x
x

RADIAL HEAD FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Pediatric Radial Head fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Pediatric Radial Head Fractures, the historical and specifically named fractures include:

Jeffery type 2 fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

The elbow is common site for injury in children and adolescents, but only about 4–16% of elbow fractures involve the radial head or neck. Radial head and neck fractures most commonly occur in children aged 9–10 years, and the typical mechanism of injury is a fall on an outstretched hand that produces a valgus compressive force across the elbow. Isolated fractures of the radial head or neck are extremely rare, while concomitant elbow dislocations and medial epicondyle fractures are more likely. Extraarticular fractures occur more frequently than intraarticular fractures because the radial head is still primarily cartilaginous in younger ages. Most pediatric radial head and neck fractures can be treated successfully with closed reduction and/or immobilization only, while severely displaced and/or angulated fractures often require surgery.1-6

Definitions

  • A pediatric radial head fracture is a disruption of the mechanical integrity of the pediatric radial head.
  • A pediatric radial head fracture produces a discontinuity in the distal humeral contours that can be complete or incomplete.
  • A pediatric radial head fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.7-9
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting or casting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable pediatric radial head fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern2

  • Several classification systems may be used in the diagnosis of pediatric radial head and neck fractures, which classify fractures based on displacement, anatomic location, or configuration. Among the most frequently used are the Judet classification and the Wilkins classification systems, with most authors preferring the Judet system.
  • Judet classification system for radial neck fractures
    • Type I: nondisplaced
    • Type II: angulation <30°, translation <50%
    • Type III: angulation 30–60°, translation 50–100%
    • Type IV: angulation >60°, translation >100%
  • Wilkins classification system for radial neck fractures
    • Grade A: Salter-Harris I or II physeal fracture
    • Grade B: Salter-Harris III or IV intra-articular fracture
    • Grade C: metaphyseal fracture

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the pediatric radial head or neck require antibiotics with surgical irrigation and wound debridement.7,10,11

R - Rotation

  • Pediatric radial head fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Pediatric radial head and neck fractures can have fragment involvement at the proximal radioulnar joint or radiocapitellar joint.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.
  • Intraarticular fractures of the radial head are relatively rare in children because the radial head is primarily cartilaginous until the proximal epiphysis begins to close around 14–15 years in boys and 12–14 years in girls.1

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Pediatric radial head fractures: named fractures, fractures with eponyms and other special fractures

Jeffery type 2 fracture

  • Also known as the Jeffery type 2 lesion, this injury involves a radial neck fracture with a posterior subluxation or dislocation of the radiocapitellar joint.12,13
  • Jeffery type 2 fractures result from the impact of the capitellum on the anterior lip of the radial head, creating a 90° backward tilt of the radial head.12,13
  • This type of injury is uncommon but can lead to dangerous consequences if not recognized or properly treated.14

Imaging

  • Radiology studies - X-ray
    • Anteroposterior (AP) and lateral radiographs of the elbow are recommended.14

Treatment13,14

  • Closed or percutaneous reduction
    • May be considered in some cases.
  • Open reduction and internal fixation (ORIF)
    • Typically recommended due to the risks associated with percutaneous and closed reductions.

Complications

  • Avascular necrosis
  • Premature physeal closure
  • Radial head overgrowth
  • Radioulnar synostosis

Outcomes

  • ORIF has been associated with early recovery and good clinical outcomes in two case series.12,13
  • Closed reduction frequently is often unsuccessful and may lead to an upside down displacement of the radial head12; however, one case report found that a 10-year-old patient treated conservatively with closed reduction experienced excellent radiological and clinical results.14

