Radial Head Injury Research Articles

RADIAL HEAD FRACTURES, EPIDEMIOLOGY, ANATOMY, MECHANISM OF INJURY, CLASSIFICATION, IMAGING PRESENTATION, CLINICAL PRESENTATION, MANAGEMENT AND COMPLICATIONS

Introduction: In recent years the understanding and comprehension of the elbow has improved, clarifying some aspects of the complex diarthrodial joint. The relevance of the radial head in the biomechanics of the elbow is recognized which helps to improve the management and treatment of fractures at this site. Elbow trauma is the most common origin of proximal radius fractures, this trauma can be direct or indirect and can cause an isolated fracture, a fracture associated with other fractures and ligament injuries. Objective: to detail the current information related to radial head fractures, epidemiology, anatomy, presentation, clinical evaluation, imaging evaluation, classification, treatment and complications. Methodology: a total of 42 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 31 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: radial head fractures, radial head prosthesis, radial head arthroplasty. Results: Radial head fractures have an incidence of 2.5 per 10,000 per year, which represents 1.7 to 5.4% of all fractures. Most radial head injuries are the result of a fall on the hand in extension. Usually the affected individuals show limitation of mobility of the forearm and elbow in addition to pain or discomfort when making passive rotational movement of the forearm; they also usually present pain on palpation over the radial head and joint effusion in the elbow. Sometimes there is a fracture-dislocation of the radial head related to a rupture of the interosseous membrane with lesion of the distal radioulnar joint called Essex-Lopresti lesion. Conclusions: The radial head together with the interosseous membrane of the forearm provide longitudinal stability; when the interosseous membrane is damaged, a proximal migration of the radial head may occur after removal of the radial head. When presenting clinical suspicion of elbow fracture, standard anteroposterior and lateral projections of the elbow should be requested, as well as oblique projections such as the Greenspan projection. The Manson, Mason-Johnston or Mason classification modified by Hotchkiss is usually used for classification. Among the indications for conservative treatment are solitary, undisplaced or minimally displaced fractures that do not present mechanical blockages in the range of motion or less than 3 mm of displacement. Studies report the effectiveness of open reduction and internal fixation of simple Mason type II fractures; Manson type III fractures are controversial. Complications usually arise from contracture subsequent to prolonged immobilization or secondary to persistent pain, edema and swelling; which may be due to undiagnosed osteochondral injury of the capitellum. KEY WORDS: fracture, radius, head, prosthesis, elbow.

SOME WORDS ABOUT FRACTURES OF RADIAL HEAD

A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology.
 Early elbow ROM is needed to prevent stiffness. If you fixed the fracture, but not well enough to move the elbow, you did not fix it.
 The “safe zone” for placing hardware on the radial head lies in the interval between the radial styloid and Lister’s tubercle.
 Examine the wrist when examining all elbow injuries; a radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint.
 The posterior interosseous nerve (controlling finger and wrist extension) can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively. The severity of these injuries runs the gamut from minimally displaced fractures needing minimal treatment to those with major displacement or comminution, requiring surgical fixation, excision, or replacement.

Management of anteromedial coronoid fractures according to a protocol focused on instability assessment provides good outcomes with infrequent need for coronoid fixation

Anteromedial coronoid fractures (AMCFs) are associated with persistent elbow instability and post-traumatic arthritis if managed incorrectly. It is unclear exactly which AMCFs require surgical intervention and how to make this decision. The aims of this study were to report outcomes of AMCFs managed using a protocol based on reproduction of instability using radiographic and clinical testingand to ascertain a threshold size of AMCF associated with instability. Forty-three AMCFs were studied. Thirty-two patientsformed the primary study group (group A). All were treated using a protocol in which the decision to perform coronoid fixation was based on the presence of radiographic or clinical evidence of instability. Functional outcomes (Oxford Elbow Score), radiographic outcomes, complications, and reoperations were collected, and a receiver operating characteristic curve analysis was performed to assess the optimal coronoid fracture height to recommend coronoid fixation. The results were compared with a historical group of 11 patientswith AMCFs not treated according to the protocol (group B). Of the patients, 23 had an isolated AMCF and 20 had a concurrent radial head injury. Complete nonoperative treatment of the elbow was performed in 16 patients (37%) (11 of 32 [34%] in group A vs. 5 of 11 [45%] in group B, P = .46). In 10 patients (23%), only repair of the lateral collateral ligament was performed (9 in group A and 1 in group B), whereas 8 patients (19%) underwent repair of the lateral collateral ligament and radial head fixation or replacement (6 in group A and 2 in group B). Acute coronoid fixation was performed in 9 patients (21%) (6 in group A and 3 in group B). At a mean follow-up of 20 months (range, 12-56 months), group A showed a significantly better Oxford Elbow Score (42 vs. 31, P = .02), lower complication rate (3 of 32 [9%] vs. 8 of 11 [72%], P < .001), and lower reoperation rate (1 of 32 [3%] vs. 6 of 11 [54%], P < .001) than group B. Persistent instability was found in 6 patients in group B and none in group A. The receiver operating characteristic curve analysis demonstrated 6.5 mm to be the optimal AMCF size for surgery to prevent persistent instability. Patients treated according to a protocol in which preoperative reproduction of instability determined the degree of surgical intervention had good clinical and radiographic outcomes. Our study demonstrated that AMCFs > 6.5 mm are likely to be more unstable and require intervention. If these principles are followed, a specifically defined subset of AMCFs can be treated nonsurgically without adverse outcomes.

