Introduction
Radial head fractures (RHF) account for less than 1% of all paediatric fractures. Most heal without complications following a 10-14 days course in a long arm cast applied without manipulation. Concomitant fractures occur in 20% to 34% of cases and affect the management, which vary greatly in published series. The most severe complication of RHF is a necrosis of the head. A critical appraisal of the management of this rare injury is of great value to evaluate the quality of care. The aims of this study were to assess the treatment modalities, complications and outcome of children with RHF treated in our institution.
Patients and Methods
Retrospective review of all paediatric RHF treated in a tertiary paediatric medical centre between the 1st of January 2011 and the 31st of December 2014. Collected data included age, gender, side of injury, time of immobilisation and concomitant fracture. Treatment modalities including in situ cast immobilisation, closed reduction, percutaneous reduction and open reduction were recorded. The degree of displacement was measured using the modified Judet and the AO classifications. Final functional outcome and radiographs were analysed, looking for mal- or non-union radial head necrosis, or radio-ulnar synostosis. The immobilisation time, number of concomitant fracture and type of different treatment methods were assessed. Complications and final range of motion were evaluated. The results were compared to the literature as well as the current guidelines of the University Hospital of Lausanne (CHUV).
Results
Out of 54 identified cases, 47 were included in the study. The mean age of the patients was 7 years (y) 10 months (m) (2y3m - 12y5m). Judet 1,2,3 and 4 fractures were identified in 31 (66%), 3 (6%), 7 (15%) and 6 (13%) cases, respectively. A concomitant fracture was identified in 28% of the cases. Girls had twice as many concomitant fractures than boys. 100% of Judet 1 single fractures were treated with a cast and had an excellent outcome. Half the Judet 4 fractures were treated with closed reduction without any significant difference in the functional outcome when compared to the surgically treated. Almost half of the Judet 3 and 4 fractures (n=13) were treated using flexible elastic nails (ESIN). Open reduction was required in less than 10% of the cases. The mean immobilisation time of patients treated without surgery was of 18.5 days, compared to 25 days for the surgically treated. Complications were identified in 6 cases. No radial head necrosis occurred.
Conclusion
Paediatric RHF were immobilised too long, with presenting a 4 days excess of immobilisation time when compared to the current literature and the guidelines of the HEL.
Almost a third of all patients had concomitant fractures which were not related to the degree of displacement. In this study twice as many girls had concomitant fractures compared to boys. It is recommended to research concomitant fractures systematically. At HEL the open reduction was rarely needed. Few complications were seen in both, conservatively treated and operatively treated patients, but were more commonly seen after operative management. Regardless of the treatment method used no radial head necrosis was recorded.
The management of RHF in our institution was adequate when compared to the literature. Children with simple radial head fracture treated in our institution would further benefit from a shorter immobilisation time while there is no increase of complications or functional loss.