SELECTE by International Educational Scientific Research Journal

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

MANAGEMENT OF RADIAL NECK FRACTURES IN CHILDREN AND ADOLESCENTS. A RETROSPECTIVE ANALYSIS OF SELECTED METHODS OF TREATMENT. SLAWOMIRKIEPURA, M.D, ABCDEF 1 | PROF. JULIAN DUTKA, PH.D., ADE 2 | MARIA WIECZOREK-GROHMAN,PH.D. D,F 3 1 PEDIATRIC

SURGERY DEPARTMENT OF SPECIALISTIC HOSPITAL ZEROMSKI IN KRAKOW, POLAND. (STUDY DESIGN A) (DATA COLLECTION B) (STATISTICAL ANALYSIS C) (DATA INTERPRETATION D) (MANUSCRIPT PREPARATION E) (LITERATURE SEARCH F). 2 ORTHOPEDIC AND TRAUMATOLOGY SURGERY DEPARTMENT OF SPECIALISTIC HOSPITAL ZEROMSKI IN KRAKOW, POLAND. (STUDY DESIGN A) (DATA INTERPRETATION D) (MANUSCRIPT PREPARATION E). 3 PEDIATRIC SURGERY DEPARTMENT OF SPECJALISTIC HOSPITAL ZEROMSKI IN KRAKOW, POLAND. (DATA INTERPRETATION D) (LITERATURE SEARCH F). ABSTRACT Objective: To compare outcome of different treatment methods according to fracture type in a retrospective study of results of treatment of radial neck fractures in children. Material and methods: In this retrospective analysis we present results of 17 children treated for radial neck fracture. There were 11 boys and 6 girls in the average age of 9.8 years (6.3 – 15). Follow up period amounted 6 – 48 months. Presence of growth plate and radio logically confirmed radial neck fracture type II – IV were including criteria for the study. Treatment results assessment was based on Mayo Elbow Score and radiological criteria of bone union. Results: In the analyzed material good and very good results were achieved in group II and III , fair results were achieved in group IV. There were no failures of treatment. Conclusion: Review of clinical and radiological results of these uncommon fractures indicate that very good and good results can be achieved in conservative and closed surgical methods. In open surgery results are inferior. Keywords:

Background

Fracture of the radial head comprises 5-10% of elbow fractures in children and 1% of all pediatric fractures. It may result in deformity, limitation of movement and functional impairment of the elbow joint. Radial neck fractures are more common than radial head fractures in this age. Other injuries like medial epicondyle avulsion fracture, lateral condyle fracture, medial collateral ligament tear and olecranon fracture may be present. Fracture occurs due to fall on outstretched upper limb with elbow in valgus or in elbow dislocation when radial head impacts against the capitellum. Judet classification of radial neck fracture is based on angular or percentage displacement of the neck against the radial shaft (table 1).

Treatment of radial neck fractures in children depends on age of the patient, angular displacement and contact of fragments. In most of the cases fracture is either undisplaced or with minimal displacement (type I, II Judet). In this case conservative treatment using above elbow cast is recommended.

Table 1. Classification Of Cervical Fractures Of The Radius Depending On Lateral And Angular Displacement According To Judet. Degre e

Lateral translocation (%)

Angular translocation (°)

0 – 10

0 – 30

11 – 50

31 - 60

III

51 - 90

61 - 90

> 90

In fractures with angular displacement exceeding 30 deg ( type III, IV Judet) surgical treatment is necessary using percutaneous K wire fixation, intramedullary fixation using titanium elastin nails ( Metaiseau technique) and open reduction and internal fixation if closed methods are unsuccessful. In segmental fractures or concomitant elbow fractures open intervention is also indicated. Open reduction, however, may result in complications reported in the literature including growth arrest with subsequent axial deformity of the forearm, avascular necrosis of the radial head due to blood supply interruption and ectopic ossification with limitation of elbow mobility. In our study we present retrospective analysis of clinical and radiological results of treatment of radial neck fractures in children using various methods of stabilization including Metaizeau method with intramedullary fixation of fracture with K wire later modified be elastic titanium

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

nail. In this method implant was introduced from distal metaphyseal area [1, 2].

