Chapter 13: Radial Neck and Olecranon Fractures

Mark Erickson, Sumeet Garg

Chapter Outline

Introduction to Fractures of the Proximal Radius and Ulna

Fractures of the proximal radius in skeletally immature patients usually involve the metaphysis or physis. True isolated radial head fractures are rare. In the proximal ulna, the olecranon, which biomechanically is a metaphysis, often fails with a greenstick pattern. Fractures in this area also may involve the physis. Fractures of the olecranon associated with proximal radioulnar joint disruption are considered part of the Monteggia fracture pattern and are discussed in Chapter 14
Fractures of the radial neck account for slightly more than 1% of all children's fractures.49 Radial neck fractures make up approximately 5% of elbow fractures in children.8,28,40,43,52,69 Radial head fractures are uncommon, and when they occur usually are Salter–Harris type IV injuries. The median age at injury is 9 to 10 years in the pediatric population.22,40,50,68,86,102,108,113 There is little difference in the occurrence rates between males and females22,40,68; however, this injury seems to occur on an average approximately 2 years earlier in girls than in boys.102 
Fractures of the proximal ulna in skeletally immature children present in three different patterns: Fractures involving the proximal apophysis, metaphyseal fractures of the olecranon, and fractures of the coronoid process. 
“Separation of the olecranon epiphysis is the rarest form of epiphyseal detachment.”77 This quote from Poland's 1898 textbook on epiphyseal fractures is still true. Few fractures of the ulnar apophysis are described in the English literature, most recently by Carney13,35,77,92,98 In addition to acute injuries in children, some have been described in young adults with open physes.48,75,96,109 In the French literature, Bracq9 described 10 patients in whom the fracture extended distal and parallel to the apophyseal line and then crossed it at the articular surface. Most reports of apophyseal olecranon fractures describe patients with osteogenesis imperfecta, who seem predisposed to this injury. 
Isolated metaphyseal fractures of the olecranon are relatively rare (Table 13-1). They are often associated with other fractures about the elbow. In the combined series of 4,684 elbow fractures reviewed, 230 were olecranon fractures, for an incidence of 4.9%. This agrees with the incidence of 4% to 6% in the major series reported.27,57,71 Only 10% to 20% of the total fractures reported in these series required an operation. Six reports totaling 302 patients with fractures of the olecranon in children are in the English literature.31,35,57,68 Considering all age groups, 25% of olecranon fractures in these reports occurred in the first decade and another 25% in the second decade.50 During the first decade, the peak age for olecranon fracture was between age 5 and 10 years.36,69 Approximately 20% of patients had an associated fracture or dislocation of the elbow, most involving the proximal radius. Only 10% to 20% required an operation. 
 
Table 13-1
Incidence of Metaphyseal Fractures of the Olecranon
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Table 13-1
Incidence of Metaphyseal Fractures of the Olecranon
Age distribution: First decade, 25%; second decade, 25%; third decade, 50%
Peak age: 5–10 y
Extremity predominance: Left (55%)
Sex predominance: Male (65%)
Associated elbow injuries: 20%
Requiring surgical intervention: 19%
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The incidence of fracture of the coronoid varies from less than 1% to 2% of elbow fractures.57 Because most fractures of the coronoid process occur with dislocations of the elbow, it seems logic that they would happen in older children. However, in a review of 23 coronoid fractures in children, Bracq9 found that the injuries occurred in two peak age groups: One was between 8 and 9 years of age and the other between 12 and 14 years. 

Assessment of Fractures of the Proximal Radius

Mechanisms of Injury for Fractures of the Proximal Radius

Most fractures of the proximal radius occur at the neck. Fractures of the proximal radius most commonly occur after a fall on an outstretched arm with elbow extended and valgus stress at the elbow.33,40,43,68,69,117 The immature radial head is primarily cartilaginous and intra-articular radial head fractures in children and adolescents are rare. The cartilaginous head absorbs the force and transmits it to the weaker physis or metaphysis of the neck.117 These fractures characteristically produce an angular deformity of the head with the neck (Fig. 13-1A). The direction of angulation depends on whether the forearm is in a supinated, neutral, or pronated position at the time of the fall. Vostal showed that in neutral, the pressure is concentrated on the lateral portion of the head and neck. In supination, the pressure is concentrated anteriorly, and in pronation it is concentrated posteriorly.117 
Figure 13-1
The most common mechanism of radial neck fractures involves a fall on the outstretched arm.
 
This produces an angular deformity of the neck (A). Further valgus forces can produce a greenstick fracture of the olecranon (B) or an avulsion of the medial epicondylar apophysis (C).
 
(Redrawn with permission from Jeffery CC. Fractures of the head of the radius in children. J Bone Joint Surg Br. 1950; 32:314–324.)
This produces an angular deformity of the neck (A). Further valgus forces can produce a greenstick fracture of the olecranon (B) or an avulsion of the medial epicondylar apophysis (C).
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Figure 13-1
The most common mechanism of radial neck fractures involves a fall on the outstretched arm.
This produces an angular deformity of the neck (A). Further valgus forces can produce a greenstick fracture of the olecranon (B) or an avulsion of the medial epicondylar apophysis (C).
(Redrawn with permission from Jeffery CC. Fractures of the head of the radius in children. J Bone Joint Surg Br. 1950; 32:314–324.)
This produces an angular deformity of the neck (A). Further valgus forces can produce a greenstick fracture of the olecranon (B) or an avulsion of the medial epicondylar apophysis (C).
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Proximal radial fractures also may occur in association with elbow dislocation. The fracture will occur either during the dislocation event, typically displaced anterior. Alternatively, the fracture may occur during spontaneous reduction of the distal humerus, driving the displacement of the proximal radius posterior (Fig. 13-2). 
Figure 13-2
Dislocation fracture patterns.
 
A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
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A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
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Figure 13-2
Dislocation fracture patterns.
A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
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A: Type D: The radial neck is fractured during the process of reduction by the capitellum pressing against the distal lip of the radial head.124 B: Type E: The radial neck is fractured during the process of dislocation by the capitellum pressing against the proximal lip of the radial head.94 C: Radiographs of a radial head that was fractured during the reduction of the dislocation (type D). The radial head (solid arrow) lies posterior to the distal humerus, and the distal portion of the neck (open arrow) is anterior. (Courtesy of Richard E. King, MD.) D: Radiograph of the dislocated elbow in which the fracture of the radial neck occurred during the process of dislocation (type E).
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Associated Injuries with Fractures of the Proximal Radius

Proximal radius fractures can occur concomitantly with distal humerus, ulna, radial shaft, or distal radius fractures.33,43,44,69,102 Fractures in combination with ulnar fractures often are part of the Monteggia fracture pattern detailed in Chapter 14. Presence of associated fractures portends a poor prognosis for patients with proximal radius fractures with higher rates of persistent stiffness and pain compared to those with isolated proximal radius fractures.104 As detailed further in Chapter 18, proximal radius fractures can also occur during traumatic elbow dislocations. The posterior interosseous nerve (PIN) wraps around the proximal radius and occasionally can be injured in association with proximal radius fractures. More typically, however, the nerve is at risk during percutaneous manipulation or open reduction of proximal radius fractures. 

Signs and Symptoms of Fractures of the Proximal Radius

Following a fracture, palpation over the radial head or neck is painful. The pain is usually increased with forearm supination and pronation more so than with elbow flexion and extension. Displaced fractures frequently result in visible bruising or ecchymosis on the lateral aspect of the elbow with significant soft tissue swelling. Neurologic examination should in particular evaluate the PIN, which can be affected by fractures of the proximal radius. 
In a young child, the primary complaint may be wrist pain, and pressure over the proximal radius may accentuate this referred wrist pain.2 The wrist pain may be secondary to radial shortening and subsequent distal radioulnar joint dysfunction. The misdirection of such a presentation reinforces the principle of obtaining radiographs of both ends of a fractured long bone and complete examination of the entire affected extremity. 

Imaging and Other Diagnostic Studies for Fractures of the Proximal Radius

Displaced proximal radius fractures are usually easy to identify on standard anteroposterior (AP) and lateral radiographs. Some variants in the ossification process can resemble a fracture. Most of these involve the radial head, although a step-off also can develop as a normal variant of the metaphysis. There may be a persistence of the secondary ossification centers of the epiphysis. Comparison views of the contralateral elbow are useful for evaluation of unusual ossification centers after an acute elbow injury. 
If the elbow cannot be extended because of pain, special views are necessary to see the AP alignment of the proximal forearm and distal humerus. A regular AP view with the elbow flexed may not show the fracture because of obliquity of the beam. One view is taken with the beam perpendicular to the distal humerus, and the other with the beam perpendicular to the proximal radius. The perpendicular views show the proximal radial physis in clear profile. 
With a minimally displaced fracture, the fracture line may be difficult to see because it is superimposed on the proximal ulna, and oblique views of the proximal radius may be helpful.10,117 One oblique view that is especially helpful is the radiocapitellar view suggested by Greenspan et al.37,38 and Hall-Craggs et al.39 This view projects the radial head anterior to the coronoid process (Fig. 13-3) and is especially helpful if full supination and pronation views are difficult to obtain because of acute injury (Fig. 13-4). 
Figure 13-3
 
A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
 
(Courtesy of Kenneth P. Butters, MD.)
A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
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A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
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Figure 13-3
A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
(Courtesy of Kenneth P. Butters, MD.)
A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
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A: Radiocapitellar view. B: Angular stress deformity: Anterior angulation of the radial head and neck in a 12-year-old baseball pitcher. There is evidence of some disruption of the normal growth of the anterior portion of the physis (black arrow). The capitellum also shows radiographic signs of osteochondritis dissecans (white arrow).
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Figure 13-4
The radiocapitellar view.
 
A: Radiographs of a 13-year-old female who sustained a radial neck fracture associated with an elbow dislocation. There is ectopic bone formation (arrows). In this view, it is difficult to tell the exact location of the ectopic bone. B: The radiocapitellar view separates the radial head from the coronoid process and shows that the ectopic bone is from the coronoid process (arrows) and not the radial neck.
A: Radiographs of a 13-year-old female who sustained a radial neck fracture associated with an elbow dislocation. There is ectopic bone formation (arrows). In this view, it is difficult to tell the exact location of the ectopic bone. B: The radiocapitellar view separates the radial head from the coronoid process and shows that the ectopic bone is from the coronoid process (arrows) and not the radial neck.
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Figure 13-4
The radiocapitellar view.
A: Radiographs of a 13-year-old female who sustained a radial neck fracture associated with an elbow dislocation. There is ectopic bone formation (arrows). In this view, it is difficult to tell the exact location of the ectopic bone. B: The radiocapitellar view separates the radial head from the coronoid process and shows that the ectopic bone is from the coronoid process (arrows) and not the radial neck.
A: Radiographs of a 13-year-old female who sustained a radial neck fracture associated with an elbow dislocation. There is ectopic bone formation (arrows). In this view, it is difficult to tell the exact location of the ectopic bone. B: The radiocapitellar view separates the radial head from the coronoid process and shows that the ectopic bone is from the coronoid process (arrows) and not the radial neck.
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The diagnosis of a partially or completely displaced fracture of the radial neck may be difficult in children whose radial head remains unossified.88 The only clue may be a little irregularity in the smoothness of the proximal metaphyseal margin (Fig. 13-5). The full extent of the injury was appreciated only by magnetic resonance imaging (MRI). Displacement of the supinator fat pad may also indicate fracture of the proximal radius90; however, this fat pad and the distal humeral anterior and posterior fat pads are not always displaced with occult fractures of the radial neck or physis.41,93,95 Arthrogram, ultrasound, or MRI are helpful to assess the extent of the displacement and the accuracy of reduction in children with an unossified radial epiphysis (Fig. 13-6).17,42,51 
Figure 13-5
Preosseous fracture.
 
The only clue to the presence of a fracture of the radial neck with displacement of the radial head was loss of smoothness of the metaphyseal margin (arrow).
The only clue to the presence of a fracture of the radial neck with displacement of the radial head was loss of smoothness of the metaphyseal margin (arrow).
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Figure 13-5
Preosseous fracture.
The only clue to the presence of a fracture of the radial neck with displacement of the radial head was loss of smoothness of the metaphyseal margin (arrow).
The only clue to the presence of a fracture of the radial neck with displacement of the radial head was loss of smoothness of the metaphyseal margin (arrow).
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Figure 13-6
 
A, B: AP and lateral radiographs demonstrating a radial neck fracture in a patient with a nonossified proximal radial epiphysis. C: Arthrogram prior to reduction demonstrating location/displacement of nonossified proximal radial epiphysis. D–F: Arthrogram/radiographs after reduction with intramedullary technique.
 
(From Javed A, Guichet JM. Arthrography for reduction of a fracture of the radial neck in a child with a nonossified radial epiphysis. J Bone Joint Surg Br. 2001; 83-B:542–543, with permission.)
A, B: AP and lateral radiographs demonstrating a radial neck fracture in a patient with a nonossified proximal radial epiphysis. C: Arthrogram prior to reduction demonstrating location/displacement of nonossified proximal radial epiphysis. D–F: Arthrogram/radiographs after reduction with intramedullary technique.
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Figure 13-6
A, B: AP and lateral radiographs demonstrating a radial neck fracture in a patient with a nonossified proximal radial epiphysis. C: Arthrogram prior to reduction demonstrating location/displacement of nonossified proximal radial epiphysis. D–F: Arthrogram/radiographs after reduction with intramedullary technique.
(From Javed A, Guichet JM. Arthrography for reduction of a fracture of the radial neck in a child with a nonossified radial epiphysis. J Bone Joint Surg Br. 2001; 83-B:542–543, with permission.)
A, B: AP and lateral radiographs demonstrating a radial neck fracture in a patient with a nonossified proximal radial epiphysis. C: Arthrogram prior to reduction demonstrating location/displacement of nonossified proximal radial epiphysis. D–F: Arthrogram/radiographs after reduction with intramedullary technique.
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In the preossification stage, on the AP radiograph, the edge of the metaphysis of the proximal radius slopes distally on its lateral border. This angulation is normal and not a fracture. In the AP view, the lateral angulation varies from 0 to 15 degrees, with the average being 12.5 degrees.113 In the lateral view, the angulation can vary from 10 degrees anterior to 5 degrees posterior, with the average being 3.5 degrees anterior.10 
Recently described posterior radiocapitellar subluxation following what appeared to be fairly innocuous radial head fractures have been attributed to undiagnosed ligamentous injury associated with the fracture. Kasser includes this in lesions he describes as “The radiographic appearance seemed harmless (TRASH).”119 MRI provides excellent anatomic detail of the elbow joint and should be considered when evaluating displaced radial head fractures, particularly if change in position is noted on serial radiographs. 

Classification of Fractures of the Proximal Radius

Chambers Classification of Proximal Radial Fractures

In a prior edition of this textbook, Chambers15 classified proximal radial fractures into three major groups based on the mechanism of injury and displacement of the radial head (Table 13-2). 
 
Table 13-2
Classification of Fractures Involving the Proximal Radius
Group I: Primary displacement of the radial head
  1.  
    Valgus fractures
    1.  
      Type A—Salter–Harris type I and II injuries of the proximal radial physis
    2.  
      Type B—Salter–Harris type IV injuries of the proximal radial physis
    3.  
      Type C—Fractures involving only the proximal radial metaphysis
  2.  
    Fractures associated with elbow dislocation
    1.  
      Type D—Reduction injuries
    2.  
      Type E—Dislocation injuries
Group II: Primary displacement of the radial neck
  1.  
    Angular injuries (Monteggia type III variant)
  2.  
    Torsional injuries
Group III: Stress injuries
  1.  
    Osteochondritis dissecans or osteochondrosis of the radial head
  2.  
    Physeal injuries with neck angulation
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  •  
    Group I: The radial head is primarily displaced (most common type)
  •  
    Group II: The radial neck is primarily displaced
  •  
    Group III: Stress injuries
Head-Displaced Fractures (Group I)
With valgus elbow injuries, the fracture pattern can be one of three types (A, B, or C) (Fig. 13-7). In the first two types, the fracture line involves the physis. Type A represents either a Salter–Harris type I or II physeal injury. In a Salter–Harris type II injury, the metaphyseal fragment is triangular and lies on the compression side. In type B fractures, the fracture line courses vertically through the metaphysis, physis, and epiphysis to produce a Salter–Harris type IV fracture pattern (Fig. 13-7). This is the only fracture type that involves the articular surface of the radial head. In type C fractures, the fracture line lies completely within the metaphysis (Fig. 13-8), and the fracture can be transverse or oblique. Type B fractures, intra-articular radial head fractures, are rare. These can have poor long-term results if posterior radiocapitellar subluxation develops (Fig. 13-9).114,119 The incidences of types A and C fractures are approximately equal.102 
Figure 13-7
Valgus (type B) injury.
 
A: Three weeks after the initial injury, there was evidence of distal migration of this Salter–Harris type IV fracture fragment. Periosteal new bone formation has already developed along the distal metaphyseal fragment (arrow). B: Six months after the initial injury, there is evidence of an osseous bridge formation between the metaphysis and the epiphysis. Subsequently, the patient had secondary degenerative arthritis with loss of elbow motion and forearm rotation.
A: Three weeks after the initial injury, there was evidence of distal migration of this Salter–Harris type IV fracture fragment. Periosteal new bone formation has already developed along the distal metaphyseal fragment (arrow). B: Six months after the initial injury, there is evidence of an osseous bridge formation between the metaphysis and the epiphysis. Subsequently, the patient had secondary degenerative arthritis with loss of elbow motion and forearm rotation.
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Figure 13-7
Valgus (type B) injury.
A: Three weeks after the initial injury, there was evidence of distal migration of this Salter–Harris type IV fracture fragment. Periosteal new bone formation has already developed along the distal metaphyseal fragment (arrow). B: Six months after the initial injury, there is evidence of an osseous bridge formation between the metaphysis and the epiphysis. Subsequently, the patient had secondary degenerative arthritis with loss of elbow motion and forearm rotation.
A: Three weeks after the initial injury, there was evidence of distal migration of this Salter–Harris type IV fracture fragment. Periosteal new bone formation has already developed along the distal metaphyseal fragment (arrow). B: Six months after the initial injury, there is evidence of an osseous bridge formation between the metaphysis and the epiphysis. Subsequently, the patient had secondary degenerative arthritis with loss of elbow motion and forearm rotation.
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Figure 13-8
Valgus type C injury.
 
The fracture line is totally metaphyseal and oblique (arrows).
The fracture line is totally metaphyseal and oblique (arrows).
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Figure 13-8
Valgus type C injury.
The fracture line is totally metaphyseal and oblique (arrows).
The fracture line is totally metaphyseal and oblique (arrows).
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Figure 13-9
 
A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
 
(From Waters PM, Beaty J, Kasser J. Elbow “TRASH” (The Radiographic Appearance Seemed Harmless) Lesions. J Pediatr Orthop. 2010; 30:S77–S81, with permission.)
A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
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A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
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Figure 13-9
A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
(From Waters PM, Beaty J, Kasser J. Elbow “TRASH” (The Radiographic Appearance Seemed Harmless) Lesions. J Pediatr Orthop. 2010; 30:S77–S81, with permission.)
A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
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A: Acute injury films revealing small displacement of radial head fracture on the flexed elbow anteroposterior (AP) view and subtle posterior subluxation not originally appreciated on the lateral view. B: Follow-up radiographs at 1 week noted more difficulty interpreting the AP view in cast, and more radiocapitellar posterior displacement on the lateral view. An MRI scan (C) was ordered urgently and revealed a marked effusion and intra-articular displacement of radial head fracture and posterior radiocapitellar subluxation. D: Open reduction internal fixation was performed to anatomically align the radial head fracture and reduce the joint.
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In two rare types of fractures of the radial neck associated with elbow dislocation, the head fragment is totally displaced from the neck.5,12,29,43,68,118 Fractures occurring during spontaneous reduction of elbow dislocation generally drive the radial head dorsal as the capitellum applies a dorsally directed force to the radial neck during reduction (type D) (Fig. 13-2A).43,118 Fractures occurring during the dislocation event generally drive the radial head volar as the capitellum applies a volarly direct force during the process of dislocating (type E) (Fig. 13-2B).5,68,113 Even with spontaneous or manipulative elbow reduction the radial head fragment will usually remain volar to the radial shaft with the fractured radial neck articulating with the capitellum. 
Regardless of the type of fracture pattern, displacement can vary from minimal angulation to complete separation of the radial head from the neck (Fig. 13-10). With minimal angulation, the congruity of the proximal radioulnar joint is usually retained. If the radial head is displaced in relation to the radial neck, the congruity of the proximal radioulnar joint is lost. Completely displaced fractures are often associated with more severe injuries. 
Figure 13-10
Displacement patterns.
 
