Mason Type Research Articles

Treatment of the terrible triad of the elbow by olecranon osteotomy: a retrospective cohort study

Background This study aims to evaluate the surgical techniques and outcomes of treating elbow dislocations with coronoid and radial head fractures, commonly referred to as the terrible triad of the elbow (TTE), through a single olecranon osteotomy. Methods A retrospective analysis was performed on 73 patients diagnosed with TTE between January 2015 and April 2022. The cohort included 44 men and 29 women, with an average age of 40.0 ± 15.1 years (range, 18–68 years). Among these patients, Mason Type I, II, and III fractures were identified in 11, 42, and 20 cases, respectively, while Morrey Type I, II, and III fractures were observed in 45, 23, and five cases, respectively. All patients underwent treatment via a single olecranon osteotomy. The average interval between injury and surgery was 5.6 ± 1.6 days (range, 3–8 days). Elbow function was assessed using the Mayo Elbow Performance Score (MEPS), pain was measured via the Visual Analogue Scale (VAS), and quality of life was evaluated using the SF-36 questionnaire. Results Patients were followed for 15 to 60 months (mean, 37.1 ± 13.3 months). All coronoid and radial head fractures achieved complete healing, with an average recovery time of 4.3 ± 1.1 months (range, 3–6 months). By the final follow-up, all patients had regained normal elbow function. The mean elbow flexion was 124.4° ± 9.2°, extension was 9.6° ± 6.5°, and the total range of flexion-extension was 114.8° ± 11.7°. Forearm pronation averaged 77.3° ± 4.8°, supination 79.2° ± 6.5°, and total forearm rotation 156.5° ± 8.4°. The mean MEPS was 89.3 ± 6.4, with 36 patients achieving excellent scores and 37 obtaining good scores. Preoperative VAS scores averaged 8.78 ± 1.11, which significantly dropped to 0.97 ± 0.83 at the final follow-up (p = 0.000). The SF-36 preoperative PCS and MCS scores were 45.77 ± 3.59 and 60.67 ± 3.91, respectively, with postoperative improvements to 93.85 ± 2.65 (p = 0.000) and 95.79 ± 3.11 (p = 0.000). Conclusion This retrospective analysis indicates that a single olecranon osteotomy could be a viable treatment option for TTE. However, additional research involving a control group is essential to substantiate the efficacy of this technique.

The outcomes of surgical treatment of complex radial head fractures.

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Irrespective of the patient's age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved.

Fracture Patterns, Outcomes, and Complications of Terrible Triad Injury in Elderly Patients

AimsThe aim of this study was to describe the fracture patterns of terrible triad elbow injury (TTEI) and to evaluate complications, functional and radiographic outcomes in mid-term follow-up in patients older than 65 years. MethodsA retrospective study of 29 patients, mean follow-up of 48.7±4.6 months (range 65-78). Fractures were classified according to the Mason and Regan-Morrey classifications. All patients were evaluated by the Mayo Elbow Performance Scale (MEPS), Quick-Dash, EQVAS, EQ5D scores, and ROM measurement. ResultsThe mean age was 72.3 years and 79% were women. Mason Type III (72%) and Reagan-Morrey type II (69%) were the most frequent fracture type. All patients were managed with a lateral approach consisting of repair or replacement of the radial head and repair of the lateral ulnar collateral ligament (LUCL); of these patients, 19 underwent re-attachment of the coronoid process or anterior capsule. Mean functional scores were MEPS 90.3±7.5, Quick-DASH 18.4±4.6, EQ5D .89± 0.33, EQ-VAS 86.2 ± 21, and VAS 2.2± 1.5. Mean postoperative flexo-extension arc of elbow motion was 105º (range, 65º-145º). Two patients (7%) required revision surgery. We did not observe any joint instability in the elbow after surgery. ConclusionsPatients over 65 years old with a terrible triad elbow injury (TTEI) are at substantial risk of complex fracture patterns, particularly Mason type III radial head fractures and Regan-Morrey type II coronoid fractures. Complications such as joint stiffness and heterotopic ossification are infrequent, while associated capitellum fractures are not rare and should be considered in the assessment as they can impact elbow stability. Despite these challenges, surgical management generally achieves favorable functional outcomes with low complication and reoperation rates.

Monobloc vs. Modular Radial-Head Arthroplasty for Complex Elbow Trauma: Long-Term Follow-Up and Comparative Evaluation.

