Fractures of the radial head and neck treated with radial head excision

Surgical management of Mason type III radial head fractures

The evidence for optimal management of Mason type III fracture of radial head is unclear hence a systematic review of the published literature was performed in April 2012. This review includes 5 prospective studies (including 2 randomized trials), 4 retrospective studies and 9 case series. No study can be interpreted as level 1 evidence. Level 2 and 3 evidence provides some insight into the success of each modality through subjective and objective measurements of function and complication rates. Radial head replacement, open reduction internal fixation (ORIF) and radial head resection all provide satisfactory outcomes for patients in most cases. One treatment modality cannot be recommended over any other due to the small number of clinical trials and cases included in each study. Further randomized control trials are needed to evaluate the full benefits and shortcomings of each of the different surgical treatment modalities.

The Essex-Lopresti lesion

The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it’s pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.

Radial head replacement with the MoPyC pyrocarbon prosthesis

BACKGROUND

Radial head fractures often pose therapeutic dilemmas. We present the early results of patients who underwent radial head replacement with the MoPyC prosthesis (Bioprofile, Tornier, Saint-Ismier, France).

MATERIALS AND METHODS

We re-evaluated patients who underwent post-traumatic radial head resection and implantation of the MoPyC prosthesis due to pain and motion restriction. All patients underwent radiographic evaluation. Clinical evaluation was performed using the Broberg-Morrey and the Mayo Elbow Performance Score (MEPS) scales.

RESULTS

Thirty-two patients (20 men, 12 women; mean age, 54 years; 22 dominant upper limbs) were evaluated. Twenty had a comminuted radial head fracture (Mason IV, 15; Mason III, 5), 2 from radial head fracture malunion, and 10 had complex elbow injuries (comminuted radial head fractures with ligamentous ruptures with or without coronoid process fractures). Mean follow-up was 27 months (range, 21-46 months). The mean results at the latest follow-up were flexion-extension, 130° (range, 105°-150°); pronation, 74° (range, 60°-80°); and supination, 72° (range, 60°-80°). No laxity was evident during valgus and varus stress tests. Mean grip strength was 96% of the contralateral side. Broberg-Morrey scores were excellent in 33%, good in 44%, and fair in 23%. MEPS results were excellent in 80%, good in 17%, and fair in 3%. There were 6 cases of periprosthetic lucencies or osteolysis of the radius without any clinical signs of loosening.

CONCLUSIONS

Radial head replacement with the MoPyC pyrocarbon prosthesis (when performed in carefully selected patients) yields satisfactory results regarding range of motion and function of the elbow joint.

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation

BACKGROUND

  Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation.

METHODS

  Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow-up time was 21 months. Using serial X-rays and the Broberg-Morrey elbow score, the six acute fractures were evaluated radiologically and functionally.

RESULTS

  All six patients had good to excellent results using the Broberg-Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date.

DISCUSSION

  We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.

Open debridement and radiocapitellar replacement in primary and post-traumatic arthritis of the elbow: a multicenter study

BACKGROUND

Postmortem and clinical studies have shown an early and prevalent involvement of the radiohumeral joint in primary and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) prosthesis has recently been developed for the treatment of lateral elbow arthritis. However, few data have been published on LRE results.

MATERIALS AND METHODS

A prospective multicenter study was designed to assess LRE preliminary results. There were 20 patients (average age, 55 years). Preoperative diagnosis were primary osteoarthritis in 11 and post-traumatic osteoarthritis in 9. All patients underwent open debridement and LRE prosthesis. Patients were evaluated preoperatively and postoperatively with the Mayo Elbow Performance Score (MEPS), modified American Shoulder Elbow Surgeons (m-ASES) elbow assessment, and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH). Mean follow-up was 22.6 months.

RESULTS

At the last follow-up, the mean improvement of MEPS and m-ASES was 35 (P = .001) and 34 (P = .001) respectively; the average Quick DASH decreased by 29 (P = .001). Average range of motion was improved by 35° (P = .001). MEPI results were excellent in 12 patients, good in 2, and fair and poor in 3 each. Mild overstuffing was observed in 5 patients, and an implant malpositioning in 3. The implant survival rate was 100%.

CONCLUSION

LRE showed promising results in this prospective investigation. Most patients had an uneventful postoperative course and have shown a painless elbow joint, with satisfactory functional recovery at short-term follow-up. Further studies with longer follow-up are warranted.

The surgical treatment of isolated mason type 2 fractures of the radial head in adults: comparison between radial head resection and open reduction and internal fixation

OBJECTIVES

To compare the outcomes of two different surgical treatments for the management of isolated closed Mason Type 2 radial head fractures.

DESIGN

Retrospective study. The Student t test and McPearson chi-square test were used to evaluate whether there was a significance difference between the groups.

PATIENTS

Fifty-nine patients with isolated Mason Type 2 radial head fractures.

INTERVENTION

Twenty-four patients treated with radial head excision (Group I) and 35 treated with open reduction and internal fixation (Group II).

