KIDS Broken Elbow
(Pediatric Radial Neck Fracture)
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related topics: broken arm, broken wrist, broken elbow, broken medial epicondyle, broken lateral condyle, broken forearm
What is a Pediatric Radial Neck Fracture (Broken Elbow)?
A radial neck fracture is a type of broken elbow commonly seen in kids.
To better understand the injury, lets take a quick look at the anatomy of our elbow and forearm. The radius bone is one of two bones in the forearm that join together with the arm bone (humerus) to form the elbow joint. The radial head is the portion of the bone that helps form the elbow.
A radial neck fracture can occur when you fall onto your elbow, or most commonly, when you fall onto an outstretched hand (and the force of impact is transmitted up the forearm to the elbow). Its an injury also commonly seen in adults (but slightly different, see talk).
Diagnosing a Pediatric Radial Neck Fracture:
Kids will report pain along the outside of the elbow and pain with elbow motion after falling onto their arm. Doctors that are suspicious for a broken elbow will order x-rays which not only diagnose the break, but are used by the doctors to determine the injury severity and plan treatment.
Treating a Pediatric Radial Neck Fracture:
Treatment depends on the severity of the break.
If the radial neck breaks and doesnt move out of position then it just needs to be protected with a hard splint for 1-2 weeks until healing is underway, and then the child can gradually begin using the arm again.
If the radial neck breaks and bends only a little (less than 30°) then the bone will remodel and become straight as it heals. Therefore this injury also just needs to be protected in a splint for 1-2 weeks.
However, If the bone is bent more than 30°, it needs a push (some help to straighten it). So the child should be sedated and the bone is straightened by pushing on the elbow with certain time-honored techniques (called the Israeli or Pattern maneuver). If it still cannot straighten to less than 30°, then surgery is required to bring the bone into better alignment. Usually a pin is used to give the broken bone an extra little push (or sometimes a pin is threaded down the center of the bone to move the broken bone back into position, this is called the Metaizeau technique) .
Other indications for surgery is if there is limited forearm rotation (sometimes a small chip of bone can block rotation) or if the broken fragment has shifted >3-4 mm.
Once re-aligned the broken bone usually stays in place with just a elbow splint, and no pins are needed to hold it. After two weeks in a splint, range of motion activities can be begin.
What is the long term outcome?
Overall these fractures heal very well and kids return to normal (or near normal) function.
Sometimes there is a mild loss of forearm rotation (especially rotation your palm to the floor, called pronation). However this rarely has any affect on function.
In more severe injuries, especially those that require surgery, doctors worry about damage to the bone's blood supply. Even though our bones are covered in calcium, bones are not like rocks but rather like a sturdy oak tree that is hard but still needs water from its roots to survive. In the same way, bones require nutrients from our bloodstream. Therefore, any injury that damages this blood supply can cause permanent injury to the bone. This is a real concern for radial neck fractures in kids.
In cases that dont require any surgery or surgery that uses a pin to push the bone back into place, the risk of injuring the blood supply is about 10%. However, in cases that need more extensive surgery (like making a full incision near the break) have a high risk of injury to blood supply (up to 70%). Therefore, doctors will spend a lot of time carefully repositioning the bone so that no open surgery is required.
References
1) Steinberg EL et al. Radial head and neck fractures in children. J Ped Ortho 1988; 8: 35-40. full article.
2) Metaizeau JP et al. Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Ped Ortho 1993; 13: 355-60. full article. classic technique.
3) Dormans JP, Rang M. Fractures of the olecranon and radial neck in children. Ortho Clin North Am 1990. 21: 257-68. full article.
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