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Reconstruction of the proximal radius following radial neck non-union in a child
Injury Extra (2007) 38, 211—214
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CASE REPORT
Reconstruction of the proximal radius following radial neck non-union in a child S.D. Kaufman, M.B. Davies, M.J. Bell, J.A. Fernandes * Department of Paediatric Orthopaedics and Trauma Surgery, Sheffield Children’s Hospital NHS Trust, Western Bank, Sheffield S10 2TH, United Kingdom Accepted 12 September 2006
Introduction Non-union of childhood radial neck fractures is extremely rare. The aims of surgical management of non-union are to achieve bony union without incurring the post-operative complications of loss of function, physeal arrest and radioulnar synostosis. We report a case of radial neck non-union treated by autologous bone grafting stabilised with flexible intramedullary wire.
Case report A 9-year old boy was referred to our tertiary centre 1 year post-injury with an established non-union of his right dominant radial neck. At the time of the initial injury, he had sustained an angulated Salter—Harris II fracture of his radial neck that had been treated with open reduction and stabilisation with smooth Kirschner wires. At the time of referral, he was complaining of an increasing ache at the elbow but had little functional impairment. Examination revealed an increased carrying angle, almost full * Corresponding author. Tel.: +44 114 2717094; fax: +44 114 2717094. E-mail address: [email protected] (J.A. Fernandes).
range of movement, but radial drift of the wrist. Radiographs confirmed a non-union (Fig. 1) and suggestion of growth arrest of the proximal radial physis with positive ulnar variance at the wrist. Further fluoroscopic screening of the elbow was performed under anaesthesia revealing a pseudarthrosis of the radial neck with pronation—supination occurring at the pseudarthrosis. In order to relieve pain, restore the relative length of the radius and avoid both progressive radial drift of the wrist and cubitus valgus, the patient underwent surgical reconstruction of the proximal radius. A cylindrical strut of mid-shaft fibula was harvested subperiosteally from the patient’s right leg. Utilising the previous incision, the non-union was exposed; a synovial pseudarthrosis was identified and was subsequently excised. The proximal fragment was asymmetrically shaped near the physis. Consequently, little further debridement was performed in order to avoid further insult to the physis. Using the Metaizeau technique,1 a 2.5 mm wire was introduced into the radial medullary canal through a small incision over the distal metaphysis of the radius and passed proximally to the tip of the distal fragment. The strut graft was fashioned to fill the void left by the pseudarthrosis and inserted into this space. The wire was advanced through the strut graft and into the proximal fracture fragment with a good hold (Fig. 2). Clinically and
1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.09.012
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S.D. Kaufman et al.
Figure 1
Plain antero-posterior radiographs demonstrating the radial neck non-union.
radiographically the radius moved in continuity with an acceptable range of movement. He was immobilised in an above-elbow cast in full supination for 4 weeks post-operatively before commencing physiotherapy. The intramedullary wire was routinely removed 9 months later as migration was noted. Subsequent clinical and radiological assessment 18 months after reconstruction confirmed integrity of the radius during movement, although radiologically the bony contour of the union remains asymmetrical (Fig. 3). The child had no limitation of flexion or extension at the elbow and equal arcs of pronation and supination on the affected limb (Fig. 4) and no further increase in the carrying angle. The growth arrest is being monitored.
Discussion In paediatric radial neck fractures, the severity of the initial fracture angulation, open reduction techniques and the inadequacy of fixation method seem to be the most important factors contributing to the risk of non-union.4 Radial neck fractures account for 5— 10% of childhood elbow injuries but non-union is extremely uncommon, limited to isolated case reports and one series of nine cases.4 As a result of this, an accepted method of treatment for non-union of the radial neck has not been established. Rodriguez-Merchan proposed that non-operative management might be possible in asymptomatic individuals.3 The recognised technique of radial head excision as a
Figure 2 Per-operative image intensification images of the elbow demonstrating the interposition graft secured using the intramedullary wire.
