EVIDENCE-BASED MEDICINE
Management of Radial Head Fracture With Elbow Dislocation Mark L. Wang, MD, PhD, Pedro K. Beredjiklian, MD THE PATIENT A 45-year-old, right-handed man fell onto his right outstretched upper extremity at work. He presented with elbow pain and swelling. Radiographic evaluation demonstrated dislocation of the elbow and a displaced and comminuted fracture of the entire radial head. The elbow was reduced and placed in an orthosis in the emergency department. THE QUESTION What is the best treatment for a displaced, comminuted fracture of the radial head associated with an elbow dislocation? CURRENT OPINION The management of elbow dislocation with a displaced radial head fracture is debated. When the coronoid is also fractured, fixation or replacement of the radial head is recommended to reduce the high risk of redislocation.1 When the coronoid is not fractured, the risk of dislocation or subluxation is low and treatment of the radial head is aimed at preserving forearm rotation and slowing the development of arthrosis. Options include nonsurgical treatment, excision of the radial head with or without prosthetic replacement, and open reduction internal fixation (ORIF). Factors that influence decision making include the number of fracture fragments, the degree of displacement, and the position of the fragments.2e4 Patient factors including functional demands, comorbidities, and preferences should also be considered.2 From the Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA. Received for publication October 20, 2014; accepted in revised form October 20, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Mark L. Wang, MD, PhD, Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107-1216; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.10.029
THE EVIDENCE Broberg and Morrey5 evaluated 24 patients with ulnohumeral dislocation with radial head fracture 2 to 35 years after injury. The radial head fractures were treated either nonsurgically or with excision and the elbows were casted for about a month. Two elbows were redislocated, one with a lateral epicondyle fracture and one with no associated fractures, but no additional details are given. Based on a new elbow evaluation system accounting for pain, motion, strength, and stability, the authors reported excellent and good results in 18 patients, some after delayed excision of the radial head. Josefsson et al6 evaluated 23 patients with an elbow dislocation associated with a displaced fracture of the radial head. Nineteen patients had radial head excision at the time of initial treatment (range, 0e16 d). A displaced fracture of the coronoid process was present in 4 patients, all of whom had re-dislocation. Osteoarthritis was identified in 12 of 19 elbows evaluated 3 to 13 years after the injury. Akesson et al7 evaluated 49 patients with displaced partial articular fractures of the radial head (2- to 5-mm displacement and involvement of 30% or more of the articular surface) initially treated nonsurgically. Although that study did not specifically address radial head fractures associated with elbow dislocation, we now know that displaced fractures tend to be associated with ligament injuries. Six patients had delayed radial head excision for unspecified reasons at an average of 5 months after injury. An average of 19 years after injury, 40 patients had no subjective symptoms, 8 had occasional elbow pain, and 1 had daily pain. Goldberg et al8 evaluated 36 patients with closed radial head fractures (20 Mason II and 16 Mason III types) an average of 16 years after delayed radial head excision. A total of 31 (86%) were satisfied with the results, 34 (94%) returned to their preoperative occupations, and 3 lost 30 or more of elbow flexion or forearm rotation. Herbertsson et al9 evaluated 61 elbows at an average of 18 years after radial head excision for fracture. A total of 73% of elbows demonstrated radiographic
Ó 2014 ASSH
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Published by Elsevier, Inc. All rights reserved.
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RADIAL HEAD FRACTURE WITH ELBOW DISLOCATION
degenerative changes compared with 7% in the contralateral uninjured limb. Among the 43 patients treated with primary radial head excision, 22 had no symptoms compared with 6 of the 18 who had had a delayed excision. According to the classification system of Steinberg10 (a relatively strict scale used in children), 25 elbows were rated as good, 26 as fair, and 10 as poor. There were no significant differences in elbow pain, strength, motion, or functional outcome score between patients treated with primary excision versus delayed excision. Ikeda et al11 evaluated ORIF of a fracture of the entire head of the radius using a small plate and screws in 10 patients (average age, 42 y), 7 of whom had an elbow dislocation. An average of 28 months after surgery (and after a second surgery for implant removal in 9 of 10 patients) all of the fractures were healed and 90% of patients had good to excellent results based on the Broberg and Morrey Functional Elbow Index. The average range of flexion and extension of the elbow was 7 to 135 with an average of 74 supination and 85 pronation. King et al12 reported only 3 of 6 good or excellent results (33%) using an early version of the Mayo Elbow Performance Index an average of 32 months after ORIF of a displaced fractures involving the entire head of the radius. Fractures associated with elbow dislocations had greater flexion contractures. Nalbantoglu et al13 evaluated 25 displaced fractures of the entire head (7 with associated elbow dislocation) treated with ORIF an average of 27 months after surgery. Patients with and without associated elbow dislocation had comparable average elbow range of motion and Broberg and Morrey elbow functional scores.5 Ring et al14 evaluated the outcomes of 56 radial head fractures, including 27 injuries with an associated fracture or ligament injury of the forearm or elbow. Four of 15 patients with a displaced comminuted fracture of part of the radial head recovered less than 100 of forearm rotation. Among 12 displaced fractures of the entire head with 3 fracture fragments (including the shaft as a fragment), there was one nonunion, no early failures, and an average range of elbow motion greater than 100 . Among the 14 patients with a fracture of the entire head and more than 3 fracture fragments, 13 had an unsatisfactory result based on the Broberg and Morrey elbow rating: 3 had loss of fixation, 6 had nonunion, and 4 had poor (less than 100 ) forearm rotation. A study comparing excision (15 fractures) and ORIF (13 fractures) for a displaced comminuted fracture of the radial head associated with other injuries (eg, J Hand Surg Am.
