Primary Surgical Treatment of Displaced Intraarticular Pediatric Radial Head Fractures Improves Outcomes and Decreases the Need for Salvage Surgery
Andrea HW Chan, MD, MA, FRCSC1, Julianna Lee, BA2, Jennifer Marks, MS3, Charles J Nesralla, MD4, Roger Cornwall, MD5, Andrea S Bauer, MD6, Apurva S. Shah, MD MBA2 and Kevin J. Little, MD7, (1)University of Toronto, Toronto Western Hospital, Toronto, ON, Canada, (2)The Children's Hospital of Philadelphia, Philadelphia, PA, (3)Cincinnati Children's Hospital Medical Center, Ciincinnatii, OH, (4)Harvard University Combined Orthopaedic Residency, Boston, MA, (5)Department of Orthopaedic Surgery, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, (6)Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, (7)Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
INTRODUCTIOIN: Intraarticular radial head fractures (IARHF) in children are rare and understudied, and can lead progressive joint subluxation and subsequent salvage surgery. Early treatment for appropriate patients should improve outcomes compared to those identified late and/or treated non-operatively.
MATERIALS&METHODS: IARHF in children < 18 years of age were identified at three tertiary-care pediatric institutions. Radiographic images confirming IARHF and minimum 6-month follow-up were required; demographics, imaging findings, and treatment course were recorded.
RESULTS: 44 IARHF in 43 patients (55% female, n=24) with mean age of 12.06±2.8 years were included in the investigation. Twenty-nine patients presented to Orthopaedics at the Tertiary Care Medical centers within 30 days of injury (mean 5.3±6.5), while the other fifteen presented later (mean 470.6±387.7). Fourteen (32%) elbows were initially treated non-operatively, of which eight (57%) healed primarily. The other six (43%) progressed to radial head nonunion resulting in radiocapitellar joint subluxation and arthritis which required salvage surgery at 4-40 months post-injury. Thirty (68%) elbows underwent primary radial head fixation, of which twenty-seven had successful healing, while only three (10%) patients underwent subsequent salvage surgery (p=0.0194). Two of the three failures had surgery more than 8 months (240 and 700 days) from injury and the other patient developed radial head avascular necrosis. Twenty-two of twenty-seven successful surgical outcomes had surgery within 7 months, and fourteen within 1 month (median 20 days, IQR 7-90, p=0.1276). All eight patients with successful non-operative management had a radiographic fracture displacement of <1.5 mm, while four of six patients in the conservative to salvage group had >1.5 mm displacement (ANOVA, p=0.00009). There was no difference amongst groups with respect to patient age, sex, open physis, or percent radial head involvement. Patients who were initially treated conservatively were more likely to undergo salvage surgery if they ended up with salvage if they had a delay in presentation to the tertiary care center of >30 days (67% vs. 25%, p=0.0483). Patients with a delay in presentation >30 days were also more likely to have a longer duration of care(792.2±778 vs. 498.2±664 days, p<0.0001) as well as a longer delay in returning to activities (605±620 vs. 213.9±249 days, p=0.0012).
CONCLUSIONS: Non-surgical treatment in children with displaced IARHF carries a significantly higher risk of poor outcomes including progressive joint subluxation and need for salvage surgery. Early surgical treatment is recommended for all patients with displacement >1.5mm, or if joint subluxation and impending radiocapitellar arthrosis is noted.
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