Material and methods In the Department of Pediatric Surgery of Specialized Stefan Zeromski Memorial Hospital in Cracow, one of the two care providing centers to nearly 800 000 population of Cracow urban agglomeration, between 2010 and 2014, 4764 children were hospitalized. There were 597 (12%) cases of upper limb fractures and dislocations and among them there were 19 (3%) cases of radial neck fracture. 17 patients appeared for the follow- up examination and are subject of this study. Including criteria were radiologically confirmed radial neck fracture type II – IV and presence of epiphyseal growth plate. Among 17 patients there were 11 ( 64%) boys and 6 ( 36%) girls in the average age of 9,8 (6.2 – 15) years. Dominant limb was affected in 14 cases (82%). Surgical treatment was necessary in 4 (24%) cases of type II fracture in 5 (29%) of type III and in 8 (47%) cases of type IV fracture respectively. Average follow up period amounted 14 ( 6-48) months. Available medical documentation including clinical and radiological data, age, gender, type of fracture according to Judet classification, clinical and functional result measured by Mayo score and assessment of bone union were analyzed. Material was divided according to type of treatment into 4 groups ie. : plaster immobilization, closed reduction and percutaneous K wire fixation, Metaizeau technique and open reduction and internal fixation with K wires. Results were calculated using MedCalc for Windows software. Table 4 presents above mentioned data. Treatment decisions were based on clinical and radiological picture including mechanism of injury and radiological picture of forearm wrist and elbow. Patients qualified for surgical treatment that necessitated general anesthesia were admitted for 2-3 days. Among surgical techniques that of Metaizeau was worth detailed description. It consisted of insertion of K wire diameter 1.4 – 1.8 mm that was bent proximally about 30 dgr and introduced from distal radial metaphyseal area above 1-2 cm proximal to growth plate to the medullary cavity. Then after reaching fracture line the wire was rotated to achieve fracture reduction pointing ulna [3,4]. In case of significant angular displacement above 60 deg additional K wire from lateral side is inserted to the radial head and manipulated to allow passage of the intramedullary wire across the fracture. Above elbow plaster slab or cast was applied and patient was followed up at 7 and 21 days. Plaster was removed when radiological signs of progressive union were present, but not more than 4 weeks from surgery. At three weeks postop plaster was shortened below elbow to allow joint movements. K wires were removed in out patient visit at 4-5 weeks postop. In the follow up examination clinical assessment was based on Mayo Elbow Performance Score that included: pain, range of movement, stability and function. 90-100 points equaled very good result and 75 – 90 as good, 60 – 74 as fair and below 60 as bad, respectively [table 2].

Table 2. Functional Mayo scale for the elbow joint. Feature

Point s

Pain

ROM

Brak

Niewielkie

Srednie

duże

Zakres ruchu łuku >100°

Joint stability

Activity

Zakres ruchu o łuku 50-100°

Zakres ruchu o łuku<50°

Staw stabilny

Nieznacznie niestabilny

Niestabilny

Samodzielne włosów

czesanie

Samodzielne spożywanie posiłów

Samodzielne czynności higieniczne

Samodzielne się

ubieranie

Samodzielne zakładanie obuwia

Radiological assessment included residual angular deformity, union disturbance and avascular necrosis [table 3].

Table 3. The assessment of therapeutic outcomes based on the results of physical and X-ray examinations. Physical examination

Plain film

Excell ent

No pain, full ROM

Anatomical reduction

Good

No pain, restriction in ROM less<20deg

Nearly anatomical reduction, translocation <20 deg

Fair

Pain and/or restriction in ROM 20-40 deg

Translocation 20-40 deg

Poor

Pain and/or restriction in ROM >40 deg

Translocation >40 deg deg

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

Results Out of the 19 patients, 17 reported to the post-treatment follow-up, including 8 boys (62%) and 6 girls (38%). Demographic data, gender, type of fracture and therapeutic outcome are presented in Table 1. The analyzed group included children aged 6.5-15 years (average age 9.8 years). The follow-up period ranged from 6 to 48 months (with an average of 14 months). The fractures mostly concerned the dominant limb 14 (82%). (Pic1 and Pic 2).

on the results of clinical examinations and the functional Mayo scale for the elbow joint, showed very good results in 4 patients treated with cast immobilization only (100%), in 4 children treated with K-wire percutaneous stabilization (80%) and in 1 child required open reduction and Metaiseau stabilization (20%). Excellent results were not observed in the group treated with open reduction and K-wire fixation. The results of treatment with division into distinguished groups of children are summarized in Table 2. The fair results involved children with Judetâ&#x20AC;&#x2122;s type IV fracture with a significant degree of radial head displacement. A radiographic follow-up examination revealed healing of all fractures with very good (anatomical) or good positioning of the fragments in 14 (82%) and 3 (18%) children, respectively. The quantitative and percentage distribution of the results is presented in Table 2. Patients treated with closed methods received a better range of flexion, extension and pronation than children treated with open reduction. Data are collected in Tables 3 and 4.