coronoid fracture, dislocation) found greater strength, better Broberg and Morrey scores (91 vs 81 points), and better American Shoulder and Elbow Surgeons Elbow Assessment (95 vs 87 points) with ORIF.15 Doornberg et al16 evaluated 27 patients with comminuted radial head fractures with associated acute elbow instability treated with a modular metal spacer arthroplasty with a loose smooth neck. Sixteen of these patients had a posterior elbow dislocation. The prosthesis was removed in 2 patients to release an elbow contracture release or treat infection. Stability was restored to all 27 elbows. Twenty-two patients had a good or excellent result using the Mayo Elbow Performance Index. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis and 9 had radiographic changes in the capitellum, but these findings were not associated with symptoms. Moro et al17 studied 25 displaced radial head fractures—including 15 associated with an elbow dislocation—treated with monoblock titanium, loose smooth neck radial head arthroplasty. Using the Mayo Elbow Performance Index, 17 patients had good or excellent results, 5 had fair ones, and 3 had poor outcomes. The fair and poor outcomes were associated with concomitant injury in 2 patients, a history of a psychiatric disorder in 3, comorbidity in 2, a workers’ compensation claim in 2, and litigation in 1. Harrington et al18 evaluated 20 patients treated with a loose smooth spacer prosthetic radial head replacement for radial head fracture combined with dislocation of the elbow, rupture of the medial collateral ligament, fracture of the proximal ulna, and/ or fracture of the coronoid process. An average of 12 years after injury, 80% had good results based on a modified Mayo Elbow Performance Index functional rating system. Bain et al19 reported the results of press-fit, monoblock titanium radial head arthroplasty for 16 displaced fractures of the entire radial head, 12 with associated medial collateral ligament injury, 2 of which had elbow dislocations. These patients were treated with a monoblock titanium radial head prosthesis over a 5-year period. The authors reported good or excellent results in 80% of patients based on the Mayo Elbow Performance Score an average of 2.8 years after surgery. The mean flexion contracture was 15 with an average loss of 10 flexion compared with that of the contralateral elbow. Both pronation and supination decreased an average of 12 compared with that of the contralateral forearm. Popovic and colleagues20 evaluated 51 patients with comminuted fractures of the radial head (34 with r
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SHORTCOMINGS OF THE EVIDENCE Most reports are retrospective case series of a single technique.11,12,14,15,17,19 Although most displaced fractures of the radial head are part of a more complex injury pattern, most studies focus on the radial head fracture alone. Associated fractures and ligament injuries were likely underdiagnosed in many of these series. This is especially true in light of studies of fractures of the radial head with more than 2 mm displacement of a fracture fragment.24 The degree of fragmentation of the radial head is uncommonly noted. This is particularly important when assessing the few studies where ORIF of displaced fractures of the entire head was successful. Perhaps the surgeons repaired only the easier fractures.
