Radial Head and Neck Fractures: Operative Treatment

Indications

Malangulated or displaced proximal radial neck fracture that will result in malunion and subsequent impingement of radiocapitellar or proximal radioulnar joint(s)
CT and/or MRI scan is often required to assess operative indications and plans

Displaced Radial Neck Fracture

Surgical Options

Closed reduction
Percutaneous pin-assisted closed reduction
Closed reduction IM rodding
Open reduction internal fixation

Closed Reduction IM Rodding

See Figure 9-1.

Position

Supine with radiolucent hand table
Turn the OR table 90° and bring patient to the edge of the table so that elbow and entire forearm can be easily visualized with fluoroscopy
Tourniquet unsterile high in upper arm
Protect patient’s head and neck from displacement off the table during reduction and fixation with padded head protector or blankets and taping
Surgeon and assistant on opposite sides of the hand table
Fluoroscopy in line with operative arm and perpendicular to the patient’s body (Figure 9-3)

Figure 9-1 ▪ Case series of images of arthrographic-assisted closed reduction and IM TEIN fixation. (Reprinted with permission from Waters PM, Skaggs DL, Flynn JM. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia, PA: Wolters Kluwer Health; 2019.)

Equipment

Smooth K-wires
TEINs range from 1.5 to 2.7 mm on table
- Choose K-wire or flexible nail that occupies >50% <75% of radial canal at isthmus. Check with fluoroscopy when prepped and draped
Curved snap and freer elevator
Power drill
Bump made with two-folded towels
Fluoroscopy

Figure 9-2 ▪ Malaligned radiocapitellar joint that will lead to chronic impingement. (Reprinted with permission from Waters PM, Bae DS. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Wolters Kluwer Health; 2012.)

Figure 9-3 ▪ OR set up with image intensifier as table coming in from medial elbow so that lateral elbow is easy to access.

General Concept

Obtain fluoroscopic view in position of forearm rotation that shows maximal displacement
Reduce and hold radial head fragment on radial neck so that radiocapitellar and proximal radioulnar joint will be acceptably aligned with fixation
Options for reduction during IM rod passage include
- Percutaneous pin reduction
- Percutaneous freer elevator reduction
- IM rod insertion and twisting
  - most often required if you are using this technique

Flexible Nail Entry Distal Radius

Identify distal radial physis on fluoroscopy
Draw incision from just proximal to physis for ˜2 cm
Options are to enter
- Proximal to Lister’s tubercle
  - Puts EPL at risk
- Between second and third compartments
  - Puts radial sensory nerve at risk
  - Our preference due to late EPL ruptures from Lister’s entry site
Spread down to distal radius metaphysis while protecting extensor tendons and radial sensory nerve branches

Figure 9-4 ▪ Fluoroscopic extension table used in this case of retrograde IM nailing. Imaging at this stage is to size IM device to canal width.
Bring in fluoroscopy to confirm your desired entry position on radius (Figure 9-4).
Use soft tissue protection as you enter radial cortex
- Can use drill or awl to open it up
Prebend K-wire or elastic nail for easy passage and to allow for twisting reduction of radial head back on neck proximally
Pass K-wire or flexible nail, using small rotational motion while checking fluoroscopy (Figure 9-5)
- Be careful not to overpower passage with mallet leading to cortical penetration
Pass all the way up to the fracture site.