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Uncomplicated Mason Type-II and III Fractures of the Radial Head and Neck in AdultsA Long-Term Follow-Up Study
Pär Herbertsson, MD1; Per-Olof Josefsson, MD, PhD1; Ralph Hasserius, MD, PhD1; Caroline Karlsson, MD, PhD1; Jack Besjakov, MD, PhD1; Magnus Karlsson, MD, PhD1
1 Department of Orthopaedics (P.H., P.-O.J., R.H., C.K., and M.K.) and Department of Radiology (J.B.), University Hospital MAS, SE-205 02 Malmo, Sweden. E-mail address for P. Herbertsson: par.herbertsson@skane.se. E-mail address for P.-O. Josefsson: peo.josefsson@skane.se. E-mail address for R. Hasserius: ralph.hasserius@skane.se. E-mail address for C. Karlsson: caroline.karlsson@skane.se. E-mail address for J. Besjakov: jack.besjakov@skane.se. E-mail address for M. Karlsson: magnus.karlsson@orto.mas.lu.se
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the University Hospital MAS, Malmo, Sweden

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):569-574
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: The purpose of this study was to evaluate the incidence and the long-term results of closed uncomplicated Mason type-II and III fractures in a defined population of adults.

Methods: Seventy women and thirty men who were a mean of forty-seven years old when they sustained a fracture of the radial head or neck (a Mason type-II fracture in seventy-six patients and a Mason type-III fracture in twenty-four) were reexamined after a mean of nineteen years. Radiographic signs of degenerative changes of the elbow were recorded. The fracture had been treated with an elastic bandage or a collar and cuff sling with mobilization for forty-four individuals, with cast immobilization for thirty-four, with resection of the radial head in nineteen, with open reduction of the radial head in two, and with a collateral ligament repair in one. Secondary excision of the radial head was performed because of residual pain in nine patients, and a neurolysis of the ulnar nerve was performed in one patient.

Results: Seventy-seven individuals had no symptoms in the injured elbow at the time of follow-up, twenty-one had occasional pain, and two had daily pain. The injured elbows had a slight flexion deficit compared with the uninjured elbows (mean and standard deviation, 138° ± 8° compared with 140° ± 7°) as well as a small extension deficit (mean and standard deviation, —4° ± 8° compared with —1° ± 6°) (p < 0.001 for both). The prevalence of degenerative changes was higher in the injured elbows than in the uninjured ones (76% compared with 16%, p < 0.001).

Conclusions: The results following uncomplicated Mason type-II and III fractures are predominantly favorable. A secondary radial head resection is usually effective for patients with an unfavorable outcome (predominantly long-standing pain).

Levels of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    Pär Herbertsson
    Posted on July 08, 2004
    Dr. Herbertsson responds
    Orthopedic Department, University Hospital MAS, 205 02 Malmö, Sweden

    To the Editor:

    We thank Dr. Roidis for his interesting comments and will attempt to answer the questions raised in his letter.

    In the total survey, including all individuals with a single radial head or neck fractures during the period 1969-1979 in Malmö, Sweden, we found 225 individuals who were above age 16 years when they sustained a fracture. The reviewers and the editor at the JBJS (Am) suggested that we designate them as having an uncomplicated Mason type II or III fracture. In addition, we found 16 adults with a Mason type IV fracture. Due to the long follow-up, the study cohort consisted of 107 of the original 225 adult individuals with a Mason type II or III fracture who were still living in Malmö. Most of the former fracture patients had died;some had relocated.

    Of these 107 individuals, seven declined to participate,leaving 100 individuals to be evaluated in our study. To reiterate, in the study we only evaluated uncomplicated Mason type II and III fracture of the radial head or neck sustained in adults.

    In retrospective long term follow-up studies like these, there are obvious problems. Even if scrutinising all referrals and reports, most surgeons did not document whether or not they performed a stability tests of the elbow two decades ago. Still we used the description "uncomplicated radial head or neck fracture" as suggested by the JBJS, even though we recognize that a ligament tear or partial rupture of the collateral ligaments of the elbow could have been present. In fact, we are of the opinion that many of the patients probably had such a ligament injury, as one of our co-authors previously has reported that this is a common finding after elbow injuries, even in the absence of signs of skeletal injury(1-4). However, a prospective randomised controlled study evaluated outcome after conservative versus operatively treated ligament injuries after elbow dislocation, found no difference in outcome in those who were treated non- operatively when compared to those who were surgically treated with ligament suture. Therefore, we are of the opinion that an elbow collateral ligament rupture could be classified as an uncomplicated injury. Thus, we infer that we can describe the fracture types in this paper as uncomplicated, even though hypothetically they were accompanied by a collateral ligament injury.