Introduction: Mason Type 3 radial-head fractures are typically treated with open reduction and internal fixation (ORIF) or radial-head arthroplasty (RHA). Prosthetic options include traditional monobloc implants and newer modular implants designed to match patient anatomy. While short- and medium-term outcomes of metallic RHA are generally favorable, this study aims to compare the long-term outcomes of patients treated with monobloc versus modular implants. Methods: The medical records of all the patients who underwent RHA at a level I trauma center between 2000 and 2011 were retrospectively reviewed. Patients who were available for follow-up were invited for reassessment, which included physical examination, questionnaires for the assessment of elbow pain and function, and follow-up radiographs. Results: Out of 35 patients who had RHA, 13 (37%) had a monobloc prosthesis and 22 (63%) had a modular prosthesis. Out of the patients that could be traced, 4 patients from the monobloc group and 10 patients from the modular group agreed to participate in the study. The mean follow-up time was 15 years in the monobloc group and 12.4 years in the modular group. Patients in the modular group demonstrated superior functional outcomes compared to the monobloc group, with statistically significant improvements in MEPS and DASH scores and a non-significant trend towards better ASES scores and VAS scores. Physical examination revealed a decline in function in the operated arm for both groups, with statistically significant differences favoring the modular group in elbow flexion and extension. Radiographic analysis showed varying degrees of implant loosening, with the modular group exhibiting less loosening compared to the monobloc group. Mild degenerative changes and heterotopic ossification were also observed, predominantly in the modular group. Conclusions: The results suggest that modular implants offer superior functional outcomes compared to monobloc implants. The modular group showed statistically significant improvements in elbow flexion and extension. These findings indicate that modular implants may be a more favorable option for enhancing patient outcomes. Further research with larger sample sizes is recommended to confirm these trends and to better understand the long-term benefits of modular implants.

Minimum 10-year Follow-up after Open Reduction and Internal Fixation of Radial Head Fractures Mason Type II and III

The treatment of complex radial head fractures remains controversial with open reduction and internal fixation (ORIF), radial head arthroplasty, and radial head excision being the most common treatment options. While ORIF is the preferred treatment strategy for Mason type II fractures, the optimal treatment of Mason type III fractures is debated. To report minimum 10-year outcomes after ORIF of Mason type II and type III radial head fractures. We hypothesized that both Mason Type II and Type III fracture patients would demonstrate satisfactory clinical outcomes at minimum 10-year follow-up. All patients with Mason type II or III radial head fractures who were treated with ORIF by a single surgeon between 2005 and 2010 were included. Fractures with significant bone defects were treated with bone grafts and elbow ligament injuries were treated with either primary ligament repair or reconstruction. Patient reported outcome (PRO) questionnaires were administered at the time of last clinical follow-up and at a minimum of 10 years postoperatively. Twenty-four patients, including 13 male and 11 female patients with an average age of 39 (range 19-60) at the time of surgery met inclusion criteria. Thirteen patients suffered from Mason type II and 11 patients from Mason type III fractures. At initial follow-up, 21 out of 24 fractures (88%) demonstrated radiographic union. Three non-unions, 2 of which were Mason type III fractures, were treated with revision ORIF and iliac crest bone grafting. 11 patients developed postoperative elbow stiffness and required capsular release surgery. At last clinical follow-up, average flexion was 139 degrees, average extension was 4 degrees, average supination was 77 degrees, and average pronation was 81 degrees. The median DASH score was 7 (ranging from 0 - 32). Minimum 10-year follow-up (mean: 14.6 years) was collected on 18 of 24 (75%) of the patients. At a minimum of 10 years postoperatively, the median QuickDASH score was 4.5 (range: 0 to 25) and the median SANE score was 96.5 (range: 75-100). Median satisfaction with the surgical outcome was 10/10 (range: 3-10). ORIF of Mason type II and III radial head fractures results in high union rates with good functional outcomes at a mean of 14.6 years postoperatively. The study results suggest that ORIF of Mason type II and III radial head fractures leads to long-term positive functional outcomes.

A Study Evaluating the Functional Outcomes of Mason Type III and IV Radial Head Fractures Treated With a Radial Head Prosthesis.