The radial head can be angulated (A), translated (B), or completely displaced (C).
The radial head can be angulated (A), translated (B), or completely displaced (C).
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Figure 13-10
Displacement patterns.
The radial head can be angulated (A), translated (B), or completely displaced (C).
The radial head can be angulated (A), translated (B), or completely displaced (C).
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Neck-Displaced Fractures (Group II)
Rarely, angular or torsional forces cause a primary disruption or deformity of the neck while the head remains congruous within the proximal radioulnar joint. Treatment of these fractures is manipulation of the distal neck fragment to align it with the head. For the neck-displaced fractures, there are two subgroups: Angular and torsional. 
An angular fracture of the radial neck may be associated with a proximal ulnar fracture. This association is recognized as a Monteggia variant. A Monteggia type III fracture pattern is created when a varus force is applied across the extended elbow, resulting in a greenstick fracture of the olecranon or proximal ulna and a lateral dislocation of the radial head.124 Occasionally, however, the failure occurs at the radial neck (Monteggia III equivalent) and the radial neck displaces laterally, leaving the radial head and proximal neck fragment in anatomic position under the annular ligament (Fig. 13-11).70 
Figure 13-11
Angular forces.
 
This 8-year-old sustained a type III Monteggia equivalent in which the radial neck fractured (arrow), leaving the radial head reduced proximally.
 
(Courtesy of Ruben D. Pechero, MD.)
This 8-year-old sustained a type III Monteggia equivalent in which the radial neck fractured (arrow), leaving the radial head reduced proximally.
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Figure 13-11
Angular forces.
This 8-year-old sustained a type III Monteggia equivalent in which the radial neck fractured (arrow), leaving the radial head reduced proximally.
(Courtesy of Ruben D. Pechero, MD.)
This 8-year-old sustained a type III Monteggia equivalent in which the radial neck fractured (arrow), leaving the radial head reduced proximally.
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Rotational forces may fracture the radial neck in young children before ossification of the proximal radial epiphysis. This has been described only in case reports with a supination force.33,40 Reduction was achieved by pronation of the forearm. Diagnosis of these injuries is difficult and may require arthrography or an examination under general anesthesia. This injury should be differentiated from the more common subluxation of the radial head (“nursemaids elbow”), in which the forearm usually is held in pronation with resistance to supination. 
Stress Injuries (Group III)
A final mechanism of injury is chronic repetitive stress, both longitudinal and rotational, on either the head or the proximal radial physis. These injuries are usually the result of athletic activity in which the upper extremity is required to perform repetitive motions. Repetitive stresses disrupt growth of either the neck or the head with eventual deformity. A true stress fracture is not present. 
In the United States, the popularity of organized sports has produced a number of unique injuries in children related to repetitive stress applied to growth centers. Most elbow stress injuries are related to throwing sports such as baseball. Most of this “Little League” pathology involves tension injuries on the medial epicondyle. In some athletes, however, the lateral side is involved as well because of the repetitive compressive forces applied to the capitellum and radial head and neck. Athletes involved in sports requiring upper extremity weight bearing, such as gymnastics or wrestling, are also at risk. In the radial head, lytic lesions similar to osteochondritis dissecans may occur (Figs. 13-12 and 13-13).24,110,123 Chronic compressive loading may cause an osteochondrosis of the proximal radial epiphysis, with radiographic signs of decreased size of the ossified epiphysis, increased radiographic opacity, and later fragmentation. If the stress forces are transmitted to the radial neck, the anterior portion of the physis may be injured, producing an angular deformity of the radial neck (Fig. 13-3).25 
Figure 13-12
Osteochondritis dissecans.
 
Radiograph of this 11-year-old Little League pitcher's elbow shows fragmentation of the subchondral surfaces of the radial head. These changes and the accelerated bone age are evidence of overuse.
Radiograph of this 11-year-old Little League pitcher's elbow shows fragmentation of the subchondral surfaces of the radial head. These changes and the accelerated bone age are evidence of overuse.
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Figure 13-12
Osteochondritis dissecans.
Radiograph of this 11-year-old Little League pitcher's elbow shows fragmentation of the subchondral surfaces of the radial head. These changes and the accelerated bone age are evidence of overuse.
Radiograph of this 11-year-old Little League pitcher's elbow shows fragmentation of the subchondral surfaces of the radial head. These changes and the accelerated bone age are evidence of overuse.
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Figure 13-13
Elevated anterior and posterior fat pads.
 
A: Illustration (adapted with permission from Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429–1433). B: White arrow: Posterior fat pad sign. Black arrow: Anterior fat pad sign.
A: Illustration (adapted with permission from Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429–1433). B: White arrow: Posterior fat pad sign. Black arrow: Anterior fat pad sign.
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Figure 13-13
Elevated anterior and posterior fat pads.
A: Illustration (adapted with permission from Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429–1433). B: White arrow: Posterior fat pad sign. Black arrow: Anterior fat pad sign.
A: Illustration (adapted with permission from Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429–1433). B: White arrow: Posterior fat pad sign. Black arrow: Anterior fat pad sign.
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Judet Classification of Radial Neck Fractures

Radial neck fractures, the most common type of proximal radius fracture, (Group IA and IC) have also been classified based on angulation by Judet (Table 13-3).59 Increasing grade has generally been associated with poorer outcomes with both nonoperative and operative care as discussed in the section on treatment outcomes. 
 
Table 13-3
Judet Classification of Radial Neck Fractures
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Table 13-3
Judet Classification of Radial Neck Fractures
Type I Nondisplaced
Type II <30-degree angulation
Type III 30–60-degree angulation
Type IVa 60–80-degree angulation
Type IVb >80-degree angulation
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Outcome Measures for Fractures of the Proximal Radius

Most previously published literature on the outcomes of pediatric proximal radius fractures have used nonvalidated functional outcome measures. Various iterations of “excellent,” “good,” “fair,” and “poor” with individualized descriptions have been utilized. The growing emphasis in orthopedics on critical functional assessments following injury or surgery should improve the quality of future evidence on this topic. It is hoped that validated functional measures for upper extremity function and global pediatric and adolescent function be utilized in future research efforts in this area. 
Range of motion following treatment of proximal radius fractures is a critical component of outcome. Usually assessments have been done manually using a goniometer. The wider availability of digital motion capture technology will hopefully provide more accurate measures of range of motion following extremity trauma in future studies. 

Pathoanatomy and Applied Anatomy Relating to Fractures of the Proximal Radius

In the embryo, the proximal radius is well defined by 9 weeks of gestation. By 4 years of age, the radial head and neck have the same contours as in an adult.69 Ossification of the proximal radius epiphysis begins at approximately 5 years of age as a small, flat nucleus (Fig. 13-14). This ossific nucleus can originate as a small sphere or it can be bipartite, which is a normal variation and should not be misinterpreted as a fracture.10,58,95 
Figure 13-14
Ossification pattern.
 
A: At 5 years, ossification begins as a small oval nucleus. B: As the head matures, the center widens but remains flat. C: Double ossification centers in developing proximal radial epiphysis.
 
(Reprinted with permission from Silberstein MJ, Brodeur AE, Graviss ER. Some vagaries of the radial head and neck. J Bone Joint Surgery Am. 1982;64.)
A: At 5 years, ossification begins as a small oval nucleus. B: As the head matures, the center widens but remains flat. C: Double ossification centers in developing proximal radial epiphysis.
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Figure 13-14
Ossification pattern.
A: At 5 years, ossification begins as a small oval nucleus. B: As the head matures, the center widens but remains flat. C: Double ossification centers in developing proximal radial epiphysis.
(Reprinted with permission from Silberstein MJ, Brodeur AE, Graviss ER. Some vagaries of the radial head and neck. J Bone Joint Surgery Am. 1982;64.)
A: At 5 years, ossification begins as a small oval nucleus. B: As the head matures, the center widens but remains flat. C: Double ossification centers in developing proximal radial epiphysis.
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No ligaments attach directly to the radial neck or head. The radial collateral ligaments attach to the annular ligament, which originates from the radial side of the ulna. The articular capsule attaches to the proximal third of the neck. Distally, the capsule protrudes from under the annular ligament to form a pouch (recessus sacciformis). Thus, only a small portion of the neck lies within the articular capsule.117 Because much of the neck is extracapsular, fractures involving only the neck may not produce an intra-articular effusion, and the fat pad sign may be negative with fracture of the radial neck.10,41,95 
The proximal radioulnar joint has a precise congruence. The axis of rotation of the proximal radius is a line through the center of the radial head and neck. When a displaced fracture disrupts the alignment of the radial head on the center of the radial neck, the arc of rotation changes. Instead of rotating smoothly in a pure circle, the radial head rotates with a “cam” effect. This disruption of the congruity of the proximal radioulnar joint (as occurs with displaced fractures of the proximal radius) may result in a loss of the range of motion in supination and pronation (Fig. 13-15).121 
Figure 13-15
 
A: Normal rotation of the forearm causes the radial head to circumscribe an exact circle within the proximal radioulnar joint. B: Any translocation of the radial head limits rotation because of the “cam” effect described by Wedge and Robertson.121
A: Normal rotation of the forearm causes the radial head to circumscribe an exact circle within the proximal radioulnar joint. B: Any translocation of the radial head limits rotation because of the “cam” effect described by Wedge and Robertson.121
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Figure 13-15
A: Normal rotation of the forearm causes the radial head to circumscribe an exact circle within the proximal radioulnar joint. B: Any translocation of the radial head limits rotation because of the “cam” effect described by Wedge and Robertson.121
A: Normal rotation of the forearm causes the radial head to circumscribe an exact circle within the proximal radioulnar joint. B: Any translocation of the radial head limits rotation because of the “cam” effect described by Wedge and Robertson.121
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Table 13-4 lists the proposed mechanisms for fractures of the radial head and neck in children. 
Table 13-4
Fractures of the Radial Head and Neck. Proposed Mechanisms in Children
  1.  
    Primary displacement of the head (incongruous)
    1.  
      Valgus injuries
    2.  
      Associated with dislocation of the elbow
      1.  
        During reduction
      2.  
        During dislocation
  2.  
    Primary displacement of the neck
    1.  
      Angular forces
    2.  
      Rotational forces
    3.  
      Chronic stress forces
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Treatment Options for Fractures of the Proximal Radius

Nonoperative Treatment of Fractures of the Proximal Radius

Indications/Contraindications

Nonoperative treatment is indicated for the majority of proximal radius fractures. A great deal of remodeling of the proximal radius can be expected in skeletally immature children. Based on multiple retrospective case series, radial neck angulation of 30 to 45 degrees generally remodels and conservative treatment will lead to good results.22,66,68,102,113 It is critical to assess forearm rotation, and if a block to full rotation is appreciated operative treatment should be considered. Intra-articular aspiration of hematoma and injection of local anesthetic can assist with pain relief and assessment of range of motion. 
In the case of nondisplaced radial head fractures (Salter–Harris IV, Group 1B in the Chambers classification) close follow-up with serial radiographs is warranted to monitor radiocapitellar alignment. If subluxation is suspected, advanced imaging with ultrasound or MRI along with consideration of operative treatment should be considered. 
Closed reduction techniques should be attempted if there is displacement or unacceptable angulation at the fracture site. The goal should be to restore the alignment to accepted indications below with full forearm rotation. Internal fixation is usually not necessary if successful closed reduction can be accomplished. 
Patients not requiring closed reduction should be immobilized for comfort for a short period of time to allow for comfort and soft tissue healing. This is generally 1 to 3 weeks based on extent of injury and age. After fracture pain has subsided patients should work on progressively increasing range of motion and resumption of activities as symptoms allow. Immobilization can be accomplished with a sling, posterior arm splint, or long-arm cast based on surgeon and patient preference (Table 13-5). 
 
Table 13-5
Proximal Radius Fractures: Nonoperative Treatment
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Table 13-5
Proximal Radius Fractures: Nonoperative Treatment
Indications Relative Contraindications
<2 mm displacement of the radial head or neck Open fracture
<30–45-degree angulation of the radial neck (<30 degrees age greater than 10, <45 degrees age less than 10) Incongruent elbow joint
Full forearm pronation and supination
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Closed Reduction Techniques

Several closed reduction techniques for proximal radius fractures have been described in the literature. All have generally good reported results and the surgeon should be familiar with multiple techniques and apply them as needed because closed treatment of proximal radius fractures generally has been shown to have improved results compared to open treatment. No technique has been demonstrated to have superiority over another. Techniques are variations on either manipulating the proximal fragment to the fixed radial shaft or manipulating the radial shaft to the fixed proximal fragment. 
Patterson74 described a reduction technique for the radial neck in 1934. Conscious sedation or general anesthesia is recommended in children to allow for adequate relaxation for the procedure. The annular ligament should be intact to stabilize the proximal radial head fragment.58 An assistant grasps the arm proximal to the elbow joint with one hand (Fig. 13-16) and places the other hand medially over the distal humerus to provide a medial fulcrum for the varus stress applied across the elbow. The surgeon applies distal traction with the forearm supinated to relax the supinators and biceps. A varus force is then placed on the elbow with added direct lateral pressure on the radial head in an attempt to reduce the fracture. Kaufman et al.45 proposed another technique in which the elbow is manipulated in the flexed position. The surgeon presses his or her thumb against the anterior surface of the radial head with the forearm in pronation. 
Figure 13-16
Patterson's manipulative technique.
 
Left: An assistant grabs the arm proximally with one hand placed medially against the distal humerus. The surgeon applies distal traction with the forearm supinated and pulls the forearm into varus. Right: Digital pressure applied directly over the tilted radial head completes the reduction.
 
(Redrawn with permission from Patterson RF. Treatment of displaced transverse fractures of the neck of the radius in children. J Bone Joint Surg. 1934; 16:695–698.)
Left: An assistant grabs the arm proximally with one hand placed medially against the distal humerus. The surgeon applies distal traction with the forearm supinated and pulls the forearm into varus. Right: Digital pressure applied directly over the tilted radial head completes the reduction.
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Figure 13-16
Patterson's manipulative technique.
Left: An assistant grabs the arm proximally with one hand placed medially against the distal humerus. The surgeon applies distal traction with the forearm supinated and pulls the forearm into varus. Right: Digital pressure applied directly over the tilted radial head completes the reduction.
(Redrawn with permission from Patterson RF. Treatment of displaced transverse fractures of the neck of the radius in children. J Bone Joint Surg. 1934; 16:695–698.)
Left: An assistant grabs the arm proximally with one hand placed medially against the distal humerus. The surgeon applies distal traction with the forearm supinated and pulls the forearm into varus. Right: Digital pressure applied directly over the tilted radial head completes the reduction.
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Although forearm supination relaxes the supinator muscle, supination may not be the best position for manipulation of the head fragment. Jeffrey43 pointed out that the tilt of the radial head depends on the position of the forearm at the time of injury. The direction of maximal tilt can be confirmed by radiograph and is also when fracture deformity will be most palpable clinically. The best position for reduction is the degree of rotation that places the radial head most prominent laterally. If the x-ray beam is perpendicular to the head in maximal tilt, it casts an oblong or rectangular shadow; if not, the shadow is oval or almost circular.43 With a varus force applied across the extended elbow, the maximal tilt directed laterally, and the elbow in varus, the radial head can be reduced with the pressure of a finger (Fig. 13-16, right). An alternative technique with the elbow in extension was described by Neher and Torch. An assistant uses both thumbs to place a laterally directed force on the proximal radial shaft while the surgeon applies a varus stress to the elbow. Simultaneously, the surgeon uses his other thumb to apply a reduction force directly to the radial head (Fig. 13-17).65 
Figure 13-17
Neher and Torch reduction technique.
 
(From Neher CG, Torch MA. New reduction technique for severely displaced pediatric radial neck fractures. J Pediatr Orthop. 2003; 23:626–628, with permission.)
(From 


Neher CG,

Torch MA
.
New reduction technique for severely displaced pediatric radial neck fractures.
J Pediatr Orthop.
2003;
23:626–628, with permission.)
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Figure 13-17
Neher and Torch reduction technique.
(From Neher CG, Torch MA. New reduction technique for severely displaced pediatric radial neck fractures. J Pediatr Orthop. 2003; 23:626–628, with permission.)
(From 


Neher CG,

Torch MA
.
New reduction technique for severely displaced pediatric radial neck fractures.
J Pediatr Orthop.
2003;
23:626–628, with permission.)
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The Israeli technique involves stabilization of the proximal fragment with the thumb anteriorly while rotating the forearm into full pronation to reduce the shaft to the proximal fragment.45 The elbow should be flexed to 90 degrees for the manipulation (Figs. 13-18 and 13-19). Another technique emphasizing reduction of the shaft to the proximal fragment was recently described by Monson. After adequate sedation or anesthesia the elbow is flexed to 90 degrees and forearm fully supinated. The proximal radial fragment should be stabilized in place by the annular ligament. A directly applied force to the radial shaft is applied to reduce the shaft to the head (Figs. 13-20 and 13-21). Initial experience with this technique in six children has been reported with excellent results and no need for additional procedures.61 
Figure 13-18
Flexion-pronation (Israeli) reduction technique.47
 
A: Radiograph of the best reduction obtained by the Patterson74 method. B: Position of the radial head after the flexion-pronation method.
 
(Courtesy of Gerald R. Williams, MD.)
A: Radiograph of the best reduction obtained by the Patterson74 method. B: Position of the radial head after the flexion-pronation method.
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Figure 13-18
Flexion-pronation (Israeli) reduction technique.47
A: Radiograph of the best reduction obtained by the Patterson74 method. B: Position of the radial head after the flexion-pronation method.
(Courtesy of Gerald R. Williams, MD.)
A: Radiograph of the best reduction obtained by the Patterson74 method. B: Position of the radial head after the flexion-pronation method.
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Figure 13-19
Flexion-pronation (Israeli) reduction technique.45
 
A: With the elbow in 90 degrees of flexion, the thumb stabilizes the displaced radial head. Usually the distal radius is in a position of supination. The forearm is pronated to swing the shaft up into alignment with the neck (arrow). B: Movement is continued to full pronation for reduction (arrow).
A: With the elbow in 90 degrees of flexion, the thumb stabilizes the displaced radial head. Usually the distal radius is in a position of supination. The forearm is pronated to swing the shaft up into alignment with the neck (arrow). B: Movement is continued to full pronation for reduction (arrow).
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Figure 13-19
Flexion-pronation (Israeli) reduction technique.45
A: With the elbow in 90 degrees of flexion, the thumb stabilizes the displaced radial head. Usually the distal radius is in a position of supination. The forearm is pronated to swing the shaft up into alignment with the neck (arrow). B: Movement is continued to full pronation for reduction (arrow).
A: With the elbow in 90 degrees of flexion, the thumb stabilizes the displaced radial head. Usually the distal radius is in a position of supination. The forearm is pronated to swing the shaft up into alignment with the neck (arrow). B: Movement is continued to full pronation for reduction (arrow).
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Figure 13-20
As the fracture is usually displaced laterally, placing the forearm in supination results in the apex being anterior.
 