MAIN OUTCOME MEASUREMENTS

Clinical outcomes were assessed using the Broberg and Morrey functional rating scores and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Orthogonal radiographs were performed on both the elbow and the wrist; these were assessed for the presence of arthritis, heterotopic ossification, and the degree of proximal radial migration.

RESULTS

The length of postoperative follow-up was 157 ± 61.84 months (Group I) and 125 ± 39.09 months (Group II). The Broberg and Morrey functional rating score was 86.21 ± 6.10 points and 95.09 ± 4.78 points, respectively. The DASH score was 21.82 ± 6.01 points and 2.81 ± 2.73 points, respectively. Radiologically moderate or severe osteoarthritis was present in the elbows of nine patients in Group I and only two patients in Group II.

CONCLUSIONS

Patients with isolated Mason Type 2 radial head fractures treated by open reduction and internal fixation (Group II) had less residual pain, greater range of motion, and better strength than patients treated by radial head excision (Group I). Additionally, Group II had a lower incidence of severe posttraumatic arthritis, which contributed to improved DASH and Broberg and Morrey functional scores. These results support open reduction and internal fixation as the treatment of choice for these fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early radial head excision for displaced and comminuted radial head fractures: considerations and concerns at long-term follow-up

OBJECTIVES

The aim of this study is to retrospectively review the outcomes of patients with comminuted radial head fractures surgically treated with early radial head excision.

DESIGN

Retrospective follow-up study.

SETTING

University orthopaedic trauma center.

PATIENTS

Forty-two patients with unilateral, isolated, closed, displaced, or comminuted radial head fracture (Mason type 2-10, Type 3-32).

INTERVENTION

Early radial head excision.

MAIN OUTCOME MEASUREMENTS

Patients were clinically and radiographically evaluated at an average follow-up of 18 years. The uninjured contralateral limb was used as a comparison. Clinical evaluation was rated using the Broberg and Morrey system, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the visual analog scale (VAS) for pain.

RESULTS

At last follow-up, 36 patients had no complaints, whereas six admitted to occasional pain. The mean Broberg and Morrey score was 91.2 ± 6.3, and the mean Disabilities of the Arm, Shoulder and Hand score was 10.1 ± 8.8.

CONCLUSION

Early radial head excision represents a viable option in case of displaced and comminuted fractures. According to the results of this study, it demonstrated a high rate of good results and patient satisfaction, a quick recovery after surgery, and a low rate of complications with durable results at long-term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures

BACKGROUND

The purpose of this study is to analyze the results of treating unreconstructable acute radial head fractures associated with other elbow fractures and soft-tissue injuries with a pyrocarbon radial head prosthesis replacement, as well as repair of the associated injuries.

MATERIALS AND METHODS

Twenty-eight patients with Mason type III unreconstructable and unstable radial head fractures and with associated injuries (according to Hotchkiss classification modified by van Riet) were treated with a pyrocarbon radial head prosthesis replacement; repair of collateral ligaments and associated elbow fractures was also carried out. Patients were evaluated in accordance with the Mayo Elbow Performance Score, measuring pain, grip strength, range of motion, and stability, as well as radiographic images.

RESULTS

After a mean of 32 months postoperatively (range, 12-62 months), the mean Mayo Elbow Performance Score was 92 points. The result was considered excellent or good in 25 patients, with a high degree of satisfaction and functional restoration.

CONCLUSION

The results of treating Mason type III radial head fractures with additional elbow fractures and soft-tissue injuries with pyrocarbon radial head prostheses are satisfactory; nevertheless, long-term follow-up is still necessary.

The applicability of the Mayo Clinic congruent radial head plate: cadaveric study

In the last few years, several anatomical plates have been introduced to improve the results of ORIF in Mason Type II and III radial head fractures. However, no study analyzed whether currently used plates match adequately the profile of the proximal radius in the "safe zone". In the present investigation, we evaluate the congruence between the proximal radius and a currently used plate. Forty-four radial dried cadaveric bones were analyzed. The plate congruence was evaluated qualitatively and quantitatively. The congruence of the tested plate with the proximal radius was good in 27.3% of specimens, while it was moderate or poor in the remaining 43.2% and 29.5% of cases, respectively. The profile of the proximal radius in the "safe zone" shows substantial morphologic variations which should be taken into account to avoid a malunion of the proximal radius. A preoperative radiograph of the contralateral uninjured radius may be helpful in order to select the most appropriate plate profile in comminuted radial head and neck fractures.

The effect of haematoma aspiration on intra-articular pressure and pain relief following Mason I radial head fractures

BACKGROUND

The aspiration of the accompanying haematoma by Mason type I radial head fractures is advocated by several authors to achieve an analgesic effect. The purpose of this study was to investigate the effect of haematoma aspiration on intra-articular pressure and on pain relief after Mason I radial head fractures.