(Pic.1)

(Pic.2)

(Pic.1 A pre-op plain film of elbow joint. AP view.) (Pic 2. A pre-op plain film of elbow joint. Lateral view.) Most treatments involved type II fracture - 6 children (%), type III - 5 children (%), type 4 (%). These data are shown in Table 1. The analysis of the results of the clinical and radiological examinations showed very good in 6 children (35%), good in 8 children (47%), fair in 3 children (18%). The study material did not include poor results, and the fair results were related to the treatment of Judet's type IV fractures by open reduction and intramedullary fixation with Kirschner wires. (Pic3 and Pic 4)

(Pic.3)

Table 4. Demographic data, gender, type of fracture, therapeutic outcome and follow-up time. Ag e (i n ye ars )

sex

Type of fracture according to Judet

Treatmen t

Results accordi ng to Mayo scale

Observa tion ( in years)

6,2

Immobilis ation alone

Bardzo dobry

2,7

7,0

III

K wire stabilisati on

Bardzo dobry

1,8

7,2

III

Metaiseau technique

dobry

7,8

Metaiseau technique

dobry

3,6

8,2

K wire stabilisati on

dobry

3,0

9,0

Immobilis ation alone

Bardzo dobry

1,5

9,3

Immobilis ation alone

Bardzo dobry

2,1

(Pic.4)

(Pic 3. A post-op plain film of elbow joint- AP view) (Pic.4. A post-op plain film of elbow joint. Lateral view.) The analysis of the distinguished groups, which was based

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

10, 7

Otwarte nastawien ie +Metaisea u

średni

3,2

11, 6

III

K wire stabilisati on

dobry

2,4

12, 0

Metaiseau

Bardzo dobry

4,0

12, 9

III

K wire stabilisati on

dobry

1,2

12, 5

Metaiseau

dobry

3,3

13, 2

Immobilis ation alone

Bardzo dobry

2,9

13, 4

K wire stabilisati on

dobry

1,3

13. 6

Open raduction and K wire stabilisati on

średni

4,0

14, 6

III

Open reduction and K wire stabilisati on

średni

3,1

15. 0

Metaiseau

dobry

0,9

None of the treated children suffered from a problem with the union of the fractured bone, avascular necrosis, extra-skeletal ossification, cross-union between the radius and ulna or vascular-nervous disorders. One patient, an 8-year-old boy, treated with open reduction and K-wire stabilization, manifested in long-term observation radial head hypertrophy limiting rotation movements of the forearm. It is characteristic that with age the incidence of fractures with a greater degree of displacement (type III and IV according to Judet) increases.

Discussion Fracture of the radial neck not uncommonly associated with other elbow injuries is difficult to treat and may result significant functional injury, however, may result in significant impairment of elbow joint function. In the discussed material fracture of the radial neck was found in 3% of patients hospitalized for upper limb trauma,

