Fractures of the radial head

Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal?

BACKGROUND

When treating complex radial head fractures, important goals include prevention of elbow or forearm instability, with restoration of radiocapitellar contact essential. When open reduction and internal fixation cannot achieve this, radial head replacement is routinely employed, but the frequency of and risk factors for prosthesis revision or removal are not well defined.

QUESTIONS/PURPOSES

We determined (1) the frequency of prosthesis revision or removal after radial head replacement for acute complex unstable radial head fractures, (2) risk factors for revision or removal, and (3) functional outcomes after radial head replacement.

METHODS

We identified from our prospective trauma database all patients over a 16-year period managed acutely for unstable complex radial head fractures with primary radial head replacement. Of the 119 patients identified, 105 (88%) met our inclusion criteria; mean age was 50 years (range, 16-93 years) and 57 (54%) were female. All implants were uncemented monopolar prostheses, of which 86% were metallic and 14% silastic. We recorded further procedures for prosthesis revision or removal for any cause, with a minimum followup of 1 year (n = 105). Cox regression analysis was used to determine independent factors associated with revision or removal when controlling for baseline patient (age, sex, comorbidities) and fracture (location, classification, associated injury) characteristics. Short-term functional outcomes (Broberg and Morrey score, ROM) were determined from retrospective review of clinic followup (n = 74), with a minimum followup of 3 months.

RESULTS

Twenty-nine patients (28%) underwent prosthesis revision (n = 3) or removal (n = 26) at a mean of 6.7 years (range, 1.8-18 years) after injury. Independent risk factors for removal or revision were silastic implant type and lower age. At a mean of 1.1 years (range, 0.3-5.5 years) after surgery, mean Broberg and Morrey score was 80 out of 100 (range, 40-99). Mean elbow flexion was 133° (range, 90°-159°; SD, 13°), extension 21° (range, 0°-80°; SD, 17°), flexion arc 112° (range, 10°-140°; SD, 25°), pronation 84° (range, 0°-90°; SD, 18°), supination 73° (range, 0°-90°; SD, 28°), and forearm rotation arc 156° (range, 0°-180°; SD, 38°).

CONCLUSIONS

We demonstrated a high removal or revision rate after radial head replacement for acute unstable complex fractures, with lower age and silastic implants independent risk factors. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. Future work should focus on long-term patient-reported outcomes after these injuries.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance

OBJECTIVES

Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance.

DESIGN

A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change.

SETTING

An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system.

PARTICIPANTS

2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol.

OUTCOME MEASURES

Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance.

RESULTS

Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment.

CONCLUSIONS

This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

A new "virtual" patient pathway for the management of radial head and neck fractures

BACKGROUND

Minimally displaced radial head and neck fractures are common and the outcome with conservative treatment is generally excellent. A new protocol was introduced to manage patients with these suspected fractures at a major urban hospital. Simple, undisplaced fractures without other associated injuries or instability were discharged with structured advice but no further face-to-face review. Patients with more complex injuries were reviewed at a "virtual clinic." The aim of this study was to examine the outcome of this process in terms of patient flow, satisfaction, reattendance, and reintervention.

METHODS

The 202 eligible patients, who presented during a 1-year period from October 2011 to October 2012, were identified retrospectively from a prospectively collected administrative database. Mason type III and IV fractures were excluded. A questionnaire was administered by mail or phone call to assess satisfaction with the process, information received, and function.

RESULTS

Twenty (10%) patients required face-to-face review in a clinic, whereas 182 (90%) were managed with direct discharge; 155 patients responded to the survey (77%). The overall satisfaction rate was 96% in the suspected fracture group and 87% in the definite fracture group (P = .08). Satisfaction with the information provided was 95%. Two (1%) required late surgical intervention.

CONCLUSION

In this study, patients with suspected Mason I or II fractures were managed with limited face-to-face follow-up with high satisfaction rates. The reintervention rate was extremely low. This process has significant benefits to patients, who have fewer hospital visits, and to orthopaedic departments, which have more time to devote to complex cases.