Reconstruction of the proximal radius
213
Figure 3 Plain antero-posterior radiographs of the elbow after wire removal and 18 months post-reconstruction of the radial neck.
Figure 4 Clinical photographs demonstrating the postoperative arc of pronation—supination of the right elbow.
method of treatment in adults has also been described in a young child.2 However, this procedure will interfere with the growth potential of the radius, particularly in younger children. Waters and Stewart described open reduction and internal fixation with bone grafting in three cases of non-union.4 Despite achieving bony union, function was restricted in two cases and all three either developed persistent deformation of the radial head, physeal arrest, avascular necrosis or heterotopic ossification. Closed intramedullary pinning has been established as a primary treatment of childhood radial neck fractures.1 To our knowledge, the technique has not been utilised for surgical management of radial neck non-union. Use of autologous fibula as an interposition strut graft allowed restoration of radial length using bone of similar dimensions to the radius. In addition, fixation was achieved by intramedullary means, precluding the need for plating with its attendant problems of bony devascularisation from further periosteal stripping and the potential morbidity from metalwork removal. We believe that further growth discrepancy at the radial neck physis will be minimal as most growth occurs around the shoulder and wrist. Reciprocal growth of the capitellum will now be maintained as the radius is in continuity with loading of compression forces and development of valgus will be arrested. Therefore, we advocate reconstruction of radial neck non-union with fibular bone grafting in childhood and the Metaizeau technique seems to be a simple and effective technique with minimal complications.
214
References 1. Metaizeau JP, Lascombes J, Lemelle JL, Finlayson D, Prevot J. Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop 1993;13(3): 355—60. 2. Reidy JA, Van Gorder GW. Treatment of displacement of the proximal radial epiphysis. J Bone Joint Surg [Am] 1963;45: 1355—72.
S.D. Kaufman et al. 3. Rodriguez-Merchan EC. Displaced fractures of the head and neck of the radius in children: open reduction and temporary trans-articular internal fixation. Orthopaedics 1991;14:697— 700. 4. Waters PM, Stewart SL. Radial neck fracture non-union in children. J Pediatr Orthop 2001;21(5):570—6.
www.elsevier.com/locate/inext
CASE REPORT
Reconstruction of the proximal radius following radial neck non-union in a child S.D. Kaufman, M.B. Davies, M.J. Bell, J.A. Fernandes * Department of Paediatric Orthopaedics and Trauma Surgery, Sheffield Children’s Hospital NHS Trust, Western Bank, Sheffield S10 2TH, United Kingdom Accepted 12 September 2006
Introduction Non-union of childhood radial neck fractures is extremely rare. The aims of surgical management of non-union are to achieve bony union without incurring the post-operative complications of loss of function, physeal arrest and radioulnar synostosis. We report a case of radial neck non-union treated by autologous bone grafting stabilised with flexible intramedullary wire.
Case report A 9-year old boy was referred to our tertiary centre 1 year post-injury with an established non-union of his right dominant radial neck. At the time of the initial injury, he had sustained an angulated Salter—Harris II fracture of his radial neck that had been treated with open reduction and stabilisation with smooth Kirschner wires. At the time of referral, he was complaining of an increasing ache at the elbow but had little functional impairment. Examination revealed an increased carrying angle, almost full * Corresponding author. Tel.: +44 114 2717094; fax: +44 114 2717094. E-mail address: [email protected] (J.A. Fernandes).
range of movement, but radial drift of the wrist. Radiographs confirmed a non-union (Fig. 1) and suggestion of growth arrest of the proximal radial physis with positive ulnar variance at the wrist. Further fluoroscopic screening of the elbow was performed under anaesthesia revealing a pseudarthrosis of the radial neck with pronation—supination occurring at the pseudarthrosis. In order to relieve pain, restore the relative length of the radius and avoid both progressive radial drift of the wrist and cubitus valgus, the patient underwent surgical reconstruction of the proximal radius. A cylindrical strut of mid-shaft fibula was harvested subperiosteally from the patient’s right leg. Utilising the previous incision, the non-union was exposed; a synovial pseudarthrosis was identified and was subsequently excised. The proximal fragment was asymmetrically shaped near the physis. Consequently, little further debridement was performed in order to avoid further insult to the physis. Using the Metaizeau technique,1 a 2.5 mm wire was introduced into the radial medullary canal through a small incision over the distal metaphysis of the radius and passed proximally to the tip of the distal fragment. The strut graft was fashioned to fill the void left by the pseudarthrosis and inserted into this space. The wire was advanced through the strut graft and into the proximal fracture fragment with a good hold (Fig. 2). Clinically and
1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.09.012
212
S.D. Kaufman et al.
