Treatment Of Radial Head Fractures Research Articles

Radial Head Fractures Treated with Open Reduction and Internal Fixation

Radial head fractures are responsible for 2 to 5% of adult fractures. Especially problematic is the treatment of dislocated and unstable fractures which often have a worst prognosis. The purpose of this study was to evaluate the results of open reduction and internal fixation (ORIF) in the treatment of radial head fractures.

Outcomes Following Radial Head Arthroplasty.

Most current series of radial head arthroplasty include small numbers of patients with short- to medium-term follow-up and significant heterogeneity in patients, treatments, and outcome measures. The purpose of this systematic review was to review outcomes for radial head arthroplasty based on injury chronicity, injury pattern, and type of implant used. The authors systematically searched electronic databases for studies containing radial head arthroplasty or radial head replacement and identified 19 studies for inclusion in the analysis. For each included study, a composite mean was obtained for Mayo Elbow Performance Score (MEPS) and range of motion. Outcomes were said to differ significantly if their confidence intervals did not overlap. The MEPS for acute treatment (90) was higher than that for delayed treatment (81). There was no difference in the pooled MEPS between the isolated (89) and complex injury pattern (87) groups or implant material. There was no difference in range of motion between the acute and delayed or isolated and complex groups, but the average degree of pronation was higher in patients treated with titanium implants (76°) compared with cobalt chromium implants (66°). This systematic review suggests that outcomes are improved following acute arthroplasty for treatment of radial head fractures compared with delayed treatment, based on MEPS. The lack of other significant differences detected is likely due to the significant heterogeneity and inadequate power in current studies. Further prospective studies isolating the different variables will be needed to determine their true effect on outcomes. [Orthopedics. 2016; 39(3):153-160.].

Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty

Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up. At an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6 mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome. The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed.

Outcomes using the extensor digitorum communis splitting approach for the treatment of radial head fractures

Surgery on the radial head is usually performed via the Kocher interval. Iatrogenic injury to the posterior interosseous nerve (PIN) and lateral ligamentous complex are known complications of lateral elbow approaches. The extensor digitorum communis (EDC) splitting approach for lateral elbow exposure is known to provide better access to the anterior half of the radial head while reducing the risk of injury to the lateral ligaments. The aim of this study was to provide clinical outcome data for the EDC splitting approach. Thirteen patients with closed radial head fractures underwent internal fixation or replacement via the EDC splitting approach. Patients were evaluated using the Mayo Elbow Performance, American Shoulder and Elbow Surgeons (ASES), and Disabilities of Arm, Shoulder and Hand scores. Clinical assessments of the elbows were also performed. Ten patients underwent open reduction and internal fixation of their radial heads, and 3 underwent radial head replacements. At final follow-up, all patients achieved good to excellent Mayo Elbow Performance scores, with a mean score of 90 (range 80-100). They had a mean ASES elbow score of 89.6 (range 77-97) and a mean Disabilities of Arm, Shoulder and Hand score of 12.8 (range 6.67-25.8). Patients reported a mean overall ASES satisfaction score of 8.5 (range 6-10). There were no significant surgical complications, including iatrogenic damage to the PIN or the lateral ligaments. The EDC splitting approach is a feasible method of exposing the lateral elbow, providing safe and reliable access to the radial head.

Current concepts in the management of radial head fractures.

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

Aspiration of the elbow joint for treating radial head fractures.