The Incidence and Risk Factors of Scaphoid Fracture Associated With Radial Head and Neck Fracture in Trauma Patients.

Background:Scaphoid and radial head fractures are two injuries derived from the common fall on outstretched hand. How these injuries are related has not been fully investigated. The aim of this study was to evaluate risk factors for having concomitant proximal radius and scaphoid fractures. The goal was to identify at-risk patient populations and drive improvement in diagnosis and management of these injuries.Methods:A retrospective review of the National Trauma Data Bank from 2007 through 2012 identified 11,309 patients with proximal radius fracture, and, as a proxy for low-energy injury, an injury severity score of less than 15. These patients were then categorized by presence of concomitant scaphoid injury. Presence of scaphoid fracture was then analyzed based on age, sex, race, trauma type, mechanism, and injury severity score.Results:Three hundred seventy-eight (3%) scaphoid fractures among the 11,309 proximal radius fractures were identified. Both age and sex reached statistical significance as risk factors for concomitant scaphoid and radial head injury. There was an incremental increase in risk for concomitant injury with younger age. Subset analysis demonstrated a 10% incidence of concomitant fractures in men aged 18 to 30 years.Discussion:This study provides a better understanding of how these two fractures are related. There is a markedly higher risk for concomitant injuries in male and young patients, especially those whose mechanism is a fall. Close examination of the wrist should be performed for any proximal radius fracture, and any pain should be a cause for further investigation of scaphoid injury.

Radial Head Injuries

Radial Head Injuries

Outcome of Early and Late Diagnosed Essex-Lopresti Injury.

The aim of this study was to investigate the outcomes in a large series of Essex-Lopresti injuries (ELIs) and to compare patients with early and late diagnoses. Thirty-one patients with an ELI (average age and standard deviation [SD], 46 ± 10 years) who were followed for a minimum of 2 years were included in the study. Patients were grouped according to whether the ELI had been diagnosed early (on the day of the injury) or late (>4 weeks after the radial head injury). Acute treatment of early-diagnosed ELI included temporary stabilization of the distal radioulnar joint (DRUJ) by Kirschner wires with the forearm in supination for 6 weeks. Clinical outcomes were assessed on the basis of the range of motion, Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), visual analog scale (VAS) score for wrist and elbow pain, and Disabilities of the Arm, Shoulder and Hand (DASH) score. The ELI was diagnosed on the day of the injury in 16 patients (52%; the early group) and late (at a mean of 7 ± 7 months; range, 1 to 24 months) in 15 (48%; the late group). After a mean duration of follow-up of 5.3 ± 3.0 years (range, 2.0 to 13.1 years), patients with an early diagnosed ELI had significantly better clinical outcomes, compared with those with a late diagnosis, with regard to the MEPS (91.3 ± 8.7 versus 74.7 ± 15.3, p = 0.003), MWS (81.3 ± 16.5 versus 66.3 ± 17.6, p = 0.019), DASH score (12.5 ± 8.7 versus 45.3 ± 23.5, p = 0.001), VAS elbow pain score (0.7 ± 1.1 versus 3.3 ± 2.1, p = 0.001), and VAS wrist pain score (0.9 ± 1.2 versus 3.9 ± 1.7, p < 0.001). The ranges of motion of the elbow and wrist did not differ significantly between the early and late groups (p > 0.05). A significantly lower percentage of patients had complications or subsequent surgical procedures in the early than in the late group (38% [6 of 16] versus 93% [14 of 15], p < 0.001). Early diagnosis of an ELI with temporary stabilization of the DRUJ leads to satisfactory clinical mid-term results, whereas late diagnosis of an ELI is associated with a deteriorated outcome. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of complex elbow fracture-dislocations.