    Furthermore, we did not specifically search for individuals with a posterior Monteggia lesion, individuals with an Essex-Lopresti injury or individuals with an additional elbow fracture in conjunction with the radial head or neck fractures in this survey. The fractures described above, are classified in the hospital archives in other files, files that was not scrutinised in the current evaluation. These fractures we choose to classify as complicated fracture, in conjunction with open fractures of the radial head or neck. However, one type of these so called complicated fracture, a Mason type IV fracture, has been specifically evaluated in another manuscript, now under consideration for publication at the JBJS (Am). In that paper we more extensively address the possible role of extensive soft tissue and ligament injury for the outcome. In addition, these questions are further discussed in the Thesis “Radial Head and Neck Fractures”, presented by Pär Herbertsson M.D., Ph.D, Lund University, Sweden 2004.

    We have not evaluated the radial head or neck fractures by magnetic resonance imaging (MRI). The most obvious reason for this is that the injuries occurred 1969-1979, a period when we had no such techniques. Therefore we can not draw conclusions and discuss the proportion of individuals with an additional chondral injury, nor can we present long term results from a subgroup of individuals with chondral injuries.

    We hope that this letter adequately responds to the questions posed by Dr. Roidis.

    Sincerely

    Pär Herbertsson M.D., Ph.D. and Magnus Karlsson MD., Ph.D. Department of Orthopaedic Surgery Malmö University Hospital Lund University SE - 20502 Malmö Sweden

    References

    1. Josefsson, P. O. and Nilsson B.E.. Incidence of elbow dislocation. Acta Orhop Scand 1986; 57(6):537-8.

    2. Josefsson, P. O., Gentz C.F. et al. Dislocation of the elbow and intraarticular fractures. Clin Orthop 1989; 246:126-130.

    3. Josefsson, P.O., Johnel O. et al. Ligamentous injuries in dislocation of the elbow joint. Clin Orthop 1987; 221: 221-5.

    4. Josefsson, P.O., Andren L. et al. Arthrography of the dislocated elbow joint. Acta Radiol Diagn 1984; 25(2):143-5

    Nikolaos T. Roidis MD, PhD
    Posted on June 05, 2004
    Osteochondral and/or Ligamentous Injuries associated with Acute Radial Head Fractures
    Orthopaedic Department, University of Thessaly, Larissa, Hellenic Republic (Greece)

    To The Editor:

    We read the article "Uncomplicated Mason Type-II and III Fractures of the Radial Head and Neck in Adults. A Long-Term Follow-Up Study" by Herbertsson et. al. with great interest.

    The initial cohort is comprised of 2965 patients who sustained an elbow fracture between 1969 and 1979. Seven hundred and fifty-six (26%) of these patients sustained a fracture of the radial head or neck, with 480 (64%) sustaining a Mason type-I fracture; 222 (29%), Mason type-II; 36 (5%), Mason type-III; and 18 (2%), Mason type-IV. Based on these numbers there are 258 patients with a Mason type II or III radial head fracture. The authors reported on 100 individuals with "uncomplicated", i.e.,absence of associated injury, radial head fractures (Mason type II and III) (1). Therefore, only 100 out of 256 pts (40%) of patients with Mason type II & III fractures have been presented. Is there any information available regarding instability problems for the majority (60%) of the Mason type II & III cases?

    Most of the reported injuries (seventy-seven of 100) were the result of low-energy trauma. Good long term results for "uncomplicated" radial head fractures are reported and the authors state that there were no recognized associated soft tissue injuries. However, they do not present information about whether the initial clinical examination focused on possible instability issues.

