Fractures of the radial head

Partial articular fractures of the radial head: How to understand them using computed tomography

BACKGROUND

The optimal treatment for different types of displaced partial articular radial head fractures is still debatable. Fractures involving the articulating portion of the radial head can be defined also as bi-articular and are often underestimated. Moreover, the complete loss of periosteal contact between fracture fragments is a marker of instability. Available classifications do not emphasize these aspects. The purpose of the present study is to describe two assessment methods to identify fractures involving the articulating portion of the radial head and complete loss of periosteal contact with the help of 2D-3D CT scan. The second purpose is to propose a classification of the displaced partial articular radial head fractures basing on these two assessment methods.

HYPOTHESIS

We hypothesize that the proposed classification is reliable.

PATIENTS AND METHODS

By observing the position of the bicipital tuberosity with respect to the ulna in reference to the coronal plane in the 3D-CT scan and by observing the location of the fracture fragment in the 2D axial scan, it is possible to understand if a displaced partial articular fracture involves the articulating portion of the radial head. Also, it is possible to understand the presence or absence of a complete loss of periosteal contact between the two fracture fragments by observing the coronal and sagittal 2D-CT scans. We identified 20 displaced partial articular radial head fractures on a series of 149 patients with radial head fractures. Following the above-described assessment methods, these 20 fractures were classified in three subgroups. Also, seven evaluators were asked to use these assessment methods to classify these 20 fractures in the three subgroups, in order to evaluate inter- and intra-observer agreement.

RESULTS

Eight fractures involved the non-articulating portion of the radial head with complete loss of periosteal contact, eight involved the non-articulating portion of the radial head without complete loss of periosteal contact, and four involved the articulating portion of the radial head with or without complete loss of periosteal contact. The kappa for intra-observer reliability ranged from 0.46 to 0.84. The average kappa for inter-observer reliability was 0.570 (range: 0.526 to 0.676). The Kendall's coefficient for inter-observer concordance was 0.673.

DISCUSSION

Prognostically, displaced partial fractures of the articulating portion of the radial head could differ from the other types, regardless of whether or not there is a complete loss of periosteal contact. Underestimating this fracture pattern can lead to poor results due to risk of forearm rotation blockage. Moreover, underestimating complete loss of periosteal contact in displaced partial fractures of the non-articulating portion of the radial head could lead to poor results. The described evaluation methods have moderate reliability, but can represent, along with other described methods, a good starting point to better understand and treat these insidious fractures.

LEVEL OF EVIDENCE

III; retrospective study.

Open Reduction Internal Fixation of Simple Versus Comminuted Radial Head Fractures: Comparison of Clinical Outcomes

PURPOSE

Current teaching suggests that modified Mason type III and IV fractures of the radial head involving more than 3 fragments should be treated with radial head arthroplasty. The purpose of this study was to compare the outcome of simple (2 or fewer intra-articular pieces) versus comminuted (3 or more intra-articular pieces) radial head fractures treated with open reduction internal fixation (ORIF).

METHODS

This was a retrospective review of 35 patients with modified Mason type III and IV fractures treated with ORIF. For the purpose of our study, simple fractures were defined as having 2 or fewer intra-articular fragments. Comminuted fractures were defined as having 3 or more intra-articular fragments. The primary outcomes were Broberg and Morrey rating system and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. Reoperation rates and complications were also noted.

RESULTS

Thirty-five patients were evaluated, with a mean follow-up of 39.3 months. Thirteen patients had radial head fractures consisting of 2 or fewer intra-articular fragments. Twenty-two patients had radial head fractures consisting of 3 or more intra-articular fragments. Ages and follow-up times were similar in the 2 groups. Similar QuickDASH and Broberg and Morrey scores were seen when evaluating subgroups of 2, 3, and 4 fragment fractures. One patient from each group underwent revision surgery for symptomatic hardware.

CONCLUSIONS

In our series, we found similar clinical outcome scores and reoperation rates between simple and comminuted radial head fractures treated with ORIF. Fractures with more than 3 intra-articular fragments can be considered for ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Early aseptic loosening of a press-fit radial head prosthesis - A case series of 6 patients

OBJECTIVE

Radial head arthroplasty (RHA) is the principal treatment option for comminuted radial head (RH) fractures. Here, we present six cases of failed RHA using a modular monopolar press-fit RHA that was subsequently withdrawn from the market because it was associated with a high incidence of loosening.

METHODS

We retrospectively collected data from six patients who had received Radial Head Prothesis System^TM at our centre between July 2015 and June 2016. The average follow-up was 40 months.

RESULTS

Aseptic loosening of the stem affected five (83%) of the six RHA. Four of these were symptomatic and RHA removal was performed. For these patients, the pain subsided and their elbow range of motion (ROM) improved.

CONCLUSION

While the ideal design for an RHA is still debatable, RHA is an efficient treatment option that restores elbow stability and function after a comminuted RH fracture. Importantly, removal of the prosthesis is an effective remedy following RHA associated elbow pain and decreased ROM.

A modified trans-anconeus approach to facilitate fixation of a posterior radial head fracture: a cadaveric feasibility study

Fixation of radial head fracture with minimally invasive posterior approach remains a significant challenge. The aim of this study was to determine the feasibility of trans-anconeus posterior elbow approach and to observe lateral ulnar collateral ligament (LUCL) in extended elbows. This cadaveric study was performed in twenty upper limbs of fresh fixed adult male cadavers. An oblique incision was made in the middle segment of anconeus until the lateral ligament complex and the joint capsule had been revealed. A deep dissection was explored to observe the anatomical relationship of the LUCL to the anconeus. Measurements of the LUCL were recorded while the elbow was fully extended. The mean distance between the edge of the radial head and the proximal insertion of the LUCL was 13.3 mm (11.5-16.2 mm); the mean distance between the edge of the radial head and the distal insertion of the LUCL was 20.9 mm (19.2-23.4 mm); the distance between the edge of the radial head and the distal edge of the annular ligament was 11.2 mm (8.22-11.7 mm). By estimate correlation of the previous measurements, the direct and accessible way to expose the posterolateral articular capsule of the elbow joint was through a window in medial 2/3 of the middle segment of anconeus muscle. These trans-anconeus approach is useful. It provides good visualization, facilitates applying the implants, and lessens the risk of radial nerve injury. Awareness of the anatomy is mandatory to avoid injury of LUCL.

Fractures of the limbs: basic concepts for the emergency department

Traumatic injuries of the limbs are very common and account for a large number of imaging examinations, especially in emergency departments. These injuries can often be resolved if they are recognized and treated appropriately. Their diagnosis requires a complete clinical assessment and the correct interpretation of the appropriate imaging tests. Radiologists play an important role, especially in diagnosing lesions that can go undetected. To this end, radiologists need to know the normal anatomy and its variants, the mechanisms of injury, and the indications for different imaging tests, among which plain-film X-rays are the main technique for the initial evaluation. This article aims to review the relevant characteristics of limb fractures in adults and of lesions that can be associated with these fractures, as well as how to describe them to ensure appropriate clinical management.

