Abstract
Background: Satisfactory internal fixation of comminuted radial head
fractures is often difficult to achieve, and radial head resection has been
the accepted treatment. In this study, we compared the results of radial head
resection with those of open reduction and internal fixation in patients with
a comminuted radial head fracture.
Methods: Twenty-eight patients with a Mason type-III radial head
fracture (some with associated injuries) were enrolled in the study. Fifteen
patients underwent radial head resection as the initial treatment (Group I),
and thirteen patients underwent open reduction and internal fixation (Group
II). The age at the operation averaged 41.1 and 38.2 years, respectively, and
the duration of follow-up averaged ten and three years, respectively. The
outcomes were assessed on the basis of pain, motion, radiographic findings,
and strength measured with Cybex testing. The overall outcome was rated with
the functional rating score described by Broberg and Morrey and with the
American Shoulder and Elbow Surgeons Elbow Assessment Form.
Results: Elbow motion averaged 15.5° (extension loss) to
131.4° (flexion) in Group I and 7.1° to 133.8° in Group II. The
carrying angle and ulnar variance averaged 8.2° and 1.9 mm in Group I and
1.5° and 0.5 mm in Group II. Compared with Group II, Group I had a loss of
strength in extension, pronation, and supination (p < 0.01). The Broberg
and Morrey functional rating score averaged 81.4 points in Group I and 90.7
points in Group II (p = 0.0034). The score on the American Shoulder and Elbow
Surgeons Elbow Assessment Form averaged 87.3 points in Group I and 94.6 points
in Group II (p = 0.0031).
Conclusions: The patients in whom the comminuted radial head
fracture was treated with open reduction and internal fixation had
satisfactory joint motion, with greater strength and better function than the
patients who had undergone radial head resection. These results support a
recommendation for open reduction and internal fixation in the treatment of
this fracture.
Level of Evidence: Therapeutic study, Level III. See
Instructions to Authors for a complete description of levels of evidence.
The treatment of displaced comminuted fractures of the radial head
is controversial, with conflicting evidence to support either resection or
open reduction and internal
fixation1-5.
It is difficult to achieve satisfactory open reduction and internal fixation
of a fracture that is comminuted and severely displaced. Improper internal
fixation interferes with the smooth congruity of the proximal radioulnar
articulation, and this limits joint motion, causes pain, and may lead to
posttraumatic osteoarthrosis of adjacent joints. Therefore, radial head
resection has been a valid therapeutic option, with reports of good long-term
functional
outcomes6-13.
However, delayed complications, including pain, joint instability, proximal
radial translation, decreased strength, osteoarthrosis, and cubitus valgus,
have also been reported after radial head
resection12-21.
Radial head resection in patients with a severely comminuted radial head
fracture, which often is associated with ligament disruption, may produce an
extremely unstable elbow.
Prior to July 1996, we performed radial head resection as the primary
treatment for comminuted radial head fractures. After July 1996, we have
performed internal fixation with small implants such as mini-plates or Herbert
screws whenever possible. Thus, we were able to study two groups of patients:
those who underwent radial head resection and those who underwent internal
fixation for a similar type of comminuted fracture of the radial head. The
purpose of this study was to evaluate and compare the outcomes in those two
groups to determine the better method of treatment of comminuted radial head
fractures.
Between April 1984 and March 2001, we performed operations on
thirty-five consecutive patients with a comminuted and displaced radial head
fracture. All fractures were classified as type III according to the
Mason6
classification system. Some patients had an associated elbow dislocation,
ligament injury, coronoid fracture, or Monteggia lesion (the so-called Mason
type-IV
variations)3. Radial
head resection was performed prior to July 1996 by two of us (M.I. and Y.O.),
and open reduction and internal fixation was performed after July 1996 by one
of us (M.I.). Two patients underwent prosthetic replacement of the radial head
after July 1996 and were excluded from this study. Five patients who had
undergone radial head resection were lost to follow-up, and the remaining
twenty-eight patients were included in the study. Eighteen patients sustained
the injury from a fall on the out-stretched hand, and ten patients sustained
the injury in a motor-vehicle accident.
