Long-term follow-up (between 16 and 21 years) of displaced fractures of the radial neck in 5 patients treated by excision of the radial head. Acta Orthopedica 2009; 80: 368-70:
Karlsson M, Herbertsson P, Nordqvist A. Long-term outcome of displaced radial neck fractures in adulthood 16-21 year follow-up of 5 patients treated with radial head excision. Acta Orthopedica 2009; 80: 368-70
The slightly displaced fractures of the head and radial neck are reputed to have a favorable evolution whereas the displaced or comminuted fractures have a more pejorative prognosis. In published studies, the types of fractures are often heterogeneous making comparisons difficult.
Goal of the study:
Long-term follow-up of five fractures of the radial neck type Mason III, all treated by excision of the head.
Material and method:
Retrospective study of cases treated between 1969 and 1979. During this period, recruitment of 756 isolated fractures of the cervix or radial head including only five Mason IIIb fractures of the radial neck secondary to a fall or direct impact. All were treated by resection of the radial head.Patients were aged 46 years at the time of the accident.
No postoperative complications were noted.
The evaluation was done by questionnaire (activities of daily life, pain, mobility, stability, strength), clinical examination (joint amplitudes, muscular strength, measurement of arm circumference), radiographs.
Results:
Three patients said they had no problems; two complain of a slight embarrassment; none of them reported permanent pain or disabling weakness. At the level of the articular amplitudes:
• the extension deficit is on average 10 ◦ ;
• defect in flexion, prognosis less than 5 </s>.
No cubitus valgus greater than 5 ◦ ; radiography, presence of cysts, osteophytes and sclerosis; a pinching of the internal joint space was noted once.
Discussion:
Eighteen years after resection of the radial head, the five patients reviewed show little or no sequellar discomfort. One of the possible complications of this surgery is the appearance of a secondary ulnar ulna, described by Mikic (1983) and Herbertsson (2004).
Secondary radiological changes have been described for a long time, with moderate clinical expression, as is the case for our patients.
The evolution of the five cases of the study is similar to that of the fractures of the radial neck Mason IIb. Arner et al.(1957) reported 95% indolence in a Mason II-type fracture cohort followed by one to 15 years. Poulsen (1974), at five years of a Mason IIb type fracture in seven patients, found no pain.
Absorbable screw fixing in the treatment of fractures of the radial head.Clin Orthop Relat Res 2008; 466: 1217-24:
Panagiotis K. Givissis, Panagiotis D. Symeonidis, Konstantinos T. Ditsios. Late Results of Absorbable Pin Fixation in the Treatment of Radial Head Fractures. Clin Orthop Relat Res 2008; 466: 1217-24
The treatment of displaced fractures of the radial head remains controversial. The decision to internalize osteosynthesis is made on the basis of subjective criteria: experience and preference of the surgeon, equipment available.
While the prosthetic replacement of the head has gained popularity, the decision of osteosynthesis still raises some doubts as to the results obtained with this long-term means.
For the last twenty years, the introduction of biodegradable screws to treat these fractures.
Objectives of the study:
Analyze the nature and period of occurrence of possible side effects related to the degradation of the material (serous formation, osteolytic reaction); evaluate the functional outcomes of patients.
Material and method:
Retrospective analysis of 23 patients operated for less than 48 hours after an elbow trauma that resulted in Mason V-type fracture and osteosyntheses (nine type II, ten type III, two type IV); average age of 37.8 years; average follow-up of 36 months; in the case of associated ligamentous lesion, repair and then fixation by miniancre.
Postoperatively, the elbow was kept in a gutter for two weeks followed by a mobilization then work of muscle building begun at four weeks.
Final evaluation:
Twenty-one by clinical examination (Mayo score: pain, mobility, stability, function, clamping force) and radiograph; two by telephone.
Results:
No local complications related to material degradation were observed in both the short and medium term.
The average Mayo score was 93.8.
The clamping force compared to the opposite side was not affected.
Mean mobility: extension-flexion: 9 to 132 ◦ (formation of bone bridges in some patients); supination: 77 ◦ ; pronation: 79 </s>.
The overall results were found to be poorly correlated with the severity of the initial fracture (Mason classification).
One patient exhibited moderate instability; two showed heterotopic ossifications on the X-ray, one on the annular ligament and one on the inside of the elbow.
Postoperatively, four patients had a small 1.5 mm lag between the fragment but no subsequent effect on the results.
Discussion:
The inclusion in the Mason II type fracture study can be discussed because in the literature, some advocate a conservative treatment or even a secondary excision of the head according to the residual discomfort. However, as the functional demands of the elbow are increasingly intense, osteosynthesis may be justified.
The absorption of the material can take up to five years.
Compared to the Ashwood study (2004), bending and the Mayo score were better in the osteosynthesis group than in the titanium prosthesis group.
Compared to the Moro study (2001), mobility was comparable but the Mayo score was better than the group with a titanium prosthesis.
The debate remains open between internal osteosynthesis and prosthetic replacement.