    The degree of ligamentous injury that occurs with a radial head fracture is not always fully appreciated (2,3,4). There is increasing evidence that displaced radial head fractures are very frequently associated with associated ligamentous injury (2,4,5,6). Some authors have cautioned that all, or nearly all, complex fractures of the entire radial head (Mason type 3) will be part of a more complex injury pattern (5). Elbow arthrography (7,8) has been utilized to demonstrate capsular or ligamentous disruptions with various types of radial head fractures. It has also been reported that the combination of radial head fracture with attenuation or tear of the medial collateral ligament occurs in 1-2% of the patients (3). Arvidsson and Johansson (7) reported positive arthrographic findings in 4 % of type I, 21% of type 11 and 85 % of type III injuries. Davidson et al, (5) reported that among 50 acute consecutive fractures of the radial head, 17 patients (17/50, 34%) had a displaced vertical shear type or an impacted fracture of the radial neck. All sustained some injury to the medial collateral ligament, with variable degrees of valgus elbow instability. A current report states thatligamentous injury may occur even in seemingly uncomplicated radial head injuries (2).

    Roidis et a1, (4,6) reported on MRI evaluation (10) of combined osteochondral and ligamentous injuries in twenty-four patients with an acute radial head fracture (Mason type 11 & III)who did not have documented dislocation or tenderness at the distal radioulnar joint. Plain elbow radiographs (anteroposterior and lateral views) were obtained on all patients as well as MR images in sagittal, coronal, axial, axial oblique and coronal oblique planes with the injured elbow in a splint. The incidence of associated injuries revealed by MRI was: medial collateral ligament not intact: 13/24 (54.16 %), lateral ulnar collateral ligament not intact: 18/24 (80.1%) both collateral ligaments not intact: 12/24 (50 %), capitellar osteochondral defects 7/24 (29.1 %), capitellar bone bruises 23/24 (95.83 %) and loose bodies 22/24 (91.67 %). We would caution that a high level of suspicion should be employed when treating displaced or comminuted radial head fractures because concurrent osteochondral injuries and/or ligamentous injuries may be present.

    1. Morgan SJ, Groshen SL, Itamura JM, Shankwiler J, Brien WW, Kuschner SH. Reliability evaluation of classifying radial head fractures by the system of Mason. Bull. Hosp. Jt Dis. 1997;56:95-8

    2. Carroll RM, Osgood G, Blaine TA. Radial head fractures: repair, excise, or replace? Current Opinion in Orthopaedic 2002,13:315-322.

    3. Morrey BF: Radial head fracture. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia: WB Saunders Co, 2000: pp 341-364.

    4. Roidis NT, Papadakis SA, Karachalios TS, Mirzayan R, Itamura JM: Radial head fractures. In: Mirzayan R, Itamura JM, eds. Shoulder and elbow trauma. New York: Thieme Medical Publishers Inc, 2004: pp 22-35.

    5. Davidson PA, Moseley JB Jr, Tullos HS. Radial head fracture. A potentially complex injury. Clin. Orthop. 1993;297:224-30.

    6. Roidis N, Itamura J, Vaishnav S, Mirzayan R, Learch T, Shean C. MRI evaluation of comminuted radial head fractures. A rather complex injury. Proceedings of the 69th AAOS Annual Meeting, Dallas, February 13-17, 2002: pp 520.

    7. Arvidsson H, Johansson O. Arthrography of the elbow joint. Acta Radiol. (Stockh) 1995;43:445.

    8. Steinbach LS, Schwartz M. Elbow arthrography. Radiol. Clin. North Am.. 1998;36:635-49.

    9. Choi J, Learch T, Itamura J, Vaishnav S, Colletti P, Moon C, Terk MR. MR imaging of collateral ligaments in the flexed elbow. Am J Roentgenology 2001;176(3)S:140.

    l0.Fritz RC, Stoller DW: The Elbow. In. Stoller DW, ed. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. 2nd ed. Philadelphia: Lippincott-Raven Publishers, 1997: pp 743-849.

    Pär Herbertsson
    Posted on April 30, 2004
    Dr Herbertsson responds to Dr. Hausman
    University Hospital MAS, Malmö, Sweden

    To the Editor:

    We thank Dr.Hausman for his interesting comments.

    In the first draft of our paper, we summarized the inclusion criteria as fractures of the radial head or neck without additional fractures or major soft tissue injuries of the upper extremity. Thus, individuals with additional injuries such as other fractures, an elbow dislocation, or an acute longitudinal radio-ulnar dissociation or Essex Lopresti fracture (ALRUD) were not evaluated.