MATERIALS AND METHODS

A total of 16 patients (10 men and six women, age 23-47 years) with an isolated Mason I radial head fracture were subjected to haematoma paracentesis. Initially, intra-articular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. After haematoma aspiration, a new pressure measurement without moving the needle was performed. Pain before and after haematoma aspiration was evaluated by using an analogue 10-point pain scale.

RESULTS

Intra-articular elbow pressure prior to haematoma aspiration varied from 49 to 120 mmHg (median, 76.5 mmHg), while following aspiration, it ranged from 9 to 25 mmHg (median, 17 mmHg). The median quantity of the aspired blood was 2.75 ml (range, 0.5-8.5 ml). Patients reported a decrease in the visual analogue score (VAS) for pain from 5.5 (4-8) before to 2.5 (1-4) after aspiration. Decrease for both pressure and pain was statistically significant (p=0.005).

CONCLUSION

The formation of an intra-articular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intra-articular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief.

Proximal radial drift following radial head resection

BACKGROUND

Proximal radial migration is a well-documented phenomenon after radial head resection, but there have been no studies evaluating other planes of proximal radial stump drift after resection. The purpose of this study is to evaluate the anatomic position of the radial stump in relation to the capitellum after radial head resection, and determine the factors affecting this position and long-term functional outcomes.

METHODS

Thirteen patients who had undergone radial head resection for a variety of injury patterns were identified and evaluated at a mean of 72 months postoperative. Each patient underwent a physical exam and outcome questionnaire evaluation (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire, Mayo Elbow Performance Score [MEPS], and pain Visual Analog Scales [VAS] questionnaire). Anterior-posterior (AP) and lateral radiographs of the elbow were also performed.

RESULTS

The proximal radius resection length was an average of 18 mm (range, 11.1-31.9) compared to the nonoperative side. The proximal radial stump was determined to have significant migration both medially (P = .01) and posteriorly (P = .002) as compared to the opposite side as determined on the AP and lateral radiographs, respectively. Greater than 2 cm of proximal radial resection was associated with greater posterior drift (P = .03). Poorer MEPS were only correlated with an initial dislocation injury pattern (P = .02).

CONCLUSION

Radial head resection for fracture often leads to posterior and medial drift of the proximal radial stump, resulting in nonanatomic alignment with the capitellum. Increased resection greater than 2 cm resulted in larger amounts of drifting. Only a dislocation injury pattern was associated with worse functional outcomes.

Is a silastic radial head still a reasonable option?

BACKGROUND

The importance of the radial head to elbow function and stability is increasingly apparent. Although preservation of the native radial head is preferred, severely comminuted fractures may necessitate resection or arthroplasty. Silastic radial head arthroplasty has been condemned on the basis of several sporadic reports of silicone synovitis. However, problems of "overstuffing," cartilage wear, and motion loss are becoming apparent with metal prostheses, indicating this also is not an ideal solution. Thus, the choices remain controversial.

QUESTIONS/PURPOSES

We asked whether intact or reconstructed primary elbow stabilizers permit use of silastic radial head implants without fragmentation, failure, and silicone synovitis.

METHODS

We retrospectively reviewed 23 patients with unreconstructable radial head fractures who were treated with silastic radial head arthroplasty and concomitant repair and/or reconstruction of the medial ulnar collateral ligament and/or lateral ulnar collateral ligament. Analysis included range of motion, pain, stability, and radiographic assessments; Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; and Mayo Elbow Performance Score (MEPS). The minimum followup was 16 months (average, 69.6 months; range, 16-165 months).

RESULTS

At last followup, the mean elbow flexion was 145°, extension 11°, supination 80°, and pronation 83°. The mean MEPS score was 88.9. The mean DASH score was 11.8. There were eight reoperations, none resulting from failure of the radial head implants.

CONCLUSIONS

These results demonstrate silastic radial heads can be used with low complication rates and without evidence of synovitis when concomitant elbow ligament repair or reconstruction is performed.

LEVEL OF EVIDENCE

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

Neck osteotomy for malunion of neglected radial neck fractures in children: a report of 2 cases

BACKGROUND

Radial neck fractures are a common injury in children as a result of a fall on an extended and supinated outstretched hand.

METHODS

We present 2 cases of osteotomy of the neck of the radius performed in 2 children with neglected radial neck fractures.

RESULTS

Preoperatively, both patients complained of pain and severely reduced mobility of the elbow. Surgery was performed at 6 weeks and 3 months, respectively, after the initial injury and the 2 children were reviewed at 6 and 16 months follow-up. Osteotomies healed within the usual time and no avascular necrosis of the radial head, proximal radioulnar synostosis, or myositis ossificans were observed. The Mayo Elbow Performance Index Score improved significantly after the operation with the 2 patients rated as excellent.

CONCLUSIONS

In this small series, we present a novel technique of proximal osteotomy of the radius to correct this deformity in children.

LEVEL OF EVIDENCE

Case series, level IV evidence.