Successful management of complex elbow fracture-dislocations requires, in part, recognition of the overall injury pattern, which can aid in the identification of concomitant bony and soft tissue injuries. Trans-olecranon fracture-dislocations are best treated surgically with stable anatomic restoration of the trochlear notch. Terrible triad elbow injuries are believed to be caused by a valgus posterolateral force. Although select terrible triad injuries can be managed non-operatively, the majority of injuries are treated with stable surgical repair to allow early elbow motion. Unlike terrible triads, varus posteromedial forces are theorized to cause anteromedial coronoid fractures. These are usually associated with LCL disruptions, but do not have concomitant MCL or radial head injuries. A subset of anteromedial coronoid fractures can also be managed non-operatively. Internal fixation is recommended for injuries associated with large fracture fragments or elbow instability preventing early motion.

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

BackgroundHigh-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 methodsPatients 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.ResultsThe 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 %).ConclusionThe 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 evidenceDiagnostic III.

Fractures in Brief: Olecranon Fractures

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

Radial Head—Resect, Fix, or Replace

Management of radial head fractures has evolved over the years, as have the techniques and implants used to treat them. However, no standardized treatment protocols exist because of the complexity with which radial head fractures may present. They range from stable, nondisplaced fractures to displaced, comminuted fractures with associated ligamentous, and osseous defects. Management of the complex fractures can be challenging. Historically, radial head excision was recommended for comminuted fractures, but with increased awareness of elbow and forearm biomechanics, the treatment choice for complex radial head injuries has evolved to internal fixation or replacement. The Mason classification may be used to guide treatment, however fracture characteristics and associated injuries must also be considered. Regardless of the treatment option, early range of motion and restoration of elbow anatomy with good surgical technique are imperative.

Fractures in Brief: Radial Head Fractures

Fractures of the radial head are common [4], constituting approximately one-third of all elbow fractures. These fractures typically occur when an axial load is applied to the forearm, causing the radial head to hit the capitellum of the humerus. The severity of these injuries runs the gamut from minimally displaced fractures needing minimal treatment to those with major displacement or comminution, requiring surgical fixation, excision, or replacement.

Ultrasonography for the evaluation of forearm interosseous membrane disruption in a cadaver model.

Recognition of interosseous membrane disruption associated with radial head injury and Essex-Lopresti injury is important, especially if radial head excision is contemplated. Because a widely accepted method to diagnose interosseous membrane disruption does not exist, we evaluated the accuracy of ultrasonography to diagnose this injury in a cadaver model. Nine pairs of cadaver forearms were randomized into 2 groups. The central third of the interosseous membrane of forearms of group 1 was cut, whereas it was visualized but not cut in group 2. A dynamic ultrasound examination was performed to determine interosseous membrane integrity, and static images were made. The static images were evaluated by 2 other radiologists and interpretations were recorded. One radiologist incorrectly interpreted 1 pair of forearms; the other 2 radiologists were 100% accurate. The accuracy of ultrasonography in detecting interosseous injuries was 96% with our methods.

Isolated traumatic radial head injury in children

Isolated traumatic radial head injury in children

Radio-ulnar dissociation. A review of twenty cases.

The results of treatment were reviewed for twenty patients who had sustained concomitant injuries of the lateral compartment of the radiohumeral joint and the ipsilateral distal radio-ulnar joint. The ages of the patients ranged from eight to seventy-four years (average, thirty-five years) and the duration of follow-up ranged from four months to twenty-seven years (average, 113 months). In fifteen patients, the injury of the wrist was diagnosed after a mean delay of seven years and eleven months (range, one month to twenty-six years). In all fifteen, the radial head injury was treated by excision, either initially or after some delay. After excision of the radial head, all fifteen patients complained of severe pain at the distal radio-ulnar joint. The results, on the basis of elbow and wrist scores of fair or better without complications, were satisfactory in only three patients. In the remaining five patients, in whom the injuries of both the elbow and the wrist had been identified at the initial evaluation, the radial head was either preserved or replaced. The results, on the basis of elbow and wrist scores of fair or better, were graded as satisfactory in four of these patients. Our data show that any injury to the lateral side of the elbow should prompt a careful evaluation of the ipsilateral distal radio-ulnar joint for associated instability.