The radial head is relatively stable and locked by the annular ligament. Pressure on the proximal radial shaft with the arm in supination reduces the shaft to the radial head.
 
(From Monson R, Black B, Reed M. A new closed reduction technique for the treatment of radial neck fractures in children. J Pediatr Orthop. 2009; 29(3);243–247.)
The radial head is relatively stable and locked by the annular ligament. Pressure on the proximal radial shaft with the arm in supination reduces the shaft to the radial head.
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Figure 13-20
As the fracture is usually displaced laterally, placing the forearm in supination results in the apex being anterior.
The radial head is relatively stable and locked by the annular ligament. Pressure on the proximal radial shaft with the arm in supination reduces the shaft to the radial head.
(From Monson R, Black B, Reed M. A new closed reduction technique for the treatment of radial neck fractures in children. J Pediatr Orthop. 2009; 29(3);243–247.)
The radial head is relatively stable and locked by the annular ligament. Pressure on the proximal radial shaft with the arm in supination reduces the shaft to the radial head.
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Figure 13-21
 
A: Preoperative anteroposterior and lateral radiographs of left elbow of a 9-year-old girl showing 34 degrees of angulation and 50% displacement. B: Anteroposterior and lateral radiographs of the fracture 5 months postreduction showing maintenance of reduction with good callus formation.
 
(From Monson R, Black B, Reed M. A new closed reduction technique for the treatment of radial neck fractures in children. J Pediatr Orthop. 2009; 29(3);243–247.)
A: Preoperative anteroposterior and lateral radiographs of left elbow of a 9-year-old girl showing 34 degrees of angulation and 50% displacement. B: Anteroposterior and lateral radiographs of the fracture 5 months postreduction showing maintenance of reduction with good callus formation.
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Figure 13-21
A: Preoperative anteroposterior and lateral radiographs of left elbow of a 9-year-old girl showing 34 degrees of angulation and 50% displacement. B: Anteroposterior and lateral radiographs of the fracture 5 months postreduction showing maintenance of reduction with good callus formation.
(From Monson R, Black B, Reed M. A new closed reduction technique for the treatment of radial neck fractures in children. J Pediatr Orthop. 2009; 29(3);243–247.)
A: Preoperative anteroposterior and lateral radiographs of left elbow of a 9-year-old girl showing 34 degrees of angulation and 50% displacement. B: Anteroposterior and lateral radiographs of the fracture 5 months postreduction showing maintenance of reduction with good callus formation.
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Lastly, use of an Esmarch bandage wrap as is done for limb exsanguination prior to tourniquet use in extremity surgery has been described to serendipitously promote fracture reduction (Fig. 13-22).15 This can be utilized as an easy adjunct in nearly all of the described closed reduction techniques. 
Figure 13-22
Elastic bandage wrap reduction.
 
A: The final position achieved after manipulation by the Patterson74 method. B: Position of the radial head after applying an elastic bandage to exsanguinate the extremity.
A: The final position achieved after manipulation by the Patterson74 method. B: Position of the radial head after applying an elastic bandage to exsanguinate the extremity.
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Figure 13-22
Elastic bandage wrap reduction.
A: The final position achieved after manipulation by the Patterson74 method. B: Position of the radial head after applying an elastic bandage to exsanguinate the extremity.
A: The final position achieved after manipulation by the Patterson74 method. B: Position of the radial head after applying an elastic bandage to exsanguinate the extremity.
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Regardless of the technique chosen alignment should be assessed by fluoroscopy. Radial neck angulation should be reduced to less than 45 degrees in children under 10 years of age and less than 30 degrees in children greater than 10 years of age. The radiocapitellar joint should be congruent. The elbow joint must be stable to stress. Immobilization for a short duration is recommended for pain control and soft tissue healing. Early range of motion should be encouraged once the acute pain has resolved, generally within 1 to 3 weeks. 

Operative Treatment of Fractures of the Proximal Radius

Indications/Contraindications

Surgical treatment is indicated in situations where acceptable alignment cannot be achieved with closed means, or if there is persistent elbow instability or restricted range of motion after closed treatment. Most fractures of the proximal radius present to the surgeon with minimal deformity and do not require treatment other than a short period of immobilization. Operative treatment should be considered when displacement remains over 2 mm, angulation is greater than 45 degrees (age < 10) or greater than 30 degrees (age < 10), and for open injuries. Nerve palsy is generally not an indication for surgery because most will recover function over time. 

Instrument-Assisted Closed Reduction

Preoperative Planning (Table 13-6)
Table 13-6
Instrument-Assisted Closed Reduction of Proximal Radius Fractures
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Smooth Kirschner wires
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet
  •  
    Esmarch bandage
X
Positioning
The patient should be positioned supine on the operating table with a radiolucent hand table attached to the operating bed. The affected extremity should be placed directly in the middle of the hand table. The entire operating table should be rotated 90 degrees from standard position to place the injure extremity opposite the anesthesiologist. Fluoroscopy will be brought in directly in line with the injured extremity with surgeon and assistant on either side of the hand table (Fig. 13-23). The patient should be brought to the lateral edge of the bed and head secured to the operating room table. We suggest a towel or blanket draped over the head surrounded by strong tape from one edge of the table to the other (Fig. 13-24). This is especially important for small patients to allow for the fluoroscopy unit to be able to image the area of interest and not be blocked by the table. Torso should be secured to the table with a safety strap. A nonsterile tourniquet should be applied to the humerus. Surgeons may be standing or seated per their preference. 
Figure 13-23
Preferred positioning and operative room setup for operative treatment of proximal radius and ulna fractures.
Flynn-ch013-image023.png
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Figure 13-24
Detailed view of showing recommended method of securing head safely to the operative table while allowing for appropriate elbow positioning on the hand table for intraoperative fluoroscopy.
Flynn-ch013-image024.png
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Surgical Approach
Percutaneous direct lateral approach is utilized as described in the technique below to minimize risk of injury to the PIN. 
Technique
Simple steel K-wires generally are appropriate to assist with closed reduction. Size will range from 2 to 2.7 mm based on the size of the child. Other instruments utilized include Steinmann pins, periosteal elevators, or a double-pointed bident.3,30,87 Fluoroscopy is used to localize the fracture site and intended entry site of the wire. This should be along the direct lateral cortex of the radial shaft to decrease risk of injury to the PIN. Pronating the forearm further moves the PIN away from the surgical field. Skin is incised with a small stab wound and a small curved clamp is utilized to bluntly dissect through the muscle to the radial cortex. The sharp end of the wire is cut for surgeon safety and the blunt end is inserted down to the radial cortex. Fluoroscopic guidance is used to localize the fracture site and the blunt end of the wire can be used to push the distal fracture fragment back into an appropriate position (Fig. 13-25). Arthrography can be helpful to assess congruency of the elbow joint. (Dormans 1994)19 Once the fracture is reduced to within appropriate guidelines the pin is removed and stability and range of motion are assessed. If the fracture remains stable through a normal arc of motion no internal fixation is needed.7,68,121 If instability is noted then internal fixation can be placed. Small antegrade K-wires can be placed percutaneously to transfix the fracture.20,28,44 (Fig. 13-26). Pins should stay lateral to minimize injury to the PIN. Pins traversing the capitellum into the proximal radius should be avoided because they have a high rate of migration and/or pin breakage.28,68,93,121 Various iterations of this technique have been described in the literature.3,6,20,76,101 
Figure 13-25
Instrument-assisted closed reduction of the proximal radius.
 
A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
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A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
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Figure 13-25
Instrument-assisted closed reduction of the proximal radius.
A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
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A: AP radiograph of an angulated radial neck fracture in a 10-year-old female. B: Lateral radiograph of the same patient. C: Intraoperative fluoroscopy showing blunt end of a K-wire assisting with reduction of the fracture by direct manipulation of the proximal fragment.
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Figure 13-26
Oblique pin.
 
A: Displaced fracture of the radial neck in a 10-year-old. B: A closed reduction was performed, and to stabilize the head fragment, two pins were placed percutaneously and obliquely across the fracture site from proximal to distal. If open reduction and pinning are done, the preferred alignment is obliquely across the fracture site from distal to proximal.
 
(From Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:57, with permission.)
A: Displaced fracture of the radial neck in a 10-year-old. B: A closed reduction was performed, and to stabilize the head fragment, two pins were placed percutaneously and obliquely across the fracture site from proximal to distal. If open reduction and pinning are done, the preferred alignment is obliquely across the fracture site from distal to proximal.
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Figure 13-26
Oblique pin.
A: Displaced fracture of the radial neck in a 10-year-old. B: A closed reduction was performed, and to stabilize the head fragment, two pins were placed percutaneously and obliquely across the fracture site from proximal to distal. If open reduction and pinning are done, the preferred alignment is obliquely across the fracture site from distal to proximal.
(From Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:57, with permission.)
A: Displaced fracture of the radial neck in a 10-year-old. B: A closed reduction was performed, and to stabilize the head fragment, two pins were placed percutaneously and obliquely across the fracture site from proximal to distal. If open reduction and pinning are done, the preferred alignment is obliquely across the fracture site from distal to proximal.
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Alternatively, the sharp end of the wire can be retained and introduced to the fracture site and the wire used as a lever to correct angulation.14 Once corrected, the pin can be driven from proximal to distal across the radial cortex and serve as a buttress against recurrent angulation of the distal fragment. In this instance, the wire is introduced through the skin closer to the fracture site than in the prior described technique to prevent soft tissue from blocking appropriate leverage of the distal fracture fragment. The pin is cut short but left out of the skin and underneath postoperative immobilization. It may be removed in 1 to 3 weeks when the surgeon is comfortable allowing range of motion at the elbow (Fig. 13-27). 
Figure 13-27
 
Leverage technique of instrument-assisted closed reduction of the proximal radius (A). Intraoperative AP fluoroscopy image demonstrating angulated radial neck fracture (B). K-wire inserted at fracture site and levering proximal fragment into a reduced position (C). AP view of elbow following pin removal in clinic showing anatomic alignment of proximal radius fracture (D). Same wire driven through the opposite cortex to hold reduced position of the proximal fragment.
Leverage technique of instrument-assisted closed reduction of the proximal radius (A). Intraoperative AP fluoroscopy image demonstrating angulated radial neck fracture (B). K-wire inserted at fracture site and levering proximal fragment into a reduced position (C). AP view of elbow following pin removal in clinic showing anatomic alignment of proximal radius fracture (D). Same wire driven through the opposite cortex to hold reduced position of the proximal fragment.
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Figure 13-27
Leverage technique of instrument-assisted closed reduction of the proximal radius (A). Intraoperative AP fluoroscopy image demonstrating angulated radial neck fracture (B). K-wire inserted at fracture site and levering proximal fragment into a reduced position (C). AP view of elbow following pin removal in clinic showing anatomic alignment of proximal radius fracture (D). Same wire driven through the opposite cortex to hold reduced position of the proximal fragment.
Leverage technique of instrument-assisted closed reduction of the proximal radius (A). Intraoperative AP fluoroscopy image demonstrating angulated radial neck fracture (B). K-wire inserted at fracture site and levering proximal fragment into a reduced position (C). AP view of elbow following pin removal in clinic showing anatomic alignment of proximal radius fracture (D). Same wire driven through the opposite cortex to hold reduced position of the proximal fragment.
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A modification described by Wallace utilizes an instrument to provide counterforce on the radial shaft. Fluoroscopy in an AP projection is used to determine the forearm rotation that exposes the maximum amount of deformity of the fracture, and the level of the bicipital tuberosity of the proximal radius is marked. A 1-cm dorsal skin incision is made at that level just lateral to the subcutaneous border of the ulna. A periosteal elevator is gently inserted between the ulna and the radius, with care not to disrupt the periosteum of the radius or the ulna. The radial shaft is usually much more ulnarly displaced than expected, and the radial nerve is lateral to the radius at this level. While counterpressure is applied against the radial head, the distal fragment of the radius is levered away from the ulna. An assistant can aid in this maneuver by gently applying traction and rotating the forearm back and forth to disengage the fracture fragments. The proximal radial fragment can be reduced either manually with thumb pressure or assisted by a percutaneous instrument as described (Table 13-7, Figs. 13-28 and 13-29). 
Table 13-7
Instrument-Assisted Closed Reduction of Proximal Radius Fractures
Surgical Steps
  •  
    Attempt closed reduction
  •  
    Percutaneous insertion of blunt end K-wire lateral forearm
  •  
    Reduce fracture by pushing on proximal fragment
  •  
    Assess stability and range of motion
    •  
      If stable: Immobilize in long-arm cast
    •  
      If unstable: Antegrade K-wire fixation
  •  
    Alternatively—use leverage technique described in text
X
Figure 13-28
Wallace radial head reduction technique.
 
A: A periosteal elevator is used to lever the distal fragment laterally while the thumb pushes the proximal fragment medially. B: Kirschner wires are used to assist the reduction if necessary. C: The position of the reduction can be fixed with an oblique Kirschner wire.
A: A periosteal elevator is used to lever the distal fragment laterally while the thumb pushes the proximal fragment medially. B: Kirschner wires are used to assist the reduction if necessary. C: The position of the reduction can be fixed with an oblique Kirschner wire.
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Figure 13-28
Wallace radial head reduction technique.
A: A periosteal elevator is used to lever the distal fragment laterally while the thumb pushes the proximal fragment medially. B: Kirschner wires are used to assist the reduction if necessary. C: The position of the reduction can be fixed with an oblique Kirschner wire.
A: A periosteal elevator is used to lever the distal fragment laterally while the thumb pushes the proximal fragment medially. B: Kirschner wires are used to assist the reduction if necessary. C: The position of the reduction can be fixed with an oblique Kirschner wire.
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Figure 13-29
 
A: Radial neck fracture angulated 45 degrees in a 14-year-old female. B: Radiograph after closed reduction using thumb pressure on the radial head. C: Final reduction after manipulation of the distal fragment with an elevator using the Wallace technique. D: Lateral view of the elbow after reduction.
A: Radial neck fracture angulated 45 degrees in a 14-year-old female. B: Radiograph after closed reduction using thumb pressure on the radial head. C: Final reduction after manipulation of the distal fragment with an elevator using the Wallace technique. D: Lateral view of the elbow after reduction.
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Figure 13-29
A: Radial neck fracture angulated 45 degrees in a 14-year-old female. B: Radiograph after closed reduction using thumb pressure on the radial head. C: Final reduction after manipulation of the distal fragment with an elevator using the Wallace technique. D: Lateral view of the elbow after reduction.
A: Radial neck fracture angulated 45 degrees in a 14-year-old female. B: Radiograph after closed reduction using thumb pressure on the radial head. C: Final reduction after manipulation of the distal fragment with an elevator using the Wallace technique. D: Lateral view of the elbow after reduction.
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Intramedullary Nail Reduction/Fixation

Preoperative Planning
Implant size should be estimated prior to surgery. The technique was initially described using K-wires which are readily available and inexpensive. Some prefer using titanium flexible nails that also work well but are more costly. The isthmus of the radius should be measured on both AP and lateral views and implant size should be chosen to easily pass. Generally an implant 60% to 70% of the width of the isthmus will pass without too much difficulty. In adolescents this will usually be a 2- or 2.4-mm K-wires. It is advised to have one size larger and smaller than planned available if needed (Table 13-8). 
Table 13-8
Intramedullary Nail Reduction/Fixation of Proximal Radius Fractures
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Smooth Kirschner wires
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
  •  
    Esmarch bandage
X
Positioning
Same as for instrument-assisted closed reduction. 
Surgical Approach(es)
The implant is inserted at the distal radius via a radial entry. The distal radial physis should be localized with fluoroscopy. A direct lateral incision of 1 to 2 cm is made just proximal to the physis of the distal radius. Careful scissor dissection to the lateral radial cortex is made with care taken not to injure the superficial radial nerve. It is not required to search for the nerve, however, if encountered it should be gently retracted. Extensor tendons from the first dorsal compartment may also be encountered and should be retracted. 
Alternatively, the implant may be inserted via a direct dorsal approach over the dorsal tubercle of the radius. Either longitudinal or transverse incisions may be utilized. Extensor tendons will be encountered and should be protected during opening of the radial cortex at the dorsal tubercle. 
Technique
Intramedullary reduction and fixation of proximal radius fractures was described by Metaizeau in 1980.60 After selection of an appropriate-sized implant (K-wire or titanium flexible nail) the distal 3 to 4 mm of the implant should be bent sharply about 40 degrees. Either a dorsal or radial approach can be utilized at the entry site of the distal radius. The wire is advanced through the radial canal to the fracture site. If necessary, closed maneuvers should be used to improve alignment at the fracture site to allow for successful passage of the distal tip of the implant into the proximal fragment. The implant should be impacted into the epiphysis to achieve maximal fixation prior to reduction attempts with the implant. Once advanced appropriately, the nail should be rotated 90 to 180 degrees as needed to reduce the proximal fragment. The forearm should be held by the assistant to prevent the radial shaft from rotating with the implant (Fig. 13-30). Stability at the elbow joint and range of motion are assessed. The implant should be cut distally balancing need for ease of recovery during implant removal with soft tissue irritation from implant prominence at the distal radius. Rigid immobilization is not necessary with use of an intramedullary implant; however, most surgeons will immobilize the extremity in a long-arm splint or cast for 7 to 10 days for pain relief and to allow for soft tissue healing. Early range of motion is encouraged to minimize postoperative stiffness (Table 13-9). 
Figure 13-30
Intramedullary pin reduction.
 
A: The insertion point for the curved flexible pin is in the metaphysis. B: The curved end of the rod passes in the shaft and engages the proximal fragment. C: Manipulation of the rod disimpacts the fracture. D, E: Once disimpacted, the head fragment is rotated into position with the intramedullary rod.
 
