Clinical Practice Guidelines

Radial neck fractures - Emergency Department

  • Fracture Guideline Index

    See also: Radial neck fractures - Fracture clinics

    1. Summary
    2. How are they classified? 
    3. How common are they and how do they occur? 
    4. What do they look like - clinically? 
    5. What radiological investigations should be ordered?
    6. What do they look like on x-ray? 
    7. When is reduction (non-operative and operative) required?
    8. Do I need to refer to orthopaedics now?
    9. What is the usual ED management for this fracture?
    10. What follow-up is required?
    11. What advice should I give to parents?
    12. What are the potential complications associated with this injury?

    1. Summary

    Fracture type

    ED management

    Follow-up

    Isolated, minimally displaced or angulated (≤30 degrees angulation, <10% translation), <10 years old

    Above-elbow backslab plus sling with elbow at 90 degree flexion and forearm in mid-position for 3 weeks

     

    Fracture clinic at 1 week with x-ray

    All other fractures

    Refer to the nearest orthopaedic on call service. Requires reduction (closed or open)

    To be arranged by orthopaedic service

     
    2.
    How are they classified?

    Fractures of the proximal radius can be classified according to:

    • anatomical location: metaphyseal, physeal (most common Salter-Harris type II)
    • degree of displacement
    • presence of other injuries of the elbow/forearm (ligamentous and/or bony)
    • presence of elbow joint dislocation/relocation

    It is important to distinguish between these as the treatment and outcome can vary significantly.

    3. How common are they and how do they occur?

    Radial neck fractures are uncommon and account for 8% of all elbow fractures in children.

    The most common mechanism is a fall onto the outstretched arm with a valgus stress at the elbow. They can also occur as a result of a posterior dislocation or reduction of the elbow joint.

     ! 

     Associated elbow injuries occur in 50% of radial neck fractures. These include avulsion of the medial epicondyle, fracture of the olecranon or proximal ulna.

     

    4. What do they look like clinically?

    There is usually pain, tenderness, and swelling over the lateral aspect of the elbow and decreased forearm rotation (pronation/supination).

    Deformity is not typically a feature unless there are associated injuries (e.g. elbow joint dislocation, ulna shaft fracture).

     

    5. What radiological investigations should be ordered?

    Anteroposterior (AP) and lateral view of the elbow should be ordered. The degree of forearm rotation should be the same in each view (e.g. mid-position). This is to ensure that the views obtained of the proximal radius are orthogonal.

     ! 

     If the patient is unable to fully extend the elbow, the AP view of the elbow may not be a true AP view of the radius (Figure 1). In this situation, a separate AP view of the proximal radius may be needed to better assess the displacement (Figure 2). 

    Radialneck_figure_1_imaging_incorrect.jpg Radialneck_figure_2_imaging_correct.jpg

    Figure 1: Incorrect view.

    Figure 2: True AP view of proximal radius.

     

    6. What do they look like on x-ray?

     The radial head should point to the capitellum in all views (Figure 3).

     

    Radialneck_figure_3_radiocapitellar_line_lat.jpg    Radialneck_figure_3_radius_capitellum_line_ap.jpg
      A

    Figure 3: A) Lateral view B) AP view

    B  

     

     

    Salter-Harris type I

    Radialneck_figure_4_elbow_shi_left_ap.jpg Radialneck_figure_4_elbow_shi_left_lat.jpg

    Figure 4: Fourteen year old boy with Salter Harris type I fracture of the proximal radius and avulsion of the medial epicondyle -- this demonstrates the valgus nature of the force which has caused both injuries.

     

    Salter-Harris type II

    Figure-5_drawing_SH-II-radial-neck_AP.jpg  Radialneck_figure_5_ap_sh_ii.jpg

    Figure-5_drawing_SH-II-radial-neck_Lat.jpg Radialneck_figure_5_lateral_sh_ii.jpg

    Figure 5: Four year old girl with a Salter-Harris type II fracture of the proximal radius in association with a fracture of the olecranon - this is a Monteggia variant injury.

