5: Radial Head/Neck Fracture: Closed Reduction, Percutaneous Reduction, and Open Reduction

Radial Head/Neck Fracture

Closed Reduction, Percutaneous Reduction, and Open Reduction

Sameer Badarudeen, Robert M. Bernstein and Saul M. Bernstein

Indications

Depending upon the extend of fracture displacement and angulation, there might be better indications for each of the three different techniques: closed reduction, percutaneous reduction, and open reduction.

Closed reduction indications: Fractures with displacement greater than 2 mm or lateral angulation greater than 20–30°.

Percutaneous reduction indications: Fractures with displacement greater than 2 mm or fractures with lateral angulation greater than 20–30° that are not reducible by closed method.

Open reduction indications: Fractures with displacement greater than 2 mm or fractures with lateral angulation greater than 20–30° that are not reducible by closed or percutaneous methods. Also, reversal of the radial head (180° rotation) is an indication for open reduction.

Pitfalls

• Reversal of the radial head (180° rotation) is a contraindication for both closed and percutaneous reduction.

• Significant soft tissue edema or a mass is a contraindication for closed reduction.

• Localized infection (cellulitis, abscess) over the radial head is a contraindication for open reduction.

• Associated dislocation of the radial head fragment is a contraindication for closed reduction.

Controversies

• Radial neck angulation greater than 65° and completely displaced fractures may be difficult or impossible to reduce closed.

• Localized infection (cellulitis, abscess) over the radial head may complicate percutaneous reduction using Steinmann pin.

• Open reduction is only rarely needed since almost all radial head/neck fractures can be reduced by closed or percutaneous means.

Examination/Imaging

Neurovascular examination (posterior interosseous nerve)

Orthogonal radiographs of the radial head and elbow joint

• Figure 1 is a radiograph showing fracture of the neck of the radius that could be treated with closed reduction or percutaneous reduction.

FIGURE 1

• Figures 2 and 3 are radiographs of a fracture of the neck of the radius with complete dislocation that may be difficult to reduce closed.

FIGURE 2

FIGURE 3

Arthrogram in children in whom the radial head secondary center has not yet ossified

Treatment Options

• Acceptance of position

• Closed reduction

• Percutaneous reduction with a Steinmann pin

• Open reduction

Surgical Anatomy

The radial head and neck are subcutaneous on the lateral side of the elbow, just distal to the lateral epicondyle.

The posterior interosseous nerve penetrates the supinator muscle just distal to the radial neck and may lie directly upon the bone (Fig. 4).

FIGURE 4

Figure 5 depicts the surface anatomy of the posterior interosseous nerve in relation to the radial neck.

FIGURE 5

Closed Reduction

Positioning

The patient is placed in the supine position on the table with the armboard at the ipsilateral head, folded in, to act as a headboard extension.

The elbow is positioned over the fluoroscopic receiver (C-arm) (Fig. 6).

FIGURE 6

The surgical assistant should stand at the ipsilateral head of the table, stabilizing the distal humerus.

Figure 7 depicts the authors’ preferred set up of the operating room for a “left” radial neck fracture, with the armboard and C-arm on the same side and the monitor on the opposite side of the table.

FIGURE 7

Pearls

• Place the armboard on the ipsilateral side at the patient’s head, folded up to the table, to allow room for the C-arm.

• Position the C-arm with the receiver acting as a table, perpendicular to the table on the ipsilateral side (between the surgeon and assistant).

• Place the monitor on the contralateral side of the table for easy viewing.

Pitfalls

• If the armboard is not placed at the head of the bed on the ipsilateral side, the patient’s head may slip off the table as the arm is manipulated over the C-arm.

Equipment

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Tags: Operative Techniques Pediatric Orthopaedic Surgery

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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