| Radial neck fractures represent 5% to 10% of elbow fractures in children. Treatment of radial neck fractures is still a clinical challenge. Blood supply to the radial neck can be disrupted by the injury or open reduction. The complex anatomy of the elbow poses further difficulty for the treatment of radial neck fractures.There are many methods for the treatment of radial neck fractures. It is mostly accepted by minimally invasive percutaneous closed reduction and fixation. This paper compares Metaizeau’s method, percutaneous K-wire leverage and combination of two minimally invasive methods. We analysised the operative time of the minimally invasive treatment, attention matters and operation effect. Minimally invasive treatment of children radial neck fracture trauma had good effect. But posterior interosseous nerve is closed to radial neck. Posterior interosseous nerve damage is common in the surgery of children radial neck fracture. We studied the anatomy of the radial neck of children to avoid the injury of posterior interosseous nerve and achieve the best therapeutic effect of radial neck fracture in children.Part â… The anatomy of the dorsal lateral approach of the posterior interosseous nerve in the proximal part of the radiusObjective: The posterior interosseous nerve has a very important function on the upper limb. It nourishes and dominates the back part of the forearm muscles. The posterior interosseous nerve passes through the supinator tunnel, winds around the proximal end of the radius, arrives at the forearm extensor, spreadly dominates each of the muscle. Although radial head and neck fracture can cause posterior interosseous nerve’s injury, the posterior interosseous nerve may also be iatrogenic injury, especially through the anterior, lateral and posterior lateral approach to expose the proximal end of the radius. Elbow arthroscopy can also cause posterior interosseous nerve’s injury. We want to reduce its incidence through learning the posterior interosseous neural anatomy.Diliberti suggested rotary anterior position could increase safety zone of the proximal end of the radius. But the posterior interosseous nerve has no structure to be localized, especially for radial neck fractures in children. Therefore, this study analyzed the posterior interosseous nerve location and relationship with the proximal radius based on the rotation of the forearm. We positioned posterior interosseous nerve and avoided the posterior interosseous nerve’s iatrogenic injury in minimally invasive treatment of radial neck fractures in children.Methods: We dissected 6 upper limbs in children’s corpses, aged 7-12. The superficial layer of supinator muscle was opened for each specimen, and the deep layer of supinator muscle was preserved. When forearm is pronated, we measured safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radial shaft posterior cortices, also measured the safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radius lateral cortical bone. When forearm is suspinated, we measured the safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radial shaft posterior cortices, also measured the safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radius lateral cortical bone. Metal wire positioned and labeled the posterior interosseous nerve. The specimens were taken to check X-ray and CT. The length of the safe area of the radius is expressed as a percentage of the length of the radius.Results: When forearms were in supination position, the safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radial shaft posterior cortices on average was（32±5.9） mm. The safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radius lateral cortical bone on average was（19.5±3.0） mm. When forearms were in full pronation position, the safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radial shaft posterior cortices on average was（39±8.3） mmmm. The safety zone from humeral capitulum articular surface to the intersection of the nerve and the axis of radius lateral cortical bone on average was（22±3.3） mmmm. Forearms were in supination position, posterior safety zone accounted for the average length of radius（15.5±2.1）%; lateral safety zone accounted for the average length of radius（9.4±1.0）%. Forearms were in pronation, the length increased to（18.8±3.1）%å'Œï¼ˆ10.7±1.0）%.Conclusion: Pronation can effectively increase the safety area of the proximal posterior interosseous nerve. Therefore, the surgical exposure of radial head should be placed in pronation, the risk of the posterior interosseous nerve’s injury was to be minimized. When we replace radial neck fractures by percutaneous Kirschner’s wire leverage, we should place the forearmes in pronation. And the back distance from the needle point to humeral capitulum articular surface is as far as possible not to exceed 15% of the total length of the radius, the lateral distance from the needle point to humeral capitulum articular surface is as far as possible not to exceed 9% of the total length of the radius.Part â…¡ Efficacy analysis of Metaizeau methods for treatment of radial neck fractures in childrenObjective: It has been difficult to reduce and fix the obviously displaced children radial neck fracture, which was treated mainly with open reduction and / or Kirschner wire fixation. The effect was not satisfied after many years of clinical observation. Especially with ischemic necrosis change or early