(From Metaizeau JP, Lascombes P, Lemelle JL, et al. Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop. 1993; 13:355–360, with permission.)
A: The insertion point for the curved flexible pin is in the metaphysis. B: The curved end of the rod passes in the shaft and engages the proximal fragment. C: Manipulation of the rod disimpacts the fracture. D, E: Once disimpacted, the head fragment is rotated into position with the intramedullary rod.
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Figure 13-30
Intramedullary pin reduction.
A: The insertion point for the curved flexible pin is in the metaphysis. B: The curved end of the rod passes in the shaft and engages the proximal fragment. C: Manipulation of the rod disimpacts the fracture. D, E: Once disimpacted, the head fragment is rotated into position with the intramedullary rod.
(From Metaizeau JP, Lascombes P, Lemelle JL, et al. Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop. 1993; 13:355–360, with permission.)
A: The insertion point for the curved flexible pin is in the metaphysis. B: The curved end of the rod passes in the shaft and engages the proximal fragment. C: Manipulation of the rod disimpacts the fracture. D, E: Once disimpacted, the head fragment is rotated into position with the intramedullary rod.
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Table 13-9
Intramedullary Nail Reduction/Fixation of Proximal Radius Fractures
Surgical Steps
  •  
    Prebend implant at distal end
  •  
    Open distal radial cortex via radial or dorsal approach
  •  
    Advance implant to the fracture site
  •  
    Closed manipulation of fracture to allow implant to enter distal fragment
  •  
    Advance implant into distal fragment
  •  
    Rotate implant as needed to reduce fracture
  •  
    Assess stability and range of motion
  •  
    Cut implant distally under the skin
  •  
    Close surgical wound
  •  
    Immobilize to allow for soft tissue healing
X

Open Reduction Internal Fixation

Preoperative Planning
Appropriate implants should be available if rigid internal fixation is planned. These may include mini fragment screws, mini-fragment plates, or specialty proximal radius plates. Small fragment screws and plates are too large for fixation of the proximal radius. Specialty plates are produced by numerous manufacturers, but are designed for adult patients. Many will be too large for children and young adolescents, however, they may fit appropriately in the older adolescent (Table 13-10). 
Table 13-10
Open Reduction Internal Fixation of Proximal Radius Fractures
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: 2–2.7-mm screws; minifragment plates versus fracture specific plates (radial neck, radial head)
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
  •  
    Esmarch bandage
X
Positioning
Same as for instrument-assisted closed reduction. 
Surgical Approach(es)
A lateral approach to the proximal radius should be utilized for open reduction of proximal radius fractures. The lateral Kocher approach provides appropriate exposure. Dissection should occur between the anconeus and extensor carpi ulnaris. Usually the interval is easier to identify distally and can be traced back proximally. The muscle fibers will be seen to run in divergent directions distally which assist with location of the interval. Often the annular ligament will be traumatically disrupted and also the joint capsule will be disrupted. Care should be taken to stay superior to the lateral collateral ligament of the elbow to prevent adding iatrogenic instability. Distally the supinator may be released if needed for plate application. 
When exposing the proximal radius the forearm should be kept in a pronated position to move the PIN further away from the surgical field. Vigorous retraction should be avoided anteriorly to limit traction on the PIN. 
Technique
After adequate exposure of the fracture site the anatomy of the fracture should be evaluated. Radial neck fractures are more common and can be reduced using manual pressure or instrumented manipulation. Often a dental pick is useful to hold a reduced position after manual reduction. The fracture can be either definitively or provisionally fixed at this point with small K-wires. Radial head fractures are usually more complex and may have multiple fragments. Attempts should be made to reduce the radial head in children and adolescents with use of small pins or bone clamps to hold provisional reduction. Radial head excision is generally a salvage operation but can be considered as a primary treatment if there is extensive comminution prohibiting reconstruction. Results have been uniformly poor after excision with high incidence of cubitus valgus and radial deviation at the wrist.21,40,44 Radial head replacement has not been described for children or adolescents but is increasingly utilized for adults. 
When proceeding with open reduction, most surgeons elect to place more rigid fixation to allow for early range of motion. Screw fixation with minifragment screws or small headless screws provides stable fixation of radial head and neck fractures (Figs. 13-31 and 13-32).97 Plates have been utilized for fixation of radial neck fractures requiring open reduction (Fig. 13-33). They should be placed in the “safe zone” of the proximal radius. This is an area of about 100 to 110 degrees of the circumference of the proximal radius that does not articulate with the proximal ulna during forearm rotation. With the forearm in 10 degrees of supination the “safe zone” is directly lateral.99 (JOT 1998 12:291-293)100 Screws should be kept unicortical to prevent perforation into the proximal radioulnar joint. Plate application requires more extensive dissection than isolated screw fixation and has led some authors to strongly advocate for multiple screw fixation alone for radial head and neck fractures. There is no good quality evidence supporting one form of internal fixation over another in the treatment of fractures of the proximal radius. 
Figure 13-31
Miniscrew fixation.
 
A, B: Anteroposterior and lateral views of the elbow of a 6-year-old male in whom the head fragment lies posterior to the capitellum (arrows). C: At the time of open reduction a Salter–Harris type III fracture through the epiphysis and proximal physis was apparent. The fragment involved 60% of the head diameter and had soft tissue attached. D: A screw placed through the epiphysis fixed the reduction. E: Six months after surgery, an arthrogram showed maintenance of the architectural structure of the medial head after screw removal. The patient had 60 degrees of supination and pronation.
 
(From Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:58, with permission.)
A, B: Anteroposterior and lateral views of the elbow of a 6-year-old male in whom the head fragment lies posterior to the capitellum (arrows). C: At the time of open reduction a Salter–Harris type III fracture through the epiphysis and proximal physis was apparent. The fragment involved 60% of the head diameter and had soft tissue attached. D: A screw placed through the epiphysis fixed the reduction. E: Six months after surgery, an arthrogram showed maintenance of the architectural structure of the medial head after screw removal. The patient had 60 degrees of supination and pronation.
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Figure 13-31
Miniscrew fixation.
A, B: Anteroposterior and lateral views of the elbow of a 6-year-old male in whom the head fragment lies posterior to the capitellum (arrows). C: At the time of open reduction a Salter–Harris type III fracture through the epiphysis and proximal physis was apparent. The fragment involved 60% of the head diameter and had soft tissue attached. D: A screw placed through the epiphysis fixed the reduction. E: Six months after surgery, an arthrogram showed maintenance of the architectural structure of the medial head after screw removal. The patient had 60 degrees of supination and pronation.
(From Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:58, with permission.)
A, B: Anteroposterior and lateral views of the elbow of a 6-year-old male in whom the head fragment lies posterior to the capitellum (arrows). C: At the time of open reduction a Salter–Harris type III fracture through the epiphysis and proximal physis was apparent. The fragment involved 60% of the head diameter and had soft tissue attached. D: A screw placed through the epiphysis fixed the reduction. E: Six months after surgery, an arthrogram showed maintenance of the architectural structure of the medial head after screw removal. The patient had 60 degrees of supination and pronation.
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Figure 13-32
Patient underwent operative intervention using low-profile fixation with 3-mm cannulated screws and repair of a torn lateral ulnar collateral ligament complex.
 
Gentle range of motion was started on postoperative day 1 and progressed as tolerated. Anteroposterior (A) and lateral (B) radiographs of the elbow at 3-month follow-up demonstrated healing of the fracture, and clinical assessment demonstrated full function and range of motion.
 
(From Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: Surgical technique and clinical experience. J Orthop Trauma. 2007; 21(10):718–724.)
Gentle range of motion was started on postoperative day 1 and progressed as tolerated. Anteroposterior (A) and lateral (B) radiographs of the elbow at 3-month follow-up demonstrated healing of the fracture, and clinical assessment demonstrated full function and range of motion.
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Figure 13-32
Patient underwent operative intervention using low-profile fixation with 3-mm cannulated screws and repair of a torn lateral ulnar collateral ligament complex.
Gentle range of motion was started on postoperative day 1 and progressed as tolerated. Anteroposterior (A) and lateral (B) radiographs of the elbow at 3-month follow-up demonstrated healing of the fracture, and clinical assessment demonstrated full function and range of motion.
(From Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: Surgical technique and clinical experience. J Orthop Trauma. 2007; 21(10):718–724.)
Gentle range of motion was started on postoperative day 1 and progressed as tolerated. Anteroposterior (A) and lateral (B) radiographs of the elbow at 3-month follow-up demonstrated healing of the fracture, and clinical assessment demonstrated full function and range of motion.
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Figure 13-33
 
Open reduction internal fixation of a proximal radius fracture (A). AP radiograph of an 11-year-old female with elbow dislocation and radial neck fracture (B). Lateral radiograph of the same patient. C: Lateral radiograph in splint after closed reduction showing persistent radiocapitellar subluxation. Examination under anesthesia demonstrated very unstable elbow joint and therefore decision made to proceed with open reduction internal fixation (D). Lateral radiograph after open reduction internal fixation with a fracture-specific plate.
Open reduction internal fixation of a proximal radius fracture (A). AP radiograph of an 11-year-old female with elbow dislocation and radial neck fracture (B). Lateral radiograph of the same patient. C: Lateral radiograph in splint after closed reduction showing persistent radiocapitellar subluxation. Examination under anesthesia demonstrated very unstable elbow joint and therefore decision made to proceed with open reduction internal fixation (D). Lateral radiograph after open reduction internal fixation with a fracture-specific plate.
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Figure 13-33
Open reduction internal fixation of a proximal radius fracture (A). AP radiograph of an 11-year-old female with elbow dislocation and radial neck fracture (B). Lateral radiograph of the same patient. C: Lateral radiograph in splint after closed reduction showing persistent radiocapitellar subluxation. Examination under anesthesia demonstrated very unstable elbow joint and therefore decision made to proceed with open reduction internal fixation (D). Lateral radiograph after open reduction internal fixation with a fracture-specific plate.
Open reduction internal fixation of a proximal radius fracture (A). AP radiograph of an 11-year-old female with elbow dislocation and radial neck fracture (B). Lateral radiograph of the same patient. C: Lateral radiograph in splint after closed reduction showing persistent radiocapitellar subluxation. Examination under anesthesia demonstrated very unstable elbow joint and therefore decision made to proceed with open reduction internal fixation (D). Lateral radiograph after open reduction internal fixation with a fracture-specific plate.
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During closure the annular ligament and joint capsule should be repaired if it was injured during the trauma or surgical dissection. The arm should be immobilized in a posterior splint for 1 to 2 weeks to allow for soft tissue healing before initiating range of motion. A regional anesthetic block prior to surgery or after surgery can provide improved patient comfort postoperatively. A detailed neurologic examination should be conducted preoperatively prior to regional nerve block (Table 13-11). 
 
Table 13-11
Open Reduction Internal Fixation Proximal Radius Fractures
Surgical Steps
  •  
    Kocher lateral approach to proximal radius
    •  
      Keep forearm pronated during exposure
    •  
      Protect lateral collateral ligament
  •  
    Provisional reduction of proximal radius fracture
    •  
      Stabilize with small K-wires or clamps
  •  
    Internal fixation with minifragment screws
  •  
    If plate fixation utilized identify “safe zone” and apply plate
  •  
    Wound closure—repair annular ligament
  •  
    Posterior arm splint
X

Outcomes

Severity of initial displacement and angulation are the best predictors of results after treatment. A higher incidence of good outcomes is found in patients who do not require fracture manipulation (closed or open) and present with fractures with minimal angulation and displacement.68,108 For patients having operative treatment, closed methods generally lead to improved results compared to open treatments. This is again largely because of increased severity of fractures requiring open reduction. In certain cases, however, open treatment is preferred and small case series demonstrates improved results with open treatment in appropriately selected patients.64,102 
The overall incidence of poor results in large series varies from 15% to 33%.28,40,44,102,113 Considering only severely displaced fractures, the incidence of poor results was as high as 50%.102 Thus, at least one in five or six children can be expected to have a poor result despite adequate treatment. It is wise to counsel the parents before beginning treatment if poor prognostic factors are present. These include injuries associated with high-energy mechanism such as elbow dislocation, olecranon fracture, or other fractures of the elbow.28,52,90,102 
Early reviews reported poor results with significant loss of range of motion in patients treated operatively,8,10,15,25 but more recently Steinberg et al.102 combined their results of open reduction of severely displaced fractures with those of five other series43,44,76,108 and reported 49% good results after operative treatment compared to 25% after nonoperative treatment. None of these authors used percutaneous pin reduction. The results of moderately displaced fractures treated operatively were equal to the results of those treated nonoperatively. If the head of the radius is completely displaced, results are usually better with surgical intervention. A completely separated radial head may remain viable if surgically replaced as late as 48 hours after injury.32,46 
Various tolerance for residual angulation has been described, and most authors believe that good results and remodeling can be achieved when there is less than 30 to 45 degrees of angulation.7,22,52,58,68,69,81,113,116 D'Souza evaluated the results in 100 children from 1972 to 1990 and described better results with closed compared to open treatment. Overall 86 had results described as “good” or “excellent.” More recently Tan and Mahadev104 reported on 108 children with radial neck fractures. The majority were treated nonsurgically with only eight requiring a closed reduction, seven requiring instrument-assisted closed reduction, and seven requiring open reduction. Results were “excellent” in 93 children. Adverse outcomes were more likely in older patients and those with associated fractures about the elbow. Most believe that ability to achieve less than 30 to 45 degrees angulation with closed treatment provides superior outcomes compared to patients having open reduction even with anatomic alignment. 
As opposed to substantial angulation, displacement is not well tolerated because of the “cam effect” described. More recently there has been increased attention paid to intra-articular radial head fractures in children. These are problematic injuries and must be monitored closely. Progressive posterior radiocapitellar subluxation has been described leading to severe cartilage deterioration (Fig. 11-34). Most patients with progressive subluxation presenting in a delayed manner end up requiring radial head excision.114 Functional outcomes are very poor when this is identified and treated in a delayed manner. Kasser has described this injury as one of his “The Radiographic Appearance Seemed Harmless (TRASH)” lesions (Fig. 13-9).114 
An increasing number of reports with good results after intramedullary wire technique for angulated and displaced proximal radius fractures have been published recently.76 (Ugutmen 2010, Prathapkumar 2006, Eberl 2010, Klitscher 2009)23,36,47,112 Self-determined “excellent” results are described in 80% to 90% patients in these reported series. Metaizeau's initial results of treatment using intramedullary K-wires reported excellent results in 30/31 children treated with his technique.59 

Author's Preferred Treatment for Fractures of the Proximal Radius

Nonoperative management is our preferred treatment for most proximal radius fractures. Operative treatment should aim to reduce displacement of the radial head/neck to less than 2 mm and restore angulation of radial neck fractures to less than 30 degrees while also confirming normal arc of forearm rotation. Open approaches are avoided if these goals can be achieved. Necessity for internal fixation should be evaluated on an individual basis and is avoided if possible. We have become more aggressive with operative treatment of radial head fractures because of the increased reports of adverse outcomes with progressive posterior radiocapitellar subluxation. Low-profile internal fixation with minifragment screws and if needed, a minifragment plate, is utilized for stable fixation to allow for early range of motion. MRI is utilized more frequently in the evaluation of radial head fractures because of its improved ability to assess for associated soft tissue injuries and evaluation of the radiocapitellar joint in skeletally immature patients (Fig. 13-35). 
Figure 13-34
A 13-year-old male patient after fall on pronated outstretched hand.
 
A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
 
(From Van Zeeland NL, Bae DS, Goldfarb CA. Intra-articular radial head fracture in the skeletally immature patient: Progressive radial head subluxation and rapid radiocapitellar degeneration. J Pediatr Orthop. 2011; 31(2):124–129, with permission.)
A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
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A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
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Figure 13-34
A 13-year-old male patient after fall on pronated outstretched hand.
A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
(From Van Zeeland NL, Bae DS, Goldfarb CA. Intra-articular radial head fracture in the skeletally immature patient: Progressive radial head subluxation and rapid radiocapitellar degeneration. J Pediatr Orthop. 2011; 31(2):124–129, with permission.)
A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
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A, B: Anteroposterior and lateral radiographs of the injured elbow. Salter–Harris III fracture of radial epiphysis without evidence of subluxation. C, D: Anteroposterior and lateral radiographs 6 weeks after the injury. No evidence of osseous union with posterolateral subluxation. E, F: Anteroposterior and lateral radiographs 8 months after injury. Posterolateral subluxation with radiocapitellar arthrosis. G: Clinical photograph showing large, painful lateral prominence. H: Intraoperative photograph showing severe radiocapitellar arthrosis. I: Gross, pathologic photograph of excised radial heal.
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Flynn-ch013-image035.png
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Figure 13-35
Author's preferred treatment algorithm.
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Postoperative Care

Immobilization should only be for symptomatic relief from surgical trauma and soft tissue healing. Generally 1 to 2 weeks is sufficient in patients with open reduction internal fixation or intramedullary fixation. Longer immobilization of 2 to 3 weeks may be required for some patients treated with no reduction or closed reduction to achieve enough symptom relief to allow for mobilization. Collar and cuff, posterior splint, and long-arm cast are all appropriate methods of immobilization. Range of motion should be allowed and encouraged when acute fracture pain has resolved and surgical scar has healed. 

Potential Pitfalls and Preventative Measures

Iatrogenic PIN injury can occur during both percutaneous and open approaches to the proximal radius. Pronation of the forearm during open exposure or during percutaneous pin insertion helps move the PIN away from the surgical field and reduces the risk of nerve injury. Vigorous anterior retraction during open exposure should also be avoided. Knowledge of the anatomy of the PIN is required to safely place instrumentation and expose the proximal radius. 
Radiocapitellar subluxation posteriorly is an extremely poor prognostic factor for outcomes of proximal radius fractures. Close vigilance is warranted in fracture patterns predisposed to this complication, especially intra-articular radial head fractures. In children with intra-articular fractures or those with unossified proximal radial epiphysis strong consideration should be made for ultrasound or MR imaging to determine the anatomic extent of injury. Surgical treatment can prevent this dangerous pitfall in appropriate cases. 
The intramedullary technique has demonstrated good results in experienced hands. Surgeons with less experience may struggle with adequate engagement of the proximal fragment and loss of fixation with attempted rotation of the implant (Fig. 13-36). To decrease this adverse event the implant should be bent sharply to 30 to 40 degrees at its distal end to promote engagement of the proximal fragment. The fragment should also be fixed all the way to the epiphysis, crossing the growth plate, to maximize purchase, and decrease risk of implant failure with the corrective force during rotation of the implant. 
Figure 13-36
Failure of fixation with intramedullary technique for proximal radius fracture.
 
A: AP view showing loss of fixation of the proximal fragment. B: Lateral view showing loss of fixation of the proximal fragment.
A: AP view showing loss of fixation of the proximal fragment. B: Lateral view showing loss of fixation of the proximal fragment.
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Figure 13-36
Failure of fixation with intramedullary technique for proximal radius fracture.
A: AP view showing loss of fixation of the proximal fragment. B: Lateral view showing loss of fixation of the proximal fragment.
A: AP view showing loss of fixation of the proximal fragment. B: Lateral view showing loss of fixation of the proximal fragment.
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Restricted range of motion after open reduction and internal fixation of proximal radius fractures is common. To minimize additional restriction because of implant placement the surgeon should take care to apply plate fixation only to the “safe zone” of the proximal radius and screws aiming toward the proximal radioulnar articulation should be unicortical (Table 13-12). 
Table 13-12
Proximal Radius Fractures: Potential Pitfalls and Preventions
Pitfall Preventions
PIN injury Pronate forearm when approaching proximal radius in open approaches
Avoid vigorous retraction during open reduction
Insert percutaneous implants for reduction assistance directly lateral
Radiocapitellar subluxation Consider ultrasound or MRI for intra-articular radial head fractures
Close radiographic surveillance out of cast/splint for patients with radial head fracture
Failure to engage proximal fragment with intramedullary implant Choose appropriate-sized implant based on preoperative templating
Ensure distal end of implant has an appropriate bend to capture proximal fragment
Mechanical block to forearm rotation Ensure any plate fixation of the proximal radius is in the “safe zone”
Screws aiming toward the proximal radioulnar joint should be unicortical
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Management of Expected Adverse Outcomes and Unexpected Complications in Fractures of the Proximal Radius

Loss of Motion in Fractures of the Proximal Radius

Loss of motion is secondary to a combination of loss of joint congruity and posttraumatic or postoperative soft tissue scarring. Loss of pronation is more common than loss of supination. Flexion and extension are rarely significantly limited. Very little improvement in motion occurs after 6 months. Steinberg et al.102 found that range of motion in their patients at 6 months was almost equal to that when the patients were examined years later. Patients should be encouraged to start range of motion early with both nonoperative and operative treatment to minimize loss of motion from posttraumatic stiffness. Both static and dynamic splinting can be useful along with aggressive therapy in the treatment of posttraumatic or postoperative elbow sand forearm stiffness. 