Radial head fracture is the most common fracture of the elbow. It usually results from a fall onto an outstretched arm. In 1954, Mason classified these fractures into type 1 (undisplaced), type 2 (simple displaced), and type 3 (comminuted fractures). Aspiration of the elbow joint aims to relieve pressure in the elbow joint and has been used as an initial treatment option for radial head fractures. However, it is an invasive technique with the potential for complications such as infection and injury to nerves and vessels. To assess the effects (benefits and harms) of elbow joint aspiration for treating radial head fracture in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (14 April 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (14 April 2014), MEDLINE (1946 to April Week 1 2014) and EMBASE (1980 to 2014 Week 15), trial registries, bibliographies and conference proceedings. Randomised and quasi-randomised controlled clinical trials comparing aspiration versus no aspiration for treating radial head fractures in adults. Two review authors independently selected articles, assessed risk of bias and extracted data. Disagreements were resolved by discussion. Where appropriate, we pooled results of comparable studies using fixed-effect meta-analysis. We included two trials that involved 126 participants but provided results for only 108 participants. Most participants were adults, typically over 30 years of age. Both trials were at high risk of selection, performance, detection and reporting bias. Reflecting this high risk of bias, we downgraded the quality of evidence two levels for study limitations and a further level for imprecision. Thus we judged the evidence for all outcomes to be 'very low' quality, meaning that we are very uncertain about these estimates.One trial included participants with Mason type 1, 2 or 3 radial head fractures and also a few cases of traumatic elbow hemarthrosis without fracture. The other trial included participants with Mason type 1 and 2 fractures. All participants were managed non-surgically.Neither trial reported functional outcome based on validated patient-reported outcome measures of function or pain using validated measures such as a visual analogue scale. Very low quality evidence (108 participants, two trials) indicates little difference between aspiration and no aspiration in impaired function (unable to carry heavy loads; discomfort when carrying loads) at 12 months (9/51 in aspiration group versus 7/57 in the no aspiration group; risk ratio 1.43 favouring no aspiration, 95% confidence interval (CI) 0.57 to 3.58). Very low quality evidence (two trials) suggests a beneficial effect of aspiration on pain relief immediately after aspiration. Very low quality evidence (one trial, 28 participants) shows less pain after aspiration at three weeks, but it is unclear whether this applies subsequently. Neither trial reported on adverse events (for example, nerve and vascular injuries; deep or superficial infection) from the procedure, but aspiration was reported as being unsuccessful in three participants (7.9%) in one trial. Very low quality evidence indicates little difference in range of motion (based on elbow extension) between the two groups at six weeks (28 participants, one trial) or 12 months (108 participants, two trials). The report of adverse events was incomplete, but one trial (80 participants) reported the absence of three specific complications: myositis ossificans, joint instability or late displacement of the fracture. There is insufficient evidence to determine the effectiveness of joint aspiration for the initial treatment of radial head fracture in terms of function, pain and range of motion or to determine the safety of the procedure. An examination of current aspiration use, the prospective collection of adverse events and consultation with patients as to their preferences and values would be helpful in guiding decisions about the future design of a multicentre randomised trial aiming to obtain definitive evidence on the use of aspiration for treating radial head fractures.

Active Elbow Rotation Delays Healing Time in Radial Head Fractures

Active elbow rotation within the first 2 weeks after radial head fracture resulted in delayed healing and increased pain compared with restricted elbow use. This article presents data from a study that evaluated the effect of active elbow rotation in the treatment of radial head fractures.

Surgical interventions for treating radial head fractures in adults

Radial head fractures are the most common type of elbow fracture and can severely affect the function of the elbow. There is uncertainty and controversy about when surgery is indicated as well as what type of surgical intervention is best. To assess the effects of surgical interventions for treating radial head fractures in adults. We aimed to compare surgical versus non-surgical treatment, and different methods of surgical intervention. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library; 2012 Issue 4), MEDLINE (1946 to May 2012), EMBASE (1980 to 2012 Week 19) and trial registers (November 2011). No language restrictions were applied. All randomised and quasi-randomised controlled trials evaluating surgical interventions for treating radial head fractures. Two review authors independently selected trials, assessed risk of bias and extracted data. Where appropriate, results were pooled. We included three randomised controlled trials, involving a total of 251 participants. All three trials were at high risk of performance bias reflecting the fact that surgeons could not be blinded. One trial was at low risk of selection bias but was undermined by a high attrition bias, in part resulting from post-randomisation exclusions. There were incomplete details of methodology for the other two trials, which usually resulted in unclear risk of bias judgements.Two trials compared radial head replacement with open reduction and internal fixation (ORIF) for treating Mason type III radial head fractures. The trial authors reported outcomes at a mean of 2.8 years and 15 months respectively. There were significant differences between the two groups in favour of radial head replacement in the Broberg and Morrey elbow scores (92.1 versus 72.4, mean difference (MD) 19.70; 95% confidence interval (CI) 15.64 to 23.76; one trial, 45 participants), excellent or good Broberg and Morrey elbow scores (33/36 versus 16/31, risk ratio (RR) 1.88; 95% CI 1.27 to 2.77; two trials), and overall adverse events (6/36 versus 15/31, RR 0.33; 95% CI 0.14 to 0.77; two trials). No statistically significant difference was found between the two groups in any of the reported individual adverse events.One trial compared biodegradable pins with standard metal screws in treating radial head fractures of AO-classification 21 B2. The two types of fixation devices yielded similar results, with no significant between-group differences in the Broberg and Morrey scores (93.3 versus 90.9, MD 2.40; 95% CI -0.10 to 4.90), excellent or good Broberg and Morrey elbow scores (72/74 versus 56/61, RR 1.06; 95% CI 0.97 to 1.15), and adverse events (13/82 versus 16/82, RR 0.81; 95% CI 0.42 to 1.58) at two-year follow-up. Only tentative conclusions can be drawn from the available evidence in this review. Compared with ORIF, there was some evidence that radial head replacement had better elbow function and fewer adverse events for Mason type III radial head fractures in the short term. However, the evidence is of low quality and it is unknown whether these results would apply in the longer term or more generally. Using biodegradable implants may be as good as metallic implants for fixation of some usually more stable fractures but more evidence is needed to confirm this. There is a need for good quality evidence for addressing the areas of uncertainty for the surgical treatment of radial head fractures.

