1825 C OPYRIGHT Ó 2013
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Surgical Management of Pediatric Radial Neck Fractures Ryan M. Zimmerman, MD, Leslie A. Kalish, ScD, M. Timothy Hresko, MD, Peter M. Waters, MD, and Donald S. Bae, MD Investigation performed at the Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts
Background: Management of pediatric radial neck fractures is controversial regarding acceptable alignment, variable reduction techniques, and suboptimal outcomes. The purpose of this study was to assess the characteristics, management, and results in a surgical cohort, in efforts to identify prognostic factors and offer treatment suggestions. It was hypothesized that less invasive reduction maneuvers would precede open reduction and that worse results would correlate with fracture severity, open reduction, and the presence of associated injuries. Methods: Retrospective analysis of 151 children in whom a radial neck fracture had been surgically treated from 2001 to 2011 was performed. The mean age (and standard deviation) and duration of follow-up were 8.4 ± 2.9 years and 13.3 ± 20.0 months, respectively; 40% of the patients were male. A successful clinical result was defined as elbow flexion of ‡120°, flexion contracture of 30°, displacement of >3 mm, associated injuries, open reduction, and delayed surgery2,10,15-18. The purpose of this study was to assess the characteristics, management patterns, and results of all pediatric radial neck fractures that underwent operative treatment at a large pediatric center over a ten-year period and to use the results to identify prognostic factors and offer treatment suggestions. It was hypothesized that (1) surgeons would begin with closed manipulation and proceed incrementally through more invasive techniques before resorting to open reduction and (2) greater fracture displacement and angulation, the presence of associated injuries, an age of ten years or more, and open reduction would be associated with worse outcomes.
SU RGIC AL MANAGE MEN T NE CK FRACTURES
OF
P E D I AT R I C R A D I A L
from 2001 to 2011. Radial neck fractures treated solely with closed reduction in the emergency department were excluded, as were patients with congenital dysplasia of the radius, sequelae of a previous radial neck fracture without injury and treatment data, infection or positive intraoperative culture, or cognitive disability precluding the attainment of a reliable history and physical examination. The medical records and radiographs of the 151 eligible children were analyzed. The mean age (and standard deviation [SD]) was 8.4 ± 2.9 years, 40% of the patients were male, and the mean body mass index (BMI) was 18.5 ± 4.6 kg/m2. The mean duration of follow-up was 13.3 ± 20.0 months, with a median (interquartile range) of 4.7 (2.0, 12.5) months (see Appendix). Clinical motion, radiographic alignment, subsequent procedures, and complications (heterotopic ossification, osteonecrosis, premature physeal arrest, and neurovascular injury) were recorded. Angulation and displacement were measured on the anteroposterior and lateral radiographs. Except where noted, the maximum values from the two planes are used in analyses. Displacement was expressed as a percentage of proximal radial metaphyseal diameter just distal to the fracture site. All fractures were classified according to the method described by 19 O’Brien . Surgical indications and procedure selection were determined by the treating surgeons, all of whom were fellowship-trained in pediatric orthopaedics. All attempted interventions, including closed manipulations in the clinic, emergency department, and operating room, were recorded, regardless of success. Procedures were categorized as (1) closed manipulation, (2) a closed or percutaneous surgical procedure, or (3) a procedure involving open reduction. Closed manipulation in the emergency department or clinic was considered distinct from manipulation in the operating room. Closed or percutaneous surgical procedures referred to any procedure that introduced an implant without exposure of the radiocapitellar joint, such as retrograde intramedullary nailing. Open procedures involved exposure of the radiocapitellar joint. A successful outcome was defined as active elbow flexion of ‡120°, a flexion contracture of
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Surgical Management of Pediatric Radial Neck Fractures Ryan M. Zimmerman, MD, Leslie A. Kalish, ScD, M. Timothy Hresko, MD, Peter M. Waters, MD, and Donald S. Bae, MD Investigation performed at the Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts
Background: Management of pediatric radial neck fractures is controversial regarding acceptable alignment, variable reduction techniques, and suboptimal outcomes. The purpose of this study was to assess the characteristics, management, and results in a surgical cohort, in efforts to identify prognostic factors and offer treatment suggestions. It was hypothesized that less invasive reduction maneuvers would precede open reduction and that worse results would correlate with fracture severity, open reduction, and the presence of associated injuries. Methods: Retrospective analysis of 151 children in whom a radial neck fracture had been surgically treated from 2001 to 2011 was performed. The mean age (and standard deviation) and duration of follow-up were 8.4 ± 2.9 years and 13.3 ± 20.0 months, respectively; 40% of the patients were male. A successful clinical result was defined as elbow flexion of ‡120°, flexion contracture of 30°, displacement of >3 mm, associated injuries, open reduction, and delayed surgery2,10,15-18. The purpose of this study was to assess the characteristics, management patterns, and results of all pediatric radial neck fractures that underwent operative treatment at a large pediatric center over a ten-year period and to use the results to identify prognostic factors and offer treatment suggestions. It was hypothesized that (1) surgeons would begin with closed manipulation and proceed incrementally through more invasive techniques before resorting to open reduction and (2) greater fracture displacement and angulation, the presence of associated injuries, an age of ten years or more, and open reduction would be associated with worse outcomes.
SU RGIC AL MANAGE MEN T NE CK FRACTURES
OF
P E D I AT R I C R A D I A L
from 2001 to 2011. Radial neck fractures treated solely with closed reduction in the emergency department were excluded, as were patients with congenital dysplasia of the radius, sequelae of a previous radial neck fracture without injury and treatment data, infection or positive intraoperative culture, or cognitive disability precluding the attainment of a reliable history and physical examination. The medical records and radiographs of the 151 eligible children were analyzed. The mean age (and standard deviation [SD]) was 8.4 ± 2.9 years, 40% of the patients were male, and the mean body mass index (BMI) was 18.5 ± 4.6 kg/m2. The mean duration of follow-up was 13.3 ± 20.0 months, with a median (interquartile range) of 4.7 (2.0, 12.5) months (see Appendix). Clinical motion, radiographic alignment, subsequent procedures, and complications (heterotopic ossification, osteonecrosis, premature physeal arrest, and neurovascular injury) were recorded. Angulation and displacement were measured on the anteroposterior and lateral radiographs. Except where noted, the maximum values from the two planes are used in analyses. Displacement was expressed as a percentage of proximal radial metaphyseal diameter just distal to the fracture site. All fractures were classified according to the method described by 19 O’Brien . Surgical indications and procedure selection were determined by the treating surgeons, all of whom were fellowship-trained in pediatric orthopaedics. All attempted interventions, including closed manipulations in the clinic, emergency department, and operating room, were recorded, regardless of success. Procedures were categorized as (1) closed manipulation, (2) a closed or percutaneous surgical procedure, or (3) a procedure involving open reduction. Closed manipulation in the emergency department or clinic was considered distinct from manipulation in the operating room. Closed or percutaneous surgical procedures referred to any procedure that introduced an implant without exposure of the radiocapitellar joint, such as retrograde intramedullary nailing. Open procedures involved exposure of the radiocapitellar joint. A successful outcome was defined as active elbow flexion of ‡120°, a flexion contracture of
