Radial head fractures

Which radial head fractures are best treated surgically?

Despite the common occurrence of radial head fractures, there is still a lack of consensus on which radial head fractures should be treated surgically. The radial head is an important secondary stabilizer in almost all directions. An insufficient radial head can lead to increased instability in varus-valgus and posterolateral rotatory directions, especially in a ligament-deficient elbow. The decision to perform surgery is often not dictated by the fracture pattern alone but also by the presence of associated injury. Comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. Displacement (>2 mm) of fragments in radial head fractures without a mechanical block to pronation/supination is not a clear indication for surgery. Mechanical block to pronation/supination and comminution of the fracture are indications for surgery. The following paper reviews the current literature and provides state-of-the-art guidance on which radial head fractures should be treated surgically.

Early range of motion results in good elbow function following conservative treatment of non-displaced radial head fractures

INTRODUCTION

The aim of this study was to evaluate the range of motion (ROM), elbow function and predictors for good elbow function after conservative treatment of non-displaced radial head fractures.

MATERIAL AND METHODS

All patients with non-displaced radial head fractures (displacement < 2 mm), that were diagnosed between January 1st 2017 and December 31st 2021 in a level I trauma center, were included in this retrospective case series and the charts were evaluated for ROM and elbow function. Elbow function was categorized as "good" or "bad" depending on the ROM measured defined by Morrey et al. Overall, 73 patients (33 male, 40 female) with an average age of 38 years (+/- 13 years) could be included.

RESULTS

Conservative treatment had good clinical results for ROM and elbow function. After 6 weeks mean flexion was 131° (SD 13°), extension 8° (SD 7°), Pronation 83° (SD 11°) and Supination 83° (SD 13). Patients with a good elbow function after one week showed a good elbow function after completing the treatment.

CONCLUSIONS

A clinical assessment after one week should always be performed and the study showed that it is a good predictor for good elbow function. In cases of bad elbow function further controls should be considered.

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.

The role of arthroscopy in the management of adult elbow trauma

Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

Functional Postoperative Outcome for 92 Cases of Radial Head Fractures: A PROM-Based Retrospective Study

Background: Fractures of the radial head are common injuries, whereas, in the case of displaced fractures, surgical treatment using screw or plate osteosynthesis, excision, or replacement of the radial head is required. However, data about patient-related outcomes (PROM) for different types of radial head fractures is limited in the current literature. Therefore, this study was conducted to evaluate the functional outcome after operatively treated radial head fractures and to further correlate these results with the initial modified Mason classification. Methods: In this retrospective study, all suitable patients with surgical treatment of a radial head fracture were identified. Only patients with Mason II-IV fractures were included. All patients completed the Elbow Self-Assessment Score (ESAS) questionnaire. Data on fracture classification, type of surgery, and revision operations (if needed) were assessed. Results: A total of 92 patients suffering from fractures of the radial head (57 Mason II, 35 Mason III-fractures) who were operatively treated at our institution were enrolled. There were 42 (47.7%) female and 50 (54.3%) male patients with an average age of 47.5 ± 14.1 years. Screw osteosynthesis was performed in 67 patients, plate osteosynthesis in 20 patients, and five patients received radial head arthroplasty. The average ESAS score accounted for 89.7 ± 16.7. Mason II fractures showed significantly better functional results with higher ESAS scores (92.3 ± 13.9 vs. 85.4 ± 20.1) as well as significantly lower rates of necessary implant removal (0 vs. 5 (14.3%) than Mason III fractures. Screw osteosynthesis showed significantly better functional ESAS scores, 91.0 ± 16.5, than plate osteosynthesis, with 85.3 ± 17.6 (p = 0.041), but was predominantly used in Mason II fractures. Conclusions: Surgical treatment using screw- and plate osteosynthesis of radial head fractures provides a good overall outcome. The postoperative function is associated with the initial Mason classification as the patients' reported outcome was worse in Mason III fractures compared to Mason type II fractures. In this context, the ESAS score can be considered a useful tool for the assessment of the patient-based functional outcome.

Elbow Arthroscopy for the Treatment of Radial Head Fractures: Surgical Technique and 10 Years of Follow Up Results Compared to Open Surgery

BACKGROUND

This study aimed to describe the ARIF (Arthroscopic Reduction Internal Fixation) technique for radial head fractures and to compare the results with ORIF (Open Reduction Internal Fixation) at mean 10 years.

