Issue 4/2012 of “Revista Española de Cirugía Ortopédica y Traumatología” (Spanish Journal of Traumatology and Orthopaedic Surgery) included the article “Radial head and neck fractures in children” by Fuentes Salguero et al.1 In it, the authors concluded that the management of these lesions should be staggered, placement of transcapital needles and excision of the radial head should be avoided and that the most common complication is loss of pronosupination. Firstly, we wish to congratulate the authors for their work and for delving into a topic which generates much debate in the field of paediatric traumatology, given that there are multiple ways to treat these injuries. After reading this interesting article we would like make the following comments:
The proportion of associated fractures published in their series, reaching up to 66.6%, was significant. This percentage was significantly lower in other works, such as that by Vocke et al.2 (42%) or that by González-Herranz et al.3 (23%), although the literature contains reports of associations with other fractures in up to 50% of cases. Being a short series, this suggests that either the number of cases included in the study were those which required special attention due to being multiple injuries, or else that the other associated lesions were more severe, thus leading to a bias in the percentage.
Regarding the Steel-Graham classification used for their cases (Group I: 12; Group II: 3; Group III: 3; Group IV: 3), we should highlight the considerable percentage of fractures with hardly any displacement or with angulation under 30° (57.6%) in which the authors did not specify the complication rate according to the severity of displacement.
The vast majority of authors link successful results with achieving a good reduction by closed methods (manual reduction, Feray or Metaizeau method). The authors of this work did not mention whether the complications observed were related to cases requiring open reduction or those treated in a closed manner in which adequate reduction was not achieved. Eleven of their patients were treated conservatively with immobilisation and without any manipulation, but they did not specify the method or period of immobilisation. Evans and Graham4 established a period of 3 weeks for fracture healing, as well as to avoid complications in terms of joint stiffness.
There was no reference to complications recorded among the group of patients treated surgically (4 cases through percutaneous reduction and 6 through open reduction). In such cases, a table recording this type of incidences would be advisable.
According to different authors, open reduction should be avoided whenever possible due to the high frequency of severe complications, such as avascular necrosis of the radial head, radioulnar synostosis or significant limitations in elbow mobility. Works such as that by D'Souza et al.,5 report using open reduction only after failing to achieve an adequate closed reduction. Meanwhile, Evans and Graham4 recommend open reduction for Steel-Graham type IV fractures. González-Herranz et al.3 reserve open reduction for irreducible fractures, cases of displaced Salter-Harris type III or IV epiphysiolysis or for incarcerated intraarticular fragments in which closed methods fail. In a series comparing open and closed reductions for displaced fractures,6 these same authors observed good results with noninvasive methods in 95% of cases. However, good results were only obtained in 52% of cases when conducting open reduction. These figures were similar to others in the published literature.
Lastly, the authors did not offer specific details regarding the postoperative management of these lesions: period of immobilisation, need for rehabilitative treatment and its effectiveness and duration, and the time and manner in which the osteosynthesis material was removed.
As a recommendation, we believe that a table of cases, including their classification, treatment, complications and mobility deficit, would bring added clarity to an otherwise excellent work.
Ethical responsibilitiesProtection of people and animalsThe authors declare that this investigation did not require experiments on humans or animals.
Confidentiality of dataThe authors declare that this study does not reflect any patient data.
Right to privacy and informed consentThe authors declare that this study does not reflect any patient data.
The authors wish to thank the Paediatric Traumatology and Orthopaedic Surgery Unit of Complexo Hospitalario Universitario A Coruña, for their teaching environment.
Please cite this article as: Domínguez Lorenzo D, et al. Fractura de la extremidad proximal de radio en niños. Rev Esp Cir Ortop Traumatol. 2012. 2013;57:83–4.