Virtual fracture clinics: be vigilant for the ligamentous elbow injury

The Covid-19 pandemic encouraged remote healthcare and led to dependency on virtual fracture clinics (VFC). VFC are orthopaedic consultant-led clinics where cases are reviewed virtually following referral by emergency department clinicians. Success is contingent on a comprehensive initial history and examination. This pathway has high patient satisfaction rates and cost-saving benefits. However, clinicians must be vigilant for high-energy mechanisms or examination findings suggestive of greater underlying injury. In this case, VFC missed a rare ipsilateral annular ligament injury in a 15-year old with an undisplaced radial neck fracture, following a fall from a horse. This led to radial head dislocation and delayed surgical repair. Untreated, radial head dislocations lead to pain and reduced range of movement. Despite the rarity of this injury pattern, face-to-face orthopaedic examination would have raised concern for significant ligamentous injury. A high-energy mechanism of injury mandates face-to-face senior orthopaedic review to avoid missing serious concomitant injury.

Non-union of Conservatively Managed Radial Neck Fractures in Adults: A Systematic Review

Non-union of radial neck fractures in adults is rare. This review aims to identify factors contributing to the non-union of undisplaced radial neck fractures and assess treatment options and outcomes.

Systematic searches of English articles in PubMed, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were undertaken in September 2021 according to the PRISMA guidelines. The search terms were (fracture) AND (radial neck) AND (non-union OR non-union). Eligible studies reported adults who experienced undisplaced radial neck fractures that went on to non-union without prior surgical intervention.

Fifteen case reports/series were included involving 29 non-unions in 27 patients. The largest study included eight patients. There were 11 males (38%) and 18 females (62%). The average age at the time of the presentation was 55 (range: 29-73). In 13 cases, comorbidities were commented on, including association with smoking in 4 (30%), diabetes in 3 (23%), and excessive alcohol in 5 (38%). The average time from injury to a diagnosis of non-union was 6.7 (range: 2-24) months. The average time of follow-up was 28.6 (range:6-84) months. Eight minimally symptomatic or asymptomatic non-unions were managed conservatively without complication. Seventeen symptomatic non-unions were managed operatively. Treatments included open fixation (1), open fixation with bone grafting (1), bone grafting alone (2), arthroplasty (2), radial head resection (2), and unknown surgery (7). Patients managed operatively achieved full or near-full, asymptomatic range of motion at an average of 5.4 (3-12) months postoperatively.

Non-union is a rare complication of an adult radial neck fracture, and risk factors may include female gender, smoking, diabetes, and chronic alcohol. Persistence with non-operative management is encouraged as it can resolve symptoms with or without a radiographic union. Operative options range from bone grafting +/- fixation to arthroplasty. On average, the time from injury to the decision made to operate is 6.5 (3-12) months. A comfortable, functional range of motion is possible with all treatment strategies.

Radial head fractures: a quantitative analysis

Several classification systems for radial head fractures discuss the number of fragments and their displacement, but not the exact location. This study aimed to evaluate the location of the radial head fracture fragments and the influence of the Mason type on the size of the fracture fragment. Forty-one radial head fractures (31 Mason type I and 10 type II) with an elliptical radial head were included in this retrospective study and 3D reconstructed. First, the fragments were repositioned to their original location. Next, the orientation of the scanned forearm was evaluated using the position of the longest axis relative to the proximal radio-ulnar joint, and all radial heads were rotated to the neutral rotation. The radial head was divided into 4 quadrants (anteromedial, anterolateral, posteromedial, and posterolateral). The location of the fracture line in correlation with these 4 quadrants was evaluated. All fracture fragments were located in the anteromedial quadrant. Thirty-eight (93%) were located in the anterolateral quadrant. The posterolateral quadrant was involved in 32%. At last, the average fracture fragment size was evaluated according to the Mason classification. A significant difference was found in the average fracture fragment size between Mason type I (38% of the radial head surface) and type II (48% of the radial head surface). It was concluded that there is an important involvement of the anterior quadrants of the fracture. The mean size of the fracture is significantly larger in Mason type II compared to type I.

Anatomic Radial Head Arthroplasty: The Importance of Implant Angle

PURPOSE

Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures. The aim of this study was to characterize the risk of RHA failure with respect to the stem angle in anatomic RHA design.

METHODS

A retrospective review of patients who underwent anatomic RHA for acute fractures between 2006 and 2019 at 2 academic centers was conducted. Initial postoperative elbow radiographs were reviewed to measure RSA on the anterior-posterior and lateral views. Radiolucency, stress shielding, and radiocapitellar arthritis were also evaluated. Implant failure was defined as prosthesis removal or revision.

RESULTS

Implant failure was associated with significantly larger lateral RSA than that in intact implants. Increasing stem shaft angle on a lateral radiograph was associated with decreased implant survival. Radiolucency, stress shielding, and radiocapitellar arthritis were similar between the 2 groups.

CONCLUSIONS

Anatomic radial head implants are commonly used; however, the importance of prosthesis positioning, specifically that of the stem within the proximal radius, remains understudied. Higher RSA is associated with the risk of implant failure and need for revision.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Regional differences in the three-dimensional bone microstructure of the radial head: implications for observed fracture patterns

INTRODUCTION

A characterization of the internal bone microstructure of the radial head could provide a better understanding of commonly occurring fracture patterns frequently involving the (antero)lateral quadrant, for which a clear explanation is still lacking. The aim of this study is to describe the radial head bone microstructure using micro-computed tomography (micro-CT) and to relate it to gross morphology, function and possible fracture patterns.

MATERIALS AND METHODS

Dry cadaveric human radii were scanned by micro-CT (17 μm/pixel, isotropic). The trabecular bone microstructure was quantified on axial image stacks in four quadrants: the anterolateral (AL), posterolateral (PL), posteromedial (PM) and anteromedial (AM) quadrant.

RESULTS

The AL and PL quadrants displayed the significantly lowest bone volume fraction and trabecular number (BV/TV range 12.3-25.1%, Tb.N range 0.73-1.16 mm^-1) and highest trabecular separation (Tb.Sp range 0.59-0.82 mm), compared to the PM and AM quadrants (BV/TV range 19.9-36.9%, Tb.N range 0.96-1.61 mm^-1, Tb.Sp range 0.45-0.74 mm) (p = 0.03).

CONCLUSIONS

Our microstructural results suggest that the lateral side is the "weaker side", exhibiting lower bone volume faction, less trabeculae and higher trabecular separation, compared to the medial side. As the forearm is pronated during most falls, the underlying bone microstructure could explain commonly observed fracture patterns of the radial head, particularly more often involving the AL quadrant. If screw fixation in radial head fractures is considered, surgeons should take advantage of the "stronger" bone microstructure of the medial side of the radial head, should the fracture line allow this.

Does Radial Head Resection Impair Hand and Wrist Function? A Long-Term Follow-Up

OBJECTIVE

To evaluate the long-term outcome in patients after radial head resection surgery for isolated Mason type III radial head fractures.

