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Primary Nonoperative Treatment of Moderately Displaced Two-Part Fractures of the Radial Head
Thomas Åkesson1; Pär Herbertsson, MD, PhD1; Per-Olof Josefsson1; Ralph Hasserius, MD, PhD1; Jack Besjakov, MD, PhD1; Magnus K. Karlsson, MD, PhD1
1 Department of Orthopaedics (T.A., P.H., P.-O.J., R.H., and M.K.K.) and Radiology (J.B.), Malmö University Hospital, Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, SE -20502 Malmö, Sweden. E-mail address for M.K. Karlsson: magnus.karlsson@med.lu.se
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The authors did not receive grants or outside funding in support of their research for 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 Departments of Orthopaedics and Radiology, Malmö University Hospital, Lund University, Malmö, Sweden

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Sep 01;88(9):1909-1914. doi: 10.2106/JBJS.E.01052
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Abstract

Background: Moderately displaced two-fragment fractures of the radial head have been treated predominantly nonoperatively. Recently, however, open reduction and internal fixation has gradually gained interest, without clear evidence that initial nonoperative treatment leads to an unfavorable outcome. As a consequence, the purpose of the present study was to evaluate the long-term outcome after the initial nonoperative treatment of this type of fracture.

Methods: Fifteen men and thirty-four women, with a mean age of forty-nine years at the time of the injury, were included in the study. All patients initially had been managed nonoperatively for a two-fragment fracture of the radial head that was displaced 2 to 5 mm and that included =30% of the joint surface (a Mason type-IIa fracture). Early mobilization had been used for twenty-seven patients, and cast immobilization for a mean of two weeks (range, one to four weeks) had been used for twenty-two. All patients were reevaluated with a questionnaire after a mean of nineteen years, and thirty-four also had a clinical and a radiographic evaluation. Six patients had had a delayed radial head excision because of an unsatisfactory primary outcome.

Results: Forty of the forty-nine patients had no subjective complaints, eight were slightly impaired as the result of occasional elbow pain, and one had daily pain. Flexion was slightly impaired in the injured elbows as compared with the uninjured elbows (137° ± 8° compared with 139° ± 7°), as was extension (—3° ± 7° compared with 1° ± 5°) and supination (86° ± 7° compared with 88° ± 4°) (p < 0.05 for all comparisons). The prevalence of degenerative changes on radiographs was higher for the injured elbows than for the uninjured elbows (82% [twenty-eight of thirty-four] compared with 21% [seven of thirty-four]; p < 0.01).

Conclusions: The initial nonoperative treatment of Mason type-IIa fractures of the radial head that are displaced by 2 to 5 mm is associated with a predominantly favorable outcome, especially if a delayed radial head excision is performed in the few cases in which the early outcome is unsatisfactory.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Turab A SYED
    Posted on November 17, 2006
    Essex Lopresti Injury & Radial Head Fractures
    Northampton General Hospital NHS Trust, UK

    To The Editor:

    I read the article by Ã…kesson et al.(1) regarding Brobery Mason Type IIa injuries. I noted that 6 of 49 patients had unsatisfactory outcomes; all of these had delayed excision of their Radial Heads.

    I was unable to find any reference to either presence or absence of Essex-Lopresti Injury in this cohort or the 6 patients with poor outcome. Was it not present at all, or was it not looked for at the time of the original injury?

    It would be helpful to know if the authors still recommend 'Non-Operative' treatment in Mason Type IIa fractures with Essex-Lopresti Injury, as this may be an entirely different beast.

    I suggest that there is a need for modification of the Broberg Modification of the Mason Classification with presence of Essex-Lopressti Injury. In order to make comparision of similar injuries/fracture patterns and their outcomes, it may be helpful to classify those with associated Essex-Lopresti with Type II & Type III to be classed as IIc & IIIc respectively.

    This would not only make management planning easier but would result in properly matched pairs in outcome studies.

    The author(s) of this letter to the editor did not receive payment 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 author(s) are affiliated or associated.

    Reference:

    1. Thomas Akesson, Pär Herbertsson, Per-Olof Josefsson, Ralph Hasserius, Jack Besjakov, and Magnus K. Karlsson. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am 2006; 88: 1909-1914

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