Radial Head Overgrowth in Fractures of the Proximal Radius

Next to loss of range of motion of the elbow and forearm, radial head overgrowth is probably the most common sequela (20% to 40%).22,113 The increased vascularity following the injury may stimulate epiphyseal growth, but the mechanisms of overgrowth following fractures are poorly understood. Radial head overgrowth usually does not compromise functional results,20,44 but it may produce some crepitus or clicking with forearm rotation.22 

Premature Physeal Closure in Fractures of the Proximal Radius

Many series report premature physeal closure28,32,68,69,102,121 after fractures of the radial head and neck. This complication did not appear to affect the overall results significantly, except in one patient described by Fowles and Kassab,28 who had a severe cubitus valgus. Newman68 found that shortening of the radius was never more than 5 mm compared with the opposite uninjured side. 

Osteonecrosis in Fractures of the Proximal Radius

The incidence of osteonecrosis is probably higher than recognized. D'Souza et al.22 reported the frequency to be 10% to 20% in their patients, 70% of whom had open reductions. In patients with open reduction, the overall rate of osteonecrosis was 25%. Jones and Esah44 and Newman68 found that patients with osteonecrosis had poor functional results. It has been our experience, however, that revascularization can occur without any significant functional loss. Only in those in whom a residual functional deficit occurs is osteonecrosis considered a problem (Fig. 13-37). 
Figure 13-37
Osteonecrosis with nonunion in a radial head 1 year after open reduction.
 
Both nonunion and osteonecrosis of the radial neck and head are present. Severe degenerative arthritis developed subsequently.
 
(Courtesy of Richard E. King, MD.)
Both nonunion and osteonecrosis of the radial neck and head are present. Severe degenerative arthritis developed subsequently.
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Figure 13-37
Osteonecrosis with nonunion in a radial head 1 year after open reduction.
Both nonunion and osteonecrosis of the radial neck and head are present. Severe degenerative arthritis developed subsequently.
(Courtesy of Richard E. King, MD.)
Both nonunion and osteonecrosis of the radial neck and head are present. Severe degenerative arthritis developed subsequently.
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Malunion in Fractures of the Proximal Radius

Failure to reduce a displaced and angulated proximal radial fracture in a young child often results in an angulated radial neck with subsequent incongruity of both the proximal radioulnar joint and the radiocapitellar joint (Fig. 13-38). Partial physeal arrest also can create this angulation (Fig. 13-3). 
Figure 13-38
Angulation.
 
A: Injury film showing 30 degrees of angulation and 30% lateral translocation of a radial neck fracture in a 10-year-old. B: Radiograph appearance of the proximal radius taken about 5 months later, showing lateral angulation of the neck. C: Lateral view showing the anterior relationship of the radial neck with proximal migration. At this point the patient had full supination and pronation but a clicking sensation with forearm rotation in the area of the radial head. D: Three-dimensional reconstruction showing the incongruity of the proximal radiocapitellar joint.
 
(Courtesy of Vince Mosca, MD.)
A: Injury film showing 30 degrees of angulation and 30% lateral translocation of a radial neck fracture in a 10-year-old. B: Radiograph appearance of the proximal radius taken about 5 months later, showing lateral angulation of the neck. C: Lateral view showing the anterior relationship of the radial neck with proximal migration. At this point the patient had full supination and pronation but a clicking sensation with forearm rotation in the area of the radial head. D: Three-dimensional reconstruction showing the incongruity of the proximal radiocapitellar joint.
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Figure 13-38
Angulation.
A: Injury film showing 30 degrees of angulation and 30% lateral translocation of a radial neck fracture in a 10-year-old. B: Radiograph appearance of the proximal radius taken about 5 months later, showing lateral angulation of the neck. C: Lateral view showing the anterior relationship of the radial neck with proximal migration. At this point the patient had full supination and pronation but a clicking sensation with forearm rotation in the area of the radial head. D: Three-dimensional reconstruction showing the incongruity of the proximal radiocapitellar joint.
(Courtesy of Vince Mosca, MD.)
A: Injury film showing 30 degrees of angulation and 30% lateral translocation of a radial neck fracture in a 10-year-old. B: Radiograph appearance of the proximal radius taken about 5 months later, showing lateral angulation of the neck. C: Lateral view showing the anterior relationship of the radial neck with proximal migration. At this point the patient had full supination and pronation but a clicking sensation with forearm rotation in the area of the radial head. D: Three-dimensional reconstruction showing the incongruity of the proximal radiocapitellar joint.
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In our experience, this malunion, because of the incongruity of the radiocapitellar joint, often results in erosion of the articular surface of the capitellum, with subsequent degenerative joint disease. In the English literature, there is little information about using osteotomies of the radial neck to correct this deformity. 

Nonunion of the Radial Neck in Fractures of the Proximal Radius

Nonunion of the radial neck is rare; union may occur93 even after prolonged treatment (Fig. 13-39). Waters and Stewart120 reported nine patients with radial neck nonunions, all of whom were treated with open reduction after failed attempts at closed reduction. These authors recommended observation of patients with radial neck nonunions who have limited symptoms and a functional range of motion. They suggested open reduction for displaced nonunions, patients with limited range of motion, and patients with restricting pain. Nonunion of intra-articular radial head fractures can also occur and should be treated with open reduction internal fixation if symptomatic and radiocapitellar joint has remained congruent (Fig. 13-40). In many cases nonunion of these fractures leads to progressive radiocapitellar subluxation and cartilage destruction as previously described. 
Figure 13-39
Nonunion.
 
A: Eight months after radial neck fracture in an 8.5-year-old female. Patient had mild aching pain, but no loss of motion. There was some suggestion of proximal subluxation of the distal radioulnar joint. B: Three months later, the fracture is united after long-arm cast immobilization and external electromagnetic stimulation.
 
(Courtesy of Charles T. Price, MD.)
A: Eight months after radial neck fracture in an 8.5-year-old female. Patient had mild aching pain, but no loss of motion. There was some suggestion of proximal subluxation of the distal radioulnar joint. B: Three months later, the fracture is united after long-arm cast immobilization and external electromagnetic stimulation.
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Figure 13-39
Nonunion.
A: Eight months after radial neck fracture in an 8.5-year-old female. Patient had mild aching pain, but no loss of motion. There was some suggestion of proximal subluxation of the distal radioulnar joint. B: Three months later, the fracture is united after long-arm cast immobilization and external electromagnetic stimulation.
(Courtesy of Charles T. Price, MD.)
A: Eight months after radial neck fracture in an 8.5-year-old female. Patient had mild aching pain, but no loss of motion. There was some suggestion of proximal subluxation of the distal radioulnar joint. B: Three months later, the fracture is united after long-arm cast immobilization and external electromagnetic stimulation.
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Figure 13-40
Nonunion of intra-articular radial head fracture.
 
This 15-year-old female presented 1 year after elbow injury because of persistent pain (A). AP radiograph demonstrating nonunion of the radial head fracture (B). Lateral radiograph after open reduction and internal fixation (C). AP radiograph after open reduction and internal fixation (D). Lateral radiograph of the same patient.
This 15-year-old female presented 1 year after elbow injury because of persistent pain (A). AP radiograph demonstrating nonunion of the radial head fracture (B). Lateral radiograph after open reduction and internal fixation (C). AP radiograph after open reduction and internal fixation (D). Lateral radiograph of the same patient.
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Figure 13-40
Nonunion of intra-articular radial head fracture.
This 15-year-old female presented 1 year after elbow injury because of persistent pain (A). AP radiograph demonstrating nonunion of the radial head fracture (B). Lateral radiograph after open reduction and internal fixation (C). AP radiograph after open reduction and internal fixation (D). Lateral radiograph of the same patient.
This 15-year-old female presented 1 year after elbow injury because of persistent pain (A). AP radiograph demonstrating nonunion of the radial head fracture (B). Lateral radiograph after open reduction and internal fixation (C). AP radiograph after open reduction and internal fixation (D). Lateral radiograph of the same patient.
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Changes in Carrying Angle (Cubitus Valgus) in Fractures of the Proximal Radius

In patients who have fractures of the radial neck, the carrying angle often is 10 degrees more (increased cubitus valgus) than on the uninjured side.22,44 The increase in carrying angle appears to produce no functional deficit and no significant deformity. 

Nerve Injuries in Fractures of the Proximal Radius

Partial ulnar nerve injury40 and PIN injury may occur as a direct result of the fracture, but most injuries to the PINs are caused by surgical exploration22 or percutaneous pin reduction.5 These PIN injuries usually are transient and exploration is not generally warranted. 

Radioulnar Synostosis in Fractures of the Proximal Radius

Proximal radioulnar synostosis can occur following treatment of proximal radius fractures (Fig. 13-41). It occurs most often after open reduction of severely displaced fractures,32,40,68,101 but has been reported to occur after closed reduction. Case reports argue that delayed treatment increases the likelihood of this complication. Treatment is based on functional limitation and disability. 
Figure 13-41
Radioulnar synostosis.
 
A: Surgical intervention with wire fixation was necessary for a satisfactory reduction in this patient who had a totally displaced radial neck fracture. B: Six weeks after surgery, there was evidence of a proximal radioulnar synostosis. C: Radiograph taken 6 months after reduction shows a solid synostosis with anterior displacement of the proximal radius.
 
(Courtesy of R. E. King, MD.)
A: Surgical intervention with wire fixation was necessary for a satisfactory reduction in this patient who had a totally displaced radial neck fracture. B: Six weeks after surgery, there was evidence of a proximal radioulnar synostosis. C: Radiograph taken 6 months after reduction shows a solid synostosis with anterior displacement of the proximal radius.
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Figure 13-41
Radioulnar synostosis.
A: Surgical intervention with wire fixation was necessary for a satisfactory reduction in this patient who had a totally displaced radial neck fracture. B: Six weeks after surgery, there was evidence of a proximal radioulnar synostosis. C: Radiograph taken 6 months after reduction shows a solid synostosis with anterior displacement of the proximal radius.
(Courtesy of R. E. King, MD.)
A: Surgical intervention with wire fixation was necessary for a satisfactory reduction in this patient who had a totally displaced radial neck fracture. B: Six weeks after surgery, there was evidence of a proximal radioulnar synostosis. C: Radiograph taken 6 months after reduction shows a solid synostosis with anterior displacement of the proximal radius.
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Myositis Ossificans in Fractures of the Proximal Radius

Myositis ossificans is relatively common but usually does not impair function. Vahvanen113 noted that some myositis ossificans occurred in 32% of his patients. In most, it was limited to the supinator muscle. If ossification was more extensive and was associated with a synostosis, the results were poor (Table 13-13). 
Table 13-13
Proximal Radius Fractures: Common Adverse Outcomes and Complications
Loss of range of motion
Radial head overgrowth
Avascular necrosis of the radial head
Nonunion
Malunion
Proximal radioulnar synostosis
Cubitus valgus
Posterior interosseous nerve injury
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Assessment of Fractures of the Proximal Ulna

Mechanisms of Injury for Fractures of the Proximal Ulna

Fractures Involving the Proximal Apophysis

The location of the triceps expansive insertion on the metaphysis distal to the physis probably accounts for the rarity of fracture along the physeal line. Only a few reports mention the mechanism of these physeal injuries. In most of the fractures reported by Poland,77 three of which were confirmed by amputation specimens, the force of the injury was applied directly to the elbow. The force may be applied indirectly, producing an avulsion type of fracture. In our experience, this fracture is usually caused by avulsion forces across the apophysis with the elbow flexed, similar to the more common flexion metaphyseal injuries. Children with osteogenesis imperfecta (usually the tarda form) seem especially predisposed to this injury.18,62 
Stress fractures of the olecranon apophysis can occur in athletes (especially throwing athletes) who place considerable recurrent tension forces on the olecranon.72 Stress injuries also have been reported in surfers, elite gymnasts,54 and tennis players.85 If the recurring activity persists, a symptomatic nonunion can develop.75,85,109,111,122 

Metaphyseal Fractures of the Olecranon

Three main mechanisms produce metaphyseal olecranon fractures. First, in injuries occurring with the elbow flexed, posterior tension forces play an important role. Second, in injuries in which the fracture occurs with the elbow extended, the varus or valgus bending stress across the olecranon is responsible for the typical fracture pattern. Third, a less common mechanism involves a direct blow to the elbow that produces an anterior bending or shear force across the olecranon. In this type, the tension forces are concentrated on the anterior portion of the olecranon. 

Flexion Injuries

A fall with the elbow in flexion places considerable tension forces across the posterior aspect of the olecranon process. Proximally, the triceps applies a force to the tip of the olecranon process. Distally, there is some proximal pull by the insertion of the brachialis muscle. Thus, the posterior cortex is placed in tension. This tension force alone, if applied rapidly enough and with sufficient force, may cause the olecranon to fail at its midportion (Fig. 13-42). A direct blow applied to the posterior aspect of the stressed olecranon makes it more vulnerable to failure. With this type of mechanism, the fracture line is usually transverse and perpendicular to the long axis of the olecranon (Fig. 13-43). Because the fracture extends into the articular surface of the semilunar notch, it is classified as intra-articular. 
Figure 13-42
Mechanism of flexion injuries.
 
Center: In the flexed elbow, a tension force develops on the posterior aspect of the olecranon (small double arrow). Right: Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon. Arrows represent pull of brachialis (left arrow) and triceps (right arrow).
Center: In the flexed elbow, a tension force develops on the posterior aspect of the olecranon (small double arrow). Right: Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon. Arrows represent pull of brachialis (left arrow) and triceps (right arrow).
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Figure 13-42
Mechanism of flexion injuries.
Center: In the flexed elbow, a tension force develops on the posterior aspect of the olecranon (small double arrow). Right: Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon. Arrows represent pull of brachialis (left arrow) and triceps (right arrow).
Center: In the flexed elbow, a tension force develops on the posterior aspect of the olecranon (small double arrow). Right: Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon. Arrows represent pull of brachialis (left arrow) and triceps (right arrow).
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Figure 13-43
Radiograph of flexion injury showing greater displacement on the posterior surface.
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The degree of separation of the fracture fragments depends on the magnitude of the forces applied versus the integrity of the soft tissues. The low incidence of displaced olecranon fractures indicates that the soft tissues are quite resistant to these avulsion forces. In flexion injuries, there are relatively few associated soft tissue injuries or other fractures.67 

Extension Injuries

Because the ligaments are more flexible in children, the elbow tends to hyperextend when a child breaks a fall with the outstretched upper extremity. In this situation, the olecranon may be locked into the olecranon fossa. If the elbow goes into extreme hyperextension, usually the supracondylar area fails. If, however, the major direction of the force across the elbow is varus or valgus, a bending moment stresses the olecranon. Most of this force concentrates in the distal portion of the olecranon. Because the olecranon is metaphyseal bone, the force produces greenstick-type longitudinal fracture lines (Fig. 13-44). Most of these fracture lines are linear and remain extra-articular. In addition, because the fulcrum of the bending force is more distal, many of the fracture lines may extend distal to the coronoid process and into the proximal ulnar shaft regions. The major deformity of the olecranon with this type of fracture is usually an angulated greenstick type of pattern. 
Figure 13-44
 
A: Anteroposterior view of a linear greenstick fracture line (arrow) in the medial aspect of the olecranon. B: Lateral view showing the posterior location of the fracture line (arrow).
A: Anteroposterior view of a linear greenstick fracture line (arrow) in the medial aspect of the olecranon. B: Lateral view showing the posterior location of the fracture line (arrow).
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Figure 13-44
A: Anteroposterior view of a linear greenstick fracture line (arrow) in the medial aspect of the olecranon. B: Lateral view showing the posterior location of the fracture line (arrow).
A: Anteroposterior view of a linear greenstick fracture line (arrow) in the medial aspect of the olecranon. B: Lateral view showing the posterior location of the fracture line (arrow).
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Many of these fractures are associated with other injuries in the elbow region, which depend on whether the bending force is directed toward varus or valgus. If a child falls with the forearm in supination, the carrying angle tends to place a valgus stress across the elbow. The result may be a greenstick fracture of the ulna with an associated fracture of the radial neck or avulsion of the medial epicondylar apophysis (Fig. 13-45). If the fracture involves the radial neck, Bado4 classified it as an equivalent of the type I Monteggia lesion. 
Figure 13-45
Valgus pattern of an extension fracture.
 
A: A fall with the elbow extended places a valgus stress on the forearm. B: With increased valgus, a greenstick fracture of the olecranon can occur with or without a fracture of the radial neck or avulsion of the medial epicondylar apophysis. C: Radiograph of a valgus extension fracture of the olecranon with an associated fracture of the radial neck.
A: A fall with the elbow extended places a valgus stress on the forearm. B: With increased valgus, a greenstick fracture of the olecranon can occur with or without a fracture of the radial neck or avulsion of the medial epicondylar apophysis. C: Radiograph of a valgus extension fracture of the olecranon with an associated fracture of the radial neck.
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Figure 13-45
Valgus pattern of an extension fracture.
A: A fall with the elbow extended places a valgus stress on the forearm. B: With increased valgus, a greenstick fracture of the olecranon can occur with or without a fracture of the radial neck or avulsion of the medial epicondylar apophysis. C: Radiograph of a valgus extension fracture of the olecranon with an associated fracture of the radial neck.
A: A fall with the elbow extended places a valgus stress on the forearm. B: With increased valgus, a greenstick fracture of the olecranon can occur with or without a fracture of the radial neck or avulsion of the medial epicondylar apophysis. C: Radiograph of a valgus extension fracture of the olecranon with an associated fracture of the radial neck.
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Shear Injuries

Anterior tension failure is a rare injury that can occur when a direct blow to the proximal ulna causes it to fail with an anterior tension force; the proximal radioulnar joint maintains its integrity. The most common type of shear injury is caused by a force applied directly to the posterior aspect of the olecranon, with the distal fragment displacing anteriorly (Figs. 13-46 and 13-47). The intact proximal radioulnar joint displaces with the distal fragment. In this type of injury, the elbow may be either flexed or extended when the direct shear force impacts the posterior aspect of the olecranon. These fractures are caused by a failure in tension, with the force concentrated along the anterior cortex. This is opposite to the tension failure occurring on the posterior aspect of the cortex in the more common flexion injuries. In the shear-type injury, the fracture line may be transverse or oblique. The differentiating feature from the more common flexion injury is that the thick posterior periosteum usually remains intact. The distal fragment is displaced anteriorly by the pull of the brachialis and biceps muscles. Newman68 described one patient in whom a shear force was directed medially; the radial neck was fractured, and the radial head remained with the proximal fragment. 
Figure 13-46
Flexion shear injuries.
 
A, B: Fracture with the elbow flexed. The direct blow to the distal portion of the posterior olecranon causes the fracture to fail in tension of the anterior surface. The intact proximal radioulnar joint displaces anteriorly. C: Radiograph of a flexion shear injury showing the distal fragments displaced anteriorly as a unit.
A, B: Fracture with the elbow flexed. The direct blow to the distal portion of the posterior olecranon causes the fracture to fail in tension of the anterior surface. The intact proximal radioulnar joint displaces anteriorly. C: Radiograph of a flexion shear injury showing the distal fragments displaced anteriorly as a unit.
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Figure 13-46
Flexion shear injuries.
A, B: Fracture with the elbow flexed. The direct blow to the distal portion of the posterior olecranon causes the fracture to fail in tension of the anterior surface. The intact proximal radioulnar joint displaces anteriorly. C: Radiograph of a flexion shear injury showing the distal fragments displaced anteriorly as a unit.
A, B: Fracture with the elbow flexed. The direct blow to the distal portion of the posterior olecranon causes the fracture to fail in tension of the anterior surface. The intact proximal radioulnar joint displaces anteriorly. C: Radiograph of a flexion shear injury showing the distal fragments displaced anteriorly as a unit.
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Figure 13-47
Extension shear injuries.
 
