In this section
See also: Radial neck fractures - Fracture clinics
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
Fractures of the proximal radius can be classified according to:
It is important to distinguish between these as the treatment and outcome can vary significantly.
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.
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).
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).
Figure 1: Incorrect view.
Figure 2: True AP view of proximal radius.
Figure 3: A) Lateral view B) AP view
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.
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.
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.
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.
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:
Indications for prompt consultation include:
Table 1: ED management of radial neck fractures.
Type of reduction
Immobilisation method & duration
Isolated, minimally displaced or angulated (≤30 degrees angulation, <10% translation), <10 years
Above-elbow backslab (Figure 8) plus sling with elbow at 90 degrees flexion and forearm in mid-position for 3 weeks
Refer to the nearest orthopaedic on call service
Figure 8: An above-elbow backslab is applied and then secured by a bandage.
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:
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.
Early complications mainly relate to failure to recognise associated injuries.
See fracture clinics for other potential complications.
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.