The majority of pediatric radial neck fractures can be managed without operative intervention (Table 1). Minimally to moderately displaced proximal radius fractures can often be treated conservatively due to the potential for remodeling. In children younger than 6–8 years of age, up to 30° of angulation and less than 50 % translation is acceptable because predictable remodeling occurs in this age group (Chambers 2001). Younger children with more severe angulation and older children and adolescents with greater than 10–15° of angulation, however, are best treated with fracture reduction.

Minimally displaced Salter-Harris I and II fractures and metaphyseal fractures, regardless of the age of the child, can be treated in a long arm cast with the elbow flexed to 90° for 3-week duration. After cast removal, active elbow range of motion is initiated. Most children return to full activities within 3–6 weeks after cast removal.

Closed reduction can be achieved using one of several described techniques. One method involves flexing the elbow to 90° and fully supinating the forearm. Next, pressure is applied to the shaft of the proximal radius in order to reduce the head. Applying the pressure to the shaft as opposed to the head utilizes a long lever arm, achieving a greater mechanical advantage (Monson et al. 2009).

Other commonly used techniques are two-person maneuvers. One such technique involves rotating the forearm under fluoroscopy to identify the position in which the maximum degree of angulation is visible on the AP view of the elbow (Fig. 2). Next, longitudinal traction and varus stress is applied to the elbow by an assistant while the surgeon pushes downward and laterally on the radial shaft in the interosseous space (Neher and Torch 2003).

Another technique fully supinates the forearm first. Longitudinal traction and a varus force is then applied across the elbow, while a medially directed force is applied via thumb pressure to the skin overlying the radial head (Patterson 1934).

One final closed reduction technique involves wrapping an Esmarch bandage from distal to proximal in an attempt to realign the proximal radial fragment over the radial shaft.

Following the chosen maneuver, repeat radiographs or fluoroscopic images are obtained to assess the reduction. Fractures that are not adequately reduced are then taken to the operating room for further manipulation. Once an acceptable reduction is obtained, the patient is placed in a long arm cast at 90° of elbow flexion for 3 weeks.

Both Vocke and Berntstein demonstrated good results with conservative management of radial neck fractures angulated up to 50–60° in children aged under 6 and under 10, respectively (Bernstein et al. 1993; Vocke and Von Laer 1998). However, there is a lack of research to support an exact age cutoff as it relates to an acceptable degree of angulation and predicted outcomes.

Operative intervention should be performed for all pediatric radial neck fractures that are significantly angulated (greater than 30°) despite failed closed reduction maneuvers and all fractures that have significant displacement (greater than 50 % translation). Additionally, fractures with small “flecks” of bone in young children should be brought to the operating room to have an arthrogram performed to ensure adequate alignment is present. Should closed reduction attempts fail to achieve an acceptable reduction, percutaneous or open techniques should be employed. Advancing directly to an open reduction is sometimes necessary when significant displacement of the fracture is present, as there can be soft-tissue interposition or the radial head fragment can be extracapsular. However, open techniques are associated with worse outcomes, and therefore, a closed or percutaneous technique should be attempted prior to proceeding to open reduction when possible.

A systematic approach in the operating room is utilized to reduce the fracture in the most minimally invasive manner.

The algorithm begins by performing an elbow arthrogram in children with minimal or no ossification of the proximal radial epiphysis, typically children 5 years of age and younger. Subsequently, closed reduction maneuvers are attempted with the patient under general anesthesia. If a closed reduction maneuver reduces the fragment, stability is checked with live fluoroscopy, and if the fragment is stable, a long arm cast is applied. Due to the thick periosteum and typical SH II fracture pattern, there is almost always continuity of the periosteum, which aids in maintaining the reduction once it is achieved.

If closed reduction maneuvers fail, the arm is prepped and draped in the usual fashion and reduction of the fracture utilizing a percutaneous pin reduction is attempted. Successful reduction of the fragment allows for treatment with casting alone.

If percutaneous pin reduction maneuvers are unsuccessful, the Metaizeau technique is performed, as long as the fracture is angulated 60° or less (Judet Type III). Fractures that have no bony contact between the fragments and/or are angulated more than 60° are difficult to treat with the Metaizeau technique and require open reduction (Endele et al. 2010). Furthermore, manipulative reduction attempts for fractures angulated more than 60° have the potential to damage the cartilaginous epiphysis (O’Brien 1965).

The final step in the algorithm is to perform an open reduction and utilize K-wire fixation. As outcomes are less optimal and there is a higher complication rate following open reduction, this technique is reserved until after all other means of obtaining a successful reduction have been attempted (D’souza et al. 1993; Schmittenbecher et al. 2005).

Regardless of the procedure that is being executed, positioning is the same (Table 2). The patient is placed supine on the operating room table with a hand table that permits fluoroscopic evaluation of the elbow and forearm. Alternatively, the elbow can be placed directly onto the inverted fluoroscopy unit. A nonsterile pneumatic tourniquet is applied to the upper arm, and the remainder of the upper extremity is prepped and draped in the usual fashion. These steps permit the progression through the aforementioned algorithm if necessary without having to spend time re-prepping or draping.