Objective This research aimed to assess the functional result of type III and IV radial head fractures that were treated using a radial head prosthesis. Methods A retrospective investigation was conducted on 70 patients with type III and IV radial head and neck fractures, as classified by Mason. The patients were hospitalized and received treatment at the Orthopaedics Department, where they had radial head prosthesis surgery for three years. Results Among the total of 70 cases, 42 (60%) cases were below the age of 40, while 28 (47%) cases were over 40 years. The average age was 36.4 years. The maximum age recorded was 54 years, while the lowest age recorded was 30 years. The female population outnumbered the male population. The majority of instances (42, 60%) were attributed to falls, while the remaining cases were caused by road traffic accidents (RTAs). Out of the total 70 instances, 52 cases (74.28%) exhibited right-side dominance, whereas 18 cases (25.72%) exhibited left-side dominance. Within our case study group, 56 (80%) cases fell under modified Mason's classification type Ill, totaling 56 instances. The remaining 20% of the cases, amounting to 11 cases, were classified as modified Mason's classification type IV. Among the 70 patients, 55 cases (78.58%) did not have any ligamentous damage, whereas seven (10%) cases had lateral ulnar collateral ligament (LUCL) injury and eight (11%) cases had medial collateral ligament (MCL)injury. The P value for flexion, extension, pronation, and supination was shown to be very significant. Out of the total, 47 (67%) instances had an MEPI score (Mayo Elbow Performance Index) of more than 90, indicating exceptional performance. In addition, 16 cases (22.85%) had an MEPI score ranging from 75 to 89, which is considered a good result. Lastly, seven cases (10%) had an MEPI score ranging from 60 to 74, indicating a fair result. Conclusion The use of a radial head prosthesis is considered a viable option for managing severe and irreparable fractures of the radial head. Effective outcomes hinge on meticulous preoperative planning, skilled intraoperative techniques, and intensive postoperative rehabilitation. These elements collectively contribute to achieving consistent and favorable results in patients undergoing this surgical intervention.

Arthroscopic Percutaneous Fixation of Mason Type 2 Radial Head Fractures.

Management of radial head fractures around the elbow with open techniques can predispose to edema, postoperative pain, and adhesions. The resultant limitation in elbow range of motion negatively affects functional outcomes. Rehabilitation is then rendered a challenge in a joint with proneness to stiffness. Arthroscopic percutaneous fixation of Mason type 2 radial head fractures would provide satisfactory radiological and clinical outcomes. Case series; Level of evidence, 4. A total of 24 patients diagnosed with isolated Mason type 2 radial head fractures at a single institution between February 1, 2021, and December 31, 2021, received arthroscopic percutaneous fixation by headless screws. Functional evaluation included Mayo Elbow Performance Score and postoperative elbow range of motion measurements. Radiological evaluation was performed using elbow radiographs and computed tomography scans. Patients were evaluated for a minimum of 24 months. This study included 12 male and 12 female participants with a mean age of 37.29 ± 11.93 years. At the end of the follow-up period (mean, 27.75 months; range, 24-32 months), the mean elbow flexion was 140.17° ± 8.21° and the extension deficit was 4.17° ± 3.81°. The Mayo Elbow Performance Score revealed 21 patients with excellent results and 3 patients with good results. All patients returned to preinjury activities at a mean time of 3.1 months (range, 2-6 months) postoperatively. Union was reached in all patients at a mean time of 7.63 weeks (range, 6-10 weeks). No neurological complications or reoperations were reported at the end of the follow-up period. Arthroscopic fixation was demonstrated to be a valid and valuable technique for managing isolated Mason type 2 radial head fractures. It allowed for accurate reduction without the need for soft tissue dissection, resulting in excellent clinical outcomes.

Comprehensive Classification of the Capitellar Injury Concurrent with Radial Head Fracture.