Our institutional review board approved the retrospective review, and the
physical and radiographic examinations, including the assessment protocol,
were carried out after the patients gave informed consent to participate in
the study.
Group I: Radial Head Resection
Group I included fifteen patients (eleven men and four women) who had
undergone primary radial head resection. Their average age at the time of the
operation was 41.1 years (range, twenty-five to seventy years). There were
nine Mason type-III fractures and six Mason type-IV variations. Four patients
had a simple fracture of the entire radial neck with the head completely
displaced from the shaft (Fig. 1,
A), seven had an articular fracture of the entire head
consisting of more than two large displaced fragments
(Fig. 1, B), and four
had a fracture with an impacted articular fragment and small, comminuted,
completely displaced fragments (Fig 1,
C). Three patients who had a Mason type-IV variation with
a posterior elbow dislocation initially underwent manipulative reduction and
immobilization in a plaster splint. The average time from the injury to the
operation was nine days (range, one to fourteen days).
Radial head resection was carried out through a lateral or posterolateral
approach, with the head removed at the level of the annular ligament. The
lateral collateral ligament was repaired with number-1 nonabsorbable braided
sutures or an anchoring system (Mitek GII Quick Anchor Plus; Ethicon, Johnson
and Johnson, Westwood, Massachusetts) at joint closure.
Four patients had a coronoid fracture. According to the
Regan-Morrey22
classification system, three of these fractures were type I (simple avulsion
of the tip of the process), and one was type II (a single fracture involving
approximately 50% of the process). The coronoid fracture fragment was removed
in the three patients with a type-I fracture, and the type-II fracture was
internally fixed. A Monteggia lesion was present in one patient who had a
posteriorly angulated fracture of the proximal third of the ulna with a
posterior dislocation of the fractured radial head. The fracture of the ulna
was internally fixed when the radial head was resected. In five patients with
a medial collateral ligament injury, the ligament was repaired with number-1
nonabsorbable braided sutures or an anchoring system.
The average period of immobilization after the radial head resections was
eight days (range, one to fourteen days). Active forearm rotation exercises
were initiated with the arm in a sling and the elbow at a right angle. Active
range-of-motion exercises of the elbow were started two weeks after the
operation. The five patients with a repaired medial collateral ligament wore a
long arm cylinder cast instead of a sling to keep the elbow at a right angle
in order to allow forearm rotation. The cast was changed to a hinged brace,
and active elbow movement was started two weeks postoperatively. The brace was
worn continuously for four weeks. The average period of postoperative
follow-up was ten years (range, three to eighteen years).
Group II: Open Reduction and Internal Fixation
Group II included thirteen patients (seven men and six women) who underwent
open reduction and internal fixation. The average age at the time of the
operation was 38.2 years (range, twenty to seventy-one years). There were
three Mason type-III fractures and ten Mason type-IV variations. Nine patients
had an articular fracture of the entire head. Three of those fractures
consisted of two large fragments, and the other six consisted of more than
three large fragments with or without marginal fragments. Four fractures
included large impacted articular fragments and two or three small fragments.
Two patients who had a Mason type-IV variation with a posterior elbow
dislocation initially underwent manipulative closed reduction. A Mason
type-III fracture, classified as a type-II open fracture according to the
criteria of Gustilo et
al.23, was treated
initially with débridement and irrigation and the wound was closed
primarily. The average time from the injury to the operation was twelve days
(range, eight to sixteen days).