METHODS

A total of 32 patients affected by Mason II or III fractures of the radial head who underwent ARIF or ORIF by screws fixation were retrospectively selected and evaluated. A total of 13 patients were treated (40.6%) by ARIF and 19 patients (59.4%) by ORIF. Mean follow-up was 10 years (7-15 years). All patients underwent MEPI and BMRS scores at follow-up, and statistical analysis was performed.

RESULTS

No statistical significance was reported in Surgical Time (p = 0.805) or BMRS (p = 0.181) values. Significative improvement was recorded in MEPI score (p = 0.036), and between ARIF (98.07, SD ± 4.34) and ORIF (91.57, SD ± 11.67). The ARIF group showed lower incidence of postoperative complications, especially regarding stiffness (15.4% with ORIF at 21.1%).

CONCLUSIONS

The radial head ARIF surgical technique represents a reproducible and safe procedure. A long learning curve is required, but with proper experience, it represents a tool that might be beneficial for patients, as it allows a radial head fracture to be treated with minimal tissue damage, evaluation and treatment of the concomitant lesions, and with no limitation of the positioning of screws.

Revision of Failed Radial Head Arthroplasty

BACKGROUND

Revision of radial head arthroplasty (RHA) may be indicated in cases of prosthesis loosening and malposition. Inherent difficulties in revision surgery include poor bone stock and disrupted soft tissue envelope. Although cases of RHA used for revision of failed RHA are rare, there is reasonable expectation for increasing frequency of these cases due to the increasing incidence of primary RHA. Furthermore, there is an increasing demand for postoperative recovery of function; thus, surgeons may consider revising a failed RHA to a new RHA. We report on series of failed RHA which were revised to a new radial head prosthesis.

METHODS

A retrospective review was performed at multiple institutions for a single radial head prosthesis used for revision of a failed radial head prosthesis. Clinical and radiographic outcomes were collected with a minimum of 1 year of follow-up.

RESULTS

Across 11 patients at a mean follow-up of 45.1 months, the mean Mayo Elbow Performance Score was 81.7; mean Disabilities of the Arm, Shoulder, and Hand scores were 24.4; and mean Visual Analog Scale for pain was 0.6. Radiographic analysis yielded no evidence of capitellar wear or stem loosening.

CONCLUSION

A radial head prosthesis can produce satisfactory results when used for revision of a failed prosthesis. Inherent difficulties in revision surgery include the potential for reduced bone stock and a disrupted soft tissue envelope. Elements of prosthesis design which may contribute to effectively managing revision surgery include a long stem with in-growth surface and prosthetic head alignment to the axis of forearm rotation.

[Radial head prosthesis for acute fractures]

Non-reconstructible radial head fractures with concomitant injuries and resultant instability of the elbow are often treated by implantation of a radial head prosthesis. Various prosthetic designs and implantation techniques are available. Several pitfalls have to be respected during implantation. This article provides tips and tricks for successful implantation and aftercare and gives an overview of long-term outcomes and revision rates.

Survivorship of anatomic press-fit short-stem radial head replacement with a pyrocarbon bearing

BACKGROUND

Restoring the radial head as a stabiliser of the elbow is considered important in cases where there is an associated bony or ligamentous injury. A variety of radial head prostheses are available. There are no reports of the survivorship of a short-stem press-fit radial head prostheses with pyrocarbon bearing.

PATIENTS AND METHODS

With institutional review board approval, a retrospective case-note analysis was performed of a consecutive single-surgeon case series of the Integra LifeScience pyrocarbon radial head prostheses (Carbon Modular Radial Head) from October 2010 to October 2019 in a tertiary referral centre. The series was divided into acute trauma and salvage cohorts. Kaplan-Meier survivorship analysis was conducted.

RESULTS

36 patients were included, 23 (64%) for acute injuries and 13 (36%) for failed initial treatment. Of the acute injuries, 20 (87%) had a Wrightington type-C elbow fracture-dislocation. Reoperation was performed in 4 (11%) patients; 10 (28%) had possible loosening on radiographs. The implant survival rate was 94% at shortest follow-up of 17 months (mean 70 months).

DISCUSSION

Treatment of complex radial head fractures using a pyrocarbon-bearing, anatomic press-fit design provides satisfactory short-term survivorship in this case series. The implant should be used with caution in salvage cases, due to higher rates of loosening seen in this cohort.