Capitellar injury (CI) includes capitellar cartilage injury (CCI) and capitellar fracture (CF). A comprehensive classification of CI concurrent with radial head fracture (RHF) that can guide surgical strategy is lacking in the literature. Therefore, this study aimed to introduce a comprehensive classification of CI concurrent with RHF and investigate its value. A total of 35 patients with CI concurrent with RHF confirmed by surgical exploration were retrospectively analyzed, includingmales in 19 cases and females in 16 cases. RHF was classified according to the Mason classification, and CI was classified into six types, including 3 types of CCI and CF, each based on the site and degrees of injuries (comprehensive classification method proposed in this study). The classification results were analyzed. Two radiologists were selected to independently classify the CI, and the inter- and intra-observer agreements were analyzed with kappa statistics. Mason Type I, II, III, and IV RHF accounted for 14.3%, 48.6%, 37.1%, and 0% of cases, respectively. Type I, II, III, IV, V, and VI CIs accounted for 22.9%, 34.3%, 25.7%, 11.4%, 2.9%, and 2.9% of cases, respectively. Therewas no obvious relationship between the CI and RHF types (p > 0.05). All Type I CIs underwent removal, 9 Type II CIs underwent microfracture repair, and 3 Type II CIs underwent removal. All Type III CIs underwent fixation, one Type IV CI underwent removal, and 3 Type IV CIs underwent fixation, one Type V CI underwent fixation, and one Type VI CI underwent arthroplasty. The inter- and intra-observer kappa coefficients were 0.830 ~ 0.905 and 0.805 ~ 0.892, respectively. At 12 months postoperatively, the elbow function evaluated by MEPS was 91, with an excellent and good rate of 97%. Different types of CI differ not only in pathology but also in treatment methods. The CI comprehensive classification put forth in this paper for the first time reflects different types of pathology well, with high consistency and repeatability, and can guide the selection of surgical methods, leading to satisfactory postoperative results.

Added transverse screw in tripod construct increases stiffness in Mason III radial head fractures: a finite element analysis

BackgroundThe tripod screw configuration has been shown to offer similar stiffness characteristics to a laterally placed plate. However, concern has been raised that the construct may be prone to failure in scenarios where the screw intersects at the fracture line. We performed a finite element analysis to assess potentially ideal and unideal screw placements in the tripod construct among Mason III radial head fractures. MethodsA 3-dimensional proximal radius model was developed using a computed tomography scan of an adult male radius. The fracture site was simulated with a uniform gap in transverse and sagittal planes creating a Mason Type III fracture pattern comprising 3 fragments. Three configurations were modelled with varying screw intersection points in relation to the radial neck fracture line. A fourth configuration comprising an added transverse interfragmentary screw was also modelled. Loading scenarios included axial and shear forces to simulate physiological conditions. Von mises stress and displacement were used as outcomes for analysis. ResultsSome variation can be seen among the tripod configurations, with a marginal tendency for reduced implant stress and greater stiffness when screw intersection is further from the neck fracture region. The construct with an added transverse interfragmentary screws demonstrated greater stiffness (2269N/mm) than an equivalent tripod construct comprising three screws (612N/mm). ConclusionThe results from this study demonstrate biomechanical similarity between tripod screw constructs including where screws intersect at the radial neck fracture line. An added fourth screw, positioned transversely across fragments increased construct stiffness in our model.

Percutaneous treatment of radial neck fractures in adult patients.

Radial neck fractures in adults are rare, but outcomes are often poor. Closed reduction and internal fixation (CRIF) technique has been advocated for the treatment of minimally displaced fractures in children, with a few reports on adult subjects. The aim of the present paper is to investigate mid-term results of a CRIF technique in adults with retrograde intramedullary K-wires in Mason's type II and III fractures. The proposed technique yields to good anatomical reduction of displaced neck fractures, faster rehabilitation, and easier hardware removal after fracture consolidation. A consecutive series of 17 patients were treated with closed reduction and intramedullary osteosynthesis, and outcomes were retrospectively evaluated. Elbow X-ray (XR) and CT scan were obtained preoperatively. Objective assessment before surgery and at an average 36-month follow-up included active and passive elbow range of motion (ROM). Functional evaluation was carried out through the collection of the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Elbow Self-Assessment Score (ESAS). XR at last follow-up was evaluated. The cohort included 10 males and seven females, with a mean age of 32 years. Patients returned for a follow-up evaluation at a mean of 36 months (range 6-43 m) form the surgery. The DASH score revealed good to excellent outcomes with a mean of 6.32 ± 10.24 points at last follow-up. The ESAS was 98.35 ± 1.89, indicating a non-restricted elbow function. Acceptable radiographic healing was achieved in all patients. The advocated technique is promising for obtaining good reduction and stabilization, and good to excellent satisfaction for patients. Given the challenging technique, the learning curve could be long and initial results unsatisfactory. More research with larger cohorts and improved study design could be carried out, comparing the technique with the current choice of treatment (ORIF, radial head resection).

