What is the step-by-step procedure for managing a pediatric patient with a fracture of the radial head using nailing?

Pediatric Radial Head Fracture Management with Intramedullary Nailing: Step-by-Step Procedure

The Métaizeau technique is the preferred method for managing displaced radial head fractures in pediatric patients, as it allows for closed reduction and stable fixation while preserving the blood supply to the radial head.

Patient Selection and Preoperative Considerations

• Indications:

  • Displaced radial neck fractures (angulation >30°)
  • Pediatric patients (typically 4-16 years old)
  • Closed fractures with minimal comminution

• Contraindications:

  • Open fractures with significant soft tissue damage
  • Severe comminution of the radial head
  • Associated elbow instability (relative contraindication - requires caution)

• Preoperative Imaging:

  • Standard radiographs (AP, lateral, and oblique views) of the elbow and forearm 1
  • CT scan may be considered for complex fracture patterns to better visualize fracture morphology 1

Equipment Required

• Fluoroscopy (C-arm)
• Titanium elastic nails (1.5-2.5mm diameter depending on patient size)
• T-handle chuck
• Wire cutter
• Basic orthopedic instruments
• Tourniquet (optional)

Surgical Technique: Step-by-Step Procedure

1. Patient Positioning and Preparation

• Position patient supine with the affected arm on a radiolucent table
• Prepare and drape the entire upper extremity from shoulder to fingertips
• Apply tourniquet if desired (not mandatory)

2. Entry Point Selection and Preparation

• Make a 1-2cm longitudinal incision over the distal lateral radius (2-3cm proximal to the distal radial physis)
• Carefully dissect down to the bone, protecting the superficial radial nerve
• Create an entry hole in the lateral cortex using an awl or drill

3. Nail Preparation

• Select appropriate nail size (typically 1.5-2.5mm diameter)
• Prebend the nail with a slight curve at the tip (15-20°) to facilitate engagement with the radial head fragment 2
• Mount the nail on the T-handle chuck

4. Nail Insertion and Fracture Reduction

• Insert the nail with the curve facing the fracture site
• Advance the nail proximally under fluoroscopic guidance until it reaches the fracture site
• Key Technical Point: Use oscillating movements of the T-handle for smooth proximal progression of the nail 2
• Once the nail reaches the fracture site, rotate the T-handle to engage the distal fragment of the radial head
• Apply gentle external manipulation to assist reduction if needed
• Important: Apply gentle stabilizing counterforce over the radial head during entry into the proximal epiphysis to prevent displacement 2

5. Fracture Fixation

• Advance the nail into the radial head while rotating the T-handle to achieve reduction
• Confirm reduction and nail position with fluoroscopy in multiple views
• Technical Tip: Move the C-arm instead of the elbow during imaging to avoid losing reduction 2
• For severely displaced fractures, consider using two short elastic nails for more stable fixation 3

6. Final Steps

• Cut the nail at the entry point, leaving 5-10mm protruding for later removal
• Close the wound in layers
• Apply a removable short arm splint

Postoperative Management

• Immobilization in a removable splint for 1-2 weeks 3
• Begin active finger motion exercises immediately to prevent stiffness 1
• Progressive range of motion exercises after 2 weeks
• Avoid contact sports for 6-8 weeks
• Nail removal after fracture consolidation (typically 3-4 months)

Potential Complications and Management

• Loss of reduction (17% incidence) 4

  • Monitor with weekly radiographs for the first 3 weeks
  • Consider revision if angulation exceeds 30°

• Skin irritation at nail entry site 3

  • Usually resolves after nail removal
  • Consider earlier nail removal if persistent

• Compartment syndrome 5

  • Higher risk with multiple reduction attempts, especially with concurrent elbow instability
  • Monitor compartment pressures if multiple attempts are required
  • Perform fasciotomy if compartment syndrome develops

• Radial head necrosis (rare) 4

  • More common with open reduction
  • Preserve medial periosteal continuity and vascular supply during any open approach 6

Special Considerations

• Late-presenting fractures (>2 weeks):

  • Open reduction may be necessary
  • Preserve medial periosteal continuity and vascular supply with meticulous dissection 6
  • Consider Kirschner wire fixation as an alternative

• Associated elbow dislocation:

  • Use extreme caution as these cases are more challenging
  • Higher risk of compartment syndrome with multiple reduction attempts 5
  • Consider alternative fixation methods if closed reduction fails

The Métaizeau technique has shown excellent results in 90% of cases with appropriate patient selection and technique 4. By following these detailed steps and being aware of potential pitfalls, surgeons can achieve stable fixation while minimizing complications and allowing early mobilization.