similarly to other reports by Kruppa and Ugutman [6, 7]. With increasing age of patients incidence of fractures with higher degree of displacement (Judet III and IV) is also increasing. In presented material male patients (62%) and right side prevailed reflecting higher activity and participation in sports [8, 9, 10]. Surgical treatment most commonly was used in fracture type IV (47%) and less commonly in type III (29%) and type II (24%). Our findings are similar to other authors i.e. that fractures with angular displacement above 30 dgr (type III, IV) most commonly need surgery [9, 11]. In all our children with type II treated with plaster immobilization alone we achieved very good results. In percutaneous fixation with K wires used in fractures type III and IV very good and good results were achieved in 75% and 25% respectively. In type IV fractures with significant displacement selected for Metaizeau technique 25% of cases resulted in very good outcome and in 50 % results were good and in 25% results were fair. In fractures type IV in which closed reduction failed and open reduction with K wire fixation was used results were inferior to other discussed groups and it was similar to other published studies [6,9,16]. Therefore indications to this mode of treatment were limited to 4 cases only due to fear of complications. Following contemporary opinions, closed reduction followed by plaster of Paris immobilization of the forearm is the treatment of choice for uncomplicated fractures with angular displacement less than 30 dgr in children below age of 10 years, and with angular displacement less than 15 dgr in children above 10 years old [9]. According to opinions presented in the bibliography final result of treatment depends much more on the type of treatment used than on the type of fracture i.e. it is better to accept some displacement of the radial head and avoid open reduction that may affect blood supply of the radial head and cause its avascular necrosis [11, 14]. Few reports on comparative studies on treatment methods of radial neck fracture are available. According to polish and international study results closed methods of treatment give better results as compared with open methods. In our experience both, closed reduction and K wire fixation as well as intramedullary technique of Metaiseau give good and very good long term results together with good shape and function of elbow. Tarallo etal. found better results of Metaiseau method as compared with percutaneous K wire fixation in terms of range of movement ( flexion/ext, pro/supination) [9]. In one retrospective study of 100 cases, good and very good results were found in 99 % of cases treated with closed methods as compared with only 55 % of good and very good results in patients treated by open reduction [14,15]. In case of secondary displacement or failure to achieve reduction a method of percutaneous fixation with K wires presented in 1969 by Feray can be used. Good results were achieved in 75 – 94% by using this method [5,13]. Possible complications like: avascular necrosis of the radial head, premature closure of epiphyseal plate with

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

bone shortening, valgus elbow deformity, ectopic ossification with radioulnar synosthosis, deformity with overgrowth of the radial head and joint fibrosis with stiffness have been widely reported in the literature [ 16,17]. In our material no such complications were found except one 8 year’s old boy who have been treated by open reduction and fixation by K wire with release of soft tissues incarcerated in the fracture line. It resulted in hypertrophy of the radial head with limitation of rotational movements of the forearm.

Table 5. The results of treatment depending on the type of therapy. Clinical results Treatment / Results

Excel lent

Goo d

N(%) N(% )

Radiographic results Fair N(% )

Poo r N(% )

Anatom ical reductio n

Goo d red ucti on

N(%) N(% )

Table 6. Mayo scores by the treatment method. Differences in elbow ROM of injured and uninjured limb extensi on

flexion

pronat ion

supina tion

Immobilisati on alone

0+/-0

2,0+/-1 ,2

0+/-0

93,5

K wire stabilisation

0,5+/-0 ,5

13,5+/12

3,1+/2,8

2,1+/2

91,4

Metaiseau technique

1,8+/-2 ,0

6,8+/-8 ,5

4,3+/1,5

4,7+/2,5

91,8

Open raduction and K wire stabilisation

2,0+/-2

32,3+/22,5

16,4+/ -11

12,3+/ -4

90,2

Table 7. Flexion and extension obtained after therapy by the treatment method. Elbow ROM Extremity

Immobilisa tion alone Typ II (N=4)

4(10 0)

4(100)

Flexion (°)

Extension(°)

Inju red

Uninjur ed

Injure d

Uninjure d

150

Immobilisa tion alone Typ II

K wire stabilisatio n

Typ III (N=3)

3(10 0)

3(100)

Typ III

1+/-1

1(50 )

1(5 0)

1(50)

1(5 0)

148 +/-5

150

Typ IV (N=2)

Typ IV

146 +/-7

150+/4

1+/-1

Metaiseau technique Typ III

141 +/-2

152+/2

1+/-2

Typ IV

139 +/-6

151+/4

2+/-2

128 +/-5

151+/5

1+/-1

Metaiseau technique Typ III (N=1)

Typ IV (N=4)

1(25 )

1(1 00)

2(5 0)

1(25 )

1(100) 3(75)

1(2 5)

Open raduction and K wire stabilisatio n Typ IV (N=3)

1(2 5)

2(75 )

2(67)

1(3 3)

Mean Mayo score

Open raduction and K wire stabilisatio n Typ IV

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL

Research Paper

E-ISSN NO : 2455-295X | VOLUME : 3 | ISSUE : 8 | AUG 2017

Table 8. Pronation and supination achieved after therapy by the treatment method. Elbow ROM Extremity