Figure 1
Plain antero-posterior radiographs demonstrating the radial neck non-union.
radiographically the radius moved in continuity with an acceptable range of movement. He was immobilised in an above-elbow cast in full supination for 4 weeks post-operatively before commencing physiotherapy. The intramedullary wire was routinely removed 9 months later as migration was noted. Subsequent clinical and radiological assessment 18 months after reconstruction confirmed integrity of the radius during movement, although radiologically the bony contour of the union remains asymmetrical (Fig. 3). The child had no limitation of flexion or extension at the elbow and equal arcs of pronation and supination on the affected limb (Fig. 4) and no further increase in the carrying angle. The growth arrest is being monitored.
Discussion In paediatric radial neck fractures, the severity of the initial fracture angulation, open reduction techniques and the inadequacy of fixation method seem to be the most important factors contributing to the risk of non-union.4 Radial neck fractures account for 5— 10% of childhood elbow injuries but non-union is extremely uncommon, limited to isolated case reports and one series of nine cases.4 As a result of this, an accepted method of treatment for non-union of the radial neck has not been established. Rodriguez-Merchan proposed that non-operative management might be possible in asymptomatic individuals.3 The recognised technique of radial head excision as a
Figure 2 Per-operative image intensification images of the elbow demonstrating the interposition graft secured using the intramedullary wire.
Reconstruction of the proximal radius
213
Figure 3 Plain antero-posterior radiographs of the elbow after wire removal and 18 months post-reconstruction of the radial neck.
Figure 4 Clinical photographs demonstrating the postoperative arc of pronation—supination of the right elbow.
method of treatment in adults has also been described in a young child.2 However, this procedure will interfere with the growth potential of the radius, particularly in younger children. Waters and Stewart described open reduction and internal fixation with bone grafting in three cases of non-union.4 Despite achieving bony union, function was restricted in two cases and all three either developed persistent deformation of the radial head, physeal arrest, avascular necrosis or heterotopic ossification. Closed intramedullary pinning has been established as a primary treatment of childhood radial neck fractures.1 To our knowledge, the technique has not been utilised for surgical management of radial neck non-union. Use of autologous fibula as an interposition strut graft allowed restoration of radial length using bone of similar dimensions to the radius. In addition, fixation was achieved by intramedullary means, precluding the need for plating with its attendant problems of bony devascularisation from further periosteal stripping and the potential morbidity from metalwork removal. We believe that further growth discrepancy at the radial neck physis will be minimal as most growth occurs around the shoulder and wrist. Reciprocal growth of the capitellum will now be maintained as the radius is in continuity with loading of compression forces and development of valgus will be arrested. Therefore, we advocate reconstruction of radial neck non-union with fibular bone grafting in childhood and the Metaizeau technique seems to be a simple and effective technique with minimal complications.
214
References 1. Metaizeau JP, Lascombes J, Lemelle JL, Finlayson D, Prevot J. Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop 1993;13(3): 355—60. 2. Reidy JA, Van Gorder GW. Treatment of displacement of the proximal radial epiphysis. J Bone Joint Surg [Am] 1963;45: 1355—72.
S.D. Kaufman et al. 3. Rodriguez-Merchan EC. Displaced fractures of the head and neck of the radius in children: open reduction and temporary trans-articular internal fixation. Orthopaedics 1991;14:697— 700. 4. Waters PM, Stewart SL. Radial neck fracture non-union in children. J Pediatr Orthop 2001;21(5):570—6.