Fractures of the radial neck are very uncommon in children. The incidence of these fractures is only 1% of all pediatric fractures and accounts for 5%–10% of all fractures around the elbow in children ^[1]. The postulated mechanism is a fall with valgus loading of the elbow, leading to a fracture of the radial neck, which may be accompanied by radial head dislocation [2, 3] Jeffery  classified these fractures on the basis of the displacement of the epiphysis of the radial head: ^[4] Type 1 is the lateral inclination from 0 to 90° due to valgus overload. Type 2 is the rotation of the epiphysis by 90° posteriorly. This is the rarest form of injury that occurs on trying to reduce a subluxation or dislocation of the elbow. This type of injury occurs as a result of the capitellum striking the anterior edge of the radial head, causing the epiphysis of the radial head to rotate posteriorly. Jeffery has compared this mechanism of injury to that of a bottle opener. Newman described the third type, in which the epiphysis of the radial head is displaced anteriorly during posterior elbow dislocation. ^[5] The displacement, angulation, and comminution of the fracture, as well as the patient’s skeletal maturity, govern the modality of treatment for radial neck fractures. Non-displaced and uncomminuted fractures with an angle <30° and an intact periosteum can be managed by closed reduction and a cast [6, 7]. On reviewing the literature, we found only one case of closed reduction of a Type 2 Jeffery fracture. We report two cases of surgical treatment of Type 2 Jeffrey’s fracture with good clinical results and review the literature on this difficult-to-treat injury.

Case 1 involved a 13-year-old male (Patient 1) and Case 2 an 11-year-old male child (Patient 2) who presented to the emergency department after falling on their left and right sides, respectively. The patient complained of a painful and swollen elbow with restriction of movement. At the time of presentation, the elbow was not dislocated and distal neurovascular status was normal. Anteroposterior and lateral view radiographs showed Jeffery Type 2 lesions in both patients (Fig. 1a, 1b, Fig. 2 and 3). Both patients were managed similarly. Closed reduction of the fracture was tried under anesthesia but failed, so an open reduction was planned in the same setting. Using Kocher’s lateral approach, an incision was made starting from the lateral humeral condyle and curving to the radial head. The lateral collateral ligament was found to be normal. The radial head was stuck in the joint, and linear traction was given to distract the joint (Fig. 4). A skin hook and K-wire were used to joystick the radial head. After the radial head was reduced, it was found to be stable under fluoroscopy. We inserted a K-wire to achieve further stability (Fig. 5a, 5b and 6). The patient was immobilized in an above-elbow slab. Postoperatively, posterior interosseous nerve function was intact. At the 6-month follow-up, Patient 1 achieved full flexion with temporarily limited extension (10°) of the affected elbow, and Patient 2 regained full movement (Fig. 7a, b, 8a, 8b, 9a, 9b, 10a, 10b). However, supination and pronation of the forearm were complete in both patients. Both children were able to continue all daily activities and participate in sports with ease at 1 year.

Radial neck fractures are uncommon in children. Jeffery ^[4] studied 450 radial head fractures, of which he included 24 rare cases in his study. Twenty-two cases were Type 1 injuries and only two were Type 2 injuries. He suggested that Type 2 injuries are rare and are caused by a mechanism similar to that of the bottle opener. To diagnose a Jeffrey Type 2 fracture before the age of five, when ossification of the radial head has not occurred, is challenging. ^[6] Therefore, soft-tissue shadows such as a fat pad sign require additional investigation such as ultrasound, arthrography, or magnetic resonance imaging. The interposition of the capitellum under the head and above the radial metaphysis rather than a complete dislocation is also suggestive of a Jeffrey Type 2 mechanism. Capitellum interposition leads to the failure of closed manipulation methods and further to the inversion of the radial head. Therefore, open-reduction techniques are used by many authors [6, 8]. Jeffery Type 2 fractures can present in the emergency department in two ways [4, 9]. It may be having a posterior dislocation of the elbow initially, along with a fracture of the radial neck with capitellum interposition and closed reduction is not possible either spontaneously or by manipulation. It may also present as just the fracture of the radial neck, with 90° posterior tilt of the head, without dislocation or a spontaneously reduced dislocation ^[10] Both these stages of the same mechanism of injury need to be identified promptly. In a series of 22 cases by Chotel et al. ^[6] and two cases by Wood ^[8], nine patients had 180° inversion of the radial head with a radiographic picture of an apparently well-reduced fracture, and five cases were found to persist after reduction with a rotation posteriorly, of at least 90°. They used open reduction for the treatment. Two were fixed with Kirschner wires, one with absorbable sutures, and the remaining two were treated in a cast only. In another patient series, the inverted radial head was put in a cast or fixed upside down because the lesion could not be identified, resulting in worse outcomes [6, 8, 11]. The treatment remains controversial and the incidence of unsatisfactory results ranges from 15% to 33%. ^[2] Evans and Graham  ^[12] in their study of radial neck fractures showed that if the angulation of the fractured fragment is 60° or more, closed reduction is unsuccessful. In a study by Metaizeau et al. ^[13], poor results were also found to be related to the initial angle of inclination and associated forearm fractures, which require perfect reduction to prevent further periosteal, physeal, and vascular injuries. Most authors recommend immediate open reduction for these fractures. Chotel et al. performed a percutaneous reduction with Kirschner wire using an intact posterior periosteal hinge. He also recommended immediate open reduction if the closed method failed, and described the risk of damage to the articular surface with open reduction. ^[14] The closed reduction method involves extension and adduction of the affected elbow and digital pressure upward and inward at the most laterally prominent part of the elbow. Complications associated with this injury are avascular necrosis, growth arrest, or overgrowth of the radial head, and toppling of the radial head due to closed reduction maneuvers ^[15]. However, the radial head cannot be sacrificed in children and should be replaced for good results ^[6].

The Jeffery lesion must be recognized promptly with due suspicion kept in mind in case of such injuries. Manipulation is often not helpful and many authors prefer open reduction. This rare injury in childhood presents a pitfall for closed reduction and may result in permanent restriction of forearm rotation. Every posterior elbow dislocation in children should be suspected and carefully evaluated with high-quality radiographs for a radial neck injury and Jeffery Type 2 fracture to avoid poor outcomes and elbow stiffness.

Jeffery fracture needs to be recognized promptly on radiographs and accurate reduction is required for good results, and surgical treatment is more successful in these cases.