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Radial neck fracture
- 1. Rockwood and wilkins’fracture Radial neck fracture/桡颈骨折 Presenter: Anil KC Guangxi Medical University
- 2. Epidemiology/流行病学 • Mean ageis 9 to 10 years. • It accounts for 1 to 3 % of all children’s fractures and 5 to 10% of elbow fracture. • Only little difference in incidences between sexes. • 平均年龄为9至10岁。 • 占所有儿童骨折的1-3%，肘部骨折的5-10%。 • 男女发病率差别不大。
- 3. Mechanism of injury/损伤机制 •Fall on an outstretched arm with elbow extended and valgus stress at elbow. • This produces an angular deformity of neck . • Further valgus forces can produce a greenstick fracture of the olecranon or an avulsion of the medial epicondylar apophysis. 摔倒在伸直的手臂上，肘部伸直，外翻应力在肘部。这导致颈部有角畸形。进一步的外翻力可导致鹰嘴 的绿枝骨折或内侧上髁隆起撕脱。
- 4. Mechanism of injury/损伤机制 •Also associated elbow dislocation and relocation. • 同时伴有肘关节脱位和移位 Figure A: radial neck fractured during the process of reduction by capitellum pressing against the distal lip of radial head. Figure B: radial neck is fractured during process of dislocation by the capitellum pressing against the proximal lip of the radial head.
- 5. Associated injuries/相关伤害 • Distalhumerus fracture • Olecranon fracture • Radial shaft and distal radius fracture • Elbow dislocation • Presence of associated fractures portends a poor prognosis for patients. • 肱骨远端骨折 • 尺骨鹰嘴骨折 • 桡骨干桡骨远端骨折 • 肘脱 • 臼合并骨折的存在预示着病人预后不良。
- 6. Clinical features/临床特征 Symptom elbow pain refusalto move Physical examination inspection: soft tissue swelling with visible bruising on lateral aspect of elbow. Motion: pain exaggerated by motion especially with supination and pronation Neurological examination: evaluate the PIN (test for wrist, digit and thumb extension). occasionally, pain may referred to wrist. 症状：手肘痛，拒绝移动 体格检查检查：肘关节外侧软组织肿胀，可见瘀伤。 运动：由于运动而加剧的疼痛，尤其是在旋后和旋前 神经系统检查：评估PIN（手腕、手指和拇指伸展测试）。 偶尔，疼痛可能指腕关节
- 7. Imaging and otherdiagnostic studies/影像学和其他诊断研究 Radiographs • Recommended views: AP, LAT and radiocapitellar(greenspan) view. radiocapitellar/greenspan view: oblique lateral view performed by placing the arm on the radiographic table with the elbow flexed 90 degrees and the thumb pointing upward. • Beam is directed 45 degrees proximally • 射线照片 • 推荐视图：AP，LAT和radiocapitellar（格林斯潘）视图。 • RadioCapital/greenspan视图：斜侧视图，由将手臂放在射线检查台上，弯曲肘部90度，拇指朝上 • 光束指向近45度
- 8. Importance of radiocapitellarview A: radiograph of a 10 year old female who sustained a radial neck fracture associated with an elbow dislocation. There is an ectopic bone formation(arrows). In this view it is difficult to tell the exact location of ectopic bone .B: radiocapitellar view separates the radial head from the coronoid process and shows that the ectopic bone is from the coronoid process(arrows) and not the radial neck.
- 9. Imaging and otherdiagnostic studies/影像学和其他诊断研究 • The diagnosis of a partially or completely displaced fracture of the radial neck may be difficult in children whose head remain unossified. The only clue may be loss of smoothness of metaphyseal margin. Other imaging modalities such as arthrogram, ultrasound, and MRI are helpful to assess the extent of displacement and accuracy of reduction in children with an unossified radial epiphysis. 桡骨部分或完全移位骨折的诊断头颅不清的儿童颈部可能有困难。唯一的线索可能是干骺端边缘光滑度的丧 失 其他成像方式，如关节造影、超声和核磁共振成像有助于评估位移程度和复位精度桡骨骨骺未分化的儿童
- 10. • Displacement ofthe supinator fat pad may also indicate fracture of the proximal radius; however, this fat pad and the distal humeral anterior and posterior fat pads are not always displaced with occult fractures of the radial neck or physis because a portion of radial neck is extra-articular. • 旋后肌脂肪垫的移位也可能意味着桡骨近端骨折；然而，由于桡骨颈的一部分是关节外的，这个脂肪垫 和肱骨远端的前后脂肪垫并不总是随着桡骨颈或桡骨的隐性骨折而移位
- 11. Classification of radialneck fracture
- 12. Classification of radialneck fracture
- 13. Treatment option forradial neck fracture/桡骨颈骨折的 治疗选择 • Immobilization with no manipulation • Manipulative close reduction • Instrument assisted closed reduction • Intramedullary nail reduction/fixation • Open reduction and internal fixation • 无操纵固定手法闭合复位器械辅助闭合复位髓内钉复位/固定切开复位内固定
- 14. Indication of nonoperativetreatment: <2 mm displacement of the radial head or neck <30 to 45 degree angulation of the radial neck(<30 degrees if age >10, <45 degrees if age <10)
- 15. Close reduction techniques/闭合复位技术 •Patterson maneuver: hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head • Patterson 机动: 手肘伸直，在前臂旋后的情况下进行远端牵引， 将前臂拉入内翻，同时对桡骨头施加直接压力
- 16. Israeli technique • pronatethe supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head • 旋前旋入旋后的前臂，同时肘部弯曲至90°，直接压力使桡骨头稳定
- 17. Neher and torchreduction technique • elbow held in extension and supination with distal traction and varus force with assistant pushing laterally on radial shaft and surgeon pushing medially on radial head • 肘关节伸直和旋后，由远端牵引和内翻力支撑，辅助桡骨干侧推，外科医生向桡骨头内侧推
- 18. Elastic bandage wrapreduction • tight application of an elastic bandage (esmarch) beginning at the wrist continuing over the forearm and elbow may lead to spontaneous reduction • 紧绷绷带（esmarch）从手腕开始，持续到前臂和肘部，可能会导致自发性复位
- 19. Instrument assisted closedreduction • K wire joystick technique: Push technique: • blunt end of a large k-wire is pushed against the posterolateral aspect of the proximal fragment and pushed into place.
- 20. • Lever technique:k-wire is placed into the fracture site and levered proximally • 杠杆技术：将克氏针置于骨折部位，并在近端撬起
- 21. Metaizeau technique: • involvesretrograde insertion of a pin/nail across the fracture site • fracture is reduced by rotating the pin/nail • 包括在骨折部位逆行插入一个针/钉旋转针/钉可减少骨折
- 22. Wallace reduction technique •A periosteal elevator is used to lever the distal fragment laterally while thumb pushes the proximal fragment medially. • 骨膜升降器用于侧向撬起远端骨块，而拇指将近端骨片推向内侧
- 23. Open reduction andinternal fixation • Approach: kocher or Kaplan approach to proximal radius • Fixation: with screws and plate
- 24. Complications • Loss ofrange of motion • Radial head overgrowth • AVN of radial head • Physeal arrest may leads to cubital valgus deformity • Malunion • Nonunion • Proximal radioulnar synostosis
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