The application of absorbable self-enhancing cartilage nails in the treatment of radial head fractures

Objective To evaluate the clinical effect of absorbable self-enhancing cartilage nails in the treatment of radial head fractures.Methods Data of 22 patients with radial head fractures,who had undergone open reduction and internal fixation with absorbable self-enhancing cartilage nails from January 2008 to December 2011,were retrospectively analyzed.Among them,data of 18 patients were complete,including 10 males and 8 females.According to the Mason classification,there were 14 cases of Mason Ⅱ,3 cases of Mason Ⅲ and 1 case of Mason Ⅳ.Two patients were combined with radial neck fractures,9 with osteochondral fractures of capitellum,and 1 with posterior dislocation of the elbow and olecranon avulsion fracture.The radial head fractures were temporarily fixed with Kirschner wires after open reduction,then absorbable self-enhancing cartilage nails with length from 16 to 24 mm and diameters of 1.5 mm were applied to reach final fixation.The heads of nails were right underneath of cartilages without penetrating bone cortexes on the contralateral side.The radial neck fractures were reduced and fixed with T-plates or anatomical plates after the radial head fractures were fixed with cartilage nails.Four cases of osteochondral fracture of capitellum were fixed with absorbable sutures to external epicondyle of humerus.For other 5 cases of osteochondral fracture of capitellum,the bone fragments were removed due to too small to fix.Results All 18 patients were followed up for 6 to 54 months (average,31.3 months).All fractures achieved bone union,and the healing time ranged from 5 to 12 weeks (average,8.7 weeks).There were no complications,such as internal fixation failure,nonunion,hematoma,sinus formation,osteolytic changes of radial heads and so on.According to the Broberg-Morrey elbow performance score,13 cases were excellent,4 good,and 1 fair,with the total excellent and good rate of 94.44％ (17/18).At final follow-up,the elbow range of motion was 90° to 150° (average,123.8°),and the range of forearm rotation was 130° to 180° (average,152.5°).Conclusion Absorbable self-enhancing cartilage nails can be used to treat various kinds of radial head fractures,and the results are satisfactory. Key words: Radius fractures; Bone nails; Absorbable implants

Results of operative treatment for radial head fractures

Results of operative treatment for radial head fractures

Clinical efficacy of open reduction and internal fixation plus radial head resection in treatment of radial head fractures

Objective To investigate the prognostic outcome of open reduction and internal fixation(ORIF)with radial head resection in treatment of comminuted radial head fractures so as to discuss the corresponding operation options.Methods A series of 23 patients with Mason type Ⅲ or Ⅳ radial head fractures were enrolled in the study including 11 males and 12 females.Eight patients(three with Mason type Ⅲ and five with Mason type Ⅳ)underwent radial head resection and 15(seven with Mason type Ⅲ and eight with Mason type Ⅳ)received open reduction and internal fixation including nail and plate fixation in eight and screw and K-wire fixation in seven.The outcomes were assessed in regard of range of motion,radiographic findings,visual analogous scale(VAS)of pain,patient satisfaction degree,disabilities of the arm,shoulder and hand score system(DASH)and the Broberg & Morrey elbow performance score system.Results The follow-up period ranged from 12 to 65 months(mean 35 months),which showed fracture healing in all patients,with no traumatic arthritis happened.The mean range of flexion and extension arc at the elbow of ORIF group and resection group was 132°and 79.4°(P＜0.01)and the patient satisfaction was 9.1 and 8.0(P ＜0.05)respectively.According to the Broberg & Money elbow performance score system,the score was average 93.9 in the ORIF group,with excellent result in nine patients,good in five and fair in one,while the score was average 80.6 in the resection group,with excellent result in two patients,good in two and fair in four.There was statistical difference between two groups(P ＜0.01).The DASH score of the ORIF and resection group was 2.9 and 18.1 respectively(P＜0.05).Conclusions ORIF has better elbow motion,elbow function,daily living and satisfactory outcomes than radial head resection and is recommended for treatment of Mason type Ⅲ or Ⅳ radial head fractures for repair of the radial head as far as possible. Key words: Radius fractures; Fracture fixation, internal; Resection of conninuted radial head

