1. Definition & Key Points
Fractures of the proximal radius in skeletally immature patients, most often involving the radial neck (metaphysis) rather than the articular surface.
Considered pediatric elbow trauma; majority are extra-articular, with true intra-articular radial head fractures being rare before physeal closure.
Management choice (nonoperative vs operative) is primarily based on angulation, translation, rotation, patient age, and associated injuries.
2. Epidemiology
Account for 5–10% of all pediatric elbow fractures and about 1% of all pediatric fractures.
Peak age: 9–10 years; no consistent sex predominance.
In many series, radial neck fractures constitute the majority of proximal radius injuries in children.
3. Relevant Anatomy & Biomechanics
· Elbow ossification centers (CRITOE): Capitellum, Radius, Internal (medial epicondyle), Trochlea, Olecranon, External (lateral epicondyle).
· Radial head ossification:
o Appears around 3–5 years, may be bipartite.
o Fuses with radial shaft at 16–18 years.
· Annular ligament:
o Continuation of joint capsule, drapes over epiphysis and physis.
o Protects physis but creates a stress riser at the metaphysis, so fractures preferentially occur at the neck.
· Blood supply: largely from the metaphysis → aggressive dissection & open reduction risk osteonecrosis.
4. Mechanism & Associated Injuries
Mechanism:
Extension + valgus load on an outstretched elbow is classic.
Less commonly associated with elbow dislocation or Monteggia variants.
Associated injuries (must be actively excluded):
Elbow dislocation.
Olecranon fracture.
Medial epicondyle fracture.
Forearm compartment syndrome (rare but serious).
5. Clinical Presentation
Symptoms:
Lateral elbow pain and tenderness over radial head/neck.
Refusal to move the elbow; pain with forearm rotation (pronation–supination) is very typical.
Physical exam:
Lateral swelling, sometimes minimal deformity.
Pain increased by passive rotation; flexion/extension may be less painful.
Neurovascular exam: specifically assess radial, median, ulnar nerves; check compartments (especially if high-energy trauma).
6. Imaging
Standard radiographs:
AP and lateral of the elbow.
Assess:
Radiocapitellar line: line along radial shaft axis should intersect capitellum on all views (not fully reliable in very young children).
Lateral humeral line: tangent to lateral condyle, lies lateral to radial neck in normal elbows; may be more reliable in younger children to assess alignment.
Look for:
Subtle metaphyseal fracture lines at neck.
Radial head tilt / translation, rotation.
Posterior or anterior fat pad sign (note: partial extra-articular location of radial neck → effusion may be absent).
Special view:
Radiocapitellar (Greenspan) view: oblique lateral with beam angled 45° proximally to better visualize radial head.
CT:
Reserved for older children with comminuted intra-articular head fractures and for preoperative planning.
MRI:
Rarely needed; may help in a pre-ossified elbow or for occult compression fractures and ligamentous injury; cost vs benefit must be considered.
7. Classification
O’Brien classification (angulation of radial neck)
Type I: <30° angulation.
Type II: 30–60°.
Type III: >60°.
Judet classification
I: Undisplaced.
II: <30° angulation.
III: 30–60°.
IVa: 60–80°.
IVb: >80°.
Chambers classification (by primary displacement & mechanism – less used clinically).
Treatment algorithms and prognostic studies generally use angulation + translation + age rather than pure fracture type.
8. Treatment Principles
Aim: restore radiocapitellar alignment, preserve motion, avoid iatrogenic damage (especially osteonecrosis and synostosis).
General rules:
Less invasive first (closed reduction, percutaneous techniques) whenever acceptable reduction can be obtained.
Avoid open reduction unless absolutely necessary; strongly associated with higher rates of stiffness, osteonecrosis, and synostosis.
9. Nonoperative Management
Immobilization alone (no reduction)
Indications (commonly accepted):
Angulation <30°.
Translation <3 mm.
Satisfactory motion (no gross mechanical block).
Reliable follow-up and no significant associated injuries.
Technique:
Long arm cast or splint, elbow 90° flexion, forearm neutral or slight supination.
Immobilization 7–21 days, then early active ROM.
Outcomes:
Systematic review data show excellent ROM and function for fractures with post-treatment angulation ≤20–30° treated conservatively; greater angulation correlates with loss of motion.
Closed reduction + immobilization (no internal fixation)
Indications:
Initial angulation >30° where acceptable reduction (<30° and <3 mm translation) can be achieved by manipulation alone.
Maneuvers:
Patterson maneuver (traction, varus, direct pressure on radial head).