Resection arthroplasty for radial head fractures: Long-term follow-up

BACKGROUND

Complex radial head fractures treated by early resection arthroplasty yield good clinical results at long-term follow-up.

METHODS

Fifty-one radial head excisions were performed for the treatment of radial head fractures. Twenty-seven patients (20 men, 7 women) were retrospectively reviewed. The mean age was 37 (range, 18-61) and their fracture types according to the Mason classification were 5 type II, 16 type III, and 6 type IV. The mean follow-up period was 17 years (range, 10-24). Patients were clinically evaluated: Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH), visual analogue scale (VAS) for pain scores, and strength. Degenerative changes, proximal migration of the radius, and carrying angle were measured.

RESULTS

The overall outcome of the MEPS was 96.4 (range, 70-100), 22 patients (81%) achieving an excellent result, 4 patients a good (15%), and 1 patient a fair result (4%). The mean DASH score was 4.89, with slightly better results in the Mason II group than the Mason III and IV patients (P = .15). VAS averaged 0.48 (range, 0-10). Twenty-three patients (85%) reported no pain. The mean range of motion was from 5° to 135°. Pronation averaged 83° and supination averaged 79°. Strength was maintained in 24 cases (88%). In 24 patients, osteoarthritic changes were present without clinical relevance. Proximal migration of the radius was recorded in 7 cases. Carrying angle increased significantly by 7° (15° compared with 8°).

CONCLUSION

Radial head fractures treated by early resection arthroplasty offer satisfactory functional results in 96% of patients at long-term follow-up, in spite of the radiographic degenerative changes present in the great majority of cases.

Radial head arthroplasty

Radial head arthroplasty remains an encouraging treatment option for comminuted radial head fractures in an unstable elbow or forearm. This article discusses the surgical considerations related to radial head arthroplasty, including anatomy, indications, and surgical technique. Radial head arthroplasty outcomes literature and a review of current implant options are also discussed.

On-table reconstruction of comminuted fractures of the radial head

The most widely accepted treatment for comminuted fractures of the radial head is either the excision or open reduction and internal fixation. The purpose of the present study is to evaluate the value of an 'on-table' reconstruction technique in severely comminuted fractures of the radial head. In this study, two patients with a Mason type-III and four patients with a Mason type-IV radial-head fracture were treated with 'on-table' reconstruction and fixation using low-profile mini-plates. After a mean follow-up of 112 months (47-154 months), the mean elbow motion was 0-6-141 degrees extension flexion with 79 degrees of pronation and 70 degrees of supination. The mean Broberg and Morrey functional rating score was 97.0 points, the Mayo Elbow Performance Index was 99.2 points and the mean Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure score was 1.94 points. One patient had symptoms of degenerative changes, with a slight joint-space narrowing. There were no radiographic signs of devitalisation at final examination. Comminuted fractures of the radial head, which would otherwise require excision, can be successfully treated with an 'on-table' reconstruction technique.

Management of complex elbow instability

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.

Comminuted fractures of the radial head

BACKGROUND

There have been few reports on the long-term outcome of comminuted radial head fractures in adults.

METHOD

10 women and 9 men with a mean age of 45 (21-65) years when they sustained a comminuted fracture of the radial head were re-evaluated after 15-25 years. 6 patients had been nonoperatively (NO) treated while 13 had had a radial head excision. The uninjured elbow served as a control.

RESULTS

At follow-up, 11 patients (4 NO patients) rated their fractured elbow as being without deficits, 7 (1 NO) as being slightly impaired, and 1 (NO) as being severely impaired. Range of motion and elbow strength were not impaired, and even though there were more degenerative changes such as cysts, osteophytes, and sclerosis in the injured elbows by radiography, the prevalence of joint space reduction was not higher.

INTERPRETATION

Most patients with an isolated comminuted fracture of the radial head treated nonoperatively or with a radial head excision report no or only minor long-term complaints.

Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old

BACKGROUND

In the past, radial head resection was the surgical treatment of choice for radial head fractures that could not be internally fixed. More recently, radial head implant arthroplasty has gained popularity for the treatment of isolated radial head fractures. The purpose of the present study was to review the long-term results of radial head resection after radial head fractures not associated with elbow instability in patients younger than forty years of age.

METHODS

Twenty-six patients younger than forty years of age who had sustained an isolated fracture of the radial head (including six patients who had sustained a Mason type-II fracture and twenty who had sustained a Mason type-III fracture) that had been treated with primary radial head resection were reviewed retrospectively at a minimum of fifteen years (mean, twenty-five years). Outcomes were evaluated according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score. Radiographic assessment of osteoarthritic changes and the carrying angle was also performed.