Diagnosis and treatment of acute Essex-Lopresti injury

Objective To study the methods of diagnose and treatment of acute radial head fracture accompanied by distal radioulnar joint dislocation (Essex-Lopresti injury). Methods From 2002 to 2009,3 patients with acute Essex-Lopresti injury were diagnosed and treated in our department. Radial head fractures were treated with fixation repair or radial head prosthesis replacement. Distal radioulnar joint dislocations were treated with reduction and fixation. All three patients were followed-up and the effects were assessed. Results Total time of follow-up ranged from 15 to 48 months. According to the elbow joint and wrist joint scoring systems,results of postoperative functions were satisfactory. Conclusion Acute Essex-Lopresti injuries should be treated with radial head fracture fixation or replacement,and simultaneous reduction and fixation of the dislocated distal radioulnar joint. When fracture of the radial head is too comminuted to be repaired,simple resection of the radial head is not an option since it will result in failure. Key words: Fractures,bone; Arthroplasty,replacement; Dislocations; Essex-Lopresti injury

Resection arthroplasty for radial head fractures: Long-term follow-up

Complex radial head fractures treated by early resection arthroplasty yield good clinical results at long-term follow-up. Fifty-one radial head excisions were performed for the treatment of radial head fractures. Twenty-seven patients (20 men, 7 women) were retrospectively reviewed. The mean age was 37 (range, 18-61) and their fracture types according to the Mason classification were 5 type II, 16 type III, and 6 type IV. The mean follow-up period was 17 years (range, 10-24). Patients were clinically evaluated: Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH), visual analogue scale (VAS) for pain scores, and strength. Degenerative changes, proximal migration of the radius, and carrying angle were measured. The overall outcome of the MEPS was 96.4 (range, 70-100), 22 patients (81%) achieving an excellent result, 4 patients a good (15%), and 1 patient a fair result (4%). The mean DASH score was 4.89, with slightly better results in the Mason II group than the Mason III and IV patients (P = .15). VAS averaged 0.48 (range, 0-10). Twenty-three patients (85%) reported no pain. The mean range of motion was from 5° to 135°. Pronation averaged 83° and supination averaged 79°. Strength was maintained in 24 cases (88%). In 24 patients, osteoarthritic changes were present without clinical relevance. Proximal migration of the radius was recorded in 7 cases. Carrying angle increased significantly by 7° (15° compared with 8°). Radial head fractures treated by early resection arthroplasty offer satisfactory functional results in 96% of patients at long-term follow-up, in spite of the radiographic degenerative changes present in the great majority of cases.

Fracturas conminutas de la cabeza radial: estudio comparativo entre resección y fijación interna

Introduction The treatment of radial head fractures continues to be controversial. The open reduction and internal fixation (ORIF) method is expanding due to improvements in the techniques and the implants. However, it can be very demanding technically and is not free of complications. On the other hand, resection shows satisfactory results in the long term in stable elbows, although it is also associated with complications. We compared resection and ORIF in comminuted fractures of the radial head. Material and Method A total of 23 patients with type III Mason fractures were included, of which 11 were subjected to resection of the radial head (Group A), and 12 to internal fixation of their fracture (Group B). The mean age was 54 and 45 years, respectively. The fractures were clinically and radiologically evaluated, with a mean follow-up of 80 months in Group A and 76 months in Group B. Results The flexion-extension movement range was 121°–(−11°) in Group A and 131°–0° in Group B. The functional results obtained according the Broberg and Morrey scale were: 82 points in Group A and 90.9 points in Group B. Discussion Patients with comminuted fractures of the radial head subjected to open reduction and internal fixation have a satisfactory movement range, with greater strength, and therefore, better function. We recommend open reduction and internal fixation in the treatment of these fractures, particularly in young patients.

The acute bipolar radial head replacement for isolated unreconstructable fractures of the radial head

For the acute treatment of radial head fractures, radial head arthroplasty can be considered if open reduction and internal fixation is not technically possible and if simple radial head resection is contraindicated. We report our experience with a bipolar Judet radial head prosthesis. After a mean follow-up of 41.7 months, 16 patients were assessed following radial head replacement. The outcome was assessed clinically, functionally, and radiographically. Outcome was satisfactory in 87.5% of cases. The mean post-operative ranges of motion were greater than the functional arcs both in flexion-extension and in pronation-supination, and the results did not appear to be influenced in a significant way by the type of original lesion. All elbows were stable. The main complication was the development of heterotopic ossifications. Bipolar radial head prosthesis represents a suitable option for acute treatment of unreconstructable radial head fractures, either isolated or associated with elbow dislocation and in the absence of other bony lesions.