    We agree with the notion that radial head fractures are frequently associated with ligament injuries. However, individuals with an additional ligament injury were included in the current study. Arvidson et al. (1, 2) reported that 85 % of all individuals with a Mason type III fracture had a medial collateral ligament rupture of the elbow and Josefsson et al.(3) reported that all individuals with a dislocations of the elbow had both lateral and medial collateral ligament ruptures. However, based on a paper by Josefsson et al. (4, 5), a prospective randomized study, collateral ligament injuries of the elbow were not regarded as a complicated injury as most individuals with a rupture of the collateral ligament,treated non operatively, were without adverse results at follow-up. Due to these findings, we regard a collateral ligament rupture associated with a Mason fracture as an uncomplicated Mason fracture.

    We also agree that the outcomes in the present study are favorable. There are several published studies that present a similar outcome (6, 7). Other studies that reported inferior results may included individuals with additional fractures about the elbow and have reporte patients with a shorter follow-up. In the long term follow-up presented in our study, the patient may accept the outcome of the elbow injury or decrease the demands of the elbow, thus rating the outcome as acceptable. Furthermore, other classification systems, as the Steinman classification system, may rate a higher proportion of individuals with an unfavorable outcome compared to classification we used. This notion is actually supported in other studies (8, 9).

    We hope that these answers are helpful to the reader.

    Yours sincerely

    Pär Herbertsson M.D. (parherbertsson@msn.com) Magnus K Karlsson M.D., Ph.D. (magnus.karlsson@orto.mas.lu.se) Department of Orhopaedics Malmö University Hospital SE – 205 02 Malmö,Sweden

    1. Arvidsson, H. and O. Johansson (1955) Arthrography of the elbow- joint. Acta radiol. (43.):445-452 2. Johansson, O. (1962) Capsular and ligament injuries of the elbow joint Acta chir Scand (287 Suppl:1) 3. Josefsson, P. O., L. Andren, et al. (1984). Arthrogrphy of the dislocated elbow joint. Acta Radiol Diagn (Stockh) 25(2):143-5. 4. Josefsson, P. O., O. Johnell, et al. (1984). Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am 66(6):927-30. 5. Josefsson, P. O., O. Johnell, et al. (1987). Ligamentous injuries in dislocation of the elbow joint. Clin Orthop (221):221-5. 6. Arner, O. K, Ekengren, et al. (1957). Fractures of the head and neck of the radius. Acta Chir Scand 1 112:115-34. 7. Poulsen, J. O. and K. Tophoj (1974). Fracture of the head and neck of the radius. Follow-up on 61 patients. Acta Orthop Scand 45(1):66-75. 8. Herbertsson, P. et al. (2004)Mason type IV fractures of the elbow an up to 46 year follow-up of 21 cases. Submitted to J Bone Joint Surg Am. 9. Herbertsson, P. (2004) Radial head and neck fractures. Thesis. Department of Orthopaedic Surgery, University Hospital MAS. University of Lund. Sweden.

    Pär Herbertsson
    Posted on April 30, 2004
    Dr. Herbertsson responds to Dr. Ring
    University hospital MAS. Malmö. Sweden

    To the Editor:

    We will try to answer the questions raised Ring in his recent letter to the Editor.

    In the total survey including all isolated radial head or neck fractures during the period 1969-1979 we found 225 adult individuals with as the JBJS (Am) suggest us to call them, uncomplicated Mason type II or III fractures, and 16 adults with a Mason type IV fracture. Due to the long follow-up, it was no more than 107 out of the original 225 individuals with a Mason type II or III fracture that were still living in Malmö and out of these 107 individuals, seven refused to participate in the study. In this paper we only evaluated the individuals with an uncomplicated Mason type II and III fracture of the radial had or neck. As the paper report, the outcome was in virtually all individuals acceptable, that is with the small proportion of individuals with an unsatisfactory outcome, we could not find any discrepancy when comparing individuals with a radial head or neck fracture.

    This survey did not evaluate the incidence of isolated radial head fracture with elbow dislocation, but we have previously found that 10 % of all individuals with an elbow dislocation was accompanied with a radial head fracture (1, 2). Furthermore, previous literature also indicate that no more than 2 % of all individuals with a radial head fracture are accompanied with a dislocation of the elbow (3). Furthermore, we did not search for individuals with a posterior Monteggia lesion, individuals with an Essex-Lopresti variant or individuals with additional elbow fractures. These types of fractures are in the hospital archives classified in another way and was thus not scrutinised in our search, that is the incidence of these types of injuries could not be stated in this survey.