A, B: Fracture with the elbow extended. If the elbow is extended when the direct blow to the posterior aspect of the elbow occurs, the olecranon fails in tension but with an oblique or transverse fracture line (arrows). C: With the elbow extended, the initial failure is in the anterior articular surface (arrows).
A, B: Fracture with the elbow extended. If the elbow is extended when the direct blow to the posterior aspect of the elbow occurs, the olecranon fails in tension but with an oblique or transverse fracture line (arrows). C: With the elbow extended, the initial failure is in the anterior articular surface (arrows).
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Figure 13-47
Extension shear injuries.
A, B: Fracture with the elbow extended. If the elbow is extended when the direct blow to the posterior aspect of the elbow occurs, the olecranon fails in tension but with an oblique or transverse fracture line (arrows). C: With the elbow extended, the initial failure is in the anterior articular surface (arrows).
A, B: Fracture with the elbow extended. If the elbow is extended when the direct blow to the posterior aspect of the elbow occurs, the olecranon fails in tension but with an oblique or transverse fracture line (arrows). C: With the elbow extended, the initial failure is in the anterior articular surface (arrows).
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Fractures of the Coronoid Process

Isolated coronoid fractures are theoretically caused by avulsion by the brachialis or secondary to an elbow dislocation that reduced spontaneously, which is usually associated with hemarthrosis and a small avulsion of the tip of the olecranon process (Fig. 13-48). 
Figure 13-48
Lateral radiograph of an 11-year-old male who injured his left elbow.
 
Displaced anterior and posterior fat pads, plus a small fracture of the coronoid (arrow), indicate a probable partially dislocated elbow as the primary injury.
Displaced anterior and posterior fat pads, plus a small fracture of the coronoid (arrow), indicate a probable partially dislocated elbow as the primary injury.
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Figure 13-48
Lateral radiograph of an 11-year-old male who injured his left elbow.
Displaced anterior and posterior fat pads, plus a small fracture of the coronoid (arrow), indicate a probable partially dislocated elbow as the primary injury.
Displaced anterior and posterior fat pads, plus a small fracture of the coronoid (arrow), indicate a probable partially dislocated elbow as the primary injury.
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Associated Injuries with Fractures of the Proximal Ulna

Metaphyseal Fractures of the Olecranon and the Proximal Apophysis

Associated injuries occur in 48% to 77% of patients with olecranon fractures,11,36,71,106 especially varus and valgus greenstick extension fractures, in which the radial head and neck most commonly fracture (Fig. 13-44). Other associated injuries include fractures of the ipsilateral radial shaft,103 Monteggia type I lesions with fractures of both the ulnar shaft and olecranon,70 and fractures of the lateral condyle (Fig. 13-49).9 
Figure 13-49
 
A: Undisplaced fracture of the lateral condyle (arrows) associated with a varus greenstick fracture of the olecranon. B: Lateral view showing greenstick fractures in the olecranon (solid arrows) and a nondisplaced fracture of the lateral condyle (open arrows).
A: Undisplaced fracture of the lateral condyle (arrows) associated with a varus greenstick fracture of the olecranon. B: Lateral view showing greenstick fractures in the olecranon (solid arrows) and a nondisplaced fracture of the lateral condyle (open arrows).
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Figure 13-49
A: Undisplaced fracture of the lateral condyle (arrows) associated with a varus greenstick fracture of the olecranon. B: Lateral view showing greenstick fractures in the olecranon (solid arrows) and a nondisplaced fracture of the lateral condyle (open arrows).
A: Undisplaced fracture of the lateral condyle (arrows) associated with a varus greenstick fracture of the olecranon. B: Lateral view showing greenstick fractures in the olecranon (solid arrows) and a nondisplaced fracture of the lateral condyle (open arrows).
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Fractures of the Coronoid Process

Although most coronoid fractures are associated with elbow dislocations, fractures of the olecranon, medial epicondyle, and lateral condyle also can occur.68 The fracture of the coronoid may be part of a greenstick olecranon fracture (i.e., the extension-type metaphyseal fracture; Fig. 13-50). 
Figure 13-50
Fracture of the coronoid (arrow) as part of an extension valgus olecranon fracture pattern.
 
There was an associated fracture of the radial neck. Both the neck fracture and the distal portion of the coronoid process show periosteal new bone formation (open arrows).
There was an associated fracture of the radial neck. Both the neck fracture and the distal portion of the coronoid process show periosteal new bone formation (open arrows).
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Figure 13-50
Fracture of the coronoid (arrow) as part of an extension valgus olecranon fracture pattern.
There was an associated fracture of the radial neck. Both the neck fracture and the distal portion of the coronoid process show periosteal new bone formation (open arrows).
There was an associated fracture of the radial neck. Both the neck fracture and the distal portion of the coronoid process show periosteal new bone formation (open arrows).
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Signs and Symptoms of Fractures of the Proximal Ulna

Metaphyseal Fractures of the Olecranon and the Proximal Apophysis

Flexion injuries cause soft tissue swelling and tenderness over the olecranon fracture. The abrasion or contusion associated with a direct blow to the posterior aspect of the elbow provides a clue as to the mechanism of injury. If there is wide separation, a defect can be palpated between the fragments. In addition, there may be weakness or even lack of active extension of the elbow, which is difficult to evaluate in an anxious young child with a swollen elbow. Associated proximal radius fractures may be noted clinically by swelling and tenderness laterally with palpation in this region. 

Fractures of the Coronoid Process

Because of the common association of these fractures with elbow dislocations, a high index of suspicion is necessary when evaluating these injuries. Significant soft tissue swelling about the elbow is a consistent finding. The patient may also recall the “clunking” sensation of dislocation and spontaneous relocation with specific inquiry. 

Imaging and Other Diagnostic Studies for Fractures of the Proximal Ulna

Metaphyseal Fractures of the Olecranon and the Proximal Apophysis

The radiographic diagnosis may be difficult before ossification of the olecranon apophysis. The only clue may be a displacement of the small ossified metaphyseal fragment (Fig. 13-51), and the diagnosis may be based only on the clinical sign of tenderness over the epiphyseal fragment. If there is any doubt about the degree of displacement, injection of radiopaque material into the joint may delineate the true nature of the fracture. Alternatively, an MRI may be useful if uncertainty remains. 
Figure 13-51
Apophysitis.
 
A: Chronic stimulation with irregular ossification of the articular apophyseal center (arrows) in a basketball player who practiced dribbling 3 hours per day. B: Normal side for comparison.
A: Chronic stimulation with irregular ossification of the articular apophyseal center (arrows) in a basketball player who practiced dribbling 3 hours per day. B: Normal side for comparison.
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Figure 13-51
Apophysitis.
A: Chronic stimulation with irregular ossification of the articular apophyseal center (arrows) in a basketball player who practiced dribbling 3 hours per day. B: Normal side for comparison.
A: Chronic stimulation with irregular ossification of the articular apophyseal center (arrows) in a basketball player who practiced dribbling 3 hours per day. B: Normal side for comparison.
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Fractures of the Coronoid Process

The radiographic diagnosis of this fracture is often difficult because on the lateral view the radial head is superimposed over the coronoid process. Evaluation of a minimally displaced fracture may require oblique views (Fig. 13-52).102 The radiocapitellar view (Fig. 13-4) shows the profile of the coronoid process. 
Figure 13-52
 
A: Based on this original lateral radiograph, a 12-year-old male with a swollen elbow was thought to have a fracture of the radial neck (arrow). B: With an oblique view, it is now obvious that the fragment is from the coronoid process. C: Five months later, the protuberant healed coronoid process (arrow) is seen on this radiocapitellar view.
A: Based on this original lateral radiograph, a 12-year-old male with a swollen elbow was thought to have a fracture of the radial neck (arrow). B: With an oblique view, it is now obvious that the fragment is from the coronoid process. C: Five months later, the protuberant healed coronoid process (arrow) is seen on this radiocapitellar view.
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Figure 13-52
A: Based on this original lateral radiograph, a 12-year-old male with a swollen elbow was thought to have a fracture of the radial neck (arrow). B: With an oblique view, it is now obvious that the fragment is from the coronoid process. C: Five months later, the protuberant healed coronoid process (arrow) is seen on this radiocapitellar view.
A: Based on this original lateral radiograph, a 12-year-old male with a swollen elbow was thought to have a fracture of the radial neck (arrow). B: With an oblique view, it is now obvious that the fragment is from the coronoid process. C: Five months later, the protuberant healed coronoid process (arrow) is seen on this radiocapitellar view.
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Classification of Fractures of the Proximal Ulna

Fractures Involving the Proximal Apophysis

Injuries to the apophysis of the olecranon can be classified as one of three types (Table 13-14). Type I is a simple apophysitis in which there is irregularity in the secondary ossification center (Fig. 13-53A).16,54 The apophyseal line may widen. Type II is an incomplete stress fracture that involves primarily the apophyseal line, with widening and irregularity (Fig. 13-53B). A small adjacent cyst may form, but usually the architecture of the secondary ossification center is normal. These injuries occur primarily in sports requiring repetitive extension of the elbow, such as baseball pitching,72 tennis,85 or gymnastics.54 Type III injuries involve complete avulsion of the apophysis. True apophyseal avulsions (type IIIA) occur in younger children as a fracture through the apophyseal plate (Fig. 13-53A,B). In some of his amputation specimens, Poland77 found that the proximal apophyseal fragment included the distal tongue, which extended up to the coronoid process. Apophyseal–metaphyseal combination fractures (type IIIB), in which metaphyseal fragments are attached to the apophysis (Fig. 13-53C,D), usually occur in older children. Grantham and Kiernan35 likened it to a Salter–Harris type II physeal injury. Proximal displacement of the fragment is the only clue seen on a radiograph that a type IIIB fracture has occurred. 
 
Table 13-14
Classification of Apophyseal Injuries of the Olecranon
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Table 13-14
Classification of Apophyseal Injuries of the Olecranon
Type I: Apophysitis
Type II: Incomplete stress fracture
Type III: Complete fractures
A. Pure apophyseal avulsions
B. Apophyseal–metaphyseal combinations
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Figure 13-53
Apophyseal avulsions.
 
Pure apophyseal avulsions. A: The fracture follows the contour of the apophyseal line. B: The distal fracture line is in the shape of the apophyseal line (open arrow) with a small metaphyseal flake attached to the apophysis (solid arrow). Apophyseal–metaphyseal combination. C: The fracture line follows the line of tension stress. D: A large portion of the metaphysis (arrow) is often with the proximal metaphyseal fragment.
Pure apophyseal avulsions. A: The fracture follows the contour of the apophyseal line. B: The distal fracture line is in the shape of the apophyseal line (open arrow) with a small metaphyseal flake attached to the apophysis (solid arrow). Apophyseal–metaphyseal combination. C: The fracture line follows the line of tension stress. D: A large portion of the metaphysis (arrow) is often with the proximal metaphyseal fragment.
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Figure 13-53
Apophyseal avulsions.
Pure apophyseal avulsions. A: The fracture follows the contour of the apophyseal line. B: The distal fracture line is in the shape of the apophyseal line (open arrow) with a small metaphyseal flake attached to the apophysis (solid arrow). Apophyseal–metaphyseal combination. C: The fracture line follows the line of tension stress. D: A large portion of the metaphysis (arrow) is often with the proximal metaphyseal fragment.
Pure apophyseal avulsions. A: The fracture follows the contour of the apophyseal line. B: The distal fracture line is in the shape of the apophyseal line (open arrow) with a small metaphyseal flake attached to the apophysis (solid arrow). Apophyseal–metaphyseal combination. C: The fracture line follows the line of tension stress. D: A large portion of the metaphysis (arrow) is often with the proximal metaphyseal fragment.
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Metaphyseal Fractures of the Olecranon

The classification is based on the mechanism of injury, flexion/extension/shear (Table 13-15). This classification system is useful in guiding treatment options. 
 
Table 13-15
Classification of Metaphyseal Fractures of the Olecranon
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Table 13-15
Classification of Metaphyseal Fractures of the Olecranon
Group A: Flexion injuries
Group B: Extension injuries
  1.  
    Valgus pattern
  2.  
    Varus pattern
Group C: Shear injuries
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Fractures of the Coronoid Process

Regan and Morrey84 classified coronoid fractures into three types based on the amount of the coronoid process involved (Table 13-16). This classification is useful in predicting the outcome and in determining the treatment. Type I fractures involve only the tip of the process (Fig. 13-48), type II fractures involve more than just the tip but less than 50% of the process (Fig. 13-52), and type III fractures involve more than 50% of the process. 
 
Table 13-16
Classification of Fractures of the Coronoid Process
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Table 13-16
Classification of Fractures of the Coronoid Process
Type I: Involves only tip of coronoid
Type II: A single or comminuted fragment involving <50% of the coronoid process
Type III: A single or comminuted fragment involving >50% of the coronoid process
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Outcome Measures for Fractures of the Proximal Ulna

The current literature is deficient in the area of functional outcome instruments for fractures of the proximal ulna. The previously published studies on the outcomes of these fractures have used descriptive assessments that are currently nonvalidated techniques. Elbow range of motion after these injuries continues to be a driver of functional outcomes. As such, there is a definite need for both accurate methods of measuring range of motion as well as validated techniques for reporting the results. 

Pathoanatomy and Applied Anatomy Relating to Fractures of the Proximal Ulna

Fractures Involving the Proximal Apophysis in Fractures of the Proximal Ulna

At birth, the ossification of the metaphysis of the proximal ulna extends only to the midportion of the semilunar notch. At this age, the leading edge of the metaphysis is usually perpendicular to the long axis of the olecranon (Fig. 13-54A,B). As ossification progresses, the proximal border of the metaphysis becomes more oblique. The anterior margin extends proximally and to three-fourths of the width of the semilunar notch by 6 years of age. At this age, the physis extends distally to include the coronoid process (Fig. 13-53C). A secondary center of ossification occurs in the coronoid process. Just before the development of the secondary center of ossification in the olecranon, the leading edge of the metaphysis develops a well-defined sclerotic margin.92 Ossification of the olecranon occurs in the area of the triceps insertion at approximately 9 years of age (Fig. 13-54D).92 Ossification of the coronoid process is completed about the time that the olecranon ossification center appears.77 
Figure 13-54
Olecranon ossification.
 
A: Limits of the border of ossification at birth, 8 years, and 12 years. B: Lateral view of olecranon at 6 months of age. The proximal margin is perpendicular to the long axis of the ulna. C: Lateral view of the olecranon at 6 years of age. The proximal margin is oblique. D: Secondary ossification center developing in the olecranon in a 10-year-old. A sclerotic border has developed on the proximal metaphyseal margin. E: Bipartite secondary ossification center. The larger center is the traction center (open arrow). The smaller, more proximal center is the articular center (white arrow). F: Before complete fusion, a partial line remains (arrow), bordered by a sclerotic margin.
A: Limits of the border of ossification at birth, 8 years, and 12 years. B: Lateral view of olecranon at 6 months of age. The proximal margin is perpendicular to the long axis of the ulna. C: Lateral view of the olecranon at 6 years of age. The proximal margin is oblique. D: Secondary ossification center developing in the olecranon in a 10-year-old. A sclerotic border has developed on the proximal metaphyseal margin. E: Bipartite secondary ossification center. The larger center is the traction center (open arrow). The smaller, more proximal center is the articular center (white arrow). F: Before complete fusion, a partial line remains (arrow), bordered by a sclerotic margin.
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Figure 13-54
Olecranon ossification.
A: Limits of the border of ossification at birth, 8 years, and 12 years. B: Lateral view of olecranon at 6 months of age. The proximal margin is perpendicular to the long axis of the ulna. C: Lateral view of the olecranon at 6 years of age. The proximal margin is oblique. D: Secondary ossification center developing in the olecranon in a 10-year-old. A sclerotic border has developed on the proximal metaphyseal margin. E: Bipartite secondary ossification center. The larger center is the traction center (open arrow). The smaller, more proximal center is the articular center (white arrow). F: Before complete fusion, a partial line remains (arrow), bordered by a sclerotic margin.
A: Limits of the border of ossification at birth, 8 years, and 12 years. B: Lateral view of olecranon at 6 months of age. The proximal margin is perpendicular to the long axis of the ulna. C: Lateral view of the olecranon at 6 years of age. The proximal margin is oblique. D: Secondary ossification center developing in the olecranon in a 10-year-old. A sclerotic border has developed on the proximal metaphyseal margin. E: Bipartite secondary ossification center. The larger center is the traction center (open arrow). The smaller, more proximal center is the articular center (white arrow). F: Before complete fusion, a partial line remains (arrow), bordered by a sclerotic margin.
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The secondary ossification center of the olecranon may be bipartite (Fig. 13-54E).79 The major center within the tip of the olecranon is enveloped by the triceps insertion. This was referred to by Porteous79 as a traction center. The second and smaller center, an articular center, lies under the proximal fourth of the articular surface of the semilunar notch. 
Fusion of the olecranon epiphysis with the metaphysis, which progresses from anterior to posterior, occurs at approximately 14 years of age. The sclerotic margin that defines the edge of the metaphysis may be mistaken for a fracture (Fig. 13-54F).92 Rarely, the physeal line persists into adulthood.48,75,109 If this does occur, it is usually in athletes who have used the extremity in repetitive throwing activities.16,85,96,111,122 The chronic tension forces applied across the apophysis theoretically prevent its normal closure. 
Occasionally, a separate ossification center called a patella cubiti develops in the triceps tendon at its insertion on the tip of the olecranon.107 This ossicle is completely separate and can articulate with the trochlea. It is usually unilateral, unlike other persistent secondary ossification centers, which are more likely to be bilateral and familial. Zeitlin125 believed that the patella cubiti was a traumatic ossicle rather than a developmental variation. 

Metaphyseal Fractures of the Olecranon

Because the olecranon is a metaphyseal area, the cortex is relatively thin, allowing for the development of greenstick-type fracture deformities. The periosteum in children is immature and thick, which may prevent the degree of separation seen in adults. Likewise, the larger amount of epiphyseal cartilage in children may serve as a cushion to lessen the effects of a direct blow to the olecranon. In the production of supracondylar fractures, ligamentous laxity in this age group tends to force the elbow into hyperextension when the child falls on the outstretched upper extremity. This puts a compressive force across the olecranon and locks it into the fossa in the distal humerus, where it is protected. An older person, whose elbow does not go into hyperextension, is more likely to fall with the elbow semiflexed. This unique biomechanical characteristic of the child's olecranon predisposes it to different fracture patterns than those in adults. 

Fractures of the Coronoid Process

Up to age 6 years, the coronoid process consists of epiphyseal cartilage and physeal cartilage at the distal end of a tongue extending from the apophysis of the olecranon. The coronoid process does not develop a secondary center of ossification, but instead ossifies along with the advancing edge of the metaphysis (Fig. 13-54). 

Treatment Options for Fractures of the Proximal Ulna

Nonoperative Treatment of Fractures Involving the Proximal Apophysis in Fractures of the Proximal Ulna

Indications/Contraindications

For apophysitis and undisplaced stress fractures, we ask the patient to cease the offending activity. During this period of rest, the patient should maintain upper extremity strength with a selective muscle exercise program as well as maintain cardiovascular conditioning. 
In a recently published series by Rath82, isolated epiphyseal fractures of the olecranon were met with good long-term outcomes after nonoperative management with up to 2 mm of intrafragmentary displacement (Table 13-17). 
Table 13-17
Fractures Involving the Proximal Apophysis: Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced fractures Displaced fractures
Apophysitis Open fractures
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Techniques

With minimal displacement of the fracture, satisfactory closed reduction can be obtained with the elbow extended. The elbow can then be immobilized in extension with a long-arm cast. 