Radial head arthroplasty vs. open reduction and internal fixation for the treatment of terrible triad injury of the elbow: A systematic review and meta‑analysis update

Terrible triad injury of the elbow (TTIE) is a severe high-energy injury to the elbow, mainly including elbow dislocation, coronoid fracture and radial head fracture. It is difficult to maintain the stability of the elbow joint using traditional conservative treatment, and there is a high risk of redislocation and various complications. Therefore, surgical treatment is currently advocated, mainly for repairing damaged ligaments and reconstructing bony structures, but there is still controversy about the treatment plan for the radial head. The current meta-analysis was conducted to compare the differences in efficacy of radial head arthroplasty (RHA) and open reduction internal fixation (ORIF) in the treatment of TTIE. Published literature related to the treatment (either ORIF or RHA) of TTIE was searched for in Embase, PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical Literature Database. According to the search strategy, a total of 1,928 related publications were retrieved. The patient must have been diagnosed with TTIE and required surgery on the radial head. The interventions were RHA and ORIF. Non-case-control studies, case reports, review articles, letters, duplicate reports and literature without sufficient relevant data were excluded. The quality of the literature was evaluated according to the Cochrane systematic review methodology and the Jadad scale. After data extraction, meta-analysis was performed using ReviewManager 5.4 software (Cochrane). A total of 15 studies involving 455 patients (189 who underwent RHA and 266 who underwent ORIF) were included. Range of motion (ROM) of the forearm (pronation-supination arc) after surgery in the RHA group [95% CI (0.28, 9.59); P=0.04] was found to be significantly superior to the ORIF group, with a lower incidence of complications [95% CI (0.22, 0.84); P=0.01]. However, there was no statistically significant difference for the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand Score nor for ROM of the elbow (flexion-extension arc). Overall, compared with the ORIF group, the RHA group had better forearm rotational ROM and fewer complications after surgery. Therefore, RHA was found to be superior to ORIF in the treatment of TTIE.

Relative Prevalence and Associated Factors of Complex Regional Pain Syndrome Type I in Patients with Radial Head Fractures Treated with Open Reduction and Internal Fixation: A Cross-Sectional Study

Objective

This cross-sectional study aimed to examine the incidence and associated factors of complex regional pain syndrome type I (CRPS I) in patients who underwent open reduction and internal fixation (ORIF) for radial head fractures.

Methods

The study enrolled 601 radial head fracture patients treated with ORIF, 523 of which completed the 1-year follow-up. The incidence of CRPS I in those patients was assessed using the Budapest criteria. Patients were then divided into 2 groups: patients with CRPS I (n = 28) and patients without CRPS I (n = 495). The patients' demographic and clinical data before the operation were prospectively collected by our team. Independent t-tests and χ² tests were used as univariate analyses to compare the demographic and clinical data between the two groups. Meanwhile, multivariate regression analysis was conducted to identify the associated risk factors for CRPS I.

Results

The incidence of CRPS I in patients with radial head fractures treated with ORIF was 5.5% during the first year following surgery. Significant differences were observed in age, gender, type of trauma, modified Mason Classification, and depressive personality disorders. The logistic regression analysis revealed that the female gender, modified Mason type III fractures, and depressive patients were significantly more likely to develop CRPS I (p=0.021, 0.023, and 0.025, respectively).

Conclusions

The incidence of CRPS I among radial head fracture patients undergoing ORIF was 5.5%. In addition, early detection of CRPS I and providing adequate intervention will likely result in greater benefits for those patients.

Clinical long-term results of radial head arthroplasty in comminuted radial head fractures

Modern radial head prostheses have recently become more common in the treatment of comminuted radial head fractures. The goal of this study was to evaluate how well the EVOLVE^® modular metallic radial head implant prosthetic restores the functional range of motion and stability of the elbow. 30 patients with comminuted radial head fractures received an arthroplasty with an EVOLVE^® prosthesis in our institution. 20 of those patients were available for long-term follow-up (mean > 10 years). The outcomes were assessed on the basis of pain, motion, and strength. The overall outcome was scored with functional rating scores. According to the Broberg-Morrey elbow evaluation score, after a mean follow-up period of 10.2 years, ten (50.0%) patients were rated as very good, four (20.0%) as good, six (30.0%) as satisfactory, and none as poor. In the long-term results the Broberg-Morrey score increased from 79 (in short-term results) to 89 points. The Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure questionnaire showed an average of 16.2 points. Initially, patients had an extension deficit of 20°, which was reduced to 5° at the latest follow-up. In our long-term results, an improvement in the function of the elbow was observed after arthroplasty using a metallic modular radial head implant. Comminuted radial head fractures with elbow instability can be treated effectively with the EVOLVE^® radial head prosthesis, which restores stability in acute treatment. Our long-term results after 10.2 years demonstrate good functional outcome and low major complication rate. IV.