All fractures of the radial head were internally fixed with use of
low-profile
mini-plates24
(Stryker Leibinger, Freiburg, Germany) and/or Herbert screws (Zimmer, Warsaw,
Indiana) (Figs. 2-A,
2-B,
2-C, 2-D,
2-E and
2-F). The radial head fracture
was accessed through an approach similar to that used for the radial head
resections. When the medial collateral ligament was torn, it was anchored with
a number-1 nonabsorbable braided suture or an anchoring system prior to
fracture reduction. The anchor suture was tied after fracture fixation. The
fracture was reduced and was held with small forceps or tenacular clamps, or
it was temporarily fixed with 1.0-mm Kirschner wires. The low-profile
mini-plate used in this series was T-shaped with a 0.55-mm profile height and
a 1.7-mm screw diameter. In eleven patients, cancellous bone chips or graft
blocks, obtained from the ipsilateral olecranon in three patients and from the
iliac crest in eight, were placed between the radial head and neck or in other
areas of bone deficit of the reduction. The annular ligament was sutured with
number-1 non-absorbable braided sutures, and the lateral collateral ligament
was repaired with number-1 nonabsorbable braided sutures or an anchoring
system subsequently.
Eight fractures were fixed with low-profile mini-plates, three fractures
were fixed with Herbert screws, and two fractures were fixed with a
combination of the two. Bone-grafting was performed in eleven fractures. The
medial collateral ligament was repaired in seven patients who had the Mason
type-IV variation, and the lateral collateral ligament was repaired in four. A
type-I fracture of the coronoid tip was present and the fragment was removed
in two patients with a Mason type-IV variation. One patient had a small
avulsion fracture of the olecranon, and the triceps tendon was repaired at its
insertion. An osteochondral fracture of the capitellum in a patient with a
Mason type-IV variation was fixed with a bone peg graft obtained from the
olecranon crest.
Forearm rotation exercises, with the extremity in a long arm cylinder cast
and the elbow at a right angle, were started two days (range, one to four
days) after the surgery. The cast was worn for two weeks, after which it was
changed to a hinged brace and active elbow movement was started. The brace was
worn continuously for four weeks. Of the ten patients in whom the fracture was
fixed with low-profile mini-plates, nine had the plates removed after five to
seven months to prevent deterioration of the proximal radioulnar cartilage.
One patient with a Mason type-IV variation refused to have the plates removed.
The follow-up period after the initial operation averaged three years (range,
two to four years).
Outcome Measures and Statistical Methods
The outcome assessment included a questionnaire inquiring about pain,
impairment, and elbow disability. The responses were incorporated into the
Broberg and Morrey functional rating
score9 and the
American Shoulder and Elbow Surgeons Elbow Assessment
Form25. Physical
assessment included measurement of the ranges of motion of the elbow and
forearm and of grip strength. A standard long-limb goniometer was used to
measure range of motion. Flexion and extension of the elbow were measured with
the forearm in neutral rotation, and rotation of the forearm was measured with
the elbow at a right angle. Bilateral anteroposterior and lateral radiographs
of the elbow were made to assess osseous union, congruity, and posttraumatic
osteoarthrosis. Bilateral anteroposterior radiographs of the wrist and elbow
were made in supination to measure the carrying angle and ulnar variance.
Osteoarthrosis in the elbow was classified, according to the Broberg and
Morrey system9, as
grade zero (absent; normal elbow), grade one (mild, with slight joint space
narrowing or minimum osteophyte formation), grade two (moderate, with moderate
joint space narrowing or moderate osteophyte formation), or grade three
(severe, with severe degenerative change and joint destruction). The strength
of flexion and extension of the elbow and of pronation and supination of the
forearm was measured with the Cybex 770-NORM (Cybex International, Ronkonkoma,
New York). The peak torques of flexion and extension of the elbow and
pronation and supination of the forearm were measured at 60°/sec and
30°/sec, respectively.
Twenty normal subjects were studied to determine the normal variation in
grip strength and the results of Cybex testing between dominant and
nondominant sides, as described by Morrey et
al.12. The ratio of
the nondominant to the dominant side was 0.87 for grip strength, 0.89 for
extension, 0.91 for flexion, 0.78 for pronation, and 0.72 for supination.
These values were used to calculate and normalize the loss of strength on the
dominant or nondominant extremity independently.
The outcome was rated with the Broberg and Morrey functional rating
score9 and the
American Shoulder and Elbow Surgeons Elbow Assessment
Form25.
