Treatment principles, prognostic factors and controversies in radial neck fractures in children: A systematic review

Abstract

Introduction: Radial Neck fractures are rare injuries in children. There is controversy surrounding their prognosis and management.

Aims: This review aims to produce an up-to-date summary to clarify prognostic factors and management principles, in the light of recent, better-quality evidence.

Methods: A systematic review was undertaken in accordance to PRISMA guidelines, applying pre-defined selection criteria. 6 papers were found suitable after quality assessment. All were observational cohort studies, one prospective and the rest retrospective. A semi-qualitative review was undertaken as heterogeneity, especially in the fracture classification and outcome assessment tools used, prevented quantitative synthesis.

Results: Majority of these fractures occur at the metaphysis. Consistently good results are seen with simple immobilization in fractures angulated<30° with translation<50%, with nearly all achieving a good outcome. In more displaced fractures, results are poorer and only about 70% patients achieve a good outcome. Both higher fracture displacement and more invasive treatment are associated with worse outcomes, but also with each other. Associated injuries are common, with Proximal Ulna fractures being commonest (71%), but their effect on outcomes is unclear. Age more than 10 years is associated with worse displacement, more invasive treatment and worse results. There is much confounding among all these factors which remains to be convincingly addressed. An algorithmic approach is advisable for these fractures, with stepwise application of more invasive treatment only if less invasive methods fail. Percutaneous fixation with either K-wires or retrograde intramedullary elastic nails is acceptable. Fractures reduced closed in theatre fare better if fixed percutaneously to prevent re-displacement. Open treatment should be considered only if the fracture can't be reduced to within the displacement limits of angulation<30° and translation<50%. Incidence of serious complications is generally low (3-5%), but their effect on outcomes is unclear.

Conclusions: The treatment of higher-grade radial neck fractures is still controversial, needing further research, possibly through multi-center prospective data collection in pediatric fracture registries using validated outcome measures.

Keywords: Cohort studies; Confounding; Management guidelines; Radial neck fractures in children; Systematic review.