RESULTS

Twenty-one patients (81%) had no elbow pain, three had mild pain, and two had moderate pain. The mean arc of motion was from 9 degrees to 139 degrees of flexion. All but one patient had a functional arc of motion. The mean pronation was 84 degrees, and the mean supination was 85 degrees. Nineteen elbows had normal strength in comparison with the unaffected side. The mean Mayo Elbow Performance Score was 95 points; the score was classified as good or excellent for twenty-four elbows (92%) and as fair for two. The mean Disabilities of the Arm, Shoulder and Hand score was 6 points. Three patients complained of wrist pain, which was mild in two patients and moderate in one. In four patients, some degree of elbow instability could be detected on physical examination. The mean carrying angle of the involved elbow was significantly greater than that of the uninjured elbow (21 degrees compared with 10 degrees). Radiographic changes of arthritis were considered mild in seventeen elbows and moderate in nine. We could not detect significant differences in functional outcome on the basis of the degree of radiographic change.

CONCLUSIONS

Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment.

Microarchitecture of the radial head and its changes in aging

Fractures of the radial head are common; however, it remains to be determined whether the radial head has to be considered as a typical location for fractures associated with osteoporosis. To investigate whether the human radial head shows structural changes during aging, we analyzed 30 left and 30 right human radial heads taken from 30 individuals. The specimens taken from the left side were analyzed by peripheral quantitative computed tomography (pQCT) and micro-CT. The specimens taken from the right elbow joint were analyzed by radiography and histomorphometry. In these specimens pQCT revealed a significant decrease of total and cortical bone mineral density (BMD(to) BMD(co)) with aging, regardless of sex. Histomorphometry revealed a significant reduction of cortical thickness (Ct.Th), bone volume per tissue volume (BV/TV), and trabecular thickness (Tb.Th) in male and female specimens. In this context, mean BV/TV and mean trabecular number (Tb.N) values were significantly lower and, accordingly, mean trabecular separation (Tb.Sp) was significantly higher in female samples. The presented study demonstrates that the radial head is a skeletal site where different age- and sex-related changes of the bone structure become manifest. These microarchitectural changes might contribute to the pathogenesis of radial head fractures, especially in aged female patients where trabecular parameters (BMD(tr) and Tb.Sp) change significantly for the worse compared to male patients.

Fractures of the radial head and neck

Fractures of the radial head and neck are common injuries that largely result from a fall onto an outstretched hand. They can range from simple injuries amenable to conservative management, to complex injuries requiring operative intervention. Undisplaced and minimally displaced fractures can usually be managed non-operatively with satisfactory results. Open reduction and internal fixation (ORIF) is generally indicated for significantly displaced or complex fractures, with radial head replacement reserved for cases refractory to ORIF. However, there remains debate regarding optimal treatment of complex radial head fractures and further evidence is required before definitive management guidelines can be produced.

Mason type IV fractures of the elbow

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° (sd 4) and extension by a mean of 9° (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space.

We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

Osteotomy of the head of the radius for partial articular malunion

Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy.

The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p < 0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications.

In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes.

Long-term outcome of displaced radial neck fractures in adulthood: 16-21 year follow-up of 5 patients treated with radial head excision

BACKGROUND

There have been no reports on the long-term outcome of radial neck Mason type IIIb fractures in adults.

METHODS

3 women and 2 men, aged 46 (22-69) years when they sustained a radial neck Mason type IIIb fracture, were evaluated after an average of 18 (16-21) years. All had been treated with radial head excision.

RESULTS

3 individuals had no subjective elbow complaints while 2 reported occasional weakness. None had severe elbow complaints. The maximum elbow-to-elbow difference in range of motion was a deficit of mean 10 degrees in extension in the injured elbow. Mean deficits in elbow flexion, forearm pronation, and forearm supination were below 5 degrees and the mean difference in cubitus valgus angle was only 2 degrees. There was no instability and no recurrent elbow dislocations. Radiographically, there were cysts, sclerosis, and osteophytes in all formerly injured elbows but none in the uninjured elbows. We found reduced joint space in 1 elbow that had been formerly injured.

INTERPRETATION

Mason type IIIb fracture in adults, treated with radial head excision, appears to have a favorable long-term outcome.

Radial head implant arthroplasty

Radial head arthroplasty has developed into a reliable procedure to address fractures of the radial head not amenable to reconstruction, particularly when associated with an unstable elbow or forearm. Good to excellent results can be anticipated when used for the correct indications and when care is taken to understand and address the concomitant injuries. This article will discuss the technique of radial head arthroplasty in the context of the injuries that often accompany radial head fractures.

Capitellar cartilage injuries concomitant with radial head fractures

PURPOSE

To evaluate the incidence and types of capitellar cartilage injuries associated with higher-grade radial head fractures.

METHODS

Fifty-one consecutive patients with operatively treated, unstable, displaced Mason type II to III radial head fractures were identified. Ten of 51 patients had capitellar cartilage injuries concomitant with these fractures. All cartilage injuries were identified at the time of surgery except in 1 patient whose injury was determined via computed tomography. There were 8 men and 2 women with an average age of 33 years (range, 24-39 years). Lesions were seen with direct inspection and recorded by location, size, and thickness.

