Open reduction; internal fixation

Radial head/neck and olecranon fractures are treated individually with internal fixation.

The following treatment combination is often used:

• Cerclage compression wire fixation of the olecranon fracture
• ESIN of the radial neck fracture

Note: “Cerclage compression wire fixation” was referred to as “Tension band fixation”. We now prefer the term “Cerclage compression wire fixation” because the tension band mechanism cannot be applied consistently to each component of the fracture fixation. An explanation of the limits of the Tension band mechanism/principle can be found here.

Whilst the child remains in bed, the elbow and forearm should be elevated on pillows to reduce swelling and pain.

Fixation of olecranon fractures with cerclage compression wiring is intrinsically stable and supplementary casting or splinting is therefore not required.

Ibuprofen and paracetamol should be administered regularly during the first 24-48 hours after surgery, with opiate analgesia for breakthrough pain.

Opiates should not be necessary after 48 hours and regular ibuprofen and paracetamol should be sufficient until 4-5 after injury or surgery.

The child should be examined if the level of pain is increasing or prolonged analgesia is needed.

The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.

Neurological and vascular examination should also be performed.

Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which is a late phenomenon.

See also the additional material on complications and postoperative infections.

Compartment syndrome is a possible early postoperative complication that may be difficult to diagnose in younger children.

The presence of full passive or active finger extension, without discomfort, excludes muscle compartment ischemia.

If there are signs of a compartment syndrome:

1. Remove or split constrictive dressings or casts.
2. Elevate the limb.
3. Encourage active finger movement.
4. Reexamine the child after 30 min.

If a definitive diagnosis of compartment syndrome is made, then a fasciotomy should be performed without delay.

Discharge from hospital follows local practice and is usually possible after 1-3 days.

The parent/carer should be taught how to assess the limb.

They should also be advised to return if there is increased pain or decreased range of finger movement.

It is important to provide parents with the following additional information:

• The warning signs of compartment syndrome, circulatory problems and neurological deterioration
• Hospital telephone number
• Information brochure

For the first few days, the elbow and forearm can be elevated on a pillow, until swelling decreases and comfort returns.

The arm can be placed in a sling for a few days until the patient is pain free. Many children are more comfortable without support.

Early movement of the elbow should be encouraged as soon as the patient is pain free.

Formal physiotherapy is normally not indicated, but children should have a sheet of exercises to stimulate mobilization. See also the additional material on elbow stiffness.

The first clinical and radiological follow-up is usually undertaken 2-3 weeks postoperatively.

At this point, the child should be able to move the elbow with only slight restriction.

AP and lateral x-rays are required.

See also the additional material on complications and healing times.

Cerclage wire removal is delayed until function has fully recovered and can be performed as a day case, under general anesthesia.

Usually the incision is smaller than for open reduction if the twisted wire ends lay close to the olecranon tip. Sometimes for cosmetic reasons, it is best to resect the whole scar and use cosmetic wound closure.

Make a small incision over the olecranon tip and extract the two K-wires with pliers.

Unwind or cut the twisted wire and pull it out of the bony track.

Close the wound in layers.

Nail removal is delayed until the fracture has modelled completely and can be performed as a day case, under general anesthesia.

The nail end may slip under tendons and nerves. This may irritate the soft tissues and make it difficult to palpate the nail tip.

Exposure of the nail end should be performed under direct vision with small retractors.

In most cases, a small bursa forms over the nail tip. Once this bursa is opened, the end of the nail can be seen.

The nail can be removed with the extraction pliers, or a similar clamp. A strong needle holder is also useful.