Obert L, Lepage D, Huot D. Non-synthetic radial head fracture: resection, Swanson implant or prosthesis? Comparative retrospective study. Chir Main 2005, 24: 17-23:
Goal of the study:
Revision of patients with a comminuted fracture of the radial head treated with three different techniques: resection, Swanson implant, Judet radial head prosthesis.
Material and method:
Evaluation by an independent operator of the function of the elbow and the wrist associated with a radiographic analysis of these two joints.
Results:
• Resection group: n = 16; average age of 39; preoperative period of 29.6 days; mean follow-up of 18.9 years (6-27.7);Mason III fractures in 75% of cases, association with elbow dislocation in 18% of cases;
• Swanson group: n = 8; average age of 36 years; preoperative period of 4.1 days; average follow-up of 12 years (8.1-20); Mason III fractures in 88% of cases, no luxation;
• prosthesis group: n = 8; average age of 49; preoperative period of 8.6 days; average follow-up of 17.6 months;Mason III fractures in 100% of cases, combined with dislocation in 37.5% of cases.
Group “ resection “ and “ Swanson “
Functional scores are similar, as are joint amplitudes (elbow flexion (130), extension deficit (18 ◦ ), pronation (60 ◦ ), supination (67 </s>), strength of the grip (90% the rate of osteoarthritis of the elbow (87%) or the wrist (66%) The rate of satisfied patients is almost similar (94% group “ resection “ , 89% group “ Swanson “ in the resection group there are twice as many sensory disorders related to irritation of the ulnar nerve, three times more instabilities of the distal radioulnaris (RUD), five times more periarticular ossifications of the elbow and one ulnar variance always positive and three times higher (+3.20 mm).
In the “ Swanson ” group , in two cases (25%) the implants were destroyed.
Judet Prosthetics Group
According to the functional scores used, 62.5 to 75% of excellent and good results were found. A single poor result was reported in a patient with severe psychiatric history with dislocation of the prosthesis on a stiffened elbow.
Discussion:
Some fractures are difficult to classify. In addition to the therapeutic proposals of the study, conservative osteosynthesis associated with a filling of the commutation must always be part of the therapeutic arsenal, a fortiori in a young subject. For Ring, conservative osteosynthesis is possible if the number of fragments does not exceed three.
The difference between resection and implant of Swanson is at the level of the complications:
• resection: valgus ulnar, radial ascent with subluxation of the RUD joint, decreased muscle strength and joint mobility, especially pronation and supination;
• Swanson implant: Inability to transmit forces to the humeral condyle due to its soft consistency, implant fractures and silicone complications.
Prosthesis with double mobility of Judet:
The first results are encouraging (under the guise of an experienced surgeon) but the retreat is still too short to see the possible loosening (and / or conflicts of the metal prostheses) appear.
Fractures of the radial head in adults. Curr Orthop 2007; 21: 59-64:
Harrison JWK, Chitre A, Lammin K. Radial head fractures in adults. Curr Orthop 2007; 21: 59-64
Anatomical Reminders:
• The annular ligament participates in the rotational movements but also prevents the tendency for the proximal migration of the radius, bent elbow, by pulling the biceps;
• the forearm muscles constitute a posterior-direction force holding the radial head in its position;
• at the wrist, 80% of the stresses are absorbed by the lower end of the radius and then transmitted to the ulna via the oblique fibers of the interosseous membrane. After excision of the radial head, forces are taken up by the interosseous membrane and the triangular fibrocartilaginous complex. In the case of progressive stretching of this membrane, a proximal migration of the head is observed;
• the Essex-Lopresti lesion is a tear in the interosseous membrane associated with fracture of the radial head. In case of disregard of this combined lesion, there is very often a lower radio-ulnar dislocation associated with wrist pain;
• at the elbow, the main brake to the valgus stresses is the anterior beam of the medial collateral ligament (LCM). The radial head constitutes the second brake but its role in this function is modest if the ligament is integral.
Mechanisms of injury
It is most often a fall on the hand, elbow stretched, forearms in pronation. The stress forces transmitted at the elbow are then axial and in valgus, attracting the radial head towards the rear, putting its anterolateral edge under stress. If the trauma is intense the LCM is reached, which can lead to a dislocation of the elbow. In the event of tearing of the interosseous membrane, the forces are not transmitted to the ulna.
Injury assessment:
It is based on the analysis of standard face, profile and oblique radiographs. In case of doubt, a CT may be requested.
Classification:
The most commonly used classification is Mason-Johnston:
• type I: marginal fracture with minimal displacement;
• type II: marginal fracture with displacement;
• type III: comminuted fracture;
• type IV: association with elbow dislocation.
The fractures of the coronoid were classified by Regan-Morrey in 1989:
• type I: avulsion of the summit;
• type II: fracture less than 50% of the total area;
• type II: fracture greater than 50% of the total area.