DESIGN

An observational retrospective case series.

SETTING

A Hand and Upper-Extremity Surgery Unit in a tertiary care center.

PATIENTS

Data were collected from files of patients who were operated between the years 1980 and 2020. Of 352 patients who underwent surgery for radial head fractures, 25 patients were eligible and were enrolled in the study.

INTERVENTION

All participants underwent radial head resection surgery and a follow-up clinical and radiographic evaluation by 2 senior orthopaedic surgeons.

OUTCOME MEASUREMENTS

Objective evaluation included active range of motion of the elbow and wrist joints, ulnohumeral angle, key pinch and grip measurements, and radiographic imaging of elbow and wrist joints. Subjective evaluation included visual analog scale measurements, disability of arm shoulder and hand questionnaire, Mayo wrist score, Michigan hand outcome, and Oxford elbow score.

RESULTS

The mean follow-up was 18 years. Mean elbow range of motion and mean grip strength were lower in the operated hand, as compared to the contralateral hand. Mean proximal radial migration was 1.6 mm. Mean results of visual analog scale, disability of arm shoulder and hand, Mayo wrist score, Michigan hand outcome, and Oxford elbow score indicated good functional outcome and high patient satisfaction.

CONCLUSIONS

In our study population, long-term functional outcomes after radial head resection were encouraging. Thus, this procedure may be considered as a surgical alternative when radial head reconstruction or replacement fails.

LEVEL OF EVIDENCE

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

The Radial Floating Cup radial head prosthesis to treat radial head fractures: functional and radiographic results after more than 12 years of mean follow-up

INTRODUCTION

This study was performed to evaluate the long-term clinical and radiographic results of patients presenting with a radial head fracture who were treated surgically with a Judet Radial Floating Cup 2 (RFC 2) radial head prosthesis.

MATERIALS AND METHODS

This was a retrospective, monocentric, observational, multi-operator, and continuous study performed between July 1997 and June 2009 on the treatment of radial head fracture using an RFC 2 radial head prosthesis. The primary efficacy endpoint was the functional status of the operated elbow, evaluated using the Disability of Arm-Shoulder-Hand (Quick-DASH) score and the Mayo Elbow Performance Index (MEPI). The secondary endpoints were mobility and stability of the operated elbow, residual pain and grip strength, nature and rate of complications, as well as possible radiographic abnormalities during follow-up.

RESULTS

Twenty-two patients were treated with the RFC 2 for radial head fractures over the study period. Three (13.6%) were lost to follow-up, including one death. Of the remaining 19 patients, three RFCs had to be removed (15.8%). The final analysis involved 16 patients. The mean follow-up was 144 months (range 109-225 months; standard deviation [SD] = 49.9 months) or 12 years. The average Quick-DASH score was 23.01/100 (range 0-50; SD = 7.8) and three cases were rated as having "excellent" results according to the MEPI (18.7%), nine cases were rated as having "good" results in (56.2%), and four cases were rated as having "average" results (25%). The average mobility values were: 132° of flexion (range 120°-150°; SD = 11), 14.5° of extension deficit (range 0°-40°; SD = 5), 84.4° of pronation (range 20°-90°; SD = 8°), and 67.7° of supination (range 25°-85°; SD = 10). All patients had a stable elbow. The average grip strength on the affected side thus corresponded to 79% (range 44-100%; SD = 8.3%) of the grip strength on the healthy side. Four patients (25%) developed complications: three cases of algodystrophic syndrome (18.7%) and one case of early dislocation (6.2%). Radiographic evaluation revealed that there was a periprosthetic radio-lucencies in eight patients (50%), periarticular ossifications in 12 patients (75%), and lysis of the capitulum in two patients. There was no significant difference in MEPI ratings between patients with and without a periprosthetic radio-lucencies (P = 0.8018).

CONCLUSIONS

Our results indicated that using the RFC 2 prosthesis to surgically treat radial head fractures provides good long-term functional results, including satisfactory mobility and stability.

The treatment of isolated Mason type II radial head fractures: a systematic review

BACKGROUND

Fractures of the radial head represent the most common bony injury of the elbow in adults. Radial head fractures are classified according to Mason or one of its classification modifications. Current literature does not indicate consensus on whether to treat isolated stable type II radial head fracture patterns with open reduction and internal fixation (ORIF) or nonoperatively, especially, when there is no mechanical block to motion.

METHODS

We systematically reviewed the available literature searching electronic databases, that is, MEDLINE using the PubMed interface and Embase, for studies published between 2011 and 2020. The primary objective was to contrast the outcome scores of these 2 different study groups and the pitfalls accompanied with the 2 different approaches. The PRISMA guidelines were applied.

RESULTS

The literature search left 11 studies for inclusion, all but 1 retrospective in design, comprising 319 patients. A total of 218 patients (68.3%) were treated with ORIF and 101 patients (31.7%) were treated nonoperatively. Our findings indicate that ORIF does not provide better results when compared to nonoperatively treated patients concerning functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score or the Broberg and Morrey score, among the patients treated with ORIF was 90.9%; 7.1% were in need of subsequent surgery and 5.2% had radiologic osteoarthritic changes of the radial column. In addition, 95.1% of the nonoperative cohort were treated successfully, and osteoarthritis was present in 11.9%. Mean follow-up period of the ORIF and the nonoperative cohort was 73 and 39 months, respectively.

CONCLUSION

ORIF and nonoperative treatment of isolated Mason type II radial head fractures provide comparably satisfactory functional outcomes, without significant differences. Consideration of age, activity level and potential risks is recommended before making any treatment decision. Subsequent surgery rates were higher for patients treated with ORIF than for those treated nonoperatively and should be discussed. However, development of osteoarthritis of the radial column appears to be more likely after nonoperative treatment. The study pool remains limited, and implications of this review should be handled with caution.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant-led virtual fracture clinic in an Australian level 1 trauma centre

BACKGROUND

In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting.

METHODS

A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates.

RESULTS

A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P = 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P < 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P < 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P < 0.01). No complications or adverse events were reported.

CONCLUSION

This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.

Severe Osteoarthritis of the Elbow after a Non-Displaced Radial Head Fracture: Case Report

Fractures of the radial head account for over 50% of all fractures of the forearm. Broberg and Morrey (modification of the Mason classification) classify them in four types. Type 1 fractures are non-displaced or minimally displaced, considered stable and without mechanical joint blockage. In this type of fracture, a non-operative management with a short period of immobilization leads to a good clinical result without adverse outcomes. Clinically relevant associated lesions are not common. Because of this, arthritis of the radiocapitellar and ulnohumeral joint after the non-displaced radial head fracture is uncommon. This case report presents a young patient diagnosed with isolated non-displaced radial head fracture, that evolved 8 months later, to global arthritis of the elbow.

