Computer-Assisted Corrective Osteotomy of Malunited Pediatric Radial Neck Fractures-Three-Dimensional Postoperative Accuracy and Clinical Outcome

Opening Wedge Osteotomy for the Treatment of Pediatric Radial Neck Malunion and Anterior Radiocapitellar Dislocation: A Case Report

Radial neck fractures are common injuries of the elbow in the pediatric patient. Surgical intervention is recommended for significant angulation and displacement or mechanical blocks to motion. Radial neck malunion is a rare complication and may result in altered joint mechanics and, if severe, joint incongruency. Dislocation of the radial head has yet to be reported in this population after radial neck malunion. Treatment for radial neck malunions with dislocation varies and can include radial head excision or radial neck osteotomy. Outcomes after radial neck osteotomy is limited to case reports and small cases series. We present a case report of pediatric patient with radial neck malunion and anterior radiocapitellar dislocation treated with joint realignment via opening wedge osteotomy. To our knowledge, this is the first report of a pediatric case with radial head dislocation secondary to neck malunion and the first described report using this technique.

Corrective Osteotomy for Symptomatic Radial Head and Neck Malunions in the Skeletally Immature

BACKGROUND

Radial head and neck fracture malunion can lead to pain, stiffness, deformity, and functional limitations. This study analyzed the early radiographic and functional outcomes of corrective osteotomy for symptomatic radial head and/or neck malunion in skeletally immature patients.

METHODS

Thirteen pediatric patients treated with corrective osteotomy for symptomatic radial head and/or neck malunion from 2004 to 2018 were identified. Radiographic union, range of motion, pain, and complications were recorded. Functional outcomes were assessed using the Broberg and Morrey Elbow Scale.

RESULTS

The average age at the time of surgery was 12.3 years (range: 8.6 to 16.3). The mean time from injury to osteotomy was 7.5 months (range: 2 to 24.1 mo). Before osteotomy, mean radial head-shaft angulation was 23 degrees (range: 5 to 57 degrees), mean displacement was 76% (range: 0 to 55), average elbow flexion contracture was 18 degrees (range: 0 to 60 degrees), and average elbow flexion was 112 degrees (range: 95 to 135 degrees). After a mean follow-up of 14.3 months, 12 of 13 osteotomies (92%) healed; 1 patient had a painless nonunion. The number of patients reporting pain decreased from 9 to 2 ( P =0.012). Radiographic alignment and range of motion improved in all patients. Mean angulation and displacement improved to 8 degrees (range: 2 to 15 degrees, P =0.001) and 3% (range: 0 to 18 degrees, P =0.001), respectively. Mean elbow flexion contracture was reduced to 5 degrees (range: 0 to 30 degrees, P =0.008), and the average elbow flexion increased to 128 degrees (range: 100 to 135 degrees, P <0.001). Three patients underwent implant removal for complications, including heterotopic ossification and avascular necrosis. Physeal arrest did not lead to any adverse sequelae. The sole case of avascular necrosis had a reduced range of motion but no pain. The mean postoperative Broberg and Morrey score was 91.1; 7 patients had excellent postoperative scores, 4 good, and 2 fair.

CONCLUSIONS

Corrective osteotomy for symptomatic malunion of the radial head and/or neck in skeletally immature patients can improve elbow alignment, motion, pain, and function. Preservation of the soft-tissue attachments to the proximal epiphysis and rigid internal fixation are critical components of this surgical technique.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Ultrasonography-Guided Combination with Elbow Arthrography-Assisted Minimally Invasive Treatment of Radial Neck Fractures in Young Children

Background

A radius neck fracture in children is a common fracture that not only affects the growth and development of children but also has a certain impact on the function of children's elbow joints.

Objective

To probe into the application value of ultrasonography- (US-) guided combination with elbow arthrography in the minimally invasive treatment of radial neck fractures in young children, summarize its clinical effect and provide a minimally invasive, safe, effective, and reliable method for treating radial neck fractures in young children.

Methods

Seventy-three patients with type III or IV radial neck fractures were treated from June 2013 to December 2020 and were divided into the Métaizeau group (n = 31, treatment group) and Kirschner wire (k-wire) k-wire group (n = 42, control group). The Métaizeau group was given US-guided combination with elbow arthrography-assisted modified Métaizeau technique, the k-wire group received open reduction and internal fixation with k-wire and compared the surgical effect of the two groups.

Results

In comparison with the k-wire group, time of operation, intraoperative bleeding volume, and hospital stay were signally junior to those in the Métaizeau group (P < 0.05). After surgery, in comparison with the k-wire group, the number of degrees to contralateral flexion or forearm rotation was visually lower in the Métaizeau group (P < 0.05), and postoperative complication incidence in the Métaizeau group was visually lower than that in k-wire group (P < 0.05).

Conclusion

In the minimally invasive treatment of radial neck fractures, US-guided combination with elbow arthrography in young children has better efficacy and high safety. It can be widely promoted and applied clinically.

Diagnosis, treatment and complications of radial head and neck fractures in the pediatric patient

Radial head and neck fractures represent up to 14% of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient. In up to 39% of proximal radius fractures, there is a concomitant fracture, which can easily be overlooked on the initial standard radiographs. The treatment options for proximal radius fractures in children range from non-surgical treatment, such as immobilization alone and closed reduction followed by immobilization, to more invasive options, including closed reduction with percutaneous pinning and open reduction with internal fixation. The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient; an angulation of less than 30 degrees and translation of less than 50% is generally accepted, whereas a higher degree of displacement is considered an indication for surgical intervention. Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures, range of motion and complications compared to severely displaced fractures requiring surgical intervention. With proper management, good to excellent results are achieved in most cases, and long-term sequelae are rare. However, severe complications do occur, including radio-ulnar synostosis, osteonecrosis, rotational impairment, and premature physeal closure with a malformation of the radial head as a result, especially after more invasive procedures. Adequate follow-up is therefore warranted.

Physeal bar resection using a patient-specific guide with intramedullary endoscopic assistance for partial physeal arrest of the distal radius

The partial physeal arrest of the distal radius could result in progressive deformities and functional problems of the wrist. Despite being the most preferred surgical intervention, physeal bar resection (Langenskiöld procedure) is technically demanding. This manuscript aims to illustrate the technical tricks and present an illustrative case of premature physeal arrest of the distal radius managed with a novel method for the Langenskiöld procedure, involving complete removal of the bar using a patient-specific guide in combination with an intramedullary endoscopy technique that facilitated direct observation.