an associated posterior elbow dislocation, 11 with an isolated radial head fractures, and 6 with a proximal ulna fracture and posterior radial head dislocation) an average of 8 years after bipolar radial head prosthetic replacement. Based on the Mayo Elbow Performance Index, 14 were excellent, 25 were good, 9 were fair, and 3 were poor. A total of 37 patients (72%) demonstrated radiographic signs of osteolysis related to polyethylene wear. In a prospective, randomized study of 22 patients, Ruan and colleagues21 performed ORIF (n ¼ 8) or bipolar prosthetic head replacement (n ¼ 14) for displaced fractures of the entire head of the radius. Functional evaluation in the arthroplasty group revealed excellent results in 9 patients, good ones in 4, and fair ones in 1. In the ORIF group, the results were good in 1 patient, fair in 4, and poor in 3, with complications including nonunion in 4 patients and hardware loosening in another 4. The difference in outcomes using Broberg and Morrey functional scores between the prosthesis group (93%) and the ORIF group (12%) was statistically significant. Chen et al22 prospectively randomized 45 patients with unstable, comminuted fractures of the radial head, some of which were associated with soft tissue injuries. The authors did not provide details of the associated injuries. Patients were prospectively randomized to prosthetic replacement (n ¼ 22) or ORIF with plates and screws (n ¼ 23). Using functional Broberg and Morrey scores, patients with radial head prosthetic replacement had 91% (20 of 22) good or excellent outcomes compared with patients in the ORIF group, who had 65% (15 of 23) good or excellent results. These differences were statistically significant. Similarly, postoperative complication rates in the replacement group were significantly lower than those in the ORIF group (14% vs 48%). Flinkkila et al23 evaluated 42 patients with radial head fractures with associated acute traumatic instability of the elbow treated with modular, uncemented press-fit radial head prostheses. An average of 4 years after surgery, 25 prostheses were well-fixed and 12 implants were loose, 9 of which were removed. At the time of removal, the authors reported an average time from implantation to loosening of 11 months, with periprosthetic radiolucent lines that were mild in 3 patients, moderate in 1, and severe in 5. Elbow motion and grip strength were significantly lower in the affected elbow than those of the contralateral side; average Mayo Elbow Performance score was 86 (range, 40e100), and mean Disabilities of the Arm, Shoulder and Hand score was 23 (range, 0e81). J Hand Surg Am.
3
DIRECTIONS FOR FUTURE RESEARCH Future studies should: (1) specifically investigate and document associated fractures and ligament injuries; (2) study fractures associated with elbow dislocations separate from isolated fractures and other types of forearm and elbow traumatic instability; and (3) characterize the radial head fractures in some detail (number, size and position of fragments; metaphyseal comminution; deformation of fragments; and lost or irreparable fragments). Our understanding of the advantages and disadvantages of initial nonsurgical treatment followed by selective radial head excision, immediate excision of the radial head with or without prosthetic replacement, and ORIF would be improved by multicenter, prospective, randomized trials comparing treatments with long-term evaluation. OUR CURRENT CONCEPTS FOR THIS PATIENT Radial head excision and nonsurgical treatment are options for patients with a displaced fracture of the radial head and dislocation of the elbow, but we favor repair or replacement of the radial head. Although degenerative changes and more than a few millimeters of proximal migration of the radius are subclinical and well-tolerated in most patients in decades after excision, we favor repair or reconstruction in the younger, active patient based on the theory that restoration of radiocapitellar contact will reduce problems. Although prospective studies suggest an advantage of arthroplasty over ORIF for comminuted displaced fractures, we believe that these studies present weaker evidence owing to limitations in study design and methods of treatment. We appreciate that prosthetic replacement offers the ability to restore alignment and stability promptly while avoiding the potential for early failure of fixation, later nonunion, r
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and problems with forearm rotation associated with ORIF, but we favor preservation of the native radial head in the younger, active patient because of the long-term potential for loosening or osteolysis and wear of the capitellum with a radial head prosthesis. If the fracture had two or fewer articular fragments (3 total fragments including the neck/shaft), we would attempt ORIF with a plate and screws. If the fracture had three or more articular fragments, or was thought not to be amenable to stable internal fixation at the time of surgery, we would prefer excision of the radial head and prosthetic replacement. We prefer monopolar, metallic radial head implants with modular components and a smooth neck because we believe they allow a more reproducible restoration of the native anatomy. To prevent overstuffing of the radiocapitellar joint, we choose implant sizes that are slightly smaller than the patient’s bony dimensions templated intraoperatively. As such, our implants represent a loose, smooth spacer arthroplasty. We prefer implant designs with smooth stems because of our experience with difficulties in removing implants with porous stems. After addressing the radial head fracture, we reattach the lateral collateral ligament origin to the lateral epicondyle with suture anchors. If the ulnohumeral joint dislocates after repair of the lateral soft tissues and radial head repair or replacement, we reattach the medial collateral ligament to the medial epicondyle.
8.
9.
10. 11.
12. 13.
14.
15.
16.
17.