Related Anatomy3,4,15-19

  • The elbow is a hinge-type synovial joint comprised of the radius, ulna, and humerus, and formed by three articulations: the ulnohumeral joint, radiocapitellar joint, and proximal radioulnar joint (PRUJ).
  • The radiocapitellar joint is the articulation of the radial head with the capitellum of the humerus. It is essential to elbow longitudinal and valgus stability and has an integral relationship with the LCL.
    • The radius consists of a rectangular epiphysis at its distal end, a long shaft, and a radial neck and head at its proximal end. The radial head is important because it influences all three elbow articulations. The stability of the radiocapitellar joint is based on the opposite congruity of the convex capitellum with the concave radial head. Articular cartilage covers this concave surface and at least an arc of ~280° around the rim of the radial head.
  • The PRUJ is formed by the articulation of the radial head with the lesser sigmoid notch of the proximal ulna and is stabilized by the annular ligament.
  • The key ligaments of the elbow include the LCL (which extends from the lateral epicondyle and blends with the annular ligament of the radius), the MCL (which originates from the medial epicondyle and attaches to the coronoid process and olecranon of the ulna), and the annular ligament (which encircles the radial head and stabilizes the PRUJ and radiocapitellar joint).
  • The key tendons of the elbow include the tendons associated with the biceps, triceps, extensor carpi radialis brevis (ECRB), and extensor carpi radialis longus (ECRL) muscles.
  • The radius and ulna are also connected by a sheet of thick fibrous tissue called the IOM.
  • There are six ossification centers around the elbow joint, which ossify at different ages in a child’s development. These centers and the approximate age of ossification are as follows:
    • Capitellum: 1 year
    • Radial head: 3 years
    • Internal or medial epicondyle: 5 years
    • Trochlea: 7 years
    • Olecranon: 9 years
    • External or lateral epicondyle: 11 years
  • The radial head fuses with the radial shaft between ages 16–18.
  • The proximal radius growth plate is responsible for only 20­–30% of the radius’ growth.

Incidence

  • Radial head and neck fractures account for 4–16% of all elbow injuries and <1% of all fractures in the pediatric population.1
  • The average age for pediatric radial head and neck fractures is 9–10 years.3,5
  • Most of these fractures involve the extraarticular and/or metaphyseal regions of the proximal radius, usually occurring as Salter-Harris type II fractures that transect the physis and extend into the metaphysis. Intraarticular fractures are uncommon at younger ages. 1,20
ICD-10 Codes

  • RADIAL HEAD FRACTURE - PEDIATRIC

    Diagnostic Guide Name

    RADIAL HEAD FRACTURE - PEDIATRIC

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    RADIAL HEAD FRACTURE - PEDIATRIC    
    - DISPLACED S52.122_S52.121_ 
    - NONDISPLACED S52.125_S52.124_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S52
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis and/or tenderness
Abrasion
Typical History

A typical patient is a 9-year-old girl who was injured while playing a game of tag with her friends. The girl was chasing another child during the game and failed to notice a patch of ice, which she slipped on and fell forward. She landed on her right, outstretched hand, which created a valgus compressive force across her elbow and resulted in a fracture of the radial neck. The girl noticed pain immediately and was unable to flex or extend her elbow. She told her parents about the injury and went straight to the emergency department for treatment.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric radial head fractures, the treating surgeon has 4 basic goals:7,11
    1. An elbow with a normal appearance. The X-ray may not need to be perfect, but the elbow should have no obvious deformity (ie, the elbow looks normal!)
    2. Avoid elbow stiffness by maintaining a normal functional ROM (ie, the elbow works!)
    3. The elbow is not painful (ie, the elbow does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the elbow does not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Treatment decisions for pediatric radial head and neck fractures are based primarily on the severity of the fracture—including the degree of angulation and translation—and the age of the patient. In general, most of these fractures can be successfully treated with closed reduction and/or immobilization alone, while fractures that are severely displaced and/or angulated, particularly in older children, may necessitate surgical intervention.1
  • Immobilization alone
    • Indicated for fractures with <30° of angulation and <50% translation (Judet type II fractures).
    • Involves immobilization in a long arm cast or splint for 7–14 days, followed by early ROM exercises to prevent elbow stiffness.
  • Closed reduction and immobilization
    • Indicated for fractures with >30° of angulation.
    • Reduction techniques include the Patterson maneuver, the Israeli (Kaufman) technique, the Nehar and Torch technique, and an elastic bandage technique.
    • Closed reduction is followed by immobilization in a long arm cast or splint for 7–14 days if sufficient reduction is achieved, followed by early ROM exercises.1,2,5,20
Operative
  • Surgical treatment of pediatric radial head fractures must always be an individualized therapeutic decision.1,2,5,20 However, surgical pediatric radial head fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced pediatric radial head fracture involving the PRUJ or radiocapitellar joint.
    3. Open pediatric radial head fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Although the specific indications for surgical intervention are controversial, the best available evidence suggests that surgery may be needed when there is >45° angulation or >50% translation. Some surgeons also consider angulation of >15° in children older than 10 years to be an indication for surgical intervention.2,5
  • Closed reduction and percutaneous pinning (CRPP)
    • Indicated for fractures that are still angulated >30° after closed reduction and patients with <45° of pronation and supination.
    • K-wire joystick technique
      • Can be performed either through a push (K-wire pushed proximal fragment and pushed into place) or a lever technique (K-wire placed into fracture site and levered proximally).
    • Metaizeau technique
      • Involves a retrograde insertion of a pin or nail across the fracture, then reducing the fracture by rotating the pin or nail.
  • ORIF
    • Indicated for fractures that cannot be sufficiently reduced to <45° with closed or percutaneous methods. Should only be considered as a last resort for fractures that are several unstable.
    • Typically performed with a lateral (Kocher-type) approach to the radiocapitellar joint with the elbow pronated to avoid the posterior interosseous nerve.
  • Radial head excision
    • May be considered for certain patients with open physes and severely impaired ROM due to post-traumatic malalignment or from congenital luxation.4