Isolated post-traumatic anterior radial head dislocation in adult: A very rare injury

Isolated anterior radial head dislocations are rare injuries. Few cases have been reported in the literature. Most patients are diagnosed late with restricted forearm rotations. In this report, we provide the details of an isolated radial head anterior dislocation with Mason type 1 radial head fracture in an adult.

Is the 'safe zone' identified in preoperative computed tomography helpful for choosing optimal implant for fixation of radial head fracture?

The purpose of this study is to assess the clinical significance of the radiologic safe zone based on computed tomography and to compare the outcomes of three different implants for fixation of isolated radial head fractures. We retrospectively reviewed 367 patients who underwent internal fixation for isolated radial head fractures. We newly defined two subtypes of Mason type II fractures associated with the radiographic safe zone (IIA, two-part fracture allowing for safe fixation of plate; IIB, two-part fracture not allowing for safe fixation). 170 patients (CCS group, n = 82; HCS group, n = 31; plate group, n = 57) were investigated with no significant differences in demographics. The range of pronation and supination at 1 month postoperatively (P = 0.04 and P = 0.04) and the range of supination at 6 and 12 months postoperatively (P = 0.03 and P = 0.03) were significantly smaller in the plate group. In Mason type IIB fractures, the average MEPS was higher in the CCS and HSC groups than in the plate group (P = 0.01 and P = 0.02). And the average DASH score was lower in the CCS and HCS groups (P < 0.01 and P < 0.01). Evaluation of the radiologic safe zone is potentially helpful in selecting better surgical fixation option. For type III fractures, 2.3-mm cortical screws would be a better option than Acutrak screws. Plates would not be suitable for type IIB radial head fractures.

Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture

To compare the effectiveness between the posterolateral approach and the posterolateral combined posteromedial approaches in the treatment of Mason type 2B posterior malleolar fracture. A retrospective analysis was performed on the clinical data of 79 patients with posterior ankle fracture who met the selection criteria between January 2015 and January 2022. There were 62 cases of Mason 2B Pilon subtype and 17 cases of avulsion subtype. Among Mason 2B Pilon subtype patients, 35 were treated with posterolateral approach (group A), 27 patients were treated with combined approach (group B). There was no significant difference in gender, age, injured side, cause of injury, time from injury to operation, preoperative hospital stay, preoperative visualanalogue scale (VAS) score, and intraoperative internal fixation between the two groups ( P>0.05). All patients with Mason 2B avulsion subtype were treated by posterolateral approach, including 7 males and 10 females, aged from 25 to 68 years, with an average of 46.1 years. The operation time, intraoperative blood loss, postoperative hospital stay, and complications were recorded. The reduction quality was evaluated by Ovadia deals radiographic score, and the ankle function and pain were evaluated by VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and ankle range of motion. Mason 2B Pilon subtype: There was no significant difference in operation time, intraoperative blood loss, postoperative hospital stay, and follow-up time between the two groups ( P>0.05). The radiological evaluation of Ovadia deals in group A was significantly worse than that in group B ( P<0.05). The VAS score in the two groups significantly improved at each time point after operation, and the VAS score and AOFAS score further improved with the extension of time after operation, and the differences were significant ( P<0.05). Except that the AOFAS score of group A was significantly lower than that of group B at last follow-up ( P<0.05), there was no significant difference in VAS score and AOFAS score between the two groups at other time points ( P>0.05). At last follow-up, the ankle range of motion in group A was significantly less than that in group B ( P<0.05). There was no significant difference in the incidence of sural nerve injury, deep tissue infection, limitation of toe movement, and traumatic ankle arthritis between the two groups ( P>0.05). Mason 2B avulsion subtype: The operation time was (119.47±20.61) minutes and the intraoperative blood loss was 50 (35, 55) mL. Seventeen patients were followed up 13-25 months, with an average of 18 months. The Ovadia deals score was excellent in 10 cases, good in 6 cases, and poor in 1 case at 1 week after operation, and the excellent and good rate was 94.1%. All fractures healed in 8-18 weeks with an average of 12.35 weeks. There were 1 case of sural nerve injury and 3 cases of traumatic ankle arthritis after operation. No deep tissue infection or limitation of toe movement occurred. The VAS score decreased significantly and AOFAS score increased significantly with time, and the differences were significant between different time points before and after operation ( P<0.05). The ankle range of motion at last follow-up was (56.71±2.47)°. Compared with the posterolateral approach, the combined approach is a better choice for the treatment of Mason 2B Pilon subtype. If the posteromedial bone block does not affect the reduction of the medial malleolus, the posterolateral approach can achieve good effectiveness for Mason 2B avulsion subtype.

