72.16 Fracture of the neck of the radius (children)

A child falls on his outstretched hand and breaks the neck of his radius just distal to the epiphyseal plate, proximal to the attachment of his biceps. The head of his radius angulates anteriorly and laterally on its broken neck, and usually remains attached to the shaft. The same injury may fracture his medial epicondyle, strain or rupture the medial ligament of his elbow, or fracture the upper third of his ulna.

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Figure 72.23: REDUCING A DISPLACEMENT OF THE NECK OF THE RADIUS. Treatment depends on the degree of angulation and on the child’s age. Mild angulation needs no treatment, but moderate and severe angulation must be corrected. Closed reduction like this usually succeeds.

The contour of his elbow is normal, and flexion and extension are less painful than rotation.

This injury can occur before the centre of ossification appears in the head of his radius at the age of 10. If it does, the only X–ray sign of a complete displacement of the head of his radius is this: the proximal end of his radius is closer to the lower end of his humerus on the injured side than it is on the normal one. If so, refer him.

Treatment depends on the degree of angulation and on the child’s age. Mild angulation needs no treatment. Moderate and severe angulation must be corrected, because the head may grow abnormally and ultimately dislocate, particularly after severe displacement in an older child. In very young children the head may grow almost normally, even after severe displacement. Never excise the head, because this is sure to cause a severe growth deformity.

FRACTURE OF THE NECK OF THE RADIUS

CHOICE OF PROCEDURE The following indications refer to angulation in the AP or the lateral view.

If the head is angulated less than 15 $\ensuremath{^\circ }$ , put the child’s arm in a sling for 10 days. Recovery will be complete.

If the angulation is more than 15 $\ensuremath{^\circ }$ , try closed reduction, as described below. This may succeed even if the head is severely displaced.

If the child’s elbow is also dislocated, reduce it and then treat the head of his radius.

If the head of the radius is completely separated (see above), refer him for open reduction.

CLOSED REDUCTION If the child’s elbow is very swollen, suspend his arm in extension traction (Fig. 72-11), until the swelling his reduced.

Anaesthetize him, and ask an assistant to steady his upper arm. Extend his arm, grasp his wrist with one hand, and his elbow with the other, as in Fig. 72-23. Adduct his forearm at his elbow (1), so as to open the joint between his capitulum and the head of his radius a little.

Rotate his forearm (2) into the position in which the most prominent part of the displaced head lies laterally and superficially.

Put your thumb over the displaced head of his radius. While you adduct his forearm, press the head of his radius proximally and medially (3). Now flex his forearm and supinate it sharply (4).

If closed reduction fails to reduce the angulation to 15 $\ensuremath{^\circ }$ or less, refer him for open reduction. If this is not possible, the head of his radius may remodel if he is young, so proceed with active movements only.

POST REDUCTION X–RAYS in the lateral view the forward angulation of the head should be corrected, and in the AP view the lateral angulatIon should also be corrected. In both views the surface of the head of the child’s radius should be parallel to his capitulum.

POSTOPERATIVE CARE Bandage on a plaster backslab extending two thirds of the way around his arm. After 3 weeks replace it by a collar and cuff for another 3 weeks.