Israeli (Kaufman) technique (flexion 90°, pronation with pressure on head).
Neher–Torch technique (traction, varus, radial head manipulation)
Elastic bandage (Esmarch) method (application wrist to elbow, spontaneous reduction)
Key point: reassess with fluoroscopy; avoid repeated forceful manipulations that risk AVN.
10. Operative Management
Closed reduction and percutaneous fixation (CRPP / ESIN)
Indications:
Residual angulation >30° after closed reduction.
Translation >3–4 mm.
Pronation/supination arc <45° due to block.
Techniques:
K-wire “joystick” (push or lever technique) from proximal or distal metaphysis to correct tilt and translation; wires may be left as fixation.
Metaizeau technique (ESIN): retrograde flexible nail inserted from distal radius, advanced across fracture; rotation of nail used to lever head into alignment, nail left for internal fixation.
Evidence:
JPOSNA and systematic reviews emphasize CRPP/Metaizeau as preferred for significantly angulated yet reducible fractures, with good ROM and lower complication rates versus open reduction.
Recent series suggest faster ossification and earlier radiographic healing with Metaizeau vs K-wire fixation, though functional differences may be modest.
Open reduction ± internal fixation (ORIF)
Indications (when all closed / percutaneous methods fail):
Residual angulation >45°.
Inability to obtain or maintain satisfactory alignment with closed/percutaneous techniques.
Irreducible fracture, often due to interposed tissue or severe displacement/comminution.
Principles:
Lateral approach to radiocapitellar joint.
Pronate forearm to move PIN away from surgical field.
Gentle handling, minimal periosteal stripping; avoid transcapitellar pins when possible.
Outcomes:
Consistently associated with higher rates of stiffness, osteonecrosis (up to ~70% of AVN cases), synostosis, and need for revision compared with closed techniques—partly reflecting more severe fracture patterns.
11. Complications
Loss of motion / stiffness
Most common complication (reported ~10–30% in many series). Loss of pronation is more frequent than loss of supination.
Radial head overgrowth
Radiographic enlargement or irregularity in 20–40% of cases; usually no functional consequence.
Osteonecrosis (AVN) of radial head
Occurs in ~10–20% overall; majority associated with open reduction and severe displacement.
Physeal arrest / growth disturbance
May lead to cubitus valgus deformity and elbow incongruity.
Radioulnar synostosis
Serious but rare; associated with extensive dissection, delayed treatment, and open reduction with interosseous scarring.
PIN palsy
May occur after surgical manipulation or pinning; up to ~15% transient deficits reported, usually neuropraxia.
Malunion / chronic instability
Malunited intra-articular fractures can lead to radiocapitellar incongruity, chronic pain, mechanical symptoms, and degenerative change.
12. Prognostic Factors
Worse prognosis associated with:
Age >10 years.
Higher Judet/O’Brien grade (greater angulation/displacement).
Intra-articular head involvement vs extra-articular neck fractures.
Associated injuries (olecranon, medial epicondyle, elbow dislocation, Monteggia).
Need for open reduction and extensive dissection.
Key positive factors:
Successful closed or percutaneous reduction to ≤20–30° angulation and minimal translation.
Early motion after stable fixation, within safe window.
References
1- Langenberg LC, van den Ende KIM, Reijman M, Boersen GJJ, Colaris JW. Pediatric Radial Neck Fractures: A Systematic Review Regarding the Influence of Fracture Treatment on Elbow Function. Children (Basel). 2022;9(7):1049. Published 2022 Jul 14. doi:10.3390/children9071049
2- Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999;8(2):93-99.
3- Tan BH, Mahadev A. Radial neck fractures in children. J Orthop Surg (Hong Kong). 2011;19(2):209-212. doi:10.1177/230949901101900216
4- Kalbitz M, Lackner I, Perl M, Pressmar J. Radial head and neck fractures in children and adolescents. Front Pediatr. 2023;10:988372. Published 2023 Jan 20. doi:10.3389/fped.2022.988372
5- Meng H, Li M, Jie Q, Wu Y. Effect analysis of different methods on radial neck fracture in children. Sci Rep. 2023;13(1):1181. Published 2023 Jan 21. doi:10.1038/s41598-023-28294-9
6- Stöckell M, Lampio E, Sagstetter F, Sinikumpu J. Faster healing of radial neck fractures in children treated with the Metaizeau technique compared with percutaneous Kirschner wire fixation: a population-based study. BMC Musculoskelet Disord. 2025;26(1):624. Published 2025 Jul 4. doi:10.1186/s12891-025-08830-6