Symptomatic Radial Neck Nonunion Following Traumatic Impacted Radial Neck Fracture

PURPOSE

Minimally displaced or impacted radial neck fractures are commonly sustained after elbow trauma, although few require surgical treatment or result in lasting complications. Whereas they are rare, radial neck nonunion after this injury can have adverse implications for patient function and quality of life. The current study presents a case series of 8 radial neck nonunions after minimally displaced or impacted radial neck fractures.

METHODS

Using our institution's electronic medical record database, referred to as the Synthetic Derivative database, we performed a retrospective review of all radial neck fractures that presented to our institution over 15 years.

RESULTS

Of 472 minimally displaced or impacted radial neck fractures, 8 progressed to symptomatic nonunion. Average age of these patients was 54 ± 9.3 years. One patient presented with bilateral radial neck nonunions.

CONCLUSIONS

Nonunion after an impacted radial neck fracture is a rare yet frustrating outcome for patients and providers alike. Our results estimate the rate of symptomatic radial neck nonunion after minimally displaced or impacted radial neck fractures to be 1.7%.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

A retrospective comparative cohort study of radial head arthroplasty versus resection in complex elbow dislocations

INTRODUCTION

The management of radial head fractures for the treatment of complex elbow dislocations remains controversial. Until the publication of recent therapeutic algorithms, different actions have been carried out, including resection or arthroplasty of the radial head. This study aims to compare the clinical and radiological results of these two techniques.

MATERIALS AND METHODS

A retrospective study was conducted between the years 2001 and 2016 in complex elbow dislocations associating comminuted fractures of the radial head (Mason type IV) for two cohorts: 20 patients who received a radial head prosthesis against 12 patients treated with resection. At the end of the follow-up, two functional valuation scales were applied: Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand score (DASH). Radiological study included the presence of post-traumatic osteoarthritis and heterotopic ossifications in both groups; and specific complications in the group of patients treated with an arthroplasty.

RESULTS

The average age of the sample was 52.2 years in the prosthesis group, and 58.5 for the resection group, with a mean follow-up of 83.8 and 163 months respectively. No statistically significant differences were found in the mean values of the MEPS scale between the two groups (p = 0.5). The mean DASH score was significantly higher in the resection group (29.8 versus 10.3 with p = 0.006). A significantly higher rate of reinterventions and heterotopic ossifications was documented in the group of patients treated with radial head excision. The rate of specific radiological complications in the prosthesis group was 45%.

CONCLUSIONS

Although radial head resection could be a valid treatment in this group of patients, radial head arthroplasty would remain as the main option for the treatment of these lesions.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Traumatic Elbow Mediolateral Investigatory Screening: The value of the sitting axial mediolateral projection in the diagnosis of radial head fractures

BACKGROUND

Elbow injuries are frequently encountered in hospital practice, while radial head fractures are the commonest result of such trauma. Diagnosis of radial head fractures is based on clinical and radiographic evaluation with a number of X-ray projections being available. A combination of views is chosen, comprising of routine elbow series screenings and modified techniques, as well as the assistance of the fat-pat sign; never the less fractures can still be occult on X-rays.

PURPOSE

This article aims to demonstrate the diagnostic value of the sitting axial mediolateral projection, which in our hospital is referred to as the Traumatic Elbow Mediolateral Investigatory Screening (TEMIS). This projection has been successfully used in our hospital repeatedly for the identification of occult fractures that were missed by other projections.

MATERIALS AND METHODS

62 patients who presented to our Emergency Department due to trauma in the elbow over a six-month period were X-rayed for the identification of fractures. Projections included an anteroposterior, a lateral and TEMIS.

RESULTS

Radial head fractures (Mason type I) were identified in 14 out of 62 patients. 2 of these were only visible on the TEMIS projection, while they were missed by the other two views.

CONCLUSION

Trauma to the elbow is a common type of injury. Minor fractures can be expected to heal with good results; complications, however, should not be underestimated. Improper healing can result in a permanently malfunctioning joint with restricted movement and stiffness. To avoid such consequences the choice of a reliable screening projection is significant. In our case the diagnostic value of the TEMIS projection lies in the fact that it shows all fractures seen on routine screenings and reveals fractures missed by them, also being well tolerated by patients due to comfortable arm placement during the screening. All in all, when a fracture is suspected on the basis of clinical signs but no radiographic evidence is seen on conventional screenings, the TEMIS view is recommended for further investigation.

Factors affecting outcome of partial radial head fractures: A Retrospective Cohort Study

BACKGROUND

The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes.

MATERIALS AND METHODS

This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS).

RESULTS

Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11°, p=0.004) and total ROM (-14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (-9.00°, p=0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically.

DISCUSSION

We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries.

LEVEL OF EVIDENCE

IV, Retrospective study.

Preserving the radial head in comminuted Mason type III fractures without fixation to the radial shaft: a mid-term clinical and radiographic follow-up study

BACKGROUND

The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications.

METHODS

The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P).

RESULTS

Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain.

CONCLUSIONS

Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.

High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years

BACKGROUND

The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking.

QUESTIONS/PURPOSES

(1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH?

METHODS

Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score.

RESULTS

Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH.

CONCLUSIONS

The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation. Patients must be counselled regarding this risk of secondary intervention, of which the peak risk appears to be within 1 year after implantation. Despite this, patients report low disability according to the QuickDASH at a minimum follow-up of 8 years.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Midterm outcome of partial radial head replacement with a contoured iliac crest bone graft in complex elbow dislocation

PURPOSE

To report the midterm outcome of a novel reconstructive technique using a contoured iliac crest bone graft for partial radial head replacement in the treatment of complex elbow dislocation.

MATERIAL AND METHODS

Between January 2008 and December 2013, 10 patients (5 women, 5 men; mean age, 43.8 years; mean follow-up duration, 65.9 months) with complex elbow dislocation who underwent the partial radial head replacement with the contoured bone graft were included in the study. The irreparable radial head defects averaged 49% of the articular surface (range, 36-60%). The fracture involved the entire head in four patients and partial head in six patients.

RESULTS

At the final follow-up, the mean elbow extension was 8°, flexion 143°, supination 76.5°, and pronation 73°. The mean Mayo elbow performance index was 93.2 points and the Broberg-Morrey functional rating score was 94.1 points, with seven excellent cases, two good cases, and one fair case. Radiographic union was achieved in all but one, at an average time of 6.89 weeks (range, 6-10 weeks). The final radiographs demonstrated no evidence of degenerative change in eight patients, mild arthritis in one patient, and moderate arthritis in one patient.

CONCLUSION

This technique is a viable option in the treatment of the large radial head defect in complex elbow dislocation when more than 40% of the original head is still available for incorporation.

[What do orthopedic and trauma surgeons expect from radiologists when interpreting imaging of the elbow?]

CLINICAL ISSUE

The elbow is a complex joint with a multitude of acute and chronic pathologies. In addition to the clinical examination, radiological diagnostics play a decisive role in the further therapeutic management.

DIAGNOSTIC WORK-UP/PERFORMANCE

While acute traumatic injuries often present with obvious structural changes and the need for rapid treatment decisions, chronic processes can present with less evident alterations. Especially in these cases there is a need for clear communication between the treating physician and the radiologist with respect to managing optimal imaging as the basis for a certain diagnosis and therefore optimal treatment. Basic prerequisites on both sides are detailed knowledge of all elbow pathologies, classifications and the spectrum of radiological diagnostic imaging.

ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS

From the point of view of orthopedic surgeons the radiologist is responsible for the correct performance and interpretation of the necessary imaging procedures. The aim of this article is to give an overview of important aspects in the imaging of typical orthopedic/traumatic pathologies.

Complex radial head and neck fractures treated with modern locking plate fixation

BACKGROUND

Internal fixation of complex radial head and neck (CRHN) fractures is difficult, and postoperative complications are common. This study evaluated elbow function and patient clinical status after internal fixation of CRHN fractures with modern locking plates.

METHODS

We included 40 patients with 41 fractures (1 bilateral lesion). In 25 patients (61%), a concomitant injury was found. Patients were an average age of 46 years (range, 22-70 years). The mean follow-up time was 36 months (range, 2-70 months). Postoperative assessments included evaluation of range of motion, functional scores, and radiologic findings. We assessed fracture healing, surgical complications, revision surgery, and the need for metal removal.

RESULTS

Of the 34 fractures available for follow-up, 33 (97%) healed well. The mean extension deficit was 6° (range, 0°-30°). The average elbow flexion was 134° (range, 90°-160°), pronation was 70° (range, 30°-90°), and supination was 64° (range, 20°-90°). The Mayo Elbow Performance Score showed a mean of 90 points (range, 65-100 points). We observed no "poor" results. The mean Disability of Arm, Shoulder and Hand score was 16.5 (range, 2.5-58.3; n = 29). All patients continued activity without daily analgesics. There were 12 (34%) complications. In 11 (32%) patients, the plate was removed.

CONCLUSIONS

CRHN fractures fixed with modern locking plates and treated as an osseoligamentous lesion exhibited promising midterm results. The new fixation devices represent an improvement in the treatment of this difficult and common fracture while reducing the need for joint replacement or radial head resection. Diagnosis and treatment of concomitant injuries should be emphasized.

Evaluation of MoPyC-prosthesis implantation and the use of angular stable plates in the treatment of comminuted radial head fractures

Objective

Comminuted radial head fractures are disproportionately often accompanied by injuries of the bone or ligaments and can be treated in different ways.

Methods

15 patients with a comminuted radial head fracture were treated with an angular stable plate (=G1) and 8 with a MoPyC-prosthesis (=G2).

Results

G1 shows an average Morrey-score of 83,87 points. Complications occurred in 5/15 patients. Within G2 an average Morrey-score of 86 was achieved. Complications could be shown in 2/8 patients.

Conclusion

Both the treatment provides a clear individual benefit for the patients and predict promising results for the treatment of comminuted radial head fractures.

Involvement of the proximal radial ulnar joint in partial radial head fractures: a novel three-dimensional computed tomography scan evaluation method

BACKGROUND

Partial radial head fractures (PRHF) can involve the proximal radioulnar joint (PRUJ) or be restricted to the 'safe zone' (SZ) during forearm rotation. The objective of the present study was to develop an assessment method for PRUJ involvement in radial head fractures using axial computed tomography (CT) scans.

METHODS

The area of the radial head in contact with the PRUJ zone was identified, and defined on 18 cadaveric elbows CT scans; the quantitative relationship between PRUJ zone and radial tuberosity was established. Then, four evaluators validated it on PRHF CT scan axial views, classifying the fractures as involving the PRUJ or not.

RESULTS

Using the radial tuberosity as the 0° of a 360° circle, the SZ was within 108° to 212° clockwise for a right elbow and counter clockwise for the left elbow. Fifty-five consecutive (30 men, 25 women, mean age of 49 years) partial radial head fracture CT scans were classified: four in the SZ only, three in the PRUJ zone and 48 in both the PRUJ and SZ. The kappa for the inter- and intra-observer agreement was 0.517 and 0.881, respectively.

CONCLUSIONS

Ninety-three percent of partial radial head fractures will involve the PRUJ and the geometric model developed allows their classification, potentially helping surgeons decide on optimal treatment.

LEVEL OF EVIDENCE

Retrospective basic science study. Level III: anatomic study, imaging.

Primary cemented bipolar radial head prostheses for acute elbow injuries with comminuted radial head fractures: mid-term results of 37 patients

BACKGROUND

Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason's classification type III after primary arthroplasty using a cemented bipolar design.

MATERIALS AND METHODS

In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively.

RESULTS

DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases.

CONCLUSION

Primary cemented bipolar arthroplasty for type III fractures according to Mason's classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

Evaluation of MoPyC-prosthesis implantation and the use of angular stable plates in the treatment of comminuted radial head fractures

Objective

Comminuted radial head fractures are disproportionately often accompanied by injuries of the bone or ligaments and can be treated in different ways.

Methods

15 patients with a comminuted radial head fracture were treated with an angular stable plate (=G1) and 8 with a MoPyC-prosthesis (=G2).

Results

G1 shows an average Morrey-score of 83,87 points. Complications occurred in 5/15 patients. Within G2 an average Morrey-score of 86 was achieved. Complications could be shown in 2/8 patients.

Conclusion

Both the treatment provides a clear individual benefit for the patients and predict promising results for the treatment of comminuted radial head fractures.

How to approach Monteggia-like lesions in adults: A review

Monteggia-like lesions encompass a wide spectrum of fractures of the forearm and elbow associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are either complex, not immediately usable, or not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification, and knowledge of the best surgical approach. Monteggia like lesions do not allow for mistakes during surgery, as even a minor error could be prove detrimental to performing and completing all surgical steps. In this paper, based on our extensive experience in treating these rare lesions, we suggest a practical guide to the best surgical approach for various types of Monteggia like lesions. Some technical tips and pitfalls are also described.

Morphometry of the radiocapitellar joint: is humeral condyle diameter a reliable predictor of the size of the radial head prosthesis?

BACKGROUND AND HYPOTHESIS

Radial head arthroplasty (RHA) is a reliable procedure to manage complex injuries of the elbow, but complications due to inadequate sizing have been observed. Radiocapitellar morphometry has been studied widely, but RHA preoperative planning is not yet well defined. We hypothesized that specific morphologic parameters of the radiocapitellar joint measured with simple clinical software for radiographic analysis could be useful tools for clinical practice to predict RHA size preoperatively.

METHODS

Radiologic radiocapitellar joint dimensions (humeral condyle diameter [HCDi], radial head diameter [RHDi], and radial head height) were analyzed on true anteroposterior and lateral radiographs, using commercial picture archiving and communication system software, in 43 patients with non-osseous pathology of the elbow and 24 patients with RHA. Interobserver concordance was studied, and a regression model to relate different parameters was developed.

RESULTS

Interobserver concordance was greater than 0.8 for HCDi and RHDi on the lateral view and RHDi on the anteroposterior view for the general population. The parameter with the best correlation with the radial head arthroplasty diameter (RHADi) size was HCDi on the lateral view. A regression model was calculated and defined as follows: RHADi = 6.99 + 0.733 × HCDi on lateral view. This model allows prediction of RHADi in 67% of cases.