Post-treatment Management

  • The care and precautions related to immobilization devices for the pediatric radial head fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints and casts, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can usually be mobilized after 4 weeks.
  • Therapist-guided, gentle active ROM exercises for the hand, wrist, and shoulder should begin immediately after surgery. Active ROM exercises for the elbow should begin 7–10 days post-surgically if there are no wound issues. Strengthening exercises may begin after there is radiographic evidence that the fracture has healed, which typically occurs around 8–12 weeks after surgery.22,23
Complications
  • Stiffness
    • Often associated with loss or pronation or supination.
  • Radial head overgrowth
    • Occurs in 20–40% of fractures.
  • Physeal arrest
    • May lead to cubitus valgus deformity.
  • Aseptic necrosis
  • Avascular necrosis
  • Malunion
  • Loss of elbow ROM
  • Nerve injury
  • Synostosis
  • Heterotopic ossification
  • Hardware failure
  • Nonunion
  • Post-traumatic arthritis
  • Intraarticular radial head and neck fractures are generally associated with a higher rate of complications than extraarticular fractures, which may be due to immature closure of the physes and/or annular ligament disruption.1,2
Outcomes
  • ORIF is associated with variable success rates and an increased risk for avascular necrosis, osteonecrosis, and synostosis compared to CRPP. It should therefore only be considered as a last resort.2
  • CRPP is associated with better outcomes in isolated radial neck fractures, younger patients, and those with lesser degrees of angulation.2
  • Extraarticular fractures usually heal properly and are generally associated with better outcomes than intraarticular fractures.1
  • Fractures that involve both the articular surface and an open physis of the radial head lead to predictably poor outcomes.1
  • Radial head excision can significantly improve ROM for pronation and supination, but complete restoration of ROM is unlikely, and some patients may require revision surgery.4
  • In one study of 42 pediatric patients with dislocated radial neck fractures, a CRPP technique with intramedullary retrograde nails was found to be simple, short and safe.6
  • In general, outcomes are worse for patients older than 10 years of age.
Key Educational Points
  • Although rare, intraarticular fractures of the radial head or neck should be closely monitored once recognized to detect for signs of fracture displacement or radiocapitellar joint subluxation and secondary imaging studies are recommended to determine the extent of the injury.1
  • Pediatric radial head and neck fractures are challenging injuries to treat and there is a lack of consensus among surgeons on several matters, such as acceptable fracture alignment, absolute surgical indications, and optimal reduction techniques.24
  • AP and lateral views are standard, but a Greenspan view—oblique lateral view with the elbow flexed 90° and thumb pointing upward—provides an unobstructed view of the radial head and may also be used to visualize the extent of the injury more clearly.1,2
  • MRI without contrast may be utilized in some cases to acquire more information about the extent of articular involvement and the integrity of the surrounding soft tissue.1
References

