Paediatric Radial Neck Fracture Management

Indication. A displaced fracture of the radial neck in a child whose proximal radial physis is still open. The decision to operate rests on the Judet angulation, the child's age (and therefore remodeling potential), and whether a trial of closed manipulation succeeds. State the Judet type first, the exact angulation in degrees, and the treatment threshold before proposing an operation — this is the single most important decision point in the viva. Treatment thresholds. The acceptable residual angulation depends on remodeling capacity, which falls sharply after about 10 years of age:

The technique choice, and why. The overriding principle is to reduce the head while preserving the metaphyseal blood supply. Every step further down the invasive pathway adds vascular risk, which is why the escalation ladder exists and why open reduction is the last rung:

Consent specifically for AVN of the radial head (3-10% with Métaizeau, up to 30-50% with open reduction), loss of forearm rotation (10-30%), premature physeal closure causing progressive valgus (5-15%), radioulnar synostosis (1-5%), the need for a second anaesthetic for nail removal, and the deliberate possibility of accepting an imperfect reduction in order to preserve the blood supply. Setup. Supine with the arm draped free on a radiolucent hand table, upper-arm tourniquet (200-250 mmHg by child size), image intensifier from the lateral side for true AP and lateral elbow views. General anaesthesia for all children, single-dose cefazolin at induction. Capture and save baseline AP and lateral views before draping — these are the reference for measuring the Judet angle and judging reduction.

The goal is to restore alignment of the radial head on the neck while protecting the metaphyseal blood supply and the posterior interosseous nerve, and to stabilise the reduction just enough to allow early forearm rotation. Work down an escalation ladder — closed, then percutaneous, then intramedullary, and only then open — stopping as soon as an acceptable reduction is achieved. The two exposures (the distal metaphyseal entry for Métaizeau nailing, and the Kocher interval for open reduction) are laid out in the steps below.

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Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 3-4 weeks | Above-elbow cast/backslab in neutral to slight supination | Finger active motion only; elevation for 48 hours | | 2 | 3-4 to 6-8 weeks | Removable splint after cast and nail removal | Active forearm rotation — the critical phase; physiotherapy if rotation restricted | | 3 | 6-8 to 12 weeks | Splint for heavy tasks only | Progressive rotation and light activity | | 4 | Beyond 12 weeks | Night splint if needed | Graded return; non-contact sport at 6-8 weeks, contact sport at 3 months | The Métaizeau nail is removed at 6-8 weeks under a short general anaesthetic through a small incision over the distal insertion site. Begin active forearm rotation exercises immediately after cast removal — pronation and supination are the outcome measures. NSAIDs (paracetamol and ibuprofen) provide analgesia and may also reduce heterotopic bone formation. Long-term surveillance. Serial radiographs at 6 weeks (nail removal), 3 months, 6 months and 12 months are essential. AVN may not appear radiographically until 6-12 months after injury — a normal 6-week film does not exclude it. Measure the carrying angle and document pronation/supination in degrees at every visit, comparing with the contralateral elbow. Complications

Surgical anatomy — why the neck fractures, not the head. The proximal radial physis is the weakest point of the proximal radius in a child. The radial head (epiphysis) is united to the metaphysis through this growth plate, so when the neck fractures, the epiphysis and physis remain attached to the head fragment and displace as a unit. The fracture line therefore passes through the metaphysis of the radial neck, not through the physis itself — but the vascular pedicles supplying the epiphysis travel through the metaphysis and across the physis, so disruption at the fracture site compromises the supply. The radial neck in a child is approximately 1-2 cm long, with a medullary canal that accepts a 1.5-2.0 mm elastic nail in most children and a thin cortex that will propagate a fracture if levered aggressively. The ossific nucleus of the head is small in younger children and may not be visible on radiograph before 5-6 years. Blood supply of the developing radial head. In children the supply is predominantly metaphyseal: branches of the radial artery ascend along the neck and penetrate the physis to reach the epiphysis, providing about 80-90% of the total supply. Intraosseous vessels within the canal supply the metaphyseal cortex, and minor capsular vessels enter near the articular margin (the major intra-articular supply develops only after physeal closure). This anatomy is exactly why the Métaizeau technique works — it manipulates the head through the canal without stripping the metaphyseal periosteum — and why open reduction (which strips the periosteum and opens the capsule) carries the higher AVN rate. The Judet classification is the standard system, based on the angulation (tilt) of the radial head relative to the radial neck axis measured on the lateral radiograph, together with the degree of translation:

Surgical approaches to the proximal radius. The Kocher (lateral) approach is the primary exposure for open reduction: the interval is between anconeus (posterior) and extensor carpi ulnaris (anterior), deepened onto the supinator (within which the PIN runs), giving access to the radial neck and the lateral proximal radius. The Kaplan (anterolateral) approach is an alternative between brachioradialis and extensor carpi radialis longus for anterolateral fracture patterns, where the radial nerve and its PIN branch and the superficial radial nerve must be identified and protected. Structures at risk.

Special situations. A paediatric radial neck fracture may be a Monteggia equivalent if there is plastic deformation of the ulna — the ulna bows rather than fractures, the radial head displaces because ulnar alignment is lost, and the ulna must be corrected (a gentle corrective osteotomy by hyperflexion and direct pressure on the apex of the bow) or the radial head will not stay reduced. In the adolescent near skeletal maturity, remodeling potential is limited, the blood supply is transitioning toward the adult pattern, and the threshold for anatomic reduction is lower (residual angulation greater than 20-30 degrees is less well tolerated), though Métaizeau nailing remains preferred if the canal accepts a nail. Bilateral radial neck fractures suggest a high-energy mechanism — assess for associated injuries and manage each side independently, ideally nailing both in a single anaesthetic. Key evidence. Judet's 1962 original description established the classification and the relationship between displacement and vascular complications. Métaizeau's 1993 landmark paper described the retrograde elastic intramedullary nailing technique, reporting good or excellent outcomes in the majority with lower AVN rates than open reduction. Newman's 1977 series established that forearm rotation is the primary functional measure and that residual pain is uncommon. Contemporary reviews (Macken 2022; Langenberg 2022) confirm that Métaizeau nailing offers the best balance of reduction quality and AVN avoidance for displaced fractures, and that younger children tolerate greater residual tilt.