18.
19.
REFERENCES 20.
1. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547e551. 2. Pike JM, Athwal GS, Faber KJ, King GJ. Radial head fractures—an update. J Hand Surg Am. 2009;34(3):557e565. 3. Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement—what is the evidence? Injury. 2008;39(12):1329e1337. 4. Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in management. J Am Acad Orthop Surg. 2007;15(7):380e387. 5. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987;216:109e119. 6. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res. 1989;246:126e130. 7. Akesson T, Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Karlsson MK. Primary nonoperative treatment of moderately displaced
J Hand Surg Am.
21.
22.
23.
24.
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two-part fractures of the radial head. J Bone Joint Surg Am. 2006;88(9): 1909e1914. Goldberg I, Peylan J, Yosipovitch Z. Late results of excision of the radial head for an isolated closed fracture. J Bone Joint Surg Am. 1986;68(5):675e679. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004;86(9): 1925e1930. Steinberg EL, Golomb D, Salama R, Weintroub S. Radial head and neck fractures in children. J Pediatr Orthop. 1988;8(1):35e40. Ikeda M, Yamashina Y, Kamimoto M, Oka Y. Open reduction and internal fixation of comminuted fractures of the radial head using lowprofile mini-plates. J Bone Joint Surg Br. 2003;85(7):1040e1044. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma. 1991;5(1):21e28. Nalbantoglu U, Kocaoglu B, Gereli A, Aktas S, Guven O. Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation. J Hand Surg Am. 2007;32(10):1560e1568. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84(10): 1811e1815. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head: comparison of resection and internal fixation. J Bone Joint Surg Am. 2005;87(1):76e84. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007;89(5):1075e1080. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001;83(8): 1201e1211. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma. 2001;50(1):46e52. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason typeIII radial head fractures with a titanium prosthesis, ligament repair, and early mobilization: surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1 pt 1):136e147. Popovic N, Lemaire R, Georis P, Gillet P. Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bonecement interface. J Bone Joint Surg Am. 2007;89(11):2469e2476. Ruan HJ, Fan CY, Liu JJ, Zeng BF. A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. Int Orthop. 2009;33(1):249e253. Chen X, Wang SC, Cao LH, Yang GQ, Li M, Su JC. Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop. 35(7):1071e1076. Flinkkila T, Kaisto T, Sirnio K, Hyvonen P, Leppilahti J. Short- to midterm results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br. 2012;94(6):805e810. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical contact is associated with concomitant fracture or dislocation. J Shoulder Elbow Surg. 2010;19(1):21e25.
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Management of Radial Head Fracture With Elbow Dislocation Mark L. Wang, MD, PhD, Pedro K. Beredjiklian, MD THE PATIENT A 45-year-old, right-handed man fell onto his right outstretched upper extremity at work. He presented with elbow pain and swelling. Radiographic evaluation demonstrated dislocation of the elbow and a displaced and comminuted fracture of the entire radial head. The elbow was reduced and placed in an orthosis in the emergency department. THE QUESTION What is the best treatment for a displaced, comminuted fracture of the radial head associated with an elbow dislocation? CURRENT OPINION The management of elbow dislocation with a displaced radial head fracture is debated. When the coronoid is also fractured, fixation or replacement of the radial head is recommended to reduce the high risk of redislocation.1 When the coronoid is not fractured, the risk of dislocation or subluxation is low and treatment of the radial head is aimed at preserving forearm rotation and slowing the development of arthrosis. Options include nonsurgical treatment, excision of the radial head with or without prosthetic replacement, and open reduction internal fixation (ORIF). Factors that influence decision making include the number of fracture fragments, the degree of displacement, and the position of the fragments.2e4 Patient factors including functional demands, comorbidities, and preferences should also be considered.2 From the Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA. Received for publication October 20, 2014; accepted in revised form October 20, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Mark L. Wang, MD, PhD, Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107-1216; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.10.029
THE EVIDENCE Broberg and Morrey5 evaluated 24 patients with ulnohumeral dislocation with radial head fracture 2 to 35 years after injury. The radial head fractures were treated either nonsurgically or with excision and the elbows were casted for about a month. Two elbows were redislocated, one with a lateral epicondyle fracture and one with no associated fractures, but no additional details are given. Based on a new elbow evaluation system accounting for pain, motion, strength, and stability, the authors reported excellent and good results in 18 patients, some after delayed excision of the radial head. Josefsson et al6 evaluated 23 patients with an elbow dislocation associated with a displaced fracture of the radial head. Nineteen patients had radial head excision at the time of initial treatment (range, 0e16 d). A displaced fracture of the coronoid process was present in 4 patients, all of whom had re-dislocation. Osteoarthritis was identified in 12 of 19 elbows evaluated 3 to 13 years after the injury. Akesson et al7 evaluated 49 patients with displaced partial articular fractures of the radial head (2- to 5-mm displacement and involvement of 30% or more of the articular surface) initially treated nonsurgically. Although that study did not specifically address radial head fractures associated with elbow dislocation, we now know that displaced fractures tend to be associated with ligament injuries. Six patients had delayed radial head excision for unspecified reasons at an average of 5 months after injury. An average of 19 years after injury, 40 patients had no subjective symptoms, 8 had occasional elbow pain, and 1 had daily pain. Goldberg et al8 evaluated 36 patients with closed radial head fractures (20 Mason II and 16 Mason III types) an average of 16 years after delayed radial head excision. A total of 31 (86%) were satisfied with the results, 34 (94%) returned to their preoperative occupations, and 3 lost 30 or more of elbow flexion or forearm rotation. Herbertsson et al9 evaluated 61 elbows at an average of 18 years after radial head excision for fracture. A total of 73% of elbows demonstrated radiographic
Ó 2014 ASSH
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Published by Elsevier, Inc. All rights reserved.