CONCLUSION

Radiologic radiocapitellar parameters show good interobserver reliability. RHADi can be calculated preoperatively from HCDi on the lateral view in 67% of cases.

Isolated radial neck delayed union/nonunion after conservative treatment in adults: two case reports and a literature review

BACKGROUND

Treatment recommendations for isolated radial neck delayed union/nonunion are sparse, but include mainly conservative treatment, electro-stimulation, bone grafting, open reduction and internal fixation (ORIF) and radial head resection. The purpose of this study was to perform a literature review on isolated delayed union/nonunion of radial neck fractures and to evaluate the reported outcomes of proposed treatment strategies. Furthermore, we aimed to generate data-based recommendations for this rare pathology. In the second part of this paper, we report two clinical cases of delayed union of isolated radial neck fractures recently treated at the senior authors institution.

METHODS

A literature search on PubMed was performed. We selected all papers with a documented delayed union, pseudarthrosis or nonunion of the radial neck. All papers were reviewed for patient demographics, patient occupation, treatment type and timing relative to the initial trauma, X-ray documentation and outcome. The two patients with delayed union after isolated radial neck fractures recently treated at our institution were evaluated for age, mechanism of injury, occupation, treatment and outcome. Clinical and radiological follow-up examinations were performed 6, 12 weeks, and 1 year after initial trauma. Final clinical evaluations included the Mayo Elbow Performance Score (MEPS) [1] and the Disabilities of the Arm, Shoulder and Hand (DASH) Score [2].

RESULTS

We found 17 cases reported in 11 articles matching our selection criteria of isolated radial neck delayed union or nonunion in adult patients. Average age was 55 years (range 29-73 years). The most frequent mechanism of injury was a fall on an outstretched arm from standing height. Initial treatment consisted of an arm sling for 1-4 weeks and physiotherapy. From the 17 included cases, six were operated on due to persistent pain. Three received bone grafts, one was supplemented with additional K-wire fixation, and three had radial head resections. Ten patients were treated conservatively: six were pain free and three were symptomatic at last follow-up; symptoms were not reported for one case. All surgically treated cases were pain free at the last follow-up, average 32 months (range 6-84). Of the conservatively treated group, eight of ten had documented nonunion. The two reported cases from our institution were initially treated conservatively for 4 and 6 months. Both had a radiologically documented delayed union. Both patients were operated on due to persistent pain precluding them from returning to work. At the last follow-up, MEPS and DASH scores were 100 points and 29 in one case and 100 points and 18 in the other, respectively.

CONCLUSION

Isolated delayed union or nonunion of the radial neck after conservative treatment in adult patients appears to be rare and often remains asymptomatic. Operative treatment is recommended for symptomatic delayed union/nonunion in patients with altered elbow function [3]. All surgically treated patients in our study with symptomatic delayed unions/nonunions had favorable clinical outcomes.

Elbow Fractures with Instability: Evaluation and Treatment Strategies

The treatment goals of elbow fracture dislocations are congruent reduction of the ulnohumeral and radiocapitellar joints, stable fixation of the proximal ulna, stable fixation or arthroplasty of the radial head, and soft tissue repair. Fracture dislocations occur in patterns, and recognition of these patterns help guide surgical treatment. In patients with persistently unstable fractures after standard fixation, additional temporary joint spanning implants are useful to protect repairs.

Nonunion of a Nondisplaced Radial Neck Fracture: A Case Report

CASE

We describe the case of a 66-year-old man who sustained a nondisplaced radial neck fracture and subsequently developed a symptomatic nonunion. After a period of unsuccessful conservative treatment, a radial head resection was performed.

CONCLUSION

Radial neck fractures, unlike their radial head counterparts, have a low rate of nonunion. Our patient's only positive risk factor was age, but he developed a nonunion. At the 2-year follow-up after excision of the radial head, there was a lack of proximal migration of the radius during axial loading, demonstrating a positive outcome without the need for replacement of the radial head.

Complex Elbow Dislocations and the "Terrible Triad" Injury

Background:

The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. These injuries can be categorised into groups according to their mechanism and the structures injured.

Methods:

This review includes a literature search of the current evidence and personal experiences of the authors in managing these injuries.

Results:

All injuries are initially managed with closed reduction of the ulno-humeral joint and splinting before clinical examination and radiological evaluation. Dislocations with radial head fractures should be treated by restoring stability, with treatment choice depending on the type and size of radial head fracture. Terrible triad injuries necessitate operative treatment in almost all cases. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Surgical treatment of terrible triad injuries carries a high risk of complications with an average reoperation rate of 22%. Varus posteromedial rotational instability fracture-dislocations have only recently been described as having the potential to cause severe long-term problems. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism.

Conclusion:

Complex elbow dislocations are injuries with significant risk of long-term disability. There are several case-series in the literature but few studies with sufficient patient numbers to provide evidence over level IV.

Comparison of three different fixation constructs for radial neck fractures: a biomechanical study

Background

Fixation of radial neck fractures can be achieved with a plate and screw construct or with two screws. This study evaluated the biomechanical properties of three different fixation methods following radial neck fractures.

Methods

Twenty-four fourth-generation composite radii were sawed to simulate an unstable radial neck fracture. They were then instrumented with a plate and screw construct or two different orientations (crossed and parallel) of screw fixation. Implants were tested under bending and torsional loads via a tension torsion composite test system. Bending and torsional failure loads were added to the remaining implant-radius constructs if they did not fail during the previous tests.

Results

During the bending loading test, the crossed-screw group showed the greatest stiffness, followed by the parallel-screw group, the plate group demonstrating the weakest stiffness. There was no significant difference between the crossed- and the parallel-screw groups. However, there was a significant difference between the two screw groups and the plate group. During the bending failure test, the largest stiffness was found for the crossed-screw group, while the plate group exhibited the smallest stiffness. There was a significant difference between the three groups. During the torsion loading test, the highest stiffness was observed for the crossed-screw group, while the plate group showed the lowest stiffness. In the torsion failure test, the failure torques were 11.97 ± 2.659, 8.531 ± 1.768, and 7.079 ± 1.666 N m respectively for the crossed-screw, parallel-screw, and plate groups. There was a significant difference between the crossed-screw group and the two other groups.

Conclusions

Crossed screws and plate fixation are commonly used in clinical practice to treat simple radial neck fractures. While the present study shows that the parallel-screw method results in similar biomechanical strength as the two other techniques, it has the advantages of reaching limited wound exposure and having the implant buried. Therefore, it may be widely used in clinical practice.

[Destruction of the radial head : Endoprosthesis, autologous reconstruction or anconeus arthroplasty?]