Pronation (°) Injure d

Uninjured

Supination (°) Injure d

Uninjured

Immobilisation alone Typ IIK wire stabilisation

K wire stabilisation

M. Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients. Injury. 2015 Oct; 46 Suppl 4:S10-6. 7. Ugutmen E, Ozkan K, Ozkan FU, Eceviz E, Altintas F, Unay K. Reduction and fixation of radius neck fractures in children with intramedullary pin. J Pediatr Orthop B. 2010 Jul; 19(4):289-93. 8. Bryan Hsi Ming Tan, Arjandas Mahadev. Radial neck fractures in children, Journal of Orthopaedic Surgery 2011; 19(2): 209-12 9. Tarallo L, Mugnai R, Fiacchi F, Capra F, Catani F. Management of displaced radial neck fractures in children: percutaneous pinning vs. elastic stable intramedullary nailing. J Orthop Traumatol. 2013 Dec;14(4):291-7.

Typ III

85+/2

Typ IV

86+/4

85+/-3

86+/1

86+/-3

10. Eberl R, Singer G, Fruhmann J, Saxena A, Hoellwarth ME. Intramedullary nailing for the treatment of dislocated pediatric radial neck fractures. Eur J Pediatr Surg. 2010 Jul;20(4):250-2.

Typ III

85+/3

86+/-4

84+/2

85+/-3

Typ IV

85+/2

86+/-2

82+/3

83+/-4

11. Kaiser M, Eberl R, Castellani C, Kraus T, Till H, Singer G. Judet type-IV radial neck fractures in children: Comparison of the outcome of fractures with and without bony contact. Acta Orthop. 2016 Oct;87(5):529-32.

85+/-3

REFERENCES

12. Gutiérrez-de la Iglesia D, Pérez-López LM, Cabrera-González M, Knörr-Giménez J. Surgical Techniques for Displaced Radial Neck Fractures: Predictive Factors of Functional Results.J Pediatr Orthop. 2017 Apr/May;37(3):159-165.

1. Metaizau J.P. i wsp. Reduction and fixation of displaced radial neck fractures by closed intramedullary spinning. J Pediatr Orthop 13: 355, 1993.

13. Choi WS, Han KJ, Lee DH, Lee GE, Kweon HJ, Cho JH. Stepwise percutaneous leverage technique to avoid posterior interosseous nerve injury in pediatric radial neck fracture.J Orthop Trauma. 2017 Jan 24.

2. J. P. Metaizeau. Reduction and Osteosynthesis of radial neck fractures in children by centromedullary pinning. Injury, Vol. 36, Suppl. 1, pp. 75-77, 2005.

14. J. A. Steele and H. K. Graham. Angulated Radial Neck Fractures in Children: A Prospective study of Percutaneous Reduction. The Journal of Bone and Joint Surgery (British Volume), Vol. 74-B, pp. 760-764,1992.

Metaiseau technique

Open raduction and K wire stabilisation Typ IV

78+/8

86+/-4

80+/4

3. Luo J, Halanski MA, Noonan KJ. The Métaizeau technique for pediatric radial neck fracture with elbow dislocation: intraoperative pitfalls and associated forearm compartment syndrome. Am J Orthop (Belle Mead NJ). 2014 Mar;43(3):137-40. 4. Bither N, Gupta P, Jindal N. Pediatric displaced radial neck fractures: retrospective results of a modified Metaizeau technique. Eur J Orthop Surg Traumatol. 2015 Jan; 25(1):99-103. 5. Song KS, Kim BS, Lee SW. Percutaneous leverage reduction for severely displaced radial neck fractures in children. J Pediatr Orthop. 2015 Jun;35(4):e26-30. 6. Kruppa C, Königshausen M, Schildhauer TA, Dudda

15. S. Yarar, D. W. Sommerfeldt, S. Gehrmann and J. M. Rueger. Severely Displaced Radial Neck Fractures after Minimally Invasive Joystick Reduction and Prevot Nail-ing: Long-Term Course in Childhood. Unfallchirug, Vol. 110, No. 5, pp. 460-466, 2007. 16. Falciglia F, Giordano M, Aulisa AG, Di Lazzaro A, Guzzanti V. Radial neck fractures in children: results when open reduction is indicated. J Pediatr Orthop. 2014 Dec; 34(8):756-62. 17. Badoi A, Frech-Dörfler M, Häcker FM, Mayr J. Influence of Immobilization Time on Functional Outcome in Radial Neck Fractures in Children. Eur J Pediatr Surg. 2016 Dec; 26(6).

INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL