Minimally displaced radial head/neck fractures (Mason type-I, OTA types 21A2.2 and 21B2.1): are we "over treating" our patients?

Arthroscopic Percutaneous Fixation of Mason Type 2 Radial Head Fractures

Background

Management of radial head fractures around the elbow with open techniques can predispose to edema, postoperative pain, and adhesions. The resultant limitation in elbow range of motion negatively affects functional outcomes. Rehabilitation is then rendered a challenge in a joint with proneness to stiffness.

Hypothesis

Arthroscopic percutaneous fixation of Mason type 2 radial head fractures would provide satisfactory radiological and clinical outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 24 patients diagnosed with isolated Mason type 2 radial head fractures at a single institution between February 1, 2021, and December 31, 2021, received arthroscopic percutaneous fixation by headless screws. Functional evaluation included Mayo Elbow Performance Score and postoperative elbow range of motion measurements. Radiological evaluation was performed using elbow radiographs and computed tomography scans. Patients were evaluated for a minimum of 24 months.

Results

This study included 12 male and 12 female participants with a mean age of 37.29 ± 11.93 years. At the end of the follow-up period (mean, 27.75 months; range, 24-32 months), the mean elbow flexion was 140.17° ± 8.21° and the extension deficit was 4.17° ± 3.81°. The Mayo Elbow Performance Score revealed 21 patients with excellent results and 3 patients with good results. All patients returned to preinjury activities at a mean time of 3.1 months (range, 2-6 months) postoperatively. Union was reached in all patients at a mean time of 7.63 weeks (range, 6-10 weeks). No neurological complications or reoperations were reported at the end of the follow-up period.

Conclusion

Arthroscopic fixation was demonstrated to be a valid and valuable technique for managing isolated Mason type 2 radial head fractures. It allowed for accurate reduction without the need for soft tissue dissection, resulting in excellent clinical outcomes.

Biomechanical comparison of three fixation strategies for radial head fractures: a biomechanical study

Second-generation headless compression screws (HCSs) are commonly used for the fixation of small bones and articular fractures. However, there is a lack of biomechanical data regarding the application of such screws to radial head fractures. This study evaluated the mechanical properties of the fixation of radial head fractures using a single oblique HCS compared with those obtained using a standard locking radial head plate (LRHP) construct and a double cortical screw (DCS) construct. Radial synbone models were used for biomechanical tests of HCS, LRHP, and DCS constructs. All specimens were first cyclically loaded and then loaded to failure. The stiffness for the LRHP group was significantly higher than that for the other two groups, and that for the HCS group was significantly higher than that for the DCS group. The LRHP group had the greatest strength, followed by the HCS group and then the DCS group. The HCS construct demonstrated greater fixation strength than that of the commonly used cortical screws, although the plate group was the most stable. The present study revealed the feasibility of using a single oblique HCS, which has the advantages of being buried, requiring limited wound exposure, and having relatively easy operation, for treating simple radial head fractures.

Radiocapitellar and Ulnotrochlear Pressures Increase in a Radial Head Fracture Model: A Cadaveric Biomechanical Analysis

BACKGROUND

Changes in intra-articular pressure have not been previously described in relation to the management of radial head fractures. We hypothesized that pressure within the radiocapitellar and ulnotrochlear joints would increase with progressive radial head resection, mimicking a displaced radial head fracture, in a cadaveric model.

METHODS

Ten cadaveric specimens were tested. Intra-articular pressure sensors were used to measure pressure within the radiocapitellar and ulnotrochlear joints with the forearm in full supination. The elbow was loaded to 100 N in extension, 45° of flexion, and 90° of flexion under the following conditions: (1) intact radial head, (2) 20% radial head resection, (3) 40% radial head resection, and (4) 100% radial head resection.

RESULTS

The distribution of pressure between the radiocapitellar and ulnotrochlear joints did not change with sequential, partial resection of the radial head (radiocapitellar joint, between 48.92% and 53.79%; ulnotrochlear joint, between 46.21% and 51.08%). After 20% resection, radiocapitellar peak contact pressure (PCP) increased by 22% (from 1,410 to 1,721.5 kPa) and ulnotrochlear PCP increased by 36% (from 1,319 to 1,797.5 kPa). After 40% resection, radiocapitellar PCP increased by 123% (from 1,410 to 3,145 kPa; p = 0.0003) and ulnotrochlear PCP increased by 105% (from 1,319 to 2,702 kPa; p = 0.007). Ulnotrochlear PCP increased by a total of 159% after complete radial head resection (from 1,319 to 3,415.5 kPa; p = 0.003).

CONCLUSIONS

Pressures in the radiocapitellar and ulnotrochlear joints were equally distributed with an intact radial head and after partial resection. Radiocapitellar and ulnotrochlear pressures increased with increasing radial head resection, significantly exceeding 100% of normal after radial head resection of 40% of the anterolateral diameter.

LEVEL OF EVIDENCE

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

Low-value injury care in the adult orthopaedic trauma population: A systematic review

OBJECTIVES

Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices.

METHODS

We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes.

RESULTS

Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias.

CONCLUSION

In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Prevalence and Clinical Significance of Occult Fractures in the Extremities in Children

Objective: Diagnosis of occult fractures by initial plain radiographs remains challenging in children in the emergency room. This study was to assess the prevalence and distribution of occult fracture in children with acute extremities injuries (AEI) and clinical suspicion of fracture. Methods: We conducted a retrospective study to review the medical records of all pediatric patients with AEI in the orthopedic emergency room from January 1, 2017, to December 31, 2019. For patients with concerning history and physical examination but negative initial radiographs, we conducted the following three diagnostic strategies according to the choic of children's parents: immediate MRI scanning, [2] immediate CT scanning, or [3] empiric cast immobilization with orthopedic follow-up radiographs at 2 weeks post-injury (late radiographs). Prevalence and distribution of occult fracture were recorded. Results: A total of 43,560 pediatric patients meet the inclusion criteria. A total of 4,916 fractures of the extremities were confirmed by initial plain radiographs, and 550 occult fractures were confirmed by immediate MRI, immediate CT, or late radiographs. The prevalence of occult fracture in the extremities was 10.1% (550/5,466). Supracondylar fractures were the most prevalent (2,325/5,466, 42.5%) but had the lowest rate of occult fractures (117/2,325, 5.0%). The highest rate of occult fracture was distal epiphyseal fracture of the tibia and fibula (49/145, 33.8%), but these had a relatively lower prevalence of fractures (145/5,466, 2.65%). Conclusions: We should be aware of the relative high prevalence of occult fractures in the extremities in children, especially when the injured site is in the high incidence area of occult fracture such as ankle.

Evaluating the Utility of Follow-up Radiographs for Isolated Radial Head Fractures Undergoing Initial Nonoperative Treatment

OBJECTIVES

To evaluate the utility of follow-up radiographs in patients with isolated partial articular radial head fractures (OTA/AO 2R1B1 or 2R1B3).

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENTS

Adult patients (≥18 years) with isolated partial articular radial head fractures indicated for initial nonoperative treatment.

INTERVENTION

Analysis of elbow radiographs at initial presentation and at postinjury follow-up of 3-8 weeks.

VARIABLES MEASURED

Articular gap and step-off.

MAIN OUTCOME MEASURE

Radiographic articular displacement between initial and follow-up radiographs.

RESULTS

For 72 included patients, initial radiographs were obtained on average 2.6 days after injury and follow-up radiographs 33.7 days thereafter. Equivalence tests evaluating gap and step-off thresholds of <1 mm were both significant, indicating that the cohort displaced <1 mm for both parameters between initial and follow-up radiographs. No patients proceeded to surgical treatment following the repeat radiographs.

CONCLUSIONS

These fractures do not displace in the early postinjury period, as defined as a <1 mm of change in both intra-articular gap and step-off, as compared to initial radiographs. Routine follow-up radiographs for these injuries is a source of cost, but with limited utility in detecting interval displacement or leading to a change in management. Selective use of radiographs to evaluate specific clinical concerns may lead to cost savings.

LEVEL OF EVIDENCE

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

The value of elbow arthroscopy in diagnosing and treatment of radial head fractures

Background

Surgical treatment of radial head fractures is increasingly performed arthroscopically. These fractures often feature concomitant injuries to the elbow joint, which may be under-diagnosed in the radiological examinations. Little is known about the diagnostic value of arthroscopy, the treatment options that arise from arthroscopically assisted fracture fixation and clinical results. We hypothesized that arthroscopy can detect additional concomitant injuries and simultaneously expands the therapeutic options. Therefore aim of this study was to compare arthroscopic and radiologic findings, to assess the distinct arthroscopic procedures and to follow up on the clinical outcomes.

Methods

Twenty patients with radial head fractures were retrospectively included in two study centers. All patients underwent elbow arthroscopy due to at least one of the following suspected concomitant injuries: osteochondral lesions of the humeral capitellum, injuries of the collateral ligaments or loose joint bodies. Preoperative radiological findings were compared to arthroscopic findings. Afterwards, arthroscopic treatment options and clinical outcomes were assessed.

Results

Arthroscopic findings led to revision of the classified fracture type in 70% (p = 0.001) when compared to preoperative conventional radiographs (CR) and in 9% (p = 0.598) when compared to computed tomography (CT) or magnetic resonance imaging (MRI). Diagnosis of loose bodies was missed in 60% (p < 0.001) of the CR and in 18% (p = 0.269) of the CT/MRI scans. Osteochondral lesions were not identified in 94% (p < 0.001) of the CR and in 27% (p = 0.17) of the CT/MRI scans. Percutaneous screw fixation was performed in 65% and partial radial head resection in 10%. Arthroscopy revealed elbow instability in 35%, leading to lateral collateral ligament reconstruction. After a mean follow up of 41.4 ± 3.4 months functional outcome was excellent in all cases (DASH-Score 0.6 ± 0.8; MEPI-Score 98.5 ± 2.4; OES-Score 47.3 ± 1.1).

Conclusions

Elbow arthroscopy has a significant diagnostic value in radial head fractures when compared to standard radiological imaging. Although statistically not significant, arthroscopy also revealed concomitant injuries in patients that presented with an uneventful MRI/CT. Furthermore, all intraarticular findings could be treated arthroscopically allowing for excellent functional outcomes.

Trial registration

Institutional Review Board University of Munich (LMU), Trial Number 507–14.

Minimally Displaced, Isolated Radial Head and Neck Fractures Do Not Require Formal Physical Therapy: Results of a Prospective Randomized Trial

BACKGROUND

Nondisplaced and minimally displaced fractures of the radial head and neck are common injuries, yet the role of physical therapy (PT) in their treatment is unclear. The aim of this trial was to assess the need for formal PT following a simple fracture of the radial head or neck.

METHODS

Patients who had a nondisplaced or minimally displaced fracture of the radial head or neck and presented to 1 of 2 providers were enrolled prospectively between January 2014 and August 2016. Patients were randomized to receive outpatient PT or perform self-directed home exercise. The follow-up intervals were 6 weeks, 3 months, 6 months, and at least 1 year. The outcome measures were Disabilities of the Arm, Shoulder and Hand (DASH) scores; pain; time to clinical healing; and range of motion. Demographic data were analyzed using the Mann-Whitney U test and Fisher exact test. Independent-samples t tests were utilized to compare outcome measures.

RESULTS

Fifty-one patients were enrolled in the study. The average follow-up was 16.6 months. Twenty-five patients were randomized to a home-exercise cohort, and 26 patients were randomized to a formal-outpatient-PT cohort. There were no significant differences in demographics between cohorts. At 6 weeks, the home-exercise cohort had better function as indicated by a significantly lower mean DASH score compared with the PT cohort (p = 0.021). At 3 months, 6 months, and final follow-up, there were no significant differences between cohorts for any outcome measure.

CONCLUSIONS

Patients who performed home exercises after sustaining a nondisplaced or minimally displaced fracture of the radial head or neck demonstrated better early function at 6 weeks compared with patients who received formal PT. After 6 weeks, there were no significant differences in outcomes. These data suggest that prescribing PT for patients who have an isolated nondisplaced or minimally displaced fracture of the radial head or neck is not cost-effective and that instructing the patient to perform self-directed exercises will be followed by a similar outcome.

LEVEL OF EVIDENCE

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

Effect of different orientations of screw fixation for radial head fractures: a biomechanical comparison

Background

Screw fixation is a common method used for the treatment of Mason type II radial head fractures. The purpose of our study was to evaluate the mechanical properties of three different screw orientations used for fixation of Mason type II radial head fractures.

Methods

We sawed 24 medium-frequency fourth-generation Synbone radial bones to simulate unstable radial head fractures, which we then fixed with three different screw orientations. Implants were tested under axial load by the tension-torsion composite test system. If the implant-radial constructs did not fail after the axial load test, an axial failure load was added to the remaining constructs.

Results

The stiffness of the divergent group was the highest of the three orientations, and this group had statistically significant difference from the other two groups (p < 0.05). However, there was no statistically significant difference between the convergence group and the parallel group (p > 0.05). When the displacement reached 2 mm, the load of the divergent screw was still larger than the other two groups (p < 0.05).

Conclusions

The divergent screw orientation was the most stable and had the greatest control of Mason type II fractures of these three groups. Therefore, it can be better applied in clinical settings.

Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures

OBJECTIVE

To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures.

DESIGN

Retrospective review.

SETTING

Academic Level-I trauma hospital.

PATIENTS

One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures.

INTERVENTION

Analysis of mortise view radiographs at the time of initial evaluation and final follow-up.

VARIABLES MEASURED

(1) medial clear space; (2) Mueller-Nose Distance.

MAIN OUTCOME MEASURE

Change in radiographic measurements resulting in conversion to operative intervention.

RESULTS

Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47).

CONCLUSIONS

No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients.

