Closed reduction and intramedullary pinning in the treatment of adult radial neck fractures: a case report

Closed reduction and intramedullary pinning (CIMP) in pediatric radial neck fractureswas first reported by Metaizeau in 1980 andsatisfactory results have been published several times. The current literature did not encounter any publication related to the implementation of Metaizeau method to adult patients. We applied Metaizeau technique to an adult radial neck fracture and we have achieved satisfactory results. As this case report is single case of this method applied to an adult, we decided to present this case.


Introduction
Radial neck fractures often occur as a result of falls onto an outstretched hand with elbow in extension [1]. After falling, radial head is compressed by humeral condyle with the effect of the physiological cubitus valgus while the load is transferred to the elbow through radial body. As a result of this, fracture develops in the more fragile subcapital area. This lesion may be accompanied by cartilage lesions in radial head or humeral condyles, lateral ligament injury, elbow dislocation and inferior radio-cubital separation [2].
Displaced and angled radial neck fractures are usually treated with open reduction and internal fixation method in adults [3].

Patient and observation
A 37-year-old male patient admitted to the emergency department with swelling of elbow, limitation of movement and pain after falling onto palm with elbow in extension. Patient's radiographs revealed displaced and angled radial neck fracture ( Figure 1). The angle between radial neck and long axis was measured as 52 degrees.
MRI was performed in order to evaluate possible accompanying ligament and soft tissue damage at elbow and its surrounding and chondral damage. No bony, soft tissue and chondral damage were detected on MRI. Only radial neck fracture was present in the patient. There upon surgery was planned. Closed reduction under general anesthesia was planned first. Reduction could not be achieved with twice closed reduction attempts; so closed reduction with intramedullary pinning was decided. One K-wire, which can be used as a joystick, was inserted into radial head under fluoroscopic controlin the transverse plane to achieve reduction indirectly K-wire was advanced into the proximal metaphyseal-diaphyseal region. Meantime joystick K-wire that was inserted to radial head in the transverse plane was removed. K-wire was advanced upwards, attached to metaphyseal residues of radial head and the wire was rotated 180° untilreduction was achieved. Mean while, the radial head was checked not to be drilled and cause chondral damage.
Thus radial head at the end of the wire was allowed to return to the interior by being dragged. K-wire was stopped by lateral humeral condyle, which serves as a tampon, while advancing toward radial head. In this way, excessive correction was prevented. As the patient was adult, a second intramedullary 1.8-mm K-wire was inserted to achieve a more stable fixation (Figure 3). Above elbow circular cast was applied for two weeks to complete elbow recovery.
Then active movements were started. No strenuous exercise was given to patients. Radiological control was performed at intervals of three weeks. Bone healing could be visualized radiographically at third month. Intramedullary pin was removed from the patient under local anesthesia in the outpatient clinic after 4 weeks ( Figure   4).Range of motion of the elbowjoint was 145 degrees for flexion, 90 degrees for supination and 90 degrees for pronation. Elbow joint was pain-free ( Figure 5).

Discussion
Radial head and neck fractures are the most common fractures of the elbow. They constitute 2-5% of all fractures [4]. Radial head and neck fractures constitute 33-25% of elbow fractures [3]. The treatment and outcome of radial head and neck fractures depend on the size of the fracture fragments, the integrity of the articular surface,intra-articular fragment and the angle between radial neck and radial shaft [5]. Pediatric radial neck fractures with less than 30 degrees angulation and without displacement can be treated conservatively. In this case, there is no need for any manipulation.
If fracture is angulated more than 30 degrees, manipulation under general anesthesiato achieve a better alignment is recommended.
In case of over sixty degrees or excessive displacement, surgery must be performed to ensure adequate reduction [6].

Competing interests
The authors declare no competing interests.