Standard statistical methods were employed. Descriptive statistics,
including means and standard deviations, were calculated and Groups I and II
were compared. The Mann-Whitney U test was used to evaluate the significance
of intergroup differences, and a p value of <0.01 was considered
significant.
All fractures in Group II had osseous union. When the plates were
removed after five to seven months in nine patients, they were covered by
synovial tissue and they did not seem to interfere with the function of the
proximal radioulnar joint. One patient who had no symptoms refused to have the
plates removed. One patient with an open Mason type-III fracture had a delayed
union, and it took eleven months until osseous union was evident
radiographically.
Pain
Visual-analog-scale scores in the American Shoulder and Elbow Surgeons
Elbow Assessment Form were used to compare the patients' perception of pain,
with 25 points representing the best possible score. The average score was
19.3 points (range, 12 to 25 points) in Group I and 22.4 points (range, 17 to
25 points) in Group II (p = 0.0226) (Table
I). Five patients in Group I and one in Group II had mild pain in
the elbow with strenuous use that required forearm rotation. Three patients in
Group I complained of a dull ache and numbness along the ulnar aspect of the
forearm.
Motion
Flexion contracture of the elbow averaged 15.5° (range, 5° to
46°) in Group I compared with 7.1° (range, 0° to 23°) in Group
II (p = 0.0254). The ranges of motion in the two groups were similar. Flexion
of the elbow averaged 131.4° (range, 111° to 142°) in Group I
compared with 133.8° (range, 116° to 143°) in Group II (p =
0.2790). Pronation of the forearm averaged 74.8° (range, 32° to
84°) in Group I compared with 73.3° (range, 63° to 81°) in
Group II (p = 0.0653). Supination of the forearm averaged 82.1° (range,
69° to 89°) in Group I compared with 85.3° (range, 75° to
90°) in Group II (p = 0.0226).
Strength
The average loss of grip strength was 15.0% (range, 2% to 34%) in Group I
compared with 10.4% (range, 0% to 24%) in Group II (p = 0.1971). Group I lost,
on the average, 28.6% (range, 6.5% to 40.0%) of strength in extension, 17.9%
(range, 6.2% to 35.0%) in flexion, 26.4% (range, 7.1% to 54.7%) in pronation,
and 38.3% (range, 14.3% to 55.5%) in supination. Group II lost an average of
11.8% (range, 2.3% to 29.7%) of strength in extension, 21.3% (range, 5.5% to
37.5%) in flexion, 13.6% (range, 0% to 42.3%) in pronation, and 7.7% (range,
0% to 30.1%) in supination. Loss of strength in extension (p = 0.0002),
pronation (p = 0.0046), and supination (p < 0.0001) was greater in Group I
than it was in Group II (Fig.
3). There was no significant difference between the groups with
regard to strength in flexion (p = 0.3841).
Radiographic Assessment
In comparison with the value for the contralateral limb, the average
increase in the carrying angle was 8.2° (range, 0° to 20°) in
Group I and 1.5° (range, 0° to 5°) in Group II (p < 0.0001)
(Table II). The average
increase in ulnar variance was 1.9 mm (range, 0 to 5 mm) in Group I and 0.5 mm
(range, -2 to 3 mm) in Group II (p = 0.0075)
(Table II). Degenerative
changes in Group I were grade zero in four elbows, grade one in six, and grade
two in five (Figs. 4-A and
4-B). Degenerative changes in Group II were grade zero in seven
elbows and grade one in six. Varying degrees of osteoarthrosis were recognized
in Group I but not in Group II.
Functional Assessment
The Broberg and Morrey functional rating score averaged 81.4 points (range,
57 to 92 points) in Group I and 90.7 points (range, 73 to 100 points) in Group
II (p = 0.0034) (Table I).
According to this scoring system, the result was rated as good for nine
patients, fair for five, and poor for one in Group I. The result was rated as
excellent for three patients, good for nine, and fair for one in Group II. The
average score according to the American Shoulder and Elbow Surgeons Elbow
Assessment Form was 87.3 points (range, 70 to 97 points) in Group I and 94.6
points (range, 77 to 100 points) in Group II (p = 0.0031)
(Table I).