BACKGROUND

Radiocapitellar arthritis or defects most often result from trauma. Most of the patients are young and have high functional demands with high load capacities. Therefore, endoprosthetic options should be postponed for as long as possible. If conservative treatment cannot relieve symptoms sufficiently, radial head preservation, resection or replacement options are at the surgeon's disposal. In early stages of radiocapitellar arthritis, radial head preservation options can be taken into account. The chances ofgood results decrease with increasing cartilage damage.

TREATMENT OPTIONS

In addition to radial head preservation options this article discusses radial head resection with and without anconeus interposition and radial head as well as radiocapitellar replacement. Clinical data are rare. The advantages and disadvantages of each option must be discussed with the patient and the decision should be made individually on the basis of patient specific factors. The aim must be to postpone endoprosthetic options - especially total elbow arthroplasty - for as long as possible, while assuring a functional range of motion with an acceptable pain level.

Nonsurgical treatment of Mason type II radial head fractures in athletes. A retrospective study

OBJECTIVE

The best treatment for moderately displaced radial head fractures (Mason type II) still remains controversial. In cases of isolated fractures, there is no evidence that a fragment displacement of ≥ 2 mm gives poor results in conservatively treated fractures.

PATIENTS AND METHODS

We retrospectively reviewed 52 patients (31M, 21F) affected by an isolated Mason type II fracture, treated with a long arm cast for two weeks between 2008 and 2013. All patients had practiced sports before being injured. They were all either bicyclists, or baseball, boxers, basketball, rugby, tennis or football players. The mean follow-up was 36 months. Elbow and forearm range of motion were measured. The Mayo Elbow Performance Score, the Broberg and Morrey rating system and the Disabilities of the Arm, Shoulder and Hand Score (DASH score) were analyzed. Follow-up radiographs were examined for evidence of consolidation, late displacement, early arthritis and non-unions.

RESULTS

Flexion was slightly impaired in the injured limb when compared to the uninjured limb (137°± 6° versus 139°±5°) as were extension (-3°±6° versus 1°±4°, p < 0.05), supination (86°±6° versus 88°±3°), pronation (87°±4° versus 88°±6°) and valgus deviation (10°±4° versus 8°±3°, p < 0.05). 40 patients had no elbow complaints; 9 patients experienced occasional pain, 2 a mild instability of the elbow, and 4 a mild loss of grip strength. The DASH score was excellent in 48 patients (92.31%). In only 6 cases (11.53%) degenerative changes were greater in formerly injured elbows than in uninjured elbows. All patients returned to their previous sports activities.

CONCLUSIONS

Isolated Mason type II fractures can have a good or excellent mid-term functional outcome even when treated conservatively.

Physical therapist screening and differential diagnosis for traumatic-onset elbow pain: A case report

BACKGROUND AND PURPOSE

Elbow pain can originate from many sources yet have similar signs and symptoms, thereby presenting differential diagnostic challenges. The elbow is commonly injured, thus requiring all clinicians to possess excellent diagnostic skills.

CASE DESCRIPTION

A 24-year-old woman slipped and fell on her outstretched left hand, experiencing immediate elbow pain. The same day radiographs were deemed negative by her orthopedist, who referred her to physical therapy with the diagnoses of elbow sprain and contusion. Immediately after examining the patient, the physical therapist consulted with the referring orthopedist. The decision to consult was based on: the mechanism of injury, pain severity out of proportion to the referred diagnoses, significantly limited ROM, abnormal joint end feels, exquisite pain with tactile and tuning fork bony palpation, and positive elbow extension test.

OUTCOMES

The treating physical therapist shared the above-noted findings with the orthopedist, who overruled and recommended continuing the original prescription of non-steroidal anti-inflammatory medication and physical therapist treatment for four weeks. The physical therapist's updated plan of care at four weeks noted the patient's continued reports of pain, functional limitations, and disability. A magnetic resonance image (MRI) was then ordered, revealing a radial head fracture.

DISCUSSION

A thorough history and examination by the physical therapist led to clustering of signs and symptoms, allowing for the development of a differential diagnosis list which included occult radial head fracture. All clinicians should be prepared to screen for complex conditions. Timely diagnosis and improved outcomes for clinically complex patients are increasingly necessary in contemporary healthcare reimbursement models.

Fracture mapping of displaced partial articular fractures of the radial head

BACKGROUND

Recognition of patterns of traumatic elbow instability helps anticipate specific fracture characteristics and associated injuries. The objective of this study was to assess the association of fracture line distribution and location of displaced partial articular radial head fractures with specific patterns of traumatic elbow instability using fracture mapping techniques.

METHODS

Fracture line distribution and location of 66 acute displaced partial articular radial head fractures were identified using quantitative 3-dimensional computed tomography reconstructions that allowed reduction of fracture fragments and a standardized method to divide the radial head into quadrants with forearm in neutral position. Based on qualitative and quantitative assessment of fracture maps, the association between fracture characteristics of displaced partial articular radial head fractures and specific elbow fracture patterns was determined.

RESULTS

In partial articular radial head fractures, the highest fracture line intensity was located in the anterolateral quadrant near the center of the radial head. Fracture location corresponded with fracture line distribution; most fractures involved the anterolateral quadrant (n = 65; 98%), whereas parts of the posteromedial quadrant were involved in a minority of the fractures (n = 10; 15%). The association of fracture line distribution and location with overall fracture patterns of the elbow, as depicted on fracture maps, was not statistically significant.

CONCLUSION

Fracture maps demonstrated no association between fracture line distribution and location of displaced partial articular fractures of the radial head and overall specific patterns of traumatic elbow instability, suggesting a common fracture mechanism that involves the anterolateral part of the radial head in most patients.

Acute unstable complex radial head and neck fractures fixed with a mini T-shaped plate in a 20-year-old man: a case report

Acute unstable complex radial head and neck fractures in adults are seldom reported in the literature. Early recognition and appropriate management are essential to prevent long-term consequences of the loss of elbow function, forearm rotation, and chronic pain. Here, we describe an unusual case of a 20-year-old man who exhibited acute unstable complex fractures of the head and neck of the right radius without other injuries or comorbidity. An open reduction and mini T-shaped plate fixation were performed within 3 hours after injury, and the results were satisfactory. A long plaster fixation was continued for 3 weeks. A gradual mobilization was started after the removal of the plaster under the supervision of a physiotherapist. At the 12-month follow-up, no complications associated with the use of the mini T-shaped plate were noted, and the Mayo Elbow Performance Score was 97 (excellent). To our knowledge, acute unstable complex radial head and neck fractures in adults can be successfully treated with a mini T-shaped plate reconstruction technique.

One-year results of cemented bipolar radial head prostheses for comminuted radial head fractures

INTRODUCTION

Comminuted radial head fractures (Mason type III) continue to pose a challenge to orthopedic surgeons. When internal fixation is not possible, radial head arthroplasty has been advocated as the treatment of choice. The purpose of this retrospective study was to evaluate clinical and radiological short-term results of patients with Mason type III radial head fractures treated with a cemented bipolar radial prosthesis.

