Overview of Radial Neck Fracture Repair In A Child
Fractures in the radial neck, which is near the elbow, are fairly common in children, especially when they are around 9 to 10 years old. In fact, they make up about 10% of all elbow injuries in children. These fractures usually occur when a child falls on a hand that was stretched out to break the fall. This puts pressure on the elbow joint in a specific way.
When a child comes in with a possible radial neck fracture, the doctor will first check the elbow joint. This is followed by taking simple X-rays of the elbow. It’s important to get X-rays from different angles – from the front to the back (this is called an anteroposterior or AP view) and from the side. Sometimes, the doctor will also take an oblique-lateral view, also known as the ‘Greenspan’ or radiocapitellar view. This helps the doctor to see the radial head, which is part of the elbow, more clearly.
The classification, or the severity, of radial neck injuries depends on the angle between the radial head and the neck. There are different systems to classify these injuries, and the most commonly used ones are the Judet and O’Brien systems. Sometimes, if the fracture hasn’t moved the bone (this is called an undisplaced fracture), it might be hard to see on an X-ray. If this is the case, the doctor might look for a sign called the posterior fat pad. This sign can sometimes indicate a hidden fracture.
Anatomy and Physiology of Radial Neck Fracture Repair In A Child
Long bones in our body have three main sections:
1. The ends (called the Epiphysis): These are covered by a material called articular cartilage, especially if they’re part of a joint.
2. The shaft (called the Diaphysis): This is the longest part of the bone.
3. The middle section (called the Metaphysis): This part is between the end and the shaft. In children, this section contains the growth plate which is responsible for helping bones grow and develop.
Inside the bone, there are areas known as ossification centers that help create new bone tissue, a process called osteogenesis. There are two types of these centers – primary and secondary. The primary ossification center is where the bone begins to form, usually in the shaft of long bones. The secondary ossification centers are usually in the ends of these bones.
The elbow joint, in particular, has six ossification centers. You can remember the order they appear as you grow older using the ‘CRITOE’ mnemonic. Here’s what each letter stands for:
1. Capitellum shows up first, around 1 year of age.
2. Radial head starts to form around 3 years of age.
3. Internal or medial epicondyle, become visible around at 5 years.
4. Trochlea shows up around 7 years.
5. Olecranon forms around 9 years of age.
6. External or lateral epicondyle starts to appear when you’re around 11 years old.
By the time you are 16 to 18 years old, the radial head fully fuses with the shaft. This head can sometimes get fractured, and these fractures tend to be categorized as Salter-Harris type-2 injuries. This means the fracture occurs through the growth plate and the metaphysis of the bone, typically due to a fall or other trauma.
Why do People Need Radial Neck Fracture Repair In A Child
If someone breaks the neck of their radial bone (one of the two bones in the forearm, the one on the thumb side), how it’s treated largely depends on how serious the injury is. More specifically, it depends on how much the broken bone has moved out of its original position, a condition known as angulation. If the break results in an angulation of more than 30 degrees or if the bone has moved more than 3mm from its place, or if the person experiences a decrease in the ability to turn their wrist (supination and pronation), surgery may be required. This involves repairing the fracture by “reducing” it, or moving the bone back into position.
However, if the bone angle is close to 30 degrees, rather than operating, it might be possible to deal with the break without surgery, This involves moving the bone back into place (closed reduction) and then keeping the arm stable in a long-arm cast while it heals.
For some breaks, trying to move the bone back into place without opening up the arm (closed reduction) and using a K-wire or the Metaizeau technique with an elastic nail inside the bone may be appropriate. This could be the case if moving the bone without surgery doesn’t work and the bone stays at an angle of more than 30 degrees.
But if trying to move the bone back into place (whether surgically or not) fails and the bone stays at an angle greater than 45 degrees, surgery to open up the arm (open reduction) and move the bone back into place (reduction) should be done. However, medical professionals need to perform this kind of surgery carefully.
When a Person Should Avoid Radial Neck Fracture Repair In A Child
Surgery to fix a broken collarbone is not usually recommended if the bone break is small and shifted less than 30 degrees and less than 3 mm out of place. If the broken bone is tilted more than 30 degrees, it might still be possible to fix it without surgery, but only if it can be realigned properly.
Equipment used for Radial Neck Fracture Repair In A Child
The information provided here is about the equipment used within a specific medical procedure. Below are the items generally used:
* An Image intensifier (II), which is a device used to enhance the images of the inside of the body
* Skin is prepared with a special solution that kills bacteria, to prevent infections
* Readily flexible nails that are 5-3.0 mm, are used
* A nail inserter helps in placing these nails in the right position
* A small hammer is used for applying gentle force
* A nail cutter helps in adjusting the nail length if necessary
* K-wires which are thin metal rods that help with bone alignment
* A drill or a T-handle, a tool to make holes in the bone
* A wire cutter, used to cut the K-wires to the appropriate length
* Skin and Inside scalpels, sharp tools for making incisions or cuts in the skin and inside the body
* Forceps, these are like tweezers used for holding or moving tissues
* Small retractors help to hold back the skin or muscle, revealing the area needing treatment
* Small scissors or a surgical clip, used for cutting tissues or for holding something in place
* Dental hook, a tool employed to hold or position certain tissues
* Diathermy, a heat-based method for cutting tissues or sealing blood vessels
* Sutures, also known as stitches, used to close the incision after the procedure
* A Dressing, is a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm
Who is needed to perform Radial Neck Fracture Repair In A Child?