Outcomes

In general, these injuries recover well and the patients return to full activities quickly. The highest risk group for failure of nonoperative management is the stress injuries. 

Nonoperative Treatment of Metaphyseal Fractures of the Olecranon in Fractures of the Proximal Ulna

Indications/Contraindications

Flexion Injuries. Flexion injuries are the most common type of olecranon fractures. In those with minimal displacement, nonoperative treatment is the preferred option. Nonoperative management is contraindicated in displaced olecranon fractures. 
Extension Injuries. Treatment of extension injuries requires both adequate realignment of the angulation of the olecranon and treatment of the secondary injuries. Indications for nonoperative treatment in these injuries include the ability to restore anatomic alignment. 
Zimmerman126 reported that the original angulation tends to redevelop in some fractures. If a varus force produced the fracture, the proximal ulna or olecranon may drift back into varus, which can cause a painful subluxation of the radial head. A secondary osteotomy of the proximal ulna or olecranon may be necessary if the angulation is significant. 
Shear Injuries. For anterior shear fractures, the key to management is recognition that the distal fragment is displaced anteriorly and the posterior periosteum remains intact. The intact posterior periosteum can serve as an internal tension band to facilitate reduction (Table 13-18). 
Table 13-18
Metaphyseal Fractures of the Olecranon: Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced fractures Nonreducible fractures
Fractures reducible to anatomic alignment by closed methods Open fractures
X

Techniques

Flexion Injuries
Most displace minimally and require immobilization with the elbow in no more than 75 to 80 degrees of flexion (Fig. 13-55). Even if the fracture displaces severely, immobilization in full or partial extension usually allows the olecranon to heal satisfactorily.27,98,126 
Figure 13-55
Simple immobilization of a flexion injury.
 
A: Injury film, lateral view, showing minimal displacement. B: Three weeks later, the fracture has displaced further. Periosteal new bone is along the posterior border of the olecranon (arrow). Healing was complete with a normal range of motion.
 
(Courtesy of Jesse C. DeLee, MD.)
A: Injury film, lateral view, showing minimal displacement. B: Three weeks later, the fracture has displaced further. Periosteal new bone is along the posterior border of the olecranon (arrow). Healing was complete with a normal range of motion.
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Figure 13-55
Simple immobilization of a flexion injury.
A: Injury film, lateral view, showing minimal displacement. B: Three weeks later, the fracture has displaced further. Periosteal new bone is along the posterior border of the olecranon (arrow). Healing was complete with a normal range of motion.
(Courtesy of Jesse C. DeLee, MD.)
A: Injury film, lateral view, showing minimal displacement. B: Three weeks later, the fracture has displaced further. Periosteal new bone is along the posterior border of the olecranon (arrow). Healing was complete with a normal range of motion.
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Extension Injuries
Often in varus injuries, correction of the alignment of the olecranon also reduces the radial head. The olecranon angulation corrects with the elbow in extension. This locks the proximal olecranon into the olecranon fossa of the humerus so that the distal angulation can be corrected at the fracture site with a valgus force applied to the forearm. Occasionally, in extension fractures, complete separation of the fragments requires open reduction and internal fixation (Fig. 13-56). 
Figure 13-56
Open reduction of a valgus extension injury.
 
A: Anteroposterior injury film shows complete displacement of the radial head. B: Lateral view also shows the degree of displacement of the olecranon fracture. This patient required surgical intervention with internal fixation to achieve a satisfactory reduction.
A: Anteroposterior injury film shows complete displacement of the radial head. B: Lateral view also shows the degree of displacement of the olecranon fracture. This patient required surgical intervention with internal fixation to achieve a satisfactory reduction.
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Figure 13-56
Open reduction of a valgus extension injury.
A: Anteroposterior injury film shows complete displacement of the radial head. B: Lateral view also shows the degree of displacement of the olecranon fracture. This patient required surgical intervention with internal fixation to achieve a satisfactory reduction.
A: Anteroposterior injury film shows complete displacement of the radial head. B: Lateral view also shows the degree of displacement of the olecranon fracture. This patient required surgical intervention with internal fixation to achieve a satisfactory reduction.
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Shear Injuries
Some of these fractures are reduced better in flexion, and the posterior periosteum serves as a compressive force to maintain the reduction. Smith98 reported treatment of this fracture using an overhead sling placed to apply a posteriorly directed force against the proximal portion of the distal fragment. The weight of the arm and forearm helps supplement the tension-band effect of the posterior periosteum. 

Outcomes

The majority of nondisplaced proximal ulna fractures can be treated successfully with nonoperative methods. However, these injuries need to be followed closely to ensure maintenance of alignment. Any loss of reduction/alignment should be recognized and lead to surgical management. 

Nonoperative Treatment of Fractures of the Coronoid Process in Fractures of the Proximal Ulna

Indications/Contraindications

The degree of displacement or the presence of elbow instability guides the treatment. The associated injuries also are a factor in treatment. Regan and Morrey83,84 treated types I and II fractures with early motion if there were no contradicting associated injuries (Table 13-19). 
 
Table 13-19
Fractures of the Coronoid Process: Nonoperative Treatment
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Table 13-19
Fractures of the Coronoid Process: Nonoperative Treatment
Indications Relative Contraindications
Elbow stability Elbow instability
Mild displacement (Types 1 and 2) Type 3 fractures
X

Techniques

For initial immobilization, if the fracture is associated with an elbow dislocation, the elbow is placed in approximately 100 degrees of flexion, with the forearm in full supination.68 Occasionally, in partial avulsion fractures, the fracture reduces more easily with the elbow in extension. In these rare cases, the brachialis muscle may be an aid in reducing the fragment in extension.67 

Outcomes

Regan and Morrey84 found that the elbow often was unstable in type III fractures, and they secured these fractures with internal fixation. They had satisfactory results with type I and II fractures, but in only 20% of type III fractures were the results satisfactory. 

Operative Treatment of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis in Fractures of the Proximal Ulna

Indications/Contraindications

Apophyseal Fractures. There is no standard method of treatment of fractures of the apophysis, because few such fractures have been described. Surgical treatment is indicated in situations where acceptable alignment cannot be achieved with closed methods. A recently published manuscript determined that fractures with more than 4 mm of displacement or with a noncongruent intra-articular surface should be treated surgically to achieve a better reduction and surgical outcome.82 With mild to moderately displaced fractures, if a satisfactory closed reduction can be obtained, percutaneous pinning will stabilize the reduction. This can allow for casting in flexion, which is often better tolerated. For fractures with significant displacement, treatment is usually open reduction with internal fixation using a combination of axial pins and tension-band wiring (Fig. 13-57).35,77,98 Gortzak et al.34 described a technique of open reduction using percutaneously placed Kirschner wires and absorbable sutures instead of wires for the tension band. The percutaneously placed wires are subsequently removed 4 to 5 weeks postoperatively, eliminating the need for implant removal. Most stress injuries respond to simple rest from the offending activity. However, a chronic stress fracture can result in a symptomatic nonunion. Use of a compressive screw alone across the nonunion often is sufficient,54 but supplemental bone grafting may be necessary to achieve union.48,75 
Figure 13-57
Operative treatment of an apophyseal fracture.
 
A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
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A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
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Figure 13-57
Operative treatment of an apophyseal fracture.
A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
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A: Postoperative radiograph of the fracture shown in Figure 11-40D, which was stabilized with small Steinmann pins alone. B: Five months later, growth has continued in the traction center and the articular center is ossified (arrow). C: One year after injury, the apophysis was partially avulsed a second time. The two secondary ossification centers are now fused. D: Three months after the second fracture, the fracture gap has filled in, producing a normal olecranon.
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Metaphyseal Olecranon Fractures
Flexion Injuries
If the fracture is significantly displaced or comminuted, open reduction with internal fixation usually is required. Recommended fixation devices vary from catgut or absorbable suture56 to an axial screw,55 tension-band wiring with axial pins,26,35,56,89,91,98 or a plate.105 Internal fixation allows early motion. 
Extension Injuries
Treatment of extension injuries requires both adequate realignment of the angulation of the olecranon and treatment of the secondary injuries. Occasionally, in extension fractures, complete separation of the fragments requires open reduction and internal fixation (Fig. 13-56). 
Shear Injuries
For anterior shear fractures, the key to management is recognition that the distal fragment is displaced anteriorly and the posterior periosteum remains intact. The intact posterior periosteum can serve as an internal tension band to facilitate reduction. If the periosteum is torn or early motion is desirable, Zimmerman126 advocated internal fixation of the two fragments with an oblique screw perpendicular to the fracture line (Fig. 13-58). 
Figure 13-58
Operative treatment of extension shear fractures.
 
A: If the periosteum is insufficient to hold the fragments apposed, an interfragmentary screw can be used. B: An extension shear type of fracture secured with two oblique interfragmentary screws.
A: If the periosteum is insufficient to hold the fragments apposed, an interfragmentary screw can be used. B: An extension shear type of fracture secured with two oblique interfragmentary screws.
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Figure 13-58
Operative treatment of extension shear fractures.
A: If the periosteum is insufficient to hold the fragments apposed, an interfragmentary screw can be used. B: An extension shear type of fracture secured with two oblique interfragmentary screws.
A: If the periosteum is insufficient to hold the fragments apposed, an interfragmentary screw can be used. B: An extension shear type of fracture secured with two oblique interfragmentary screws.
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Closed reduction and percutaneous pinning

Preoperative Planning
To adequately prepare for this technique, we must carefully assess the fracture pattern and determine that an attempt at closed reduction is feasible. It is good practice to also prepare for the possibility that this technique may need to be abandoned and transitioned to an open procedure in the event that an adequate closed reduction is not attainable. Accordingly the patient, family, and operating room team should all be informed of these possibilities. The OR table, positioning of the patient, and equipment necessary for both closed and open procedures should be identified and available before beginning the surgery. Equipment needed for a potential open procedure can be left unopened in the sterile packaging, but should be visually accounted for and immediately available (Table 13-20). 
Table 13-20
Closed Reduction and Percutaneous Pinning of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Smooth Kirschner wires; power drill; tension-band equipment available
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet
X
Positioning
Same as for instrument-assisted closed reduction of proximal radius fractures. 
Surgical Approach(es)
A percutaneous approach is utilized starting at the subcutaneous border of the tip of the olecranon. 
Technique
Simple steel K-wires are appropriate to use for this technique. Size will range from 2 to 2.7 mm based on the size of the child. Fluoroscopy is used to localize the fracture site and intended entry site of the wire. The fracture is then reduced with simultaneous elbow extension and thumb pressure over the olecranon. Once the fracture reduction is achieved, percutaneous K-wires are driven from the tip of the olecranon, across the fracture site, and exiting the far cortex. Fracture stability and pin configuration are then assessed with fluoroscopy. The pins are then cut and bent outside of the skin. We prefer placing a sterile felt pad between the cut pins and the skin, followed by a long-arm cast for immobilization. The pins are then removed in the office after the fracture has healed, typically 3 to 4 weeks (Table 13-21). 
Table 13-21
Closed Reduction and Percutaneous Pinning of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis
Surgical Steps
  •  
    Attempt closed reduction
  •  
    Assess reduction with fluoroscopy
  •  
    Assess stability
    •  
      If stable: Immobilize in long-arm cast
    •  
      If unstable: Antegrade K-wire fixation
  •  
    Percutaneous insertion of K-wires to stabilize fracture
  •  
    Bend, cut wires outside skin
X

Open reduction and tension-Band fixation

Preoperative Planning
Once it has been determined that satisfactory reduction is not achievable by closed methods, an open reduction is indicated. The preparation for this procedure includes ensuring proper OR table, fluoroscopy, patient positioning, and necessary equipment (Table 13-22). 
Table 13-22
Open Reduction and Tension-Band Fixation of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Smooth Kirschner wires; tension-band equipment
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet
X
Positioning
The positioning for this procedure is the same as for the closed reduction and percutaneous pinning technique described above. 
Surgical Approach(es)
A standard posterior approach to the proximal ulna is used, with the incision spanning from 1 to 2 fingerbreadths proximal to the tip of the olecranon to 2 to 3 cm distal to the fracture site. The subcutaneous location of the ulna in this location allows for quick access to the fracture site. However, particularly close attention needs to be paid to delicate handling of the soft tissue envelop as there is commonly a fair amount of soft tissue trauma locally from the injury. It is recommended to shape the incision in a curvilinear fashion proximally to avoid placing the scar directly over the bony prominence of the olecranon. 
Technique
Once the fracture is exposed a reduction can be performed with a bone reduction forceps. The reduction maneuver can be facilitated by first placing a small unicortical drill hole distal to the fracture site along the diaphysis of the ulna. Then with one tine of the forceps in the drill hole and the other tine at the tip of the olecranon, applying gentle compression with the forceps will help reduce and stabilize the fracture. 
With the fracture now reduced two K-wires are driven in an antegrade fashion, parallel to each other, starting near the tip of the olecranon and coursing obliquely to cross the fracture site and exit the cortex of the anterior ulna. The fracture reduction and K-wire position are then assessed with fluoroscopy. The K-wires are then bent and cut in preparation for capture of the tension band. The wires are pulled back 3 to 4 mm at this time so that when fully impacted later they will not protrude too far beyond the anterior ulnar cortex. 
In preparation for tension band application, a transverse tunnel is created in the ulnar diaphysis1 to 2 cm distal to the fracture site. It is critical to leave an intact cortical bridge of bone along the posterior aspect of the ulna superficial to the tunnel. A drill is used to perforate the medial and lateral cortex of the ulna at the desired level of tunnel creation. A towel clip can then be inserted into these two pilot drill holes to finish creating the ulnar bone tunnel. 
The tension-band material is then selected, either 18 to 20 gauge wire, or large absorbable or nonabsorbable suture. We frequently utilize no. 2 polyethylene core braided polyester suture (FiberWire, Arthrex, Naples FL) or no. 1 polydioxanone suture (PDS) instead of wire. The tension band is then passed through the ulnar bone tunnel and around the previously placed K-wires. Twisting the wires or tying the sutures tightens the tension band. At this point, the reduction clamp is removed and fracture stability assessed with elbow flexion/extension and fluoroscopy. The previously cut/bent K-wires are then impacted into the olecranon, finalizing the capture of the tension band (Table 13-23). 
Table 13-23
Open Reduction and Tension-Band Fixation of Fractures Involving the Proximal Apophysis
Surgical Steps
  •  
    Expose proximal ulna
  •  
    Reduce fracture and provisionally stabilize with reduction clamp
  •  
    Assess reduction with fluoroscopy
  •  
    Insert two parallel antegrade K-wires in preparation for tension band
  •  
    Bend the proximal tip for later impaction
  •  
    Prepare bone tunnel in distal fragment for tension band
  •  
    Pass tension-band material through bone tunnel and around K-wires
  •  
    Stabilize fracture by securing the tension band
  •  
    Impact the proximal K-wires into the olecranon
X

Open reduction and compression screw fixation

Preoperative Planning
The preparation for this procedure is the same as for the above tension-band technique with the exception of equipment/implant differences needed (Table 13-24). 
Table 13-24
Open Reduction and Compression Screw Fixation of Fractures Involving the Proximal Apophysis and Olecranon Metaphysis
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Large fragment set (4.5- and 6.5-mm screws); smooth Kirschner wires; tension-band equipment
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet
X
Positioning
The positioning for this procedure is the same as for the closed reduction and percutaneous pinning technique described above. 
Surgical Approach(es)
The approach for this procedure is the same as for the tension-band technique described above. 
Technique
Once the fracture is exposed a reduction can be performed with a bone reduction forceps. The reduction maneuver can be facilitated by first placing a small unicortical drill hole distal to the fracture site along the diaphysis of the ulna. Then with one tine of the forceps in the drill hole and the other tine at the tip of the olecranon, applying gentle compression with the forceps will help reduce and stabilize the fracture. 
With the fracture now reduced the guide pin from the cannulated screw system can be placed in an antegrade fashion starting near the tip of the olecranon, across the fracture site, and into the intramedullary canal of the ulna. Most commonly a 6.5-mm cancellous bone screw is selected. The screw tract is then drilled and tapped over the guide wire, followed by placement of the appropriate-sized screw. The alignment and stability are then assessed with elbow flexion/extension and fluoroscopy (Table 13-25). 
Table 13-25
Open Reduction and Compression Screw Fixation of Fractures Involving the Proximal Apophysis
Surgical Steps
  •  
    Expose proximal ulna
  •  
    Reduce fracture and provisionally stabilize with reduction clamp
  •  
    Assess reduction with fluoroscopy
  •  
    Insert antegrade guide wire for appropriate size screw
  •  
    Starting point at tip of olecranon
  •  
    Drill/tap over guide wire
  •  
    Place appropriate-sized screw over guide wire
X

Author's Preferred Treatment for Fractures of the Proximal Ulna

Apophyseal Fractures and Nondisplaced Fractures

For apophysitis and nondisplaced stress fractures, we ask the patient to cease the offending activity. During this period of rest, the patient should maintain upper extremity strength with a selective muscle exercise program as well as maintain cardiovascular conditioning. When a persistent nonunion of the olecranon in an adolescent does not demonstrate healing after a reasonable period of simple rest, we place a cannulated compression screw across the apophysis to stimulate healing. 

Displaced Fractures

With minimal displacement of the fracture, satisfactory closed reduction can be obtained with the elbow extended. We usually immobilize the elbow in a long-arm cast in extension. Percutaneous pinning will stabilize the reduction if there is any concern about loss of reduction. Completely displaced fractures are treated operatively using a tension-band technique. In young children, we use small Steinmann or Kirschner pins. Patients with large ossification centers are treated with a compression screw similar to those with metaphyseal fractures. 

Metaphyseal Olecranon Fractures

We use a classification based on the mechanism of injury in choosing the method of treatment (Table 13-15). 

Flexion Injuries
Nonoperative

We immobilize most nondisplaced flexion injuries with the elbow in 5 to 10 degrees of flexion for approximately 3 weeks. It is important to obtain radiographs of these fractures after approximately 5 to 7 days in the cast to ensure that there has not been any significant displacement of the fragment. 

Operative: Tension Band

To determine which injuries need internal fixation, we palpate the fracture for a defect and flex the elbow to determine the integrity of the posterior periosteum. If the fragments separate with either of these maneuvers, they are unstable and are fixed internally so that active motion can be started as soon as possible. 
We prefer a modification of the tension-band technique. Originally we used the standard AO technique with axial Kirschner wires or Steinmann pins and figure-of-eight stainless steel as the tension band (Fig. 13-59A). Because removal of the wire often required reopening the entire incision, we now often use an absorbable suture for the figure-of-eight tension band. no. 1 PDS suture, which is slowly absorbed over a few months, is ideal (Fig. 13-59B). When rigid internal fixation is applied, rapid healing at the fracture site produces internal stability before the PDS absorbs. We prefer Kirschner wires in patients who are very young and have very little ossification of the olecranon apophysis (Fig. 13-57). If the axial wires become a problem, we remove them through a small incision. Most recently, we have used a combination of an oblique cortical screw with PDS as the tension band (Fig. 13-59C, D) and are pleased with the results. In the past, we had to remove almost all the axial wires; very few of the screws cause enough symptoms to require removal. Occasionally, we use the tension-band wire technique with 16- or 18-gauge wire in a heavier patient. 
Figure 13-59
Internal tension-band techniques.
 