LEVEL OF EVIDENCE

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

The yield of subsequent radiographs during nonoperative treatment of radial head and neck fractures

OBJECTIVES

After diagnosis of an isolated radial head or neck fracture and selection of nonoperative treatment, the value of subsequent radiographs is uncertain. This study tested the null hypothesis that there are no patient, surgeon, or injury factors associated with alteration in patient management based on subsequent radiographs. Secondarily, we tested the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics.

METHODS

We identified 415 adult patients with nonoperative treatment for isolated Broberg and Morrey modified Mason type 1 or 2 fractures at a large urban hospital system during years 2013 and 2014. Patient demographics, fracture characteristics, provider characteristics, and treatment details were obtained from a hospital database. Bivariate analysis and multivariable logistic regression modeling were performed.

RESULTS

One of 255 patients with 262 fractures that had subsequent radiographs (0.4%) was offered surgery but declined. In multivariable analysis, displaced fractures were more likely to have subsequent radiographs, but surgeon-to-surgeon variation was a far more influential factor.

CONCLUSIONS

Radiographs subsequent to diagnosis do not alter treatment of radial head fractures with no associated ligament injuries or fractures. The substantial surgeon-to-surgeon variation in the use of subsequent radiographs suggests that this may be a good focus for quality improvement initiatives.

Results of screw fixation in Mason type II radial head fractures

PURPOSE

The treatment of Mason type II fractures is controversial, and the aim of our study is to define the outcome of surgical treatment with screw fixation in the Mason type II radial head fracture.

METHODS

The study was carried out between 2011 and 2015, and included 14 men and 9 women, with isolated Mason type II radial head fractures which were treated operatively with screw fixation. Cases involving the additional ligament injury or fractures in other areas, or having a follow-up period which is greater than 11 months were excluded. The clinical and radiological results of our patients were assessed, using the Mayo Elbow Performance Score (MEPS).

RESULTS

The average MEPS was 95.86 points. 100 degree arcs of motion were attained by a total of 21 patients (91 %) for both flexion-extension and pronation-supination. Nevertheless, 2 patients (9 %) did not recover the 100 degree arcs for the flexion-extension.

CONCLUSION

Anatomical reduction of type II radial head fractures through open surgery and fixation with screws can have favorable results.

LEVEL OF EVIDENCE

Level IV, Retrospective design.

Current concepts in the management of radial head fractures

Fracture of the radial head is a common injury. Over the last decades, the radial head is increasingly recognized as an important stabilizer of the elbow. In order to maintain stability of the injured elbow, goals of treatment of radial head fractures have become more and more towards restoring function and stability of the elbow. As treatment strategies have changed over the years, with an increasing amount of literature on this subject, the purpose of this article was to provide an overview of current concepts of the management of radial head fractures.

Diagnosis of occult radial head and neck fracture in adults

The purpose of this study was to compare imaging modalities in the diagnosis of occult radial head and neck fractures and to assess the diagnostic value of ultrasound in diagnosing occult fractures of the radial head and neck. The study included 193 patients (101 male, 92 female) who were referred by trauma surgeons from January 2011 to July 2014 and presented with history of acute elbow trauma. The mean age of the patients was 37 years (range 15-82 years); 95 right and 98 left elbows were included in the study. Clinical examinations and standard radiograms were conducted. The anteroposterior radiographic view revealed no visible signs of fracture. The lateral radiographic view showed displacement of the anterior and posterior fat pads (fat pad sign) due to joint effusion, which is an indirect sign of fracture. In all 193 cases, ultrasound examination showed intraarticular effusion. In 176 cases (91%), there was effusion in both the olecranon bursa and the elbow joint. In 10 patients (5%), there was effusion only inside the elbow joint and in seven cases (4%) there was effusion only in the olecranon bursa. Cortical discontinuity (a direct sign of fracture) was clearly visualised in 157 cases (82%), in the radial neck in 108 cases and in the radial head in 49 cases. Ultrasound findings of fracture were questionable in 36 cases (18%). Step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified as auxiliary ultrasound findings (indirect signs of fracture). Standard radiograms were repeated after 7-10 days. In 184 cases (95%), there was a clearly visible fracture: a fracture of the radial neck in 111 cases (58%) and a fracture of non-displaced radial head in 73 cases (37%). In nine cases (5%), radial fracture was not confirmed on radiogram and MRI was performed in these patients. In conclusion, ultrasound imaging proved to be an effective method for diagnosing occult fractures of the radial head or neck when initial radiograms showed only intraarticular effusion. Ultrasound imaging is a cost-effective, easy-to-use and radiation-free method. For these reasons we recommend it for early detection of occult fracture in the emergency room.