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.

Imaging the Postoperative Elbow

Evaluation of postoperative images of any joint can be a daunting task, and the elbow is no exception. Patients may be imaged with a complication of the repair, or the postoperative changes may be incidentally observed as the patient is imaged for other reasons. We divide the postoperative elbow into soft tissue procedures (covering ligament and tendon repairs, as well as compartmental release and nerve transposition), joint-related procedures (osteochondral lesion treatment, ostectomy, and joint replacement), and bone procedures (fracture fixation). We summarize the procedures and their indications, show normal imaging appearances, and finally cover common complications.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Long-term outcomes of radial head arthroplasty for radial head fractures-a systematic review at minimum 8-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following radial head arthroplasty (RHA) at a minimum of 8 years follow-up.

METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RHA with a minimum of mean 8 years' follow-up were considered for inclusion.

RESULTS

Our search found 10 studies including 432 elbows (51% males), with average age of 50 years (15-93) and mean follow-up of 117 months (98-145) met our inclusion criteria. At final follow-up, the mean Mayo Elbow Performance Score and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score were 83 (45-100) and 17 (0-63) respectively, and 86% of patients reported having no or minimal pain. The overall dislocation, subluxation, ulnar neuritis, and infection rates were 2%, 4%, 3%, and 3%, respectively. The rates of radiologic loosening, radiolucency, degenerative change, and heterotopic ossification were 9%, 46%, 27%, and 38%, respectively. The overall surgical revision rates were 20%, with 3%, 15%, and 5% requiring RHA implant revision, removal of metal or implants, and arthrolysis, respectively.

CONCLUSION

Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period.

Radial head fractures

Radial head fractures are the commonest fractures in the elbow. They are often associated with other injuries: ligamentous, cartilaginous or other fractures. Associated injuries are important determinant of the management of the radial head fracture. These should be carefully looked for, diagnosed and treated. The original Mason classification for this fracture has been modified to include the associated injuries and their treatment. CT scan is a helpful diagnostic tool and should be used if available. Radial head fractures can be treated either conservatively or operatively (by excision, open reduction and internal fixation or prosthetic replacement). Undisplaced or minimally displaced fractures should be treated non-operatively. Internal fixation by headless cannulated screws is the preferred treatment for displaced fractures. It provides satisfactory biomechanical stability, can be done through a smaller incision, has less complications and lesser requirement of later removal of screws. Small number of fractures with comminution of neck would require plate fixation. Unfixable fractures in elderly can be treated by excision while such fractures in younger population or associated with significant soft tissue or bony injuries would require prosthetic replacement.

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.

Radial head fractures with interposed capitellar cartilage fragment-hindrance to bone healing-a case series

INTRODUCTION

Radial head fractures account for the majority of bony elbow injuries. The individual treatment options have been described in detail. In some cases, however, an unusual concomitant injury occurs, which can significantly impede primary osteosynthesis and healing. This concomitant injury can be an interposing cartilaginous capitellar fragment.

METHODS

This retrospective study describes four cases of trapped cartilage fragments of the capitellum that compromised primary osteosynthesis or primary conservative healing of a radial head fracture. Radiological imaging, function and pain level are presented pre- and postoperatively (mean follow-up 9.25 months).

RESULTS

None of the four cases showed preoperative evidence of an incarcerated cartilage fragment of the capitellum. They all showed limited elbow range of motion. CT examinations were performed in all cases. In each case, the cartilage fragment was first sighted upon surgery, subsequently removed and the fractures treated with ORIF. Mean follow-up was of 9.25 months. All fractures healed, with excellent function and low pain scores.

CONCLUSIONS

This study presents rare cases of a trapped humeral cartilage fragment in radial head fractures. Radiological imaging including CT scans cannot reliably detect this concomitant injury. Therefore, this problem becomes apparent and treatable only during surgery. A high degree of suspicion is necessary especially in patients with minimally displaced fractures associated with limited elbow motion and a gap at the fracture site as treating these injuries conservatively may lead to poor outcome.