Management of Mason type 1 radial head fractures: a regional survey and a review of literature

INTRODUCTION

Despite being the most common fracture around the elbow, the management of Mason type 1 radial head fractures lacks a clear protocol in literature. The aims of this study were to assess our practice of managing this injury and to create guidance for the management of these fractures based on literature review.

METHODS

We designed a survey investigating the practice of orthopaedic surgeons in the management of Mason type 1 fracture. The literature review was carried out looking for the best practice guidelines.

RESULTS

Forty-nine surgeons (out of 56) responded, and mean duration of immobilisation was 11.69 days with the collar and cuff sling as the preferred method. 65.3% offered physiotherapy service to their patients. 20.4% recommended plain radiographic imaging follow-up. Mean duration of follow-up was 43.9 days. Decision to discharge the patient was mostly (77.6%) dependent on clinical improvement at time of last examination. 4.1% of treatment decisions were evidence based.

CONCLUSION

We observed a wide variation in the management of this common injury. Based on the current literature, the best protocol for the management of type 1 radial head fractures should be joint aspiration, followed by immobilisation in a broad arm sling for 2 days. At the first outpatient visit, assessment of the collateral stability should be performed. Patients with stable elbows should be encouraged to stretch these beyond the painful range. Patients can be discharged at this stage with an advice to come back for a clinical and radiographic assessment if there is no improvement at 6 weeks.

Surgical interventions for treating radial head fractures in adults

BACKGROUND

Radial head fractures are the most common type of elbow fracture and can severely affect the function of the elbow. There is uncertainty and controversy about when surgery is indicated as well as what type of surgical intervention is best.

OBJECTIVES

To assess the effects of surgical interventions for treating radial head fractures in adults. We aimed to compare surgical versus non-surgical treatment, and different methods of surgical intervention.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library; 2012 Issue 4), MEDLINE (1946 to May 2012), EMBASE (1980 to 2012 Week 19) and trial registers (November 2011). No language restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials evaluating surgical interventions for treating radial head fractures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias and extracted data. Where appropriate, results were pooled.

MAIN RESULTS

We included three randomised controlled trials, involving a total of 251 participants. All three trials were at high risk of performance bias reflecting the fact that surgeons could not be blinded. One trial was at low risk of selection bias but was undermined by a high attrition bias, in part resulting from post-randomisation exclusions. There were incomplete details of methodology for the other two trials, which usually resulted in unclear risk of bias judgements.Two trials compared radial head replacement with open reduction and internal fixation (ORIF) for treating Mason type III radial head fractures. The trial authors reported outcomes at a mean of 2.8 years and 15 months respectively. There were significant differences between the two groups in favour of radial head replacement in the Broberg and Morrey elbow scores (92.1 versus 72.4, mean difference (MD) 19.70; 95% confidence interval (CI) 15.64 to 23.76; one trial, 45 participants), excellent or good Broberg and Morrey elbow scores (33/36 versus 16/31, risk ratio (RR) 1.88; 95% CI 1.27 to 2.77; two trials), and overall adverse events (6/36 versus 15/31, RR 0.33; 95% CI 0.14 to 0.77; two trials). No statistically significant difference was found between the two groups in any of the reported individual adverse events.One trial compared biodegradable pins with standard metal screws in treating radial head fractures of AO-classification 21 B2. The two types of fixation devices yielded similar results, with no significant between-group differences in the Broberg and Morrey scores (93.3 versus 90.9, MD 2.40; 95% CI -0.10 to 4.90), excellent or good Broberg and Morrey elbow scores (72/74 versus 56/61, RR 1.06; 95% CI 0.97 to 1.15), and adverse events (13/82 versus 16/82, RR 0.81; 95% CI 0.42 to 1.58) at two-year follow-up.

AUTHORS' CONCLUSIONS

Only tentative conclusions can be drawn from the available evidence in this review. Compared with ORIF, there was some evidence that radial head replacement had better elbow function and fewer adverse events for Mason type III radial head fractures in the short term. However, the evidence is of low quality and it is unknown whether these results would apply in the longer term or more generally. Using biodegradable implants may be as good as metallic implants for fixation of some usually more stable fractures but more evidence is needed to confirm this. There is a need for good quality evidence for addressing the areas of uncertainty for the surgical treatment of radial head fractures.