Volume 7, Issue 2 (5-2020)                   J. Res. Orthop. Sci. 2020, 7(2): 93-96 | Back to browse issues page


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Tabrizi A, Afshar A, Taleb H. Radial Neck Fracture With 180° Rotational Displacement in Pediatrics: A Case Report of a 6-Year-Old Child. J. Res. Orthop. Sci.. 2020; 7 (2) :93-96
URL: http://jros.iums.ac.ir/article-1-2089-en.html
1- Department of Orthopedics, Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran.
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1. Introduction
A Radial neck fracture is one of the rare pediatric upper extremity traumatic injuries accounting for 5%-10% of the elbow injuries among children [1]. The common displacement mechanism is the valgus strain in the elbow which induces lateral angulation from 10° to 90. The treatment of radial neck fracture is highly challenging and depends on the radial neck-shaft and displacement distance which are among the prominent prognostic factors [1, 2]. Blood supply of radial neck may be damaged due to severe trauma or open reduction [1, 2] In this regard, non-surgical treatment and closed reduction would be the treatment of choice [1, 2]. This report presents a 6-year-old child who experienced a radial neck fracture with 180° rotational displacement due to falling on her elbow.
2. Case Presentation
The patient was a 6-year-old girl suffering from radial neck fracture as a result of falling on her outstretched hand in forearm supination. Initial examination showed that the radial neck fracture had minimal lateral displacement with 50% translation but the radial neck-shaft angle was nearly normal. Radiographic images, however, revealed that the joint surface has a 180° rotational displacement in a way that the radial neck was directed toward the distal direction (Figure 1). Elbow was swelled; neurovascular examinations were normal. The forearm range of motion in supination and pronation was disrupted. Closed reduction was conducted under general anesthesia.
Firstly, Neher torch was employed with the elbow extended and forearm supinated. Then, two thumbs stabilized the radial shaft (laterally directed force) with subsequent varus elbow stress and the pressure was laterally applied on the radial head, which was not successful [3]. Next, the Monson et al. approach was applied with the elbow flexed and forearm supinated, then posteriorly direct pressure was applied to the radial shaft [4]. The reduction was carried out under the fluoroscopic guide which was acceptable in a way that the radian neck-shaft angle was stable at about 15. The forearm supination and pronation were retained and the elbow was immobilized by a long forearm cast for 3 weeks. Three weeks later, a complete :union: was achieved (Figure 2). 
The patient started early active exercises for flexion-extension and pronation-supination. Radial neck fracture :union: occurred without osteonecrosis or heterotopic ossification. Additionally, radiographic findings revealed no avascular necrosis, collapse, or deformity of the radial head. In clinical findings, there was no restriction in the range of motion (Figure 3). 
3. Discussion
Cartilaginous radial head in children has provided a high resistance against the external forces resulting in radial neck fractures rather than the radial head. The valgus strain-induced displacement often ranges from 10° to 90  and 180° rotation is very rare.1,2 In the cases with minimal radial head translation and normal radial neck-shaft angle, the status of the joint surface is of crucial significance since 180° rotation is probable in such cases.5  Navali et al. (2006), reported a 180° displacement of the radial head due to closed reduction [5]. Based on the literature, only 5 cases of 180° rotation have been observed following radial neck fracture [5-8]. In all these cases, the fracture occurred after falling on the outstretched hand where reduction attempts finally led to 180 rotation in the radial head. Thus all these reports had occurred due to the iatrogenic malposition causes [5-8] Avascular necrosis was observed in 4 cases probably due to damaged blood supply due to open reduction [5, 7, 8] In one of these cases, fixation with k-wire led to osteomyelitis.6 In our patient, avascular necrosis did not occur as we employed closed reduction.
4. Conclusion
The radial head could experience 180° rotation as the result of radial neck fracture; thus attention to the joint surface is of crucial significance in the cases with minimal lateral displacements or angulations to avoid any misdiagnosis. The closed reduction seems to be a successful treatment with no complications.
Ethical Considerations
Compliance with ethical guidelines
The report was confirmed by the Ethics Committee of Urmia University of Medical Sciences and All ethical principles were considered in this article.
Funding
Funding was done by the office of Vice Chancellor of Research of Urmia University of Medical Sciences. 
Authors' contributions
All authors contributed in preparing this article.
Conflict of interest
The authors declared no conflict of interest.


References
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Zhang FY, Wang XD, Zhen YF, Guo ZX, Dai J, Zhu LQ. Treatment of severely displaced radial neck fractures in children with percutaneous k-wire leverage and closed intramedullary pinning. Med (Baltimore). 2016; 95(1):e2346. [DOI:10.1097/MD.0000000000002346] [PMID] [PMCID]
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Fraser KE. Displaced fracture of the proximal end of the radius in a child. A case report of the deceptive appearance of a fragment that had rotated 1800. J Bone Joint Surg Am. 1995; 77(5):782-3. [DOI:10.2106/00004623-199505000-00016] [PMID]
Wood SK. Reversal of the radial head during reduction of a fracture of the neck of the radius in children. J Bone Joint Surg Br. 1969; 51(4):707-10. [DOI:10.1302/0301-620X.51B4.707] [PMID]
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Type of Study: Case Report | Subject: Knee surgery
Received: 2020/01/22 | Accepted: 2020/05/12 | Published: 2020/05/30

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