    The individuals with a more complicated injury, a Mason type IV fracture, are specifically evaluated in another article submitted to JBJS (Am). However, if we summarise this paper it support the view by Dr. Ring, as the paper indicate an inferior outcome compared to the outcome in uncomplicated fractures of the radial head or neck. In the paper we speculate if this is due to a more extensive soft and ligament injury. These issues are more discussed in the thesis “Radial Head and Neck Fractures” presented by Pär Herbertsson MD., University of Lund, Lund, Sweden 2004.

    Dr. Ring also ask how many of the six individuals with a retained type III radial head fractures that actually had an unsatisfactory results. We must then state that also these individuals were predominantly good outcome. Four out of six individuals with this fracture had no symptoms in the previously fractured elbow at follow-up, one had occasional but not daily pain, and one had severely impairment. Five of the six individuals with a Mason type II fracture who were treated with a delayed radial head excision, had had a radial head fractures. Two out of the six individuals had no symptoms, both radial head fractures, whereas four had occasional but not daily pain.

    The Steinberg classification use both the subjective outcome and the objective range of motion in the classification system. In this classification you are rated as poor with an extension deficit exceeding 20 degrees or if you have pain at rest. In the current study, two individuals experienced pain at rest, one with a Mason II a fracture and one with a Mason type III a fracture. Three individuals had an extension deficit exceeding 20 degrees, all women treated with cast, two with Mason II fractures and one with a Mason III fracture.

    We agree with the conclusions by Ring that non-operative treatment should probably be recommended in individuals with an isolated, displaced fractures including only a part of the radial head and with no restriction of elbow motion. However, we must acknowledge that the treatment in this study was done twenty to thirty years ago and if internal fixation by the techniques used today leads to a better result than a radial head excision is not known. However, since most of the former patients had an acceptable outcome also with the old treatment strategy, we must ask if operative intervention with internal fixation or prosthesis replacement could produce a substantially better result.

    Another question that Dr. Ring rise is the current recommendations for the management of isolated Mason type III fractures of the radial head at our clinic? Currently, in patients with an isolated Mason type III fracture without associated injuries in the wrist or the membranea interossea, and with a full range of motion in the elbow we recommended non-operative treatment. If there is displaced fragment within the joint which impair the forearm rotation, we recommended extirpation of the fragment or internal fixation of the fragment. In an acute, longitudinal radioulnar dissociation (ALRUD) with a Mason type III fracture we recommended internal fixation or radial head extirpation with a prosthetic replacement, creating a spacer. If the radial head or neck fracture is followed by a severe elbow instability, sometimes we recommend the use of an external fixation instead of cast.

    We also agree with Ring when concluding that radio-capitellar arthritis is uncommon and usually with no or only minor problems. We defined arthritis as cysts, osteophytes, scleroris in conjunction with a reduced joint space of more than one milli-meter in comparison with the uninjured elbow, for the diagnosis arthritis. Additionally, in individuals treated with a radial head excision, we could only evaluate the joint space height in the medial part of the joint. By this definition we found that the prevalence of arthritis was low and mostly not related to subjective complaints.

    By this letter we hope that we have straightened the question marks for the readers

    Sincerely

    Pär Herbertsson M.D. Magnus Karlsson MD. Ph.D.

    1 Josefsson, P. O. and B. E. Nilsson (1986). Incidence of elbow dislocation. Acta Orhop Scand 57(6):537-8. 2 Josefsson, P. O., C.F. Gentz, et al. (1989). Dislocation of the elbow and intraarticular fractures. Clin Orthop(246):126-130. 3 Herbertsson, P. (2004) Radial head and neck fractures. Thesis. Department of Orthopaedic Surgery, University Hospital MAS. University of Lund. Sweden.

    Michael R Hausman
    Posted on April 07, 2004
    Outcome of Mason Type II & III Radial Head Fractures
    Department of Orthopaedic Surgery,Mount Sinai Hospital,New York

    To The Editor

    We read the article “Uncomplicated Mason Type-II and III Fractures of the Radial Head and Neck in Adults. A Long-Term Follow-Up Study” by Herbertsson et. al. with great interest given the current trend for early fixation or arthroplasty of this injury. The authors report good long term results of treatment of “uncomplicated” radial head fractures. The authors do not mention the specific inclusion criteria for “uncomplicated” fractures. Morrey adds the prefix uncomplicated to indicate absence of associated injury(2). However the authors include patients with associated injuries (medial collateral ligament repair). There is increasing evidence that displaced radial head fractures are very frequently associated with associated ligamentous injury. Indeed there is growing skepticism that a displaced radial head fracture can occur in the absence of concomitant medial or lateral collateral ligament injury. Arvidson et al. report 85% of patients with Mason type III fractures demonstrating arthrographic evidence of valgus instability(1). Biomechanical studies have clarified the key role of the medial collateral ligament particularly in the setting of radial head fracture or excision(5 -7).

