The document discusses the treatment of radial head and neck fractures in pediatric patients, which are relatively common injuries usually resulting from a valgus force. Both non-operative and operative treatments are described depending on the degree of fracture displacement and angulation, with closed reduction and percutaneous pinning using the Metaizeau technique highlighted as a good operative option that can achieve good results. Factors influencing treatment and outcome include the size of fracture fragments, integrity of the articular surface, presence of intra-articular fragments, and the angle between the radial neck and shaft.

1. ‫بما‬ ‫انفعني‬ ‫اللهم‬
‫علمتني‬
‫ينفعني‬ ‫ما‬ ‫وعلمني‬
‫علما‬ ‫وزدني‬

9. Radial Head and Neck Fractures - Pediatric
•relatively common
•Salter Harris II fractures and generally occur after a valgus load
•9-10 years of age.
•2-5% of all fractures and about 10-15% of elbow fractures
•Diagnosis - plain radiographs of the elbow.
•Treatment can be nonoperative or operative depending on the
degree of angulation, translation and displacement.

11. The treatment and outcome depend on :
the size of the fracture fragments,
the integrity of the articular surface ,
intra-articular fragment and the angle between radial neck and radial
shaft.
angle Treatment
less than 30 degrees angulation, without
displacement
Conservatively (long arm cast or splint) no need for any manipulation
more than 30 degrees angulation manipulation under general anesthesia to achieve a better alignment is
recommended
over 60 degrees angulation or excessive
displacement
Surgery performed to ensure adequate reduction
percutaneously inserted K-wire under fluoroscopic control
closed reduction and percutaneous pinning failed, open reduction
is recommended
good results have been achieved with closed reduction and
intramedullary pinning (CIMP) technique reported by Metaizeau

14. Metaizeau technique
JEAN-PAUL METAIZEAU

17. •1.5-2.5 and occasionally 3.0 mm elastic nails
• Use small scissors or a surgical clip and small
retractors to dissect to the bone under direct vision.
• Note: Avoid injury to the superficial radial nerve
and the cephalic vein.
• Place the awl or drill directly onto the bone and
perforate the near cortex, under direct vision,
perpendicular to the bone.
• Do not hammer the awl to avoid perforation of the
far cortex.
• When the medullary canal is reached, lower the
awl or drill 45° to the shaft axis and advance it with
oscillating movements to produce an oblique canal.
•

18. Precontour the first 5 cm of the nail as this enhances
reduction of the displaced radial head.
Produce a sharp tip by cutting the inner end of the nail.
This facilitates entry into the hard bone of the epiphysis.
The manufactured blunt end will displace the radial head.
Some surgeons prefer to use a sharp K-wire with a bent tip.
Fix the nail into the inserter and pass it into the canal.

19. Pearl: insertion of nail tip perpendicular to
shaft
Insert the nail with the tip perpendicular to the
shaft axis until the far cortex is felt . Rotate the
nail 180° and advance it using the curved side of
the tip as a gliding aid.
If the tip is stuck in the far cortex and cannot
be advanced, remove the nail and bend the
tip to give a slightly more pronounced
curvature.

20. Pitfall: iatrogenic fracture
In young children, the nail tip may become stuck
because of the narrow medullary canal.
Do not use a hammer if the nail is stuck as this
risks iatrogenic fracture.
Withdraw by 2 cm, rotate the nail to free the tip
and continue advancing.

21. Advance the nail to the fracture site with an
oscillating maneuver.
Pearl: A short working length (3-5 cm) between
the entry point and the inserter improves control
of the nail during insertion.

22. Orientation of forearm and nail
Rotate the arm to obtain the maximal displacement of the neck fracture on the image intensifier.
Point the nail tip to the head fragment.

23. Manual reduction
If the radial head displacement does
not allow the nail tip to be advanced
into the head, try partial reduction of
the head by traction and/or manual
pressure under varus stress and/or
pro- and supination.
If this is not successful remove the
radial nail and recontour the first 3-4
cm with a more pronounced bend
and reinsert it.

24. Percutaneous K-wire reduction
If manual reduction and recontouring
is not successful, use the blunt end
of a large percutaneous K-wire (3
mm) to push the radial head into a
partially reduced position. Pushing
with the sharp end or levering in the
fracture may injure the blood supply.
Use a stab incision in the skin to
avoid pressure necrosis.

25. joystick reduction
If reduction with the blunt end is not successful (eg
fragment too small) insert the sharp tip carefully into
the epiphysis and reduce the fragment with the K-
wire as a joystick.
Pitfall: K-wire as lever arm
To preserve the critical blood supply do not use the K-wire
as a lever arm.

26. Open reduction
Proceed with open reduction if:
•Radial head is grossly displaced
•Image intensifier unavailable
A or
a may
be used. This is associated with a
high risk of disruption of the
remaining blood supply.
Protect the remaining periosteum
throughout the reduction
maneuvers.

27. Following partial reduction, advance the nail into the
head.
Disimpact the head with gentle hammer blows to the
nail end to free the impacted annular ligament.
Turn the nail clockwise (right arm) or
counterclockwise (left arm) to anatomically reduce
the head.
If a reduction is not anatomical, withdraw the nail tip
to the metaphysis, turn it back to the initial position,
advance it and repeat the reduction maneuver.
This correction should only be performed once.
. A sharpened tip is helpful to fix the nail in the final
position.
Pearl: If the ossification center is not visible on a normal x-ray, an arthrogram may be performed .

28. when using the lateral entry point, cut the nail near
the bone.
If a dedicated nail cutter is not available, cut the nail
slightly shorter as the end will be sharper and this
prevents skin perforation.
Gently withdraw the nail by 1 cm.
The risk of redisplacement is low because of the
pressure of the radial head on the capitellum.
Cut the nail outside the skin and reinsert to the
original position with an impactor.
Ensure that the nail tip does not irritate the
superficial radial nerve.
When using the dorsal entry point, the nail should
be left long or protected with small end cap to
prevent rupture of the extensor pollicis longus.