A: Standard AO technique with stainless steel wire. The wire can be prominent in the subcutaneous tissues. B: Axial wires plus polydioxanone sutures (PDSs) 6 weeks after surgery. C: A displaced flexion-type injury in an 11-year-old male. There is complete separation of the fracture fragments. D: A cancellous lag screw plus PDS. The screw engages the anterior cortex of the coronoid process. The PDS passes through a separate drill hole in the olecranon (open arrow) and crosses in a figure-of-eight manner over the fracture site and around the neck of the screw.
A: Standard AO technique with stainless steel wire. The wire can be prominent in the subcutaneous tissues. B: Axial wires plus polydioxanone sutures (PDSs) 6 weeks after surgery. C: A displaced flexion-type injury in an 11-year-old male. There is complete separation of the fracture fragments. D: A cancellous lag screw plus PDS. The screw engages the anterior cortex of the coronoid process. The PDS passes through a separate drill hole in the olecranon (open arrow) and crosses in a figure-of-eight manner over the fracture site and around the neck of the screw.
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Figure 13-59
Internal tension-band techniques.
A: Standard AO technique with stainless steel wire. The wire can be prominent in the subcutaneous tissues. B: Axial wires plus polydioxanone sutures (PDSs) 6 weeks after surgery. C: A displaced flexion-type injury in an 11-year-old male. There is complete separation of the fracture fragments. D: A cancellous lag screw plus PDS. The screw engages the anterior cortex of the coronoid process. The PDS passes through a separate drill hole in the olecranon (open arrow) and crosses in a figure-of-eight manner over the fracture site and around the neck of the screw.
A: Standard AO technique with stainless steel wire. The wire can be prominent in the subcutaneous tissues. B: Axial wires plus polydioxanone sutures (PDSs) 6 weeks after surgery. C: A displaced flexion-type injury in an 11-year-old male. There is complete separation of the fracture fragments. D: A cancellous lag screw plus PDS. The screw engages the anterior cortex of the coronoid process. The PDS passes through a separate drill hole in the olecranon (open arrow) and crosses in a figure-of-eight manner over the fracture site and around the neck of the screw.
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X

Extension Injuries

For extension injuries, we anesthetize the patient to allow a forceful manipulation of the olecranon while it is locked in its fossa in extension. Because this is a greenstick fracture, we slightly overcorrect to prevent the development of reangulation. These fractures may require manipulation/remanipulation in 1 to 2 weeks if the original angulation recurs. Associated fractures are treated as if they were isolated injuries. 

Shear Injuries

Most shear fractures can be treated nonoperatively. We usually immobilize them in enough flexion to hold the fragments together, if the posterior periosteum is intact (Fig. 13-60). If the periosteum is torn, an oblique screw is an excellent way to secure the fracture (Fig. 13-58). If considerable swelling prevents the elbow from being hyperflexed enough to use the posterior periosteum as a tension band, an oblique screw is a good choice. 
Figure 13-60
Shear injuries.
 
A: Flexion pattern: Radiograph of the patient seen in Figure 11-45A after the elbow was flexed. The intact posterior periosteum acted as a tension band and held the fracture reduced. B: Radiograph taken 4 weeks after surgery shows new bone formation under the intact periosteum (arrows) on the dorsal surface of the olecranon. C: Extension pattern: Radiograph of patient with an extension shear injury showing an increase in the fracture gap (arrows) (see also Fig. 11-45B). D: Because the dorsal periosteum and cortex were intact, the fracture gap (arrows) closed with flexion of the elbow.
A: Flexion pattern: Radiograph of the patient seen in Figure 11-45A after the elbow was flexed. The intact posterior periosteum acted as a tension band and held the fracture reduced. B: Radiograph taken 4 weeks after surgery shows new bone formation under the intact periosteum (arrows) on the dorsal surface of the olecranon. C: Extension pattern: Radiograph of patient with an extension shear injury showing an increase in the fracture gap (arrows) (see also Fig. 11-45B). D: Because the dorsal periosteum and cortex were intact, the fracture gap (arrows) closed with flexion of the elbow.
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Figure 13-60
Shear injuries.
A: Flexion pattern: Radiograph of the patient seen in Figure 11-45A after the elbow was flexed. The intact posterior periosteum acted as a tension band and held the fracture reduced. B: Radiograph taken 4 weeks after surgery shows new bone formation under the intact periosteum (arrows) on the dorsal surface of the olecranon. C: Extension pattern: Radiograph of patient with an extension shear injury showing an increase in the fracture gap (arrows) (see also Fig. 11-45B). D: Because the dorsal periosteum and cortex were intact, the fracture gap (arrows) closed with flexion of the elbow.
A: Flexion pattern: Radiograph of the patient seen in Figure 11-45A after the elbow was flexed. The intact posterior periosteum acted as a tension band and held the fracture reduced. B: Radiograph taken 4 weeks after surgery shows new bone formation under the intact periosteum (arrows) on the dorsal surface of the olecranon. C: Extension pattern: Radiograph of patient with an extension shear injury showing an increase in the fracture gap (arrows) (see also Fig. 11-45B). D: Because the dorsal periosteum and cortex were intact, the fracture gap (arrows) closed with flexion of the elbow.
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Postoperative Care

A critical advantage of surgical management is the ability to allow and encourage early motion. Accordingly, with stable fixation, a brief period of immobilization postoperatively is in order. Typically this would entail 10 to 14 days of immobilization, to allow for wound healing, followed by active measures geared toward resumption of elbow/forearm range of motion. 

Potential Pitfalls and Preventative Measures

Murphy et al.63 compared the failure of various fixation devices under rapid loading: (a) Figure-of-eight wire alone, (b) cancellous screw alone, (c) AO tension band, and (d) cancellous screw with a figure-of-eight wire combination. The cancellous screw alone and figure-of-eight wire alone were by far the weakest. The greatest resistance to failure was found in the combination of a screw plus figure-of-eight wire, followed closely by the AO tension-band fixation. In their clinical evaluation of patients, comparing the AO tension band and combination of screw and figure-of-eight wire, they found more clinical problems associated with the AO technique.64 The main problem with the AO technique is the subcutaneous prominence of the axial wires53,73 To prevent proximal migration of these wires, Montgomery devised a method of making eyelets in the proximal end of the wires through which he passed the figure-of-eight fixation wire. 
Zimmerman126 reported that the original angulation tends to redevelop in some extension type olecranon fractures. If a varus force produced the fracture, the proximal ulna or olecranon may drift back into varus, which can cause a painful subluxation of the radial head. A secondary osteotomy of the proximal ulna or olecranon may be necessary if the angulation is significant (Table 13-26). 
Table 13-26
Proximal Ulna Apophyseal and Metaphyseal Olecranon Fractures: Potential Pitfalls and Preventions
Pitfall Preventions
Prominent implants Attention to detail
Plan for implant impaction
Incision planning
Consider use of suture instead of wire for tension band
Nonunion Consider bone grafting
Compression techniques
Loss of reduction in extension type Reduce in extension, “over” reduce
Pin if stability questionable
X

Treatment-Specific Outcomes

There are no validated outcome measures on this population in the current literature. In general, the limited studies available report good-to-excellent outcomes with the techniques described above. 

Management of Expected Adverse Outcomes and Unexpected Complications in Fractures of the Proximal Ulna

Spur Formation

Overgrowth of the epiphysis proximally may produce a bony spur. Symptomatic spurs can be treated with surgical excision. 

Nonunion

Nonunion is a rare event in these fractures, most likely occurring in the apophysitis/overuse type injuries. Bone grafting the nonunion and ensuring stable fixation with compression is the most efficacious method of treatment. Nonunion is unusual and should not be confused with congenital pseudarthrosis of the ulna, which is rare (Fig. 13-61). In the latter condition, there is no antecedent trauma. 
Figure 13-61
Congenital pseudarthrosis of the olecranon in a 9-year-old female who had limited elbow extension and no antecedent trauma.
 
The edges of the bone were separated by thick fibrous tissue.
 
(Courtesy of Michael J. Rogal, MD.)
The edges of the bone were separated by thick fibrous tissue.
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Figure 13-61
Congenital pseudarthrosis of the olecranon in a 9-year-old female who had limited elbow extension and no antecedent trauma.
The edges of the bone were separated by thick fibrous tissue.
(Courtesy of Michael J. Rogal, MD.)
The edges of the bone were separated by thick fibrous tissue.
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Apophyseal Arrest

Apophyseal arrest appears to have no significant effect on elbow function (Fig. 13-62). There has been concern that applying compressive forces across the apophysis might cause premature growth arrest. In our experience, fusion of the apophysis to the metaphysis is accelerated. Apophyseal fractures usually occur when the physis is near natural closure. The growth proximally is appositional rather than lengthwise across the apophyseal plate itself. As a result, we have not found any functional shortening of the olecranon because of the early fusion of the apophysis to the metaphysis (Fig. 13-57D). In practice, the use of a compression screw across an ossified olecranon fracture causes no loss of ulnar length. Children who sustain injuries before the development of the secondary ossification center may develop a deformity that is visible on radiographs (Fig. 13-62). Although there may be shortening of the olecranon, it does not appear to produce functional problems. There are no reports of the effects of this injury in very young children or infants. 
Figure 13-62
Preosseous apophyseal arrest.
 
A: Comminuted fracture of the proximal olecranon from a direct blow to the elbow in an 8-year-old male. This fracture was treated nonoperatively. B: Radiograph 18 months later shows cessation of the proximal migration of the metaphyseal margin and a lack of development of a secondary ossification center. Despite this arrest of the apophysis, the patient had a full range of elbow motion.
A: Comminuted fracture of the proximal olecranon from a direct blow to the elbow in an 8-year-old male. This fracture was treated nonoperatively. B: Radiograph 18 months later shows cessation of the proximal migration of the metaphyseal margin and a lack of development of a secondary ossification center. Despite this arrest of the apophysis, the patient had a full range of elbow motion.
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Figure 13-62
Preosseous apophyseal arrest.
A: Comminuted fracture of the proximal olecranon from a direct blow to the elbow in an 8-year-old male. This fracture was treated nonoperatively. B: Radiograph 18 months later shows cessation of the proximal migration of the metaphyseal margin and a lack of development of a secondary ossification center. Despite this arrest of the apophysis, the patient had a full range of elbow motion.
A: Comminuted fracture of the proximal olecranon from a direct blow to the elbow in an 8-year-old male. This fracture was treated nonoperatively. B: Radiograph 18 months later shows cessation of the proximal migration of the metaphyseal margin and a lack of development of a secondary ossification center. Despite this arrest of the apophysis, the patient had a full range of elbow motion.
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Irreducibility

An and Loder reported inability to reduce the fracture in one of their patients because the proximal fragment was entrapped in the joint. 

Delayed Union

Delayed radiographic union usually is asymptomatic.56 In Mathews's series,56 one fracture treated with suture fixation ultimately progressed to a nonunion. Despite this, the patient had only a 10-degree extension lag and grade 4 triceps strength. An accessory ossicle, such as a patella cubiti, is not a nonunion. 

Compartment Syndrome

Mathews56 described one patient with Volkmann ischemic contracture after an undisplaced linear fracture in the olecranon. 

Nerve Injuries

Zimmerman126 reported ulnar nerve neurapraxia from the development of a pseudarthrosis of the olecranon where inadequate fixation was used. 

Elongation

Elongation of the tip of the olecranon may complicate healing of a fracture. Figure 13-63 illustrates a delayed union in which the apophysis became elongated to the point that it limited extension. This proximal overgrowth of the tip of the apophysis has occurred in olecranon fractures after routine open reduction and internal fixation.71 
Figure 13-63
 
A: Injury film showing partial avulsion of the tip of the olecranon apophysis (arrow). B: Radiograph taken 4 years later shows a marked elongation and irregular ossification of the apophysis.
 
(Courtesy of Joel Goldman, MD.)
A: Injury film showing partial avulsion of the tip of the olecranon apophysis (arrow). B: Radiograph taken 4 years later shows a marked elongation and irregular ossification of the apophysis.
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Figure 13-63
A: Injury film showing partial avulsion of the tip of the olecranon apophysis (arrow). B: Radiograph taken 4 years later shows a marked elongation and irregular ossification of the apophysis.
(Courtesy of Joel Goldman, MD.)
A: Injury film showing partial avulsion of the tip of the olecranon apophysis (arrow). B: Radiograph taken 4 years later shows a marked elongation and irregular ossification of the apophysis.
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Loss of Reduction

Apparently stable fractures treated with external immobilization may lose reduction, which results in a significant loss of elbow function (Table 13-27, Fig. 13-64). 
Table 13-27
Proximal Ulna Apophyseal and Metaphyseal Olecranon Fractures: Common Adverse Outcomes and Complications
Spur formation
Nonunion
Apophyseal arrest
Loss of reduction
Olecranon elongation
Prominent implants
X
Figure 13-64
Loss of reduction.
 
A: Lateral radiograph of what appeared to be a simple undisplaced fracture (arrow) of the olecranon in a 13-year-old female. B: On the anteroposterior film, the fracture also appears undisplaced. The mild lateral subluxation of the radial head was not recognized. C: Radiographs taken 5 months later showed further lateral subluxation with resultant incongruity of the elbow joint.
 
(Courtesy of Richard W. Williamson, MD.)
A: Lateral radiograph of what appeared to be a simple undisplaced fracture (arrow) of the olecranon in a 13-year-old female. B: On the anteroposterior film, the fracture also appears undisplaced. The mild lateral subluxation of the radial head was not recognized. C: Radiographs taken 5 months later showed further lateral subluxation with resultant incongruity of the elbow joint.
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Figure 13-64
Loss of reduction.
A: Lateral radiograph of what appeared to be a simple undisplaced fracture (arrow) of the olecranon in a 13-year-old female. B: On the anteroposterior film, the fracture also appears undisplaced. The mild lateral subluxation of the radial head was not recognized. C: Radiographs taken 5 months later showed further lateral subluxation with resultant incongruity of the elbow joint.
(Courtesy of Richard W. Williamson, MD.)
A: Lateral radiograph of what appeared to be a simple undisplaced fracture (arrow) of the olecranon in a 13-year-old female. B: On the anteroposterior film, the fracture also appears undisplaced. The mild lateral subluxation of the radial head was not recognized. C: Radiographs taken 5 months later showed further lateral subluxation with resultant incongruity of the elbow joint.
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X

Operative Treatment of Fractures of the Coronoid Process in Fractures of the Proximal Ulna

Indications/Contraindications

Regan and Morrey84 found that the elbow often was unstable in type III fractures, and they secured these fractures with internal fixation. They had satisfactory results with type I and II fractures, but in only 20% of type III fractures were the results satisfactory that were treated nonoperatively. These indications were further supported by Aksu et al.1, who recommends surgical management for all type III injuries. 
The presence of a coronoid fracture alerts us to be especially thorough in looking for other injuries. In children, surgery is rarely necessary. If there is a large fragment and marked displacement, open reduction is indicated. 

Open Reduction and Internal Fixation of Coronoid Fractures

Preoperative Planning
The preparation for ORIF of the coronoid process starts with ensuring familiarity with the local anatomy and anterior approach to this region. In addition, the surgeon needs to prepare for dealing with a relatively small-sized fracture fragment that will require significant precision for reduction and screw placement (Table 13-28). 
 
Table 13-28
ORIF of Coronoid Fractures
View Large
Table 13-28
ORIF of Coronoid Fractures
Preoperative Planning Checklist
  •  
    OR table: Standard with radiolucent hand table
  •  
    Position/positioning aids: Turn table 90 degrees, bring patient to edge of table toward hand table. Secure head with blanket/towel and tape. Safety strap over torso
  •  
    Fluoroscopy location: In line with affected extremity, perpendicular to OR table
  •  
    Equipment: Minifragment set (2–2.75-mm screws); dental picks
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet
X
Positioning
The positioning for this technique is the same as described previously in the apophyseal and metaphyseal fracture section. 
Surgical Approach(es)
This procedure is performed through a Henry anterior approach to the elbow. The anatomic plane of the deep dissection lies between the brachioradialis and brachialis. The radial nerve lies within this interval, and needs to be protected. The fracture fragment will likely have at least partial attachment of the brachialis. 
Technique
As a result of the confined space anatomically in this location, the use of fracture reduction forceps will be challenging if not impossible. Accordingly, dental picks are very useful in obtaining reduction of this fracture. Once reduced, the fragment is fixed with a minifragment screw or sewn in place through two drill holes in the posterior aspect of the ulna. If there is significant comminution or the fragment is small, the pull through suture technique is superior (Table 13-29). 
 
Table 13-29
ORIF of Coronoid Fractures
View Large
Table 13-29
ORIF of Coronoid Fractures
Surgical Steps
  •  
    Expose proximal ulna via anterior Henry approach
  •  
    Protect the radial nerve
  •  
    Reduce fracture fragment using dental picks
  •  
    Fix fracture with appropriate size minifragment screw
X

Author's Preferred Treatment for Fractures of the Proximal Ulna

We usually treat coronoid fractures with early motion, much as we do elbow dislocations. The presence of a coronoid fracture alerts us to be especially thorough in looking for other injuries. In children, surgery is rarely necessary. If there is a large fragment and marked displacement, open reduction is done through a Henry anterior approach to the elbow. The fragment is fixed with a minifragment screw or sewn in place through two drill holes in the posterior aspect of the ulna. 

Postoperative Care

A short period of immobilization, 10 to 14 days, followed by active range of motion is preferred. However, tenuous fixation may be encountered when treating these injuries. Intraoperative assessment of fixation and stability is warranted, and depending on the assessment, the postoperative care may need to be adjusted accordingly. 

Potential Pitfalls and Preventative Measures (Table 13-30)

 
Table 13-30
Coronoid Fractures: Potential Pitfalls and Preventions
View Large
Table 13-30
Coronoid Fractures: Potential Pitfalls and Preventions
Pitfall Preventions
Loss of fixation Assess intraoperatively
Cast longer if fixation tenuous
Elbow instability Treat type III injuries operatively
Fragment comminution Be prepared for pull through suture technique
X

Treatment-Specific Outcomes

As noted previously, Regan and Morrey84 found that the elbow often was unstable in type III fractures, and they secured these fractures with internal fixation. They had satisfactory results with type I and II fractures, but in only 20% of type III fractures were the results satisfactory that were treated nonoperatively. 

Management of Expected Adverse Outcomes and Unexpected Complications

Because of the high association of these injuries with elbow dislocations, postinjury stiffness is a concern. Accordingly, treatment modalities are selected to allow for early range of motion when possible. Complications are rare. In fractures with a large fragment (type III), the elbow may be unstable and prone to recurrent dislocations. Nonunion with the production of a free fragment in the joint occurs rarely in children (Table 13-31).72 
Table 13-31
Coronoid Fractures: Common Adverse Outcomes and Complications
Elbow stiffness
Recurrent elbow instability
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Summary, Controversies, and Future Directions Related to Fractures of the Proximal Radius and Ulna

A large portion of proximal radius and ulna fractures in children can be treated successfully by nonoperative methods. The surgical techniques described in this chapter are effective in achieving fracture union and good clinical results. However, the current literature is deficient in the area of functional outcome instruments for fractures of the proximal ulna and radius in children. The previously published studies on the outcomes of these fractures have used descriptive assessments that are currently nonvalidated techniques. Elbow range of motion after these injuries continues to be a driver of functional outcomes. As such, there is a definite need for both accurate methods of measuring range of motion as well as validated techniques for reporting the results. 

Acknowledgment

Micaela Cyr for assistance with editing. 

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