    Poor outcomes from treatment of radial head fractures without addressing associated injuries have been reported (3;4;8). The superior results reported by Herbertsson ( <_3 degrees="degrees" of="of" loss="loss" extension="extension" are="are" at="at" odds="odds" with="with" these="these" reports="reports" and="and" our="our" personal="personal" experience.="experience." to="to" combine="combine" type="type" ii="ii" iii="iii" fracture="fracture" groups="groups" in="in" a="a" single="single" analysis="analysis" gives="gives" misleading="misleading" impression="impression" benign="benign" injury="injury" almost="almost" universal="universal" good="good" outcome.="outcome." p="p" /> Hannan Mullett FRCS (Tr.& Orth.) Michael Hausman MD

    Reference List

    1. ARVIDSSON, H. and Johansson, O.: Arthrography of the elbow-joint. Acta Radiol. 43:445-452, 1955.

    2. Broberg, M. A. and Morrey, B. F.: Results of treatment of fracture-dislocations of the elbow. Clin Orthop.109-119, 1987.

    3. Davidson, P. A., Moseley, J. B., Jr., and Tullos, H. S.: Radial head fracture. A potentially complex injury. Clin Orthop.224-230, 1993.

    4. Frankle, M. A., Koval, K. J., Sanders, R. W., and Zuckerman, J. D.: Radial head fractures associated with elbow dislocations treated by immediate stabilization and early motion. J. Shoulder. Elbow. Surg. 8:355- 360, 1999.

    5. Morrey, B. F.: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr. Course Lect. 44:175-185, 1995.

    6. Morrey, B. F., An, K. N., and Stormont, T. J.: Force transmission through the radial head. J. Bone Joint Surg. Am. 70:250-256, 1988.

    7. Morrey, B. F., Tanaka, S., and An, K. N.: Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop.187- 195, 1991.

    8. Ring, D., Quintero, J., and Jupiter, J. B.: Open reduction and internal fixation of fractures of the radial head. J. Bone Joint Surg. Am. 84-A:1811-1815, 2002.

    David Ring, M.D.
    Posted on March 03, 2004
    More information on radial head fractures.
    Massachusetts General Hospital, 11 Hancock Street, Unit 4, Boston, MA 02114

    <

    To the Editor:

    The unique hospital registry system in Malmo, Sweden has provided orthopaedic surgeons a wealth of data regarding the long-term effects of a variety of skeletal injuries. The paper by Herbertsson and colleagues continues this tradition, representing a great opportunity to learn about radial head fractures(1). There are only a few hospitals in the world where it is consistently possible to review radiographs taken between 1969 and 1979. An amazing 51% (according to my calculations) are still living in Malmo! Given this opportunity I would be indebted to the authors if they could help clarify some of the issues that I face in treating patients with fractures of the radial head.

    Herbertsson and colleagues elected to use Morrey’s modification of the Mason classification(2). This is advantageous in that this system uses quantitative criteria to define displacement as opposed to Mason’s original descriptive classification. Thus, we know that all of the patients included in this study had a fracture involving at least 30% of the articular surface and all of the patients had displacement of 2 millimeters or greater. The disadvantage of using Morrey’s modification is that fractures of the radial neck are grouped with fractures of the radial head. Because these injuries present distinct management issues, it would be beneficial to consider them separately and it would be helpful for the authors to do this for us, as I will describe below.

    Since this study included only substantially displaced fractures, it is critical to know more about those patients who had displaced fractures of the radial head as part of a more complex injury pattern and who were therefore excluded from this study. The authors have excluded patients with a fracture of the radial head and dislocation of the elbow (type 4) according to Morrey’s modification of the Mason classification), but what about all the patients with a radial head fracture associated with a posterior olecranon fracture-dislocation (posterior Monteggia lesion) or an Essex-Lopresti variant? How many such patients were identified and excluded?