RESULTS

The incidence of capitellar chondral lesions concomitant with operatively treated Mason type II to III radial head fractures appeared in 10 of 51 patients. The average size was 5 x 5 mm (range, 2 x 2 mm to 10 x 10 mm). Four patients had Mason type II and 6 had Mason type III radial head fractures. The average surface of the cartilage injury was 6 x 7 mm (range, 3 x 6 mm to 10 x 10 mm) for Mason type II fractures and 4 x 4 mm (range, 2 x 2 mm to 5 x 10 mm) for Mason type III fractures. Two Mason type III fractures had full-thickness cartilage lesions, and 4 Mason type III fractures had partial-thickness cartilage lesions. Two Mason type II fractures had full-thickness cartilage lesions and the other 2 had partial-thickness cartilage lesions.

CONCLUSIONS

Capitellar cartilage lesions frequently occurred concomitantly with higher-grade radial head fractures. The incidence of these lesions increased with greater severity of radial head fractures. Low-grade radial head fractures created higher-grade cartilage lesions as the intact radial head can cause more damage to the capitellum. Careful evaluation of the joint should be performed for these subtle injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Short-term to medium-term outcomes of cemented Vitallium radial head prostheses after early excision for radial head fractures

Studies show that the radial head is a significant stabilizer to valgus and varus stresses and external rotatory stability. We review the outcomes of patients who had radial head replacement in our institution. Six patients with Mason-Johnston type III or IV radial head fractures underwent radial head replacement and were evaluated by radiologic and clinical assessment. The American Shoulder and Elbow Surgeons score, DASH (Disabilities Arm, Shoulder and Hand) score, and Broberg and Morrey Performance Index were calculated. Average follow-up was 29.7 months. The Broberg and Morrey score was excellent for 1 patient, good for 3, fair for 1, and poor for 1. Complications included prosthetic loosening in 4 patients and 1 patient each with ulnar neuropathy, heterotrophic ossification, and wrist pain. Outcomes did not necessarily correlate with the severity of the initial injury or the eventual range of motion. Longer follow-up is required to see if the radiologic loosening will lead to clinical instability.

Stability of radial head and neck fractures: a biomechanical study of six fixation constructs with consideration of three locking plates

PURPOSE

Open reduction and internal fixation of radial neck fractures can lead to secondary loss of reduction and nonunion due to insufficient stability. Nevertheless, there are only a few biomechanical studies about the stability achieved by different osteosynthesis constructs.

METHODS

Forty-eight formalin-fixed, human proximal radii were divided into 6 groups according to their bone density (measured by dual-energy x-ray absorptiometry). A 2.7-mm gap osteotomy was performed to simulate an unstable radial neck fracture, which was fixed with 3 nonlocking implants: a 2.4-mm T plate, a 2.4-mm blade plate, and 2.0-mm crossed screws, and 3 locking plates: a 2.0-mm LCP T plate, a 2.0-mm 6x2 grid plate, and a 2.0-mm radial head plate. Implants were tested under axial (N/mm) and torsional (Ncm/ degrees ) loads with a servohydraulic materials testing machine.

RESULTS

The radial head plate was significantly stiffer than all other implants under axial as well as under torsional loads, with values of 36 N/mm and 13 Ncm/ degrees . The second-stiffest implant was the blade plate, with values of 20 N/mm and 6 Ncm/ degrees . The weakest implants were the 2.0-mm LCP, with values of 6 N/mm and 2 Ncm/ degrees , and the 2.0-mm crossed screws, with values of 18 N/mm and 2 Ncm/ degrees . The 2.4-mm T plate, with values of 14 N/mm and 4 Ncm/ degrees , and the 2.0-mm grid plate, with values of 8 N/mm and 4 Ncm/ degrees came to lie in the midfield.

CONCLUSIONS

The 2.0-mm angle-stable plates-depending on their design-allow fixation with comparable or even higher stability than the bulky 2.4-mm nonlocking implants and 2.0-mm crossed screws.

Reconstruction of a Mason type-III fracture of the radial head using four different fixation techniques

We have evaluated four different fixation techniques for the reconstruction of a standard Mason type-III fracture of the radial head in a sawbone model. The outcome measurements were the quality of the reduction, and stability.

A total of 96 fractures was created. Six surgeons were involved in the study and each reconstructed 16 fractures with 1.6 mm fine-threaded wires (Fragment Fixation System (FFS)), T-miniplates, 2 mm miniscrews and 2 mm Kirschner (K-) wires; four fractures being allocated to each method using a standard reconstruction procedure.

The quality of the reduction was measured after definitive fixation. Biomechanical testing was performed using a transverse plane shear load in two directions to the implants (parallel and perpendicular) with respect to ultimate failure load and displacement at 50 N.

A significantly better quality of reduction was achieved using the FFS wires (Tukey’s post hoc tests, p < 0.001) than with the other devices with a mean step in the articular surface and the radial neck of 1.04 mm (sd 0.96) for the FFS, 4.25 mm (sd 1.29) for the miniplates, 2.21 mm (sd 1.06) for the miniscrews and 2.54 mm (sd 0.98) for the K-wires. The quality of reduction was similar for K-wires and miniscrews, but poor for miniplates.