    Displaced fracture of radial neck

    Radialneck_figure_6_completely-displaced_ap_and_lat.jpg

    Figure 6: Sixteen year old boy with a completely displaced and severely angulated (almost 90 degrees) radial neck fracture (white arrow). The injury could be easily missed if only the lateral view is examined.

     

    Radialneck_figure_7_elbow_dispalced_right_lat.jpg Radialneck_figure_7_elbow_displaced__right_ap.jpg

    Figure 7: AP and lateral view of a thirteen year old girl with a completely displaced fracture of the radial neck. The fracture is more evident on the lateral view. The radial head is posterior to the capitellum, which is possibly related to the spontaneous reduction of a dislocated elbow.

     

    7. When is reduction (non-operative and operative) required?

    Management is based on the amount of angulation between the radial head and shaft. Fractures that are angulated 30 degrees do not require reduction.

    Any fracture reductions should be performed under x-ray image intensification under general anaesthesia by an orthopaedic surgeon. Fractures with angular deformity greater than 30 degrees usually require reduction.

    However, there are a number of considerations here:

    • the closer the child is to skeletal maturity, the less time there is for remodelling (in this situation, angular deformity >15 degrees may not be acceptable)
    • the true degree of angulation may be more than is shown on any one standard x-ray view
    • translation may compound the effects of angulation
    • associated injuries mean the degree of angulation may increase
    • intra-articular physeal fractures (Salter Harris type III and IV) have their own criteria for reduction

    8. Do I need to refer to orthopaedics now?

    Indications for prompt consultation include:

        1. Fractures requiring reduction
        2. An associated fracture in the same upper limb
        3. Extreme swelling/compartment syndrome

    9. What is the usual ED management for this fracture?

    Table 1: ED management of radial neck fractures.

    Fracture type

    Type of reduction

    Immobilisation method & duration

    Isolated, minimally displaced or angulated (≤30 degrees angulation, <10% translation), <10 years

    Not required

    Above-elbow backslab (Figure 8) plus sling with elbow at 90 degrees flexion and forearm in mid-position for 3 weeks

    All other fractures

    Refer to the nearest orthopaedic on call service. Requires reduction (closed or open)

    Refer to the nearest orthopaedic on call service

    Radialneck_figure_8_above_elbow_backslab.jpg

    Figure 8: An above-elbow backslab is applied and then secured by a bandage.

    10. What follow-up is required?

    All fractures of the radial neck should have follow-up arranged in a fracture clinic within one week of injury, with an x-ray at that visit.

    This is important because:

    • the fracture displacement may worsen over the first few days
    • healing is rapid and closed reduction (the desired method) becomes very difficult after around 5 days.
    • many of these fractures are associated with other injuries around the elbow (e.g. olecranon) that may not have been evident or appreciated initially

    11. What advice should I give to parents?

    Most do well but some become stiff (loss of forearm rotation) even with optimal treatment. A good outcome is expected for minimally angulated isolated fractures.

    As with other injuries around the elbow, especially when they occur in combination, there is the potential for a poor outcome. Close follow-up (including serial x-rays) is important. Whilst good management decreases this likelihood it does not remove it.

    Children generally recover their elbow range of motion well and do not require physiotherapy.

    12. What are the potential complications associated with this injury?

    Early complications mainly relate to failure to recognise associated injuries.

    See fracture clinics for other potential complications. 

    References (ED setting)

    Evans MC, Graham HK. Radial neck fractures in children: A management algorithm. J Pediat Ortho B 1999; 8(2): 93-9.

    Green NE, Van Zeeland NL. Fractures and dislocations about the elbow. In Green N, Swiontkowski M. Skeletal Trauma in Children, 4th Ed. Saunders Elsevier, Philadelphia 2009. p.207-82.

    Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4th Ed. Saunders, Philadelphia 2008. p.2451-536.

    Milbrandt T, Copley L. Common elbow injuries in children: Evaluation, treatment, and clinical outcomes. Curr Opin Ortho 2004; 15: 286-94.

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