Open reduction and internal fixation of modified Mason type III/IV radial head fractures with more than three fragments: an analysis of the clinical outcome and reoperation rate

PurposeIt is generally accepted that a radial head fracture (RHF) with more than three parts is not suitable for repair; therefore, most authors suggest straightforward radial head arthroplasty (RHA). With up to 20% risk for reoperation after RHA, improvement in reduction and fixation techniques may represent a valuable alternative before further extending the indications for arthroplasty. To determine the functional results and radiological failure rate after osteosynthesis of multi-fragmentary RHF with more than three articular fragments. We specifically determined (1) the one-year Broberg and Morrey functional elbow score, (2) duration of fracture healing, (3) complication rate, and (4) number of patients converted to RHA.MethodsThis study is a retrospective single-center case series. All patients who underwent primary osteosynthesis for RHF between 2012 and 2019 were included. Nine patients with an average age of 52 years had an average clinical and/or radiological follow-up of 49 months.ResultsThe preoperative imaging identified nine fractures with four fragments. Three patients underwent osteosynthesis with plates and screws, whereas six patients underwent osteosynthesis with only screws. The mean Broberg and Morrey score was 95 points. Overall, eight of the nine patients had satisfactory results. All patients retained their radial heads and showed radiological fracture healing. Only two patients presented with low-grade complications requiring no further surgery.ConclusionOur study showed that osteosynthesis of RHF with up to four fragments can achieve good functional results with a low complication rate and seems to be a valid alternative to RHA.

Morphological Analysis of Intraarticular Fragments in AO/OTA 44 Category Posterior Malleolar Fractures

Category: Ankle; Trauma Introduction/Purpose: Intraarticular fragments (IAFs) associated with posterior malleolar fractures are a major obstacle in the treatment of ankle fractures. However, their frequency, location, and morphology, as well as their relationship with the classification of ankle posterior malleolar fractures, are poorly understood and unresolved. The Purpose of this study is to clarify the frequency and morphology of IAFs in posterior malleolar ankle fractures. Methods: This study was conducted at a single institution and included 104 consecutive patients with trimalleolar ankle fractures treated between 2015 and 2022. The inclusion criteria were 1) acute fracture within 2 weeks after injury and 2) cases with computed tomography (CT) images at the time of injury. The exclusion criteria were 1) previous ipsilateral ankle fracture, 2) pathological fracture, and 3) younger age with open physis. CT images at the time of injury were reviewed and each posterior malleolar fracture was classified using the Mason classification. Frequency of occurrence, size (long diameter × short diameter), and angle (the angle between the long diameter and fracture surface of the posterior malleolar fracture) of the IAF. The location of the IAF was described from CT axial images The dislocated distance of the IAF from the articular surface was measured on the sagittal CT view. Results: The patient’s mean age was 54.6 years. 46 cases were Type 1, 32 cases were Type 2A, 9 cases were Type 2B, and 17 cases were Type 3 according to the Mason’s classification. In Mason Type 2 and 3 cases, the IAF was present in 32 (78.0%) and 12 (70.6%) cases, respectively. The IAF was more frequently observed laterally in type 2 (22 cases) and medially in type 3 (7 cases). The long × short diameter of the IAF averaged 11.2 × 4.9 mm and 9.0 × 3.7 mm for Types 2 and 3, respectively. The angle of IAF was 10.5 ± 13.4° and 8.5 ± 7.8°, the distance of displacement was 3.0 ± 2.6 mm and 2.4 ± 1.2 mm, respectively. Conclusion: This study revealed a high incidence of IAFs in posterior malleolar ankle fractures. The IAF has a long medial to lateral shape, as well as the direction of the posterior malleolus fracture, occurs more often laterally in Mason Type 2 and medially in type 3. These findings suggest a pathophysiology in which the axial force causes secondary intraarticular impingement after the main fracture of the posterior malleolus. resulting in the development of an IAF. Handling IAFs is one of the keys in the treatment of posterior malleolar fractures and the surgical approach should be also selected based on the IAF.