Radial Head Comminuted Fractures: a Comparative Study Between Resection and Internal Fixation

Introduction The treatment of radial head fractures continues to be controversial. The open reduction and internal fixation (ORIF) method is expanding due to improvements in the techniques and the implants. However, it can be very demanding technically and is not free of complications. On the other hand, resection shows satisfactory results in the long term in stable elbows, although it is also associated with complications. We compared resection and ORIF in comminuted fractures of the radial head. Material and Method A total of 23 patients with type III Mason fractures were included, of which 11 were subjected to resection of the radial head (Group A), and 12 to internal fixation of their fracture (Group B). The mean age was 54 and 45 years, respectively. The fractures were clinically and radiologically evaluated, with a mean follow-up of 80 months in Group A and 76 months in Group B. Results The flexion-extension movement range was 121°-(−11°) in Group A and 131°-0° in Group B. The functional results obtained according the Broberg and Morrey scale were: 82 points in Group A and 90.9 points in Group B. Discussion Patients with comminuted fractures of the radial head subjected to open reduction and internal fixation have a satisfactory movement range, with greater strength, and therefore, better function. We recommend open reduction and internal fixation in the treatment of these fractures, particularly in young patients.

A brief history of treatment for radial head fracture with radial head prosthesis.

Since Speed first treated the radial head fracture with a metal prosthesis in 1941, the purpose of the treatment of radial head fracture with a radial head changed from the prevention of heterotopic ossification to the prevention of proximal migration of the radius and instability of the elbow. The optimal indication is gradually determined as a non-reconstructable radial head fracture with associated injuries that would leave the elbow unstable if the radial head were resected. Types of prosthesis changed from mono-block, bipolar to modular prosthesis. Material of prosthesis changed from acrylic resin, silastic to cobalt-chrome titanium and pyrocarbon. The 60-year development indicated that the operative technology of radial head prostheses was to be improved so as to reconstruct the flexibility and stability of the elbow to meet the higher functional requirements of patents.

Late posterior interosseous nerve palsy associated with loosening of radial head implant

Radial head arthroplasty with metallic prosthesis is a safe and effective treatment for comminuted fractures of the radial head, especially in the setting of concomitant elbow instability. Injury to the posterior interosseous nerve (PIN) is a known risk associated with surgical treatment of radial head fractures. Transient PIN neurapraxia has been reported in radial head arthroplasty, occurring postoperatively and improving over time. We report a patient who had full PIN function after radial head arthroplasty, but a late PIN palsy subsequently developed associated with implant loosening and formation of a subperiosteal cyst. To our knowledge, this complication has not previously been reported. This patient was notified of the use of these data and its submission for publication.

Radial Head Prosthesis Update

Abstract Radial head arthroplasty is an essential element in the management of an unstable elbow when there is a fracture of the radial head that cannot be repaired. Similarly, radial head arthroplasty must be considered when the radial head is not repairable and there is evidence of an injury to the interosseous membrane. If replacement of the radial head is necessary, the surgeon must make preoperative decisions regarding the implant and surgical approach; he or she must make intraoperative decisions regarding stem size and head size, as well as which structures are repaired. Most of the available implants will help restore lateral stability, however, the surgeon must decide if he or she wants a monopolar or a bipolar implant and whether the implant should have a smooth stem, a stem with the potential for ingrowth or a stem that will be cemented. Approach to the radial head may be facilitated by avulsion of the lateral complex. If the lateral complex is intact, the surgeon may choose to work around the intact complex or perform a release followed by repair. In most elbows, stability will be restored with placement of a radial head and repair of the lateral complex. However, the surgeon must have a contingency plan for dealing with residual instability. This article will discuss the developments in prosthetic treatment of radial head fractures, surgical technique, decision making, and the essential features of the varied radial head implant designs on the market today.

Coronoid Process Fracture

The coronoid process is one of the main constraints providing ulnohumeral joint stability. The coronoid process and the radial head provide a buttress against posterior displacement of the elbow joint. Fracture of the coronoid process can be either an isolated finding following elbow dislocation or part of a more complex fracture-dislocation. Much attention has been focused on treatment of radial head fractures and lateral ligament reconstruction, although recently, attention has been directed at detection and treatment of coronoid fractures. Surgical approaches to coronoid fractures depend on the condition of the radial head. When an associated radial head fracture is present, a lateral approach to the coronoid fracture is often performed. An isolated coronal fracture is typically approached from the medial side. Intraoperative stress testing may be helpful in assessing the need for surgery and choosing the surgical approach.