closure of radial head epiphysis after open surgery, the elbow flexion and forearm rotation function was limited. In 1980 Metaizeau reported good results in the treatment of intramedullary pin reduction and fixation of radial neck fractures. Now we analysis children radial neck fracture cases more than 30°with Metaizeau therapy in our hospital. We estimate the therapeutic effects of Metaizeau’s method in the treatment of the radial neck fracture more than 30°in children.Methods: The clinical data of 12 cases of radial neck fractures in children treated with Metaizeau’s method in our hospital from August 2008 to February 2010 were analyzed retrospectively. The longitudinal incision was about 1-2.5cm above distal radius epiphyseal plate at the radial side.The length was about 2cm. We payed attention to the dorsal radial nerve branch and exposed the metaphysis. We drilled the cortical bone with a Nancy elastic intramedullary needle fixed by T-shaped handle. Intramedullary needle was penetrated radial medullary cavity and the end was toward the radial side. Under the monitoring of the C-arm machine, the intramedullary needle was gradually put into the fracture section. At this time, left hand in skin pressed and fixed radial head outward the top. Right hand promoted the intramedullary needle. Intramedullary needle end was penetrated into the radial head and jacked the radial head with both hands. If radial neck fracture was still horizontal displacement or not obvious angular displacement, intramedullary nail should be properly rotated, angular deformity and lateral displacement would be corrected. The elbow was fixed by plaster with neutral or forearm supination. The plaster was splitted after about 4 weeks and we began the functional exercise. The needle was removed about 3 months after operation.Results: 10 cases were successfully treated with Metaizeau’s method and the fracture was union in 3 months. According to the standard of Metaizeau reduction, 10 cases was successfully treated with Metaizeau’s method in this group, 7 cases in reduction were good, 2 cases were good, 1 case was normal. After appropriate functional exercise, the appearance of the affected limb was not abnormal, the range of motion of the elbow was basically normal. The patients were followed up for 3 to 12 months, with an average of 9 months. According to Tibone and Stoltz ’s clinical function evaluation standard, excellent: no pain and deformity, normal range of motion; good: not obvious pain was incidental, carrying angle increased < 10°, rotation and flexion was limited < 20°; common: pain was incidental, carrying angle increased > 10°, rotation and flexion was limited > 20°; bad: pain was obvious, joint activities was limited obviously and need further surgery. 10 cases were successfully treated with Metaizeau method, 8 cases were excellent, 2 cases were good. 2 cases were fail with Metaizeau’s method, 1 case was recovered excellently, 1 case was recovered excellently commomly. X-ray examination showed that the children with radial neck fracture was healing delayedly.Conclusion: Metaizeau method is a minimally invasive and effective method for treatment of radial neck fracture in children, but the success rate is not high for radial neck fracture angle shift, open reduction is necessary. It is easy to damage the blood supply of the radial head and neck by open reduction. Open reduction may cause ischemic necrosis of the radial head and fracture healing is not easy. The degree of cubitus valgus may aggravate with the children’s growth. In addition, the interference of open reduction to the surrounding tissue of the elbow can limit the function of the elbow joint. Therefore, besides Metaizeau method, it is urgent to create another minimally invasive method for the treatment of severely displaced radial neck fractures in children. Part â…¢ Treatment of Severely Displaced Radial Neck Fractures in Children With Percutaneous K-wire Leverage and Closed Intramedullary PinningObjective: Blood supply to the radial neck can be disrupted by the injury or open reduction. The complex anatomy of the elbow poses further difficulty for the treatment of radial neck fractures. Treatment options are primarily determined by the radial neck–shaft angle and displacement distance of the fracture, which are also the major prognostic factors. Radial neck fractures are usually reduced manually or with percutaneous K-wire leverage（PKWL） or with closed intramedullary pinning（CIMP）. Open reduction has largely been abandoned because of various disadvantages, such as epiphyseal ischemia, premature epiphyseal closure, and intra-articular calcification.We have treated Judet III and IV radial neck fractures using PKWL reduction in combination with CIMP and achievedgood surgical outcomes. We now assess the effect of the combination of PKWL and CIMP for severely displaced radial neck fractures.Methods: A total of 50 children with Judet III and IV radial neck fractures were treated at our hospital fromJune 2010 to December 2013. There were 31 boys and 19 girls with a mean age of 8.4 years（range, 5.6–13 years）. The fractures were on the left side in 26 patients and right side in 24 patients. All fractures were caused by falling. Eight patients were complicated with proximal ulnar fractures and 1 patient with radial nerve injury. Manual reduction was first attempted. The proximal fragment was pressed on the distal end