Injuries of the olecranon and radial head
Olecranon fractures are more common in older children as a result of direct trauma. The main difficulty is X-ray diagnostics. A child's ossification center may consist of several fragments, which an inexperienced eye mistakes for bone fragments. To avoid error, imaging of the healthy joint is mandatory.
Treatment depends on the degree of displacement:
- Conservative: for a diastasis of up to 3–4 mm, a cast is applied for 10–12 days.
- Surgical: for a diastasis of more than 5 mm or fracture-dislocations, a U-shaped Dacron or silk suture is used.
Radial head fractures are typically epimetaphyseal injuries resulting from indirect trauma (a fall on an outstretched hand). Unlike in adults, the fracture line in children runs transversely, causing epiphysiolysis or osteoepiphysiolysis. Reduction is performed using special manual maneuvers (Sivnukhov's method) or with an inserted probe (Bairov's method). It is important to remember that removing the radial head in children is an absolute contraindication, as this destroys the growth plate and irreversibly impairs limb development.
Diaphyseal fractures: the "crunch" rule
Diaphyseal fractures of both forearm bones are very common. In younger children, they often occur as "greenstick" fractures — subperiosteal and without displacement. There is no axial deformation, but local pain and a positive axial load sign are present. Treatment consists of applying a splint for 2–3 weeks.
For fractures with angular deformity, the strategy changes. Reduction is performed under general anesthesia with one important feature: the peripheral fragments are brought into a position of overcorrection until a slight crunch is felt. This crunch indicates the fracture of the bent but previously intact cortical plate. This is a mandatory traumatic step — if the plate is not fractured, its elastic resistance will lead to a recurrence of the angular displacement.
The prognosis for diaphyseal fractures is favorable: even if the bones heal with a slight residual displacement, during growth the excess periosteal callus is resorbed, and the shape of the forearm completely normalizes.
Monteggia and Galeazzi fracture-dislocations
These severe injuries account for only 1.5–3% of all forearm injuries in children and lead to gross impairments of hand function.
- Monteggia fracture: Usually treated conservatively. Residual angular displacement of the ulnar fragments up to 15–20° and displacement in width up to 1/2 of the diameter are acceptable. Surgery (open reduction of the radial head and repair of the annular ligament) is indicated only if the dislocation cannot be reduced after two attempts at closed reduction.
- Galeazzi fracture: Occurs when falling on the palm. In children, this mechanism more frequently causes osteoepiphysiolysis of the distal third of the ulna rather than dislocation of its head. It requires urgent reduction and cast immobilization with maximum ulnar deviation of the hand. Regular X-ray monitoring is mandatory due to the high risk of secondary displacements.
Injuries of the distal radial metaphysis and carpal bones
When falling on an outstretched hand, traumatic epiphysiolysis of the radius most commonly occurs, in which the distal fragment is displaced dorsally. As with the olecranon, in case of doubt, a comparative radiograph of the healthy arm is taken.
Treatment is predominantly conservative. If there is no displacement or the articular facet is tilted dorsally by no more than 10°, reduction is not performed — a dorsal plaster splint is applied for 3–4 weeks. With a more significant displacement, closed manual reduction is performed.
The main danger of this injury is damage to the growth plate. Suboptimal reduction threatens to disrupt the longitudinal growth of the radius, which eventually leads to the development of a specific Madelung deformity.
As for the carpal bones, their fractures are practically non-existent in children and are observed only in the older adolescent group.
Briefly: answers to topical questions
At what age and why do carpal bones begin to sustain fractures?
Due to the sequential ossification of the carpal bones in children, fractures are more common in the distal wrist. At birth, the carpal bones are represented by cartilage; for example, the ossification center of the scaphoid appears at 5–6 years of age, and the pisiform at 10–12 years. In young children, trauma more frequently causes a fracture of the distal radial metaphysis rather than the scaphoid, because its density is lower than that of the scaphoid.
To understand the biomechanics of diaphyseal reduction, remember the "greenstick" fracture: to straighten a bent elastic branch, its intact side must be fractured (brought into overcorrection until a crunch is heard).
Class and exam questions
In which cases is surgery indicated for a Monteggia fracture?
Surgical intervention is indicated if, after a two-time closed reduction attempt, the radial head dislocation remains unreduced.
Why should the radial head not be removed in children?
Unlike in adults, this surgery in children irreversibly destroys the active growth plate, leading to severe underdevelopment and limb deformity.
What else to study on this topic
- Technique of manual reduction of the radial head according to Sivnukhov and Bairov
- Pathogenesis and clinical presentation of Madelung deformity
- Differential X-ray diagnostics of epiphysiolysis and osteoepiphysiolysis
- Specifics of intramedullary osteosynthesis in Monteggia fractures in adolescents
- Mechanisms of formation and prevention of secondary displacement in Galeazzi fractures
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