Cited Articles

  1. Ackerson R, Nguyen A, Carry PM, Pritchard B, Hadley-Miller N, et al. Intra-articular Radial Head Fractures In the Skeletally Immature Patient: Complications and Management. J Pediatr Orthop 2015;35(5):443-448. PMID: 25171672
  2. Hill CE, Cooke S. Common Paediatric Elbow Injuries. Open Orthop J 2017;11:1380-1393. PMID: 29290878
  3. Khajuria A, J MD. Radial Neck Fracture Repair In A Child. In: StatPearls. Treasure Island (FL) 2021. PMID: 32644597
  4. Wegmann H, Heider S, Novak M, Sperl M, Kraus T, et al. Outcome following excision of the radial head in children with open physes for impaired elbow motion. J Shoulder Elbow Surg 2019;28(3):525-529. PMID: 30502032
  5. Kruppa C, Konigshausen M, Schildhauer TA, Dudda M. Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients. Injury 2015;46 Suppl 4:S10-16. PMID: 26542853
  6. 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;20(4):250-252. PMID: 20383822
  7. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-722. PMID: 27113910
  8. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-1138. PMID: 15576227
  9. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-316. PMID: 26649263
  10. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  11. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-1031. PMID: 23618458
  12. Chotel F, Vallese P, Parot R, Laville JM, Hodgkinson I, et al. Complete dislocation of the radial head following fracture of the radial neck in children: the Jeffery type II lesion. J Pediatr Orthop B 2004;13(4):268-274. PMID: 15199284
  13. Chotel F, Sailhan F, Martin JN, Filipe G, Pem R, et al. A specific closed percutaneous technique for reduction of Jeffery type II lesion. J Pediatr Orthop B 2006;15(5):376-378. PMID: 16891967
  14. Papaioannou I, Tagaris G, Baikousis A, Christodoulou G, Korovessis P. Successful Closed Reduction of a Jeffery Type 2 Radial Head Epiphysiolysis -A Case Report with Literature Review. J Orthop Case Rep 2019;9(3):22-25. PMID: 31559220
  15. Fernandez DL, Jupiter JB. Fernandez, DL and Jupiter, JB. Fractures of the Distal Radius: A Practical Approch to Management. Second ed. New York: Springer Science+Business Media New York; 2002.
  16. Zumstein MA, Hasan AP, McGuire DT, Eng K, Bain GI. Distal radius attachments of the radiocarpal ligaments: an anatomical study. J Wrist Surg 2013;2(4):346-350. PMID: 24436840
  17. Burkhart KJ, Wegmann K, Muller LP, Gohlke FE. Fractures of the Radial Head. Hand Clin 2015;31(4):533-546. PMID: 26498543
  18. van Riet RP, van den Bekerom MPJ, Tongel AV, Spross C, Barco R, et al. Radial head fractures. Shoulder & Elbow 2020;12(3):212–223. PMID: 32565923
  19. Beazley JC, Baraza N, Jordan R, Modi CS. Distal Humeral Fractures-Current Concepts. Open Orthop J 2017;11:1353-1363. PMID: 29290875
  20. Saeed W, Waseem M. Elbow Fractures Overview. In: StatPearls. Treasure Island (FL) 2021. PMID: 28723005
  21. Crean TE, Nallamothu SV. Distal Humerus Fractures. In: StatPearls. Treasure Island (FL) 2021. PMID: 30285369
  22. Lauder A, Richard MJ. Management of distal humerus fractures. Eur J Orthop Surg Traumatol 2020;30(5):745-762. PMID: 31965305
  23. Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010;18(1):20-30. PMID: 20044489
  24. Ryu SM, Yoon DH, Park SG. Clinical and Radiographic Outcomes of Pediatric Radial Head Fractures. Indian J Orthop 2018;52(5):561-567. PMID: 30237615
Subscribe to RADIAL HEAD FRACTURE PEDIATRIC
⇡