METHODS

Twelve patients received cemented bipolar radial head hemiarthroplasty for comminuted radial head fractures. In all patients a CT scan was obtained prior to surgical treatment to assess all associated injuries. Postoperatively an early motion protocol was applied. All patients were evaluated clinically and radiologically at an average of 12.7 months.

RESULTS

According to the Mayo Modified Wrist Score, the Mayo Elbow Performance Score, the functional rating index of Broberg and Morrey, and the DASH Score good to excellent results were obtained. Grip strength and range of motion were almost at the level of the unaffected contralateral side. Patient satisfaction was high, no instability or signs of loosening of the implant, and only mild signs of osteoarthritis were seen.

CONCLUSION

Overall good to excellent short-term results for primary arthroplasty for comminuted radial head fractures were observed. These encouraging results warrant the conduction of further studies with long-term follow-up and more cases to see if these short-term results can be maintained over time.

Comparison of crossed screw versus plate fixation for radial neck fractures

BACKGROUND

Fixation of radial neck fractures can be achieved with a plate and screw construct or, in absence of comminution, with two obliquely-oriented screws. This study investigated the mechanical properties, specifically the stiffness and load to failure, of these two fixation strategies in a cadaver model.

METHODS

Ten matched-pair radii were removed from fresh cadaver arms. A transverse osteotomy was created at the neck of each radius. Right-sided radii were fixed with two oblique headless compression screws; left-sided radii were fixed with a radial neck plate. The distal aspect of each radius was potted in urethane casting resin. The radial head was loaded in shear in 4 different planes (medial to lateral, lateral to medial, posterior to anterior, and anterior to posterior) using an Instron machine. Stiffness and load to failure were recorded.

FINDINGS

The stiffness of both constructs was similar in all planes except for loading from medial to lateral where the screw construct was 1.8 times stiffer. Average ultimate failure occurred at 229N for the screws and 206N for the plate. Failure strength was not statistically different. However, mode of failure differed for both fixation constructs, the plate failed in bending while the screws failed by pullout and fracture.

INTERPRETATION

The two strategies provide similar strength and stiffness for the fixation of transverse, non-comminuted radial neck fractures. While plate and screw constructs are more appropriate for axially unstable or comminuted fractures, two oblique screws might be preferred for simple transverse neck fractures since this strategy requires less exposure and the implant is buried.

Mason type II and III radial head fracture in patients older than 65: is there still a place for radial head resection?

PURPOSE

To evaluate the clinical outcomes of radial head excision for multifragmentary radial head fracture in patients over 65 years old.

METHODS

We retrospectively examined 30 patients over 65 years of age treated with radial head excision for comminuted radial head fractures. Patients were evaluated through clinical examinations, administrative questionnaires (DASH--Disabilities of the Arm, Shoulder and Hand; MEPS--Mayo Elbow Performance Score, VAS--Visual Analog Scale) and plain films.

RESULTS

The mean follow-up was 40 months (range 24-72 months); 27 out of 30 patients claimed to be satisfied. The mean DASH score was 13 (range 3-45.8) and mean MEPS was 79 (range 65-97). The radiographic evaluation showed 21 cases of elbow arthritis; only two of them complained about pain. Heterotopic ossification was evident in six cases with functional impairment in only one patient. Six patients with increased ulnar variance had clinical distal radio-ulnar joint instability.

DISCUSSION

Radial head excision has been considered a safe surgical procedure with satisfactory clinical outcomes. Development in biomechanical studies and prosthetic replacement of the radial head question the validity of radial head excision. In current literature, there are neither long-term follow-up studies on radial head prosthesis outcomes nor studies which consider elderly patient samples.

CONCLUSION

Radial head resection remains a good option when a radial head fracture occurs in elderly patients, taking into account the influence of poor bone quality and comorbidities on the outcome. Radial head excision is not indicated in the presence of associated lesions, because of the risk of residual elbow instability; complications associated with advanced age must be considered and a strict follow-up granted.

Is cross-screw fixation superior to plate for radial neck fractures?

This study compares the outcomes of two methods of fixation of displaced fractures of the radial neck. The 58 patients with a mean age of 38.5 years (18 to 56), were treated in a non randomised study with screws (n = 29) or a plate and screws (n = 29) according to the surgeon’s preference.

The patients were reviewed at one year. Radiographs and functional evaluations were carried out up to one year post-operatively, using the Broberg and Morrey functional evaluation score, range of movement, and assessment of complications.

The mean functional scores did not differ significantly between groups (90 (55 to 100) vs 84; 50 to 100, p = 0.09), but the mean range of forearm rotation in screw group was significantly better than in the plate group (152°; 110° to 170° vs 134°; 80° to 170°, p = 0.001). Although not statistically significant, the screw group had a lower incidence of heterotopic ossification than the plate group (n = 1) than the plated group (n = 3) and the pathology was graded as less severe.

Cite this article: Bone Joint J 2015;97-B:830–5

Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis

Background

High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns.

Materials and methods

Patients sustaining a radial head fracture from 2002−2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data.

Results

The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4^°. Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %).

Conclusion

The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120^° fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings.

Level of evidence

Diagnostic III.

Long-term outcomes of isolated stable radial head fractures

BACKGROUND

There is evidence to support primary nonoperative management of isolated stable fractures of the radial head, although minimal data exist regarding long-term outcomes. The aim of this study was to report subjective long-term outcomes of isolated stable fractures of the radial head and neck following primary nonoperative management.

METHODS

From a prospective database of proximal radial fractures, we identified all skeletally mature patients who sustained an isolated stable Mason type-1 or type-2 fracture of the radial head or neck during an eighteen-month period. Inclusion criteria were a confirmed isolated stable fracture of the proximal aspect of the radius, primarily managed nonoperatively. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The study cohort comprised 100 patients with a mean age of forty-six years (range, seventeen to seventy-nine years). A fall from a standing height accounted for 69% of all injuries. Thirty-five percent of the patients had one or more comorbidities. There were fifty-seven Mason type-1 fractures and forty-three Mason type-2 fractures. At a mean of ten years post injury (range, 8.8 to 10.2 years), the mean DASH score was 5.8 (range, 0 to 67.2) and the mean Oxford Elbow Score (OES) was 46 (range, 14 to 48). Fourteen (14%) of the patients reported stiffness and twenty-four (24%) reported some degree of pain. A worse DASH score was associated with older age (p = 0.002), one or more comorbidities (p = 0.008), increasing socioeconomic deprivation by Index of Multiple Deprivation quintile (p = 0.026), increasing amount of fracture displacement (p = 0.041), and involvement in compensation proceedings (p = 0.006).

CONCLUSIONS

Long-term patient-reported outcomes were excellent following the nonoperative management of isolated stable fractures of the radial head or neck. We suggest that routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients in our study requiring further intervention for persisting complaints.

LEVEL OF EVIDENCE

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

Radiographic loss of contact between radial head fracture fragments is moderately reliable

BACKGROUND

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation).

QUESTIONS/PURPOSES

(1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability?

METHODS

Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals.

RESULTS

The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision.

CONCLUSIONS

Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures.

LEVEL OF EVIDENCE

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

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.