Radial neck fractures are common in children, and a number of anatomic considerations guide orthopedic management. First, due to the relatively constrained morphology of the proximal radioulnar joint (PRUJ), excessive angulation or displacement may cause limitations in forearm rotation (Fig. 4-1). Second, given the proximity of these injuries to the adjacent radiocapitellar joint, marked displacement may result in static or dynamic radiocapitellar instability. In addition, as there are no direct ligamentous or muscular attachments to the radial head/neck, closed reduction maneuvers may be challenging, and open approaches to the proximal radial epiphysis carry the risk of osteonecrosis. Finally, due to the relatively minor contribution of the proximal physis to the longitudinal growth of the radius, remodeling potential is limited, and therefore, careful consideration of radiographic alignment is needed.

Fractures are classified according to anatomic location, displacement, and angulation. Chambers, O’Brien, and Judet have previously classified these fractures into three categories (Table 4-1). At present, surgical indications include fractures with excessive angulation and/or displacement resulting in joint instability or functional loss of forearm rotation that will not be expected to remodel with continued skeletal growth. In general, injuries with greater than 30 degrees angulation or 3 mm translation merit reduction with or without stabilization.

There are challenges associated with surgical treatment. Historic literature suggests that open and more invasive approaches to radial neck fractures are associated with worse clinical results. Therefore, rather than think about contraindications to surgery, perhaps it is best to maximize non-operative treatment unless there is a contraindication to nonsurgical care.