Comparing the outcomes of tripod technique and locked plate fixation for the treatment of Mason type 3 radial head fractures.

In this study, we aimed to compare functional outcomes and complication rates of tripod technique and locked plate fixation used in Mason type 3 radial head fractures. Between January 2012 and December 2019, a total of 27 patients (16 males, 11 females; median age: 43.2 years; range, 20 to 68 years) with Mason type 3 radial head fractures were retrospectively analyzed. The patients were divided into two groups according to fixation method used. Group 1 consisted of 12 patients who were treated with tripod technique, and Group 2 consisted of 15 patients who were treated with locked plate fixation. Operation time, follow-up period, length of hospital stay, union time, Disabilities of Arm, Shoulder and Hand (DASH) scores, range of motions and complications were recorded. The median time to bone union was 46.7 days in Group 1, which was significantly shorter than Group 2 (p<0.001). The median forearm pronation-supination arc was 123.75° (range, 30° to 180°) in Group 1 and was 94° (range, 45° to 180°) in Group 2. There was no significant difference in the forearm rotation between the groups. The median elbow flexion-extension arc was 99.17° (range, 65° to 130°) in Group 1 and was 80.33° (range, 30° to 130°) in Group 2. No statistically significant difference was found in the flexion-extension and pronation-supination arc degrees. There was no significant difference in the postoperative DASH scores between the groups (p=0.464). Our study results demonstrate that comparable results can be achieved in both techniques regarding functional outcome and range of motion. With a shorter union time and less complication rates, the tripod technique should be considered as the primary treatment method for the comminuted radial head fractures without a metaphyseal defect.

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.

Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players.

Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation. To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle. Case series; Level of evidence, 4. A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01). All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.

Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS).

The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes. We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months. At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively. PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.

Incidence et typologie des fractures concomitantes du capitellum associées aux fractures du col et de la tête radiale

BackgroundRadial head and neck fracture is a common fracture around the elbow. It is mostly caused by axial or valgus loading after a fall in elbow extension and forearm pronation. When a radial head and neck fracture occurs, the capitellum collides with the radial head and experiences a shear force, leading to capitellum fracture. The primary aim of this study was to evaluate the incidence of concurrent capitellum fracture and analyze its patterns among patients treated for radial head and neck fractures based on computed tomography. Secondary aim is to determine factors associated with concurrent capitellum fractures. HypothesisCapitellum fractures are more common than expected in radial head and neck fractures and show a consistent pattern. With the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture will be shown. MethodsA total of 101 patients treated surgically (27 patients) or non-surgically (74 patients) for radial head and neck fractures from January 2017 to December 2020 were retrospectively analyzed. Initial computed tomography was reviewed to identify concurrent capitellum fractures. A fracture was diagnosed when the bone continuity was lost in two consecutive images in any one of the three directions of computed tomography scan images. Seventeen patients with capitellum fractures were classified as group 1 and 84 patients without capitellum fractures as group 2. Each group of patients was assessed using Mason classification, whether fracture extended to the radial neck or not, fracture location, and treatment method. To determine the fracture location, radial head was trisected using three anatomical landmarks: safe zone, posteromedial zone, and anteromedial zone. And it was determined as the location where the fracture was most comminuted. ResultsThe average age of the 101 patients was 44.6 years old. There were 54 (53.5%) males and 47 (46.5%) females. Capitellum fracture was accompanied in 17 cases. Its incidence was 16.8%. The rate of accompanying capitellum fracture was 9.5% (6/63) for Mason type 1, 25.0% (6/24) for Mason type 2, and 41.7% (5/12) for Mason type 3. The ratio of radial neck extension of fracture was significantly higher in group 2. There was no isolated radial neck fracture in group 1. However, there were 33 in group 2. After eliminating isolated radial neck fracture patients, significantly more fractures were located in the safety zone in group 1. Group 1 had a significantly higher rate of surgical treatment than group 2 (52.9% (9/17) vs. 21.4% (18/84) p = 0.007). ConclusionFor radial head and neck fractures, the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture. When the fracture extended to the radial neck, the comorbidity of the capitellum fracture was decreased. Among radial head fractures, when the fracture was located in the safe zone, the comorbidity of capitellum fracture was increased. The rate of surgical treatment was higher in radial head and neck fracture patients with concurrent capitellum fractures. Level of evidenceIV; diagnostic study.