ESIN recommended for pediatric radial neck fractures

British investigators find excellent results in all but one patient.

In a recent British study, indirect reduction and fixation with an elastic stable intramedullary nail yielded excellent results and few complications in children with severely displaced radial neck fractures.

The study included 14 children with Judet’s Type III and Type IV fractures and a mean age of 10 years. At a mean 28-month follow-up, all children had excellent results, except for one child with avascular necrosis. Another child also developed neuropraxia of the posterior interosseous nerve, but recovered in six weeks, according to the study.

“[The elastic stable intramedullary nail fixation (ESIN) technique] has been shown to give better results in severely displaced fractures of the radial neck in children,” the researchers said in the study, published in the British edition of the Journal of Bone and Joint Surgery. “It has the advantage of achieving acceptable indirect reduction without disturbing the blood supply.”

Excellent outcomes

The study included nine girls and five boys treated at the Royal Liverpool Children’s Hospital in Liverpool, England, between October 2000 and March 2005. Twelve fractures were sports related, but all were closed injuries. Surgeons treated all children within two days of the injury except for one child, who was referred from another hospital one week after the injury. This child received surgery nine days after the fracture.

All procedures involved general anesthesia with the child placed in the supine position and the upper limb draped on a hand table. Surgeons made a lateral skin incision 2 cm to 3 cm long and extending proximally from the distal radial physis, taking care to avoid injuring the superficial radial nerves.

Surgeons used closed manipulation to improve the fracture position in 12 children, used open reduction in two children, and completed surgery with ESIN in all cases. Three operations required K-wire assistance because, “in Type IVb fractures, it may be difficult to catch the displaced epiphysis,” the authors said. “Percutaneous K-wires are then used to obtain partial reduction before the nail is advanced.”

Researchers assessed the children’s outcomes using the Metaizeau functional scoring system, which is based on range of movement. They found excellent functional scores (no loss of movement) in 13 children and good (less than 20° lost) in one.

Three children were immobilized for six weeks because of associated injuries, including two olecranon fractures and one ulna shaft in the same limb, according to the study.

Titanium vs. stainless steel nails

Surgeons used a single nail, measuring from the subchondral area of the head to the distal radial growth plate. Nail diameter measured 2 mm in children younger than 10 years and 2.5 mm in older children. The nail's sharp tip penetrated the cancellous bone

of the proximal epiphysis, according to the study.

They used blunt titanium nails in seven children and sharp stainless steel nails in the other seven, finding no difference in outcomes. However, “The sharp nail facilitates the technique and more easily engages the epiphysis to assist in reduction,” the authors said.

Surgeons removed the nails at a mean 12 weeks postop, but retained the nails longer in those children with associated injuries.

For more information:
Prathapkumar KR, Garg NK, Bruce CE. Elastic stable intramedullary nail fixation for severely displaced fractures of the neck of the radius in children. J Bone Joint Surg Br. 2006;88-B:358-361.