Subcapital Realignment of the Displaced Pediatric Radial Head-Technical Description and Early Clinical Results

Background: Displaced pediatric radial neck fractures are challenging injuries. Adequate reduction can be difficult to achieve via closed methods. Open reduction has been associated with avascular necrosis and growth arrest due to soft tissue stripping during surgery. We describe a modified technique that adopts lessons learned from subcapital realignment procedures of the proximal femur, prioritising preservation of the periosteal sleeve with the aim of reducing complications associated with open reduction. Methods: The modified technique includes visualisation of the radial neck fracture through the torn periosteum, preserving intact periosteum, limited shortening of the diaphyseal fracture site, followed by open reduction and fixation with retrograde elastic intramedullary nailing. A retrospective chart review of 15 patients treated with this technique was undertaken to report early clinical and radiographic outcomes. Results: Mean age at injury was 7.7 years (range 4-11). Mean follow-up was 9.9 months (range 4.5 to 20 months). There was 100% fracture union achieved at mean 9.3 weeks (SD 4.9) post-surgery. Mean flexion was 139° (SD 9°), extension 1° (SD 7°), supination 66° (SD 23°) and pronation 79° (SD 21°). There were no cases of postoperative radial head deformity or instability. One patient showed radiological signs of avascular necrosis. Six of 15 patients experienced at least one complication, including heterotopic ossification, stiffness requiring release, physeal closure and nail migration requiring revision. Conclusions: We describe a technique that aims to preserve periosteal blood supply during open reduction and fixation of pediatric radial neck fractures. Early clinical experience suggests promising results, but longer-term follow-up is required before any advantage over existing open reduction techniques can be concluded.