toward the proximal direction. Successful reduction is that the radial neck–shaft angle was reduced to <30°and that displacement was reduced to <30%. If manual reduction was successful, or if the radial neck–shaft angle was reduced to <45°, radial intramedullary nailing and CIMP were used for fixation. An elastic intramedullary nailwith a diameter 0.7 time of the narrowest site of the radial bone marrowcavity was used. The nail was inserted into the radius from the proximal side of the distal epiphyseal plate, and was advanced to the fracture site. The nail head was positioned to the radial head and the fracture ends was pushed and separated. In the meantime, manual reduction was used. The nail was rotated for 180° to reduce the radial head. After the reduction, the range of motion of the forearm was restored. The excessive part of the nail was bended for 45°. A length of 5mm XI of the nail was reserved outside of the bone. And the fracture was finally fixed. Upon unsuccessful manual reduction and CIMP, or if the radial neck–shaft angle was still >45° after manual reduction, PKWLreductionwas used. Under fluoroscopy, a K-wire of 2-mm diameter was percutaneously inserted into the bone fragment from the displacement direction of the radial neck fracture fragment. Reduction of the fracture was achieved by leveraging the K-wire and by manual reduction. The proximal fragment was pressed on the distal end toward the proximal direction. Upon incomplete anatomic reduction but a radial neck–shaft angle <45°, CIMP in combination with manual reduction were performed to achieve reduction. All the radial neck fractures were reduced to <30°and a displacement <30%. The mean time from injury to surgery was 2.3 days（range, 1–4 days）. The injured armwas fixed at the functional position using plaster for 4 to 6 weeks. Exercisewas encouraged after removal of the plaster.Results: Three surgical methods were used, including manual closed reduction and CIMP（group A, n?16）, PKWL and CIMP（group B, n?30）, and open reduction and CIMP（group C, n?4）. Percutaneous K-wire leverage reduction or open reduction were used upon unsuccessful manual reduction and CIMP, or if the radial neck–shaft angle was still >45°after manual reduction. Therefore, groups B and C showed no significant difference in the radial neck–shaft angle, fracture displacement, and angle/displacement ratio（P>0.05）. Group B had had significantly shorter operation time than group C（55.211.2 versus 81.37.5, P<0.05）, but was not significantly different from group A（55.211.2 versus 58.514.5, P>0.05）. A total of 45 patients were followed up for a mean of 2 years. Bone union was achieved in all patients within a mean time of 4.1 months（range, 2.4–6.5 months）. The fixation implants were removed within a mean time of 4.3 months（range, 2.5–7.2 months）. The functional outcomes were excellent in the patients treated with successful manual reduction, CIMP, and PKWL reduction. One patient treated with open reduction and CIMP after failed manual reduction had good functional outcomes. The other 3 patients treated with open reduction had 10° to 20° limitation in range of motion of the elbow. One patient with preoperative radial nerve injury recovered well at postoperative 3 months. No other complications were seen in our patients.Conclusion: Radial neck fractures in children are usually caused by indirect injury mechanisms. Manual reduction was not possible for patients with severely displaced radial neck fractures. Manual reduction is often used in combination with other closed reduction techniques. Percutaneous K-wire leverage reduction can be successfully performed in most cases of radial neck fracture, including those with unsuccessful CIMP reduction. Percutaneous K-wire leverage is also performed with simultaneous K-wire fixation. The PKWL technique, however, has to penetrate the distal and proximal radial fracture ends. Therefore, early exercise of the elbow is not possible in patients treated with PKWL reduction. On the contrary, CIMP has no limitation on elbow movement and therefore enables early exercise. There is a certain risk of epiphyseal plate damage during rotation reduction using CIMP. And some impacted fractures with large angles and displacements are difficult to be reduced using CIMP. These conditions need PKWL reduction. Percutaneous K-wire leverage has been proposed to be attempted first for the reduction of radial neck fracture. If the reduced fracture is unstable, CIMP is then used. This can shorten the operation time and avoid the damages to the metaphyseal trabecular bone and the epiphyseal plate caused by repeated CIMP. In our study, CIMP reduction was not possible for patients with severe radial neck fractures. These patients were first treated with PKWL for reduction, then received CIMP and intramedullary nail fixation. This may shorten the operation time compared with the repeated CIMP attempts. Therefore, we recommend PKWL+CIMP for the extremely displaced or angled radial neck fractures. The CIMP technique is effective for the treatment of moderately displaced radial neck fractures in children. For the treatment of severely displaced or heavily impacted radial neck fractures, we recommend reduction using PKWL and fixation using CIMP. The combination of PKWL and CIMP can achieve satisfactory results in the treatment of pediatric radial neck fractures. |
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