    This is important because isolated fractures of the radial head are usually minimally displaced. Displaced fractures are often associated with other fractures or ligament injuries of the elbow or forearm. This makes sense, given that substantial displacement of the radial head would by necessity be associated with substantial displacement of either the forearm or elbow articulation and this would indicate some degree of injury to the structures that stabilize these joints. Some authors have cautioned that all, or nearly all, complex fractures of the entire radial head (Mason type 3) will be part of a more complex injury pattern.3 It can be difficult to detect associated injury to the elbow or forearm when treating fractures of the radial head. Tests have been described to be certain that important ligament injuries are not overlooked(4).

    The study of Herbertsson and colleagues confirms that displaced fractures involving the entire head of the radius (Mason type 3) benefit from operative treatment. Among the 24 Mason type 3 fractures, 15 were excised as the initial treatment—presumably because they were complex or widely displaced (as depicted in the figure), because open reduction and internal fixation and prosthetic replacement were not utilized in Malmo during the study period, and also because they were isolated injuries and there was no contraindication to excision of the radial head without prosthetic replacement. Among the retained fractures, one-third were eventually excised. How many of the six retained type 3 radial head fractures had unsatisfactory results? What are the authors current recommendations for the evaluation and management of isolated Mason type 3 fractures of the radial head?

    The management of isolated displaced fractures involving part of the radial head is disputed. Morrey’s criteria for inclusion as a type 2 fracture (at least 30 percent of the radial head and 2 millimeters or greater displacement) are considered indications for operative treatment by many surgeons. At least one study has observed better results with open reduction and internal fixation of such fractures compared to non- operative treatment.5 It has been my teaching and experience that if an isolated displaced fracture of part of the radial head does not block forearm rotation, non-operative treatment will nearly always yield good results regardless of the radiographic appearance of the fracture. I was hoping the study of Herbertsson and colleagues could provide information of use in this debate. In this regard it would be helpful if the authors would distinguish their type 2 fractures that involve a partial head fracture from the displaced fractures of the radial neck. Using the data provided--and applying a worst-case analysis--I have come up with the following: If all six of the late excisions were partial radial head fractures and only 84% of the remaining fractures had good results then the 74% of the 53 isolated displaced partial radial head fractures (all involving greater than 30% of the head and 2 millimeters or greater displacement) had good long-term results. These good results were augmented by the use of radial head excision as a useful salvage procedure for the few patients with problems. Can the authors give us the correct numbers for the isolated displaced partial radial head fractures?

    Furthermore, the rating system of Steinberg and colleagues is very strict. It would be helpful if the authors could provide details regarding the patients in this subgroup that did poorly with non-operative treatment. Was it restriction of motion that was a problem? Crepitation? Pain? Were there any psychosocial factors? If even the patients with the worst results had relatively good motion and very limited pain in long- term follow-up, this would provide further support for non-operative treatment of these injuries.

    With such good results using non-operative treatment, the surgeon should not take too much credit for a good result after open reduction and internal fixation of an isolated, displaced fracture of part of the radial head. It would seem that as long as complications are avoided, the results of operative treatment will be good in at least 74% of the fractures. In the absence of wellexecuted prospective, randomized trials demonstrating a benefit for operative treatment, the data of Herbertsson and colleagues provide strong support for the non-operative treatment of isolated, displaced fractures of part of the radial head that do not block forearm rotation. Do the authors agree with this conclusion?

    The authors mention that 76% of patients had radiographic signs of arthrosis. Was this radiocapitellar or ulnohumeral arthrosis? Although radial head fractures are common, radiocapitellar arthrosis is not a common source of complaints in the office and very little has been written about it. It would seem that radiocapitellar arthrosis is uncommon and rarely problematic. Do the authors agree?

    I appreciate the immense effort that went into this study and I hope that the authors will be willing to apply a little more effort on my behalf. An opportunity like this is exceedingly rare.

    Sincerely,

    David Ring, MD

    References: 1. Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besiakov J, Karlsson M. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. J Bone Joint Surg 2004;86A:569-574. 2. Morrey BF. Radial Head Fractures. In: Morrey BF, editor. The Elbow and Its Disorders. Philadelphia: W.B. Saunders; 1985. p. 355. 3. Davidson PA, Moseley JB, Tullos HS. Radial head fracture. A potentially complex injury. Clin Orthop 1993;297:224-130. 4. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg Am. 2002;84A:1970- 6. 5. Khalfayan EE, Culp RW, Alexander AH. Mason Type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma 1992;6:283-289.

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