The ultimate failure load was similar for the FFS wires (parallel, 196.8 N (sd 46.8), perpendicular, 212.5 N (sd 25.6)), miniscrews (parallel, 211.8 N (sd 47.9), perpendicular, 208.0 N (sd 65.9)) and K-wires (parallel, 200.4 N (sd 54.5), perpendicular, 165.2 N (sd 37.9)), but significantly worse (Tukey’s post hoc tests, p < 0.001) for the miniplates (parallel, 101.6 N (sd 43.1), perpendicular, 122.7 N (sd 40.7)). There was a significant difference in the displacement at 50 N for the miniplate (parallel, 4.8 mm (sd 2.8), perpendicular, 4.8 mm (sd 1.7)) vs FFS (parallel, 2.1 mm (sd 0.8), perpendicular, 1.9 mm (sd 0.7)), miniscrews (parallel, 1.8 mm (sd 0.5), perpendicular, 2.3 mm (sd 0.8)) and K-wires (parallel, 2.2 mm (sd 1.8), perpendicular, 2.4 mm (sd 0.7; Tukey’s post hoc tests, p < 0.001)).

The fixation of a standard Mason type-III fracture in a sawbone model using the FFS system provides a better quality of reduction than that when using conventional techniques. There was a significantly better stability using FFS implants, miniscrews and K-wires than when using miniplates.

Arthroscopic management of Mason type 2 radial head fractures

During decennia the treatment of radial head fractures has been controversial. For Mason type II fractures, more recent studies agree that open reduction and internal fixation is the treatment of choice. It restores biomechanical properties, allows an early mobilisation of motion and results in better functional outcome compared with other treatments. In this study, we present the mid-to-long-term results of an arthroscopic technique for reduction and percutaneous fixation. Fourteen patients were available for follow-up with a final assessment performed at an average of 5 years 6 months (range 1 year to 11 years 3 months). Patients were evaluated for pain, motion and radiological findings. The average elbow score (Broberg and Morrey in J Bone Joint Surg Am 68:669-674, 1986) was 97.6 points (range 86-100), corresponding with 3 good and 11 excellent results. Two of the patients with only good results had associated cartilage lesions of the capitellum. Our results show that arthroscopically assisted reduction and internal fixation of type II radial head fractures is a valid technique with consistently good outcome. Although the technique is technically demanding, it allows more precise articular fracture reduction control, as well as better evaluation of associated lesions.

Fractures of the radial head and neck: current concepts in management

Despite advances in surgical techniques, fractures of the radial head are challenging to manage. Most radial head fractures can be managed nonsurgically, with emphasis on early motion to achieve good results. Treatment of more complex radial head fractures, however, especially those associated with elbow instability, remains controversial. The choice for such injury is between open reduction and internal fixation and arthroplasty. Modern implants and techniques have led to improvements in both of these technically demanding procedures. With proper care and understanding of the mechanism of elbow function, better long-term results can be achieved. The current literature suggests that the Mason classification guides choice of the best treatment modality to achieve optimal long-term function. Fracture complexity also should be used as a guide when selecting treatment, and proper surgical technique is critical for success.

Morphometric parameters of the radial neck: an anatomical study

INTRODUCTION

The purpose of this study was to describe the anatomy of the intramedullary canal of the radial neck for stem design of radial head prostheses.

METHODS

Radial neck measurement was performed from the proximal edge of the radial tuberosity to the distal border of the articular surface on 40 macerated proximal radii using X-rays and Optosil imprints of the intramedullary canal. Radial neck to shaft angle was measured under image intensification.

RESULTS

The neck length was 13.3 mm (range 8.0-20.0 mm) measured on X-rays and 13.5 mm (range 9.9-18.8 mm) on Optosil imprints. Concerning the neck's intramedullary canal we obtained a minimum diameter of 9.7 mm (range 6.3-16.4 mm) on X-ray. Corresponding Optosil imprints had a mean diameter of 11.6 mm (range 6.6-18.6 mm) at their proximal end, 10.5 mm (range 5.5-16.3 mm) in the middle and a minimum of 9.8 mm (range 6.0-16.9 mm) at the distal end. Differences between left and right sides were not significant between X-ray and Optosil imprints, nor between left X-ray and right imprints and vice versa at a P-level of 0.001. Radial neck to shaft angle was 167.8 degrees (range 160.5-178 degrees ) measured under image intensification at a rotation angle of 58.6 degrees (range 50-70 degrees ) supination.

CONCLUSION

Geometry of the radial neck's intramedullary canal has been described for stem design. The minimum diameter was seen at the distal end, just proximal to the radial tuberosity. A forearm rotation of 58.6 degrees to full supination should be considered during implantation of monopolar prostheses. The wide variety of lengths and diameters complicates standard prosthetic design, but ipsilateral and contralateral X-rays can be useful for preoperative stem size calculation.