An elbow arthrogram is typically performed prior to reduction (Fig. 3). A small-gauge needle attached to extension tubing is inserted into the elbow joint, either through the “soft spot” on the posterolateral aspect of the elbow, defined by the lateral distal humerus and the radial head, or posteriorly through the triceps into the olecranon fossa. After fluoroscopic confirmation, a 10 cc syringe filled with a solution of equal parts saline and contrast dye (Dormans 1994) is attached to the tubing. Under live fluoroscopy, the dilute contrast material is then injected. For a small child, only 3–5 cc of contrast is needed. The elbow is then taken through a range of motion to distribute the contrast material throughout the joint, and images are taken. Visualization of the entire radial head is now possible, and one can determine exactly how angulated and displaced the fracture fragment is.

When closed reduction attempts fail to achieve an acceptable reduction, percutaneous or open techniques should be employed. Percutaneous pin reduction can be performed following the elbow arthrogram, once the radial head is easily visualized (Table 3). A 0.062 in. or 5/64 in. K-wire is percutaneously inserted from the ulnar side of the radius to minimize potential injury to the PIN (Canale 2007). Once the sharp side of the wire punctures the skin, the wire is removed and turned around such that the blunt end of the wire is now inserted through the puncture hole. With the aid of fluoroscopy, the blunt end is now advanced to make contact with fracture fragment. Subsequently, the K-wire is used to “push” the radial head into anatomic alignment (Fig. 4). As some healing may have already occurred, it may be helpful to gently tap the K-wire with a mallet to facilitate movement of the fragment. This should be performed while utilizing fluoroscopy liberally, as the K-wire may not be advancing the fragment but may rather be advancing into the cartilaginous fragment. It is important to try and avoid entering the fracture site with the K-wire to avoid potential injury to the physis. Occasionally, two wires may be utilized to reduce the fragment: one to “push” the fragment up, thus improving the angulation, and one to “push” the fragment over, thus improving the translation.

The Wallace Joker technique is an alternate method of reduction. First, the level of the bicipital tuberosity is identified under fluoroscopy. A dorsal skin incision is then made at the same level lateral to the border of the ulna. Next, a joker is introduced between the radius and ulna, with care taken to avoid periosteal disruption. Using the joker, lateral pressure is then applied along the medial surface of the radius as counterpressure is applied to the proximal radial head fragment in order to achieve reduction.

If the fragment is angulated approximately 60° or less, but alignment remains unacceptable after percutaneous wire manipulation, the Metaizeau technique should be performed (Table 4). The Metaizeau technique utilizes an intramedullary K-wire or flexible titanium nail as a tool to facilitate reduction of the radial neck fracture fragment (Metaizeau et al. 1980) (Fig. 5). In either case, the last 1.5 cm should be bent approximately 20–30° prior to insertion. The intramedullary device is inserted in a retrograde fashion utilizing either a dorsal or radial starting point. The limb should be exsanguinated and the tourniquet inflated. A dorsal incision approximately 2–3 cm in length is made in the region of Lister’s tubercle, ensuring that this location is proximal to the physis by 1–2 cm. Soft-tissue dissection is carried out to identify the extensor pollicis longus (EPL) tendon in the third dorsal extensor compartment. Once it is identified, the compartment is released, and the tendon is transposed and protected to reduce the risk of injury during nail insertion and while the nail remains in place during fracture healing. Under direct visualization, with the EPL protected, an oblong hole is then made in the dorsal cortex of the radius. The intramedullary device is inserted and passed retrograde in the radius up to the fracture site. Under fluoroscopic guidance, the bent tip is now advanced across the fracture site to engage the fracture fragment. Repeating the arthrogram at this point may facilitate visualization of the fracture fragment and the reduction. Once the tip of the intramedullary device has engaged the fracture fragment, the intramedullary device is rotated 180°, thus reducing the fracture fragment. Multiple fluoroscopic images are obtained during this process to ensure that the fragment is moving appropriately. After the fragment is reduced into acceptable alignment, the intramedullary device is cut just above the dorsal radial cortex and the tourniquet is deflated. Hemostasis is obtained and the dorsal incision is closed. The child is then placed in a long arm cast, and final images are obtained to ensure maintenance of reduction.

As noted earlier, open reduction should only be used when all other attempts to reduce the fracture have failed (Table 5). A standard Kocher approach is utilized by making a posterolateral incision from the lateral condyle and extending obliquely in a distal medial direction to end approximately 5 cm distal to the tip of the olecranon. The plane between the extensor carpi ulnaris and the anconeus muscles is then identified and explored. With the forearm held in a pronated position, the anconeus is retracted ulnarly and the extensor carpi ulnaris is retracted radially. The fibers of the supinator muscle can be identified crossing at a right angle to the wound. Its proximal fibers should be gently retracted distally to avoid potential injury to the posterior interosseous nerve. The joint capsule is now visualized in the depth of the proximal aspect of the wound. The capsule is then incised to obtain adequate visualization of the fracture, and the fracture is now able to be reduced under direct visualization. Stabilization is typically performed with a minimum of two K-wires placed obliquely through the fracture site and left protruding through the skin for easy removal. Transcapitellar pins should be avoided as they make break during the healing period, even if the child is in a long arm cast.