Acceptable long-term functional outcomes have been reported after
primary or delayed radial head resection performed as a salvage operation for
Mason type-III
fractures6,7,9-11,26.
Radial head resection has been associated with long-term complications,
including wrist and forearm pain, increased valgus elbow deformity,
degenerative osteoarthrosis, and decreased strength. However, these
complications are not considered serious as long as joint mobility is
preserved6-10,12,19.
Many
authors10,12-16,18,20
have reported a 2 to 3-mm increase in proximal translation of the radius and
an increase in ulnar variance after radial head resection. These changes can
cause wrist, forearm, and elbow pain with resultant ulnar abutment,
subluxation of the distal radioulnar joint, or stretching of the interosseous
membrane14,16,18.
A 5° to 20° increase in the carrying angle of the elbow has also been
reported10,13,16-19.
This valgus elbow deformity can result in the development of ulnar nerve
symptoms. Although the conditions under which strength was measured were not
uniformly normalized in previous studies, loss of strength in elbow flexion
and extension and in forearm rotation may approach
30%8,9,12,18,27.
Our study demonstrated less elbow extension and forearm rotation strength
after radial head resection than after open reduction and internal fixation.
The main mechanism for loss of strength is probably related to the decreased
proximal support of the radius, which normally acts as a load-bearing fulcrum
to transmit forces across the radiocapitellar articulation. Other contributing
factors may include restricted joint mobility, valgus instability, functional
discomfort, and psychologic factors.
The importance of the radial head and radiocapitellar contact has been
noted both clinically and experimentally, especially after radial head
fractures associated with ligament
injuries27-33.
The most common cause of failure of open reduction and internal fixation has
been the inability to achieve rigid internal
fixation5,30.
The advent of the Herbert screw and, more recently, the mini-plate system has
created the possibility of reducing and internally fixing radial head
fractures that previously would have required
resection24,28-31,34-38.
Although repair of severely comminuted fractures is technically demanding and
not all radial head fractures are amenable to open reduction and internal
fixation, our results justify an effort to preserve the radial head.
Ideally, all comminuted radial head fractures should be treated with
internal fixation with small implants. Since we started using small implants
for internal fixation of comminuted fractures, we have fixed all but two
successfully. The two patients in whom the fracture was not fixed would not
accept the bone-grafting and the postoperative protocol for internal fixation,
including plate removal; they underwent prosthetic radial head replacement
primarily without an attempt at open reduction and internal fixation.
While there was no bias in this study with regard to patient selection
according to fracture severity or technical difficulty, the study did have
several limitations. First, it was a longitudinal study comparing a cohort of
patients who had undergone radial head resection prior to July 1996 with a
group that had been treated more recently with open reduction and internal
fixation. Thus, there is an obvious difference in the duration of follow-up
between the two groups (ten years in Group I compared with three years in
Group II), although all patients were followed for a minimum of two years.
This discrepancy may have had a substantial effect on the reported prevalence
of degenerative elbow changes, which was greater in the patients who had had
the radial head resection. Second, we attribute our good results to meticulous
surgical technique, especially the use of low-profile mini-plates and
bone-grafting. A third limitation of the study is the difference in
postoperative protocol between the groups, but the final ranges of motion of
the two groups were similar and the follow-up period was sufficient to
evaluate strength. Although the average ages of the patients in the two groups
were similar at the time of the operation, the patients in Group I were, on
the average, older than those in Group II at the final evaluation.
Despite these limitations, we concluded that open reduction and internal
fixation results in satisfactory joint mobility and provides better strength
and a better overall functional outcome than does radial head resection.
Therefore, open reduction and internal fixation should be pursued in the
treatment of comminuted fractures of the radial head unless extenuating
factors, such as poor general health or advanced age, prevent the patient from
participating in the postoperative rehabilitation protocol. ?
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