Morphometric parameters of the radial head: an anatomical study

INTRODUCTION

Exact anatomical description of the proximal radius is imperative for the development of radial head prostheses. The purpose of this study was to measure the anatomical parameters of the radial head.

METHODS

Optosil imprints of 18 pairs of proximal radii fixed with formalin were taken. All possessed their native cartilage joint surface free of any arthritic defects. After being cut into 3 mm slices, the diameter of each slice was measured in steps of 30 degrees of rotation with the margo interosseous acting as a reference point.

RESULTS

Maximum radial head diameter was seen from the 0 to the 9 mm slice at a rotation of 30 degrees to full supination perpendicular to the proximal radioulnar joint. The diameter increased from the radiocapitular joint surface to the 6 mm slice, and then it decreased (P < 0.001). At the level of 6 mm the maximum radial head diameter was 24.13 mm (range 21.2-27.3 mm). The minimum diameter was seen perpendicular to the maximum; it also increased from the radiocapitular joint surface to the 6 mm slice and then decreased. There was a significant difference between the minimum and maximum diameter of each slice at a P-level of P < 0.001. Left and right sides were not significantly different at a P-level of 0.01.

CONCLUSION

Our data show that the radial head is neither round nor conical. It has a complex shape with an increasing size from the radiocapitular joint surface to the middle of the proximal radioulnar joint surface. No statistically significant differences could be observed between right and left radii.

Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years

BACKGROUND

Treatment options in radial head fractures of Mason types III and IV range from open reduction and internal fixation (ORIF) to radial head resection with or without prosthetic replacement.

PATIENTS

In a prospective study, the radiographic and clinical outcome was evaluated in 23 patients (age median 51 years) with 23 complex radial head fractures median 2 (1-4) years after ORIF using a new fixation device (FFS; Orthofix). 14 Mason type-III fractures with 2 concomitant olecranon fractures and 1 ulnar nerve lesion, and 11 type-IV fractures with 2 olecranon fractures and 2 fractures of the coronoid process were treated. 2 patients were lost to follow-up. In 7 cases of joint instability, an elbow fixator with motion capacity was applied after ORIF of the radial head.

RESULTS

No radial head resection was necessary. No secondary dislocations or nonunion occurred. The Morrey elbow score was excellent in 8 and good in 4 Mason type-III fractures and excellent in 5, good in 3, and fair in 3 Mason type-IV fractures.

INTERPRETATION

Reconstruction of comminuted radial head fractures can be performed with this device and radial head resection can be avoided.

Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review

INTRODUCTION

Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. As of yet, there is no consensus on optimal treatment strategy for Mason II-IV fractures. The aim of this study was to compare the results of conservative treatment with different surgical strategies for radial head fractures.

MATERIALS AND METHODS

Electronic databases from 1966 to 2004 were screened. Based on our inclusion criteria, 24 studies, describing 825 patients, were included.

RESULTS

For Mason type II fractures, residual pain was present in 42% of the conservatively treated of the patients compared to 32% of the surgically treated patients. Good/excellent results for Broberg score were 52 and 88%, respectively. For Mason type III and IV fractures, no conservatively treated patients were described.

CONCLUSIONS

There is insufficient evidence to be able to draw definitive conclusions on optimal treatment of type II-IV radial head fractures. Evidence is currently limited to a maximum level II evidence. There is great need for sufficiently powered randomized controlled trials.

Displaced fractures of the neck of the radius in adults

We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space.

Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.

[Therapy for radial head fractures]

The treatment of radial head fractures is challenging for the trauma surgeon due to the complex functional anatomy of the elbow. Satisfactory results can only be achieved if the function and stability of the humeroradial joint are entirely restored. Thus, depending on the fracture type, ranging from non-displaced Mason type I fractures to comminuted Mason type III fractures, an individual treatment concept has to be established. Treatment protocols range from conservative treatment with short-term cast immobilization to open reduction and internal fixation according to AO-principles or to the implantation of a radial head prosthesis. In case of severe comminution of the radial head, resection arthroplasty might be indicated.

Radial head arthroplasty

Radial head fractures are a particularly common yet challenging problem facing orthopedic surgeons today. Over the years multiple treatment modalities have been used including conservative management, open reduction and internal fixation, head excision, and radial head arthroplasty. The clinical outcome studies of metallic radial head arthroplasty systems indicate that head replacement is a reasonable option to offer patients with comminuted radial head fractures and complex elbow trauma. Overall the results for this procedure are quite encouraging and appear durable given the severity of the elbow injuries treated with radial head arthroplasty. This article discusses the history, classification, and treatments of radial head fractures. A description of the stabilizing structures of the elbow as they relate to radial head fractures also is included. Surgical considerations that relate to radial head arthroplasty are detailed and encompass arthroplasty indications, surgical technique, postoperative rehabilitation, and complications. Finally the arthroplasty outcomes literature and a review of current implant options also are discussed.