Treatment:
• Fracture not displaced (joint shift <2mm):
◦ possible puncture of haemarthrosis,
◦ splint posterior to 90 ◦ flexion with onset of mobilization as soon as pain allows,
◦ as with any lesion of the elbow, the patient will be informed that a loss of extension is frequent but without functional repercussions;
• displaced fracture:
◦ open-pit reduction and internal fixation;
• comminuted fracture:
◦ either fixation if the fragments are of sufficient size,
◦ excision of the head,
◦ prosthetic replacement;
• Fracture associated with dislocation of the elbow ( “ terrible triad of Hotchkiss “ ):
◦ in case of fracture of the coronoid, it must be fixed or the anterior capsule repaired if avulsion of the top of the coronoid,
◦ repair of the lateral ligaments, ◦ treatment of the fracture of the head according to the lesion type,
◦ Start of mobilization from the second week with a security flessum of 30 ◦ until the end of the fourth week.
Possible Complications:
Pain, stiffness, loss of strength, post-traumatic osteoarthritis, instability, ulna valgus, pseudarthrosis.
The functional area of the elbow is 30 to 130 </s>. After a trauma, loss most often of the last 15 degrees of extension.In case of persistence after six months of evolution, the loss is generally definitive. An arthroscopic gesture of release may be necessary if the flessum is greater than 35 </s>.
Uncomplicated Mason type II and III fractures of the radial head and neck.Long-term monitoring. J Bone Joint Surg 2004; 86A: 569-74:
Herbertsson P, Josefsson PO, Hasserius R. Uncomplicated Mason Type II and III Fractures of the Radial Head and Neck in Adults. A Long-Term Follow-Up Study. J Bone Joint Surg 2004; 86A: 569-74
Goal of the study:
Evolutionary follow-up of Mason II and III fractures of the radial head and neck. Initial assumptions: low incidence of complication, minimal functional deficit in the long term, high risk of development of radiographic signs of degeneration.
Material and method:
Study on an entire city:
• 756 patients had a fracture of the radial head or neck between 1969 and 1979;
• 100 could be remotely recontacted for evolutionary monitoring;
• the average age at the time of the accident was 47 years;
• 76 Mason II-type fractures, including 23 of the radial neck;
• 24 Mason III-type fractures, including five of the radial neck;
• initial treatment with elastic bandage or posterior splint with mobilization as soon as pain was removed for 44 patients (41 Mason type II and three Mason type III, 30 fractures of the radial head and 14 of the neck);
• immobilization by plaster for two weeks for 34 patients (28 Mason II and 6 Mason III, 28 fractures of the radial head and 6 of the cervix);
Excision of the radial head in 19 cases (four Mason II and 15 Mason III, 12 fractures of the radial head and five of the cervix);
• open cut for two cases (Mason II, head fracture);
• repair of the medial collateral ligament for a case (Mason II, cervical fracture);
• nine patients had secondary resection of the radial head (six Mason II and three Mason III, eight head fractures and one cervix), on average 13 months after the initial fracture;
• one patient had ulnar nerve neurolysis three years after the trauma;
• subjective evaluation by questionnaire (pain, daily activities, lack of strength);
• 75 patients could be re-examined (mobility, strength, forearm perimeter, Tinel elbow test) and radiographs;
• Decline more than 25 years.
Results:
• Subjective elements:
◦ 77 patients were asymptomatic; 21 had occasional pain (12 Mason II and nine Mason III, 17 head fractures and 4 cervical fractures); two had daily pain (a Mason I, a Mason II),
◦ 12 patients had amplitude limitation,
Five complained of lack of strength;
• signs of examination:
◦ bending: 138 ◦ Å} 8 ◦ versus 140 ◦ Å} 7 ◦ healthy side (p <0.001),
◦ extension: -4 ◦ Å} 8 ◦ versus -1 ◦ Å} 6 ◦ (p <0.001),
◦ supination: 83 ◦ Å} 11 ◦ versus 86 ◦ Å} 6 (p <0.01),
◦ 19 signs of Tinel positive versus eight on the healthy side,
◦ 84% of results considered good, 11% average, 5% bad according to the Steinberg classification;
• Radiographic signs:
◦ 46 cystic lesions versus nine on the healthy side,
◦ 50 chondral irregularities versus 11,
◦ 41 osteophytes versus nine,
◦ eight pinches of articular interlining relative to the healthy side but six “ healthy “ elbows had a decrease in the line spacing from the injured side,
◦ no cases of pseudoarthrosis, necrosis, proximal radiolucent synostosis, periarticular ossifications;
• patients with head excision:
◦ 12 out of 19 consider the end result as good.
Discussion:
The only weakness of this study is the lack of randomization of treatments.
The results are in line with those of Arner and Poulsen: more than 95% of the patients with a fracture of the head or radial neck evolve well, any type of fracture combined.
A residual extension deficiency is common but the functional discomfort is marked only for elbows with a flessum greater than 30 ◦ or a flexion greater than 130 ◦ .
The little stiffness observed in the study may be due to the consequent retreat.
Patients with secondary resection of the radial head had worse end results: 67% of residual complaints versus 37% in the case of initial resection.
Secondary radiological changes are frequent: 76% in the series but apparently without correlation with the functional results.
In conclusion, the Mason II and III fractures have a favorable long-term evolution.