This procedure is done by highly trained surgeons who have the necessary skills and experience. The surgeon could be a resident (a doctor in training), or an attending (a doctor who supervises others). A team of medical professionals supports the surgeon in the operating room. This team includes the anesthetic team (experts who give you medicine to make you sleep or numb an area), operating department practitioners (healthcare professionals who provide care during surgery), a scrub nurse (a nurse who assists the surgeon), and a radiographer (an expert who takes pictures inside your body using medical imaging).
Preparing for Radial Neck Fracture Repair In A Child
Before the procedure, it’s important for the medical team to have a meeting. This is where everyone can introduce themselves, discuss their roles, and go over the upcoming cases. They will also discuss the order of the patients, the equipment they will need, and how the patient should be positioned. To ensure safety, the medical team will follow a safety checklist created by the World Health Organisation (WHO). For the patients part, they will be lying on their back with the arm that needs treatment placed on a board. The area above the elbow of the affected arm will then be prepared and covered for the medical procedure.
How is Radial Neck Fracture Repair In A Child performed
Closed Reduction – K-wire Joystick Technique
In the K-wire joystick technique, the doctor inserts a thin piece of metal wire (roughly 1.6 or 2.0 mm in thickness) into your arm. They push the dislocated radial head (that’s the top of your radius bone in your forearm) back into the right place. The doctor uses a special kind of X-ray (known as an II) to guide the wire and check that the bone is back in position.
Closed Reduction and Internal Fixation – Elastic Stable Intramedullary Nailing – Métaizeau technique
In this procedure, the doctor has two places where they can start. These places are on the side or back of the radius bone – 1.5 cm above where the bone starts to widen (this is the physis). The doctor makes an incision either on the side or the back of your arm. They carefully cut down to the bone, being sure to avoid any nerves or veins. They drill into the bone and insert a specialized nail. They guide the nail up into the bone towards the fracture site (where the bone is broken) using an X-ray.
If the tip of the radial bone is too out of place, the doctor may use traction or apply pressure to get it back in position. If this doesn’t work, they might use a wire to guide the bone back into place.
Once the bone is back in place, the doctor secures it with the nail. The nail is then cut and smoothened so it won’t irritate the surrounding skin or nerves. The wound is then closed.
Open Reduction
If the closed methods don’t work, the doctor might need to use the open reduction. For this, they make a larger incision over the affected arm. They navigate carefully to the radial bone, and if needed, they open the joint capsule (a tough structure that surrounds joints). They then manipulate the radial head (the top of the radius bone) with the wire or a dental hook. They then secure the head with the nail and close the wound.
Open Reduction Techniques- K-wire Fixation
This procedure is similar to the open reduction. But instead of a nail, the doctor uses K-wires to fix the bone in place. The wires are inserted into the bone and secured. They ensure that the wires are well-placed for stability and then close the wound.
The arm will need to be immobilized using a cast or a splint. After about a month, the doctor will remove the wires either in the office or in a simple surgery.
Possible Complications of Radial Neck Fracture Repair In A Child
Avascular necrosis (AVN) is a serious problem that can happen after a fracture (a break) in the neck of the radius, one of the bones in the forearm. This issue, which involves a loss of blood supply that makes bone tissue die off, may appear in 10% to 20% of these types of fractures. When the outer layer of bone (the periosteum) gets injured, the risk can go up to 70%, especially during a type of surgery called an open reduction that’s needed when the fracture is badly out of place.
Stiffness and a limited ability to move the elbow can be a tough problem to handle. So, to avoid this, it’s key to help patients start moving the area as soon as possible. For children, one simple and safe way is to teach them how to use their other arm to help the injured one move.
Other issues can come from the fractured bone healing in the wrong position (malunion) or not healing together at all (non-union). These problems point to the importance of getting the bone lined up correctly after a fracture. Each patient is unique, so treatment for these issues should be customized based on what’s happening with them, like what signs they’re showing, what symptoms they have, and how they’re able to function.
Another condition called radioulnar synostosis might come up as well. This issue happens when the radius bone fuses together with the ulna, the other bone in the forearm. It can limit the arm’s ability to turn and cause it to shorten. It’s more likely when treatment gets delayed or if the surgeon has to do a lot of work during an open reduction. A type of surgery called an osteotomy can be used to treat this issue so that the arm works better.
Lastly, compartment syndrome is a possible complication after surgery. This problem, which is when pressure builds up and causes serious damage inside the muscles, can happen quickly and may be hard to spot in kids. It should be suspected if a child’s pain is getting worse or isn’t relieved by strong painkillers. If doctors confirm that a child has compartment syndrome, they will have to do a surgical procedure called a fasciotomy right away. This surgery is performed to relieve the pressure and prevent permanent damage.
What Else Should I Know About Radial Neck Fracture Repair In A Child?
Doctors will first try to treat radial neck fractures – which occur near the elbow – in a minimally invasive way, such as closed reduction. This means they will manually move the bone back into place without cutting into the skin. However, if this isn’t successful, they may need to perform a procedure called open reduction, which involves surgically exposing the bone to fix it into place. The doctor will be very careful during this procedure to avoid damaging the fragile tissue covering the bone (the periosteum) and to keep the bone’s blood supply intact.
The potential downside to open reduction is that it can sometimes lead to more complications, such as loss of function in the arm, avascular necrosis (a condition in which bone tissue dies due to a lack of blood supply), and synostosis (when two bones that are supposed to move independently become fused together).
Keep in mind that not every fracture requires this kind of intervention. If the bone fracture is minor and the pieces of bone have not moved far out of place, a conservative approach with rest, immobilization, and pain management may be the best option.