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RADIAL HEAD FRACTURE WITH ELBOW DISLOCATION
degenerative changes compared with 7% in the contralateral uninjured limb. Among the 43 patients treated with primary radial head excision, 22 had no symptoms compared with 6 of the 18 who had had a delayed excision. According to the classification system of Steinberg10 (a relatively strict scale used in children), 25 elbows were rated as good, 26 as fair, and 10 as poor. There were no significant differences in elbow pain, strength, motion, or functional outcome score between patients treated with primary excision versus delayed excision. Ikeda et al11 evaluated ORIF of a fracture of the entire head of the radius using a small plate and screws in 10 patients (average age, 42 y), 7 of whom had an elbow dislocation. An average of 28 months after surgery (and after a second surgery for implant removal in 9 of 10 patients) all of the fractures were healed and 90% of patients had good to excellent results based on the Broberg and Morrey Functional Elbow Index. The average range of flexion and extension of the elbow was 7 to 135 with an average of 74 supination and 85 pronation. King et al12 reported only 3 of 6 good or excellent results (33%) using an early version of the Mayo Elbow Performance Index an average of 32 months after ORIF of a displaced fractures involving the entire head of the radius. Fractures associated with elbow dislocations had greater flexion contractures. Nalbantoglu et al13 evaluated 25 displaced fractures of the entire head (7 with associated elbow dislocation) treated with ORIF an average of 27 months after surgery. Patients with and without associated elbow dislocation had comparable average elbow range of motion and Broberg and Morrey elbow functional scores.5 Ring et al14 evaluated the outcomes of 56 radial head fractures, including 27 injuries with an associated fracture or ligament injury of the forearm or elbow. Four of 15 patients with a displaced comminuted fracture of part of the radial head recovered less than 100 of forearm rotation. Among 12 displaced fractures of the entire head with 3 fracture fragments (including the shaft as a fragment), there was one nonunion, no early failures, and an average range of elbow motion greater than 100 . Among the 14 patients with a fracture of the entire head and more than 3 fracture fragments, 13 had an unsatisfactory result based on the Broberg and Morrey elbow rating: 3 had loss of fixation, 6 had nonunion, and 4 had poor (less than 100 ) forearm rotation. A study comparing excision (15 fractures) and ORIF (13 fractures) for a displaced comminuted fracture of the radial head associated with other injuries (eg, J Hand Surg Am.
coronoid fracture, dislocation) found greater strength, better Broberg and Morrey scores (91 vs 81 points), and better American Shoulder and Elbow Surgeons Elbow Assessment (95 vs 87 points) with ORIF.15 Doornberg et al16 evaluated 27 patients with comminuted radial head fractures with associated acute elbow instability treated with a modular metal spacer arthroplasty with a loose smooth neck. Sixteen of these patients had a posterior elbow dislocation. The prosthesis was removed in 2 patients to release an elbow contracture release or treat infection. Stability was restored to all 27 elbows. Twenty-two patients had a good or excellent result using the Mayo Elbow Performance Index. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis and 9 had radiographic changes in the capitellum, but these findings were not associated with symptoms. Moro et al17 studied 25 displaced radial head fractures—including 15 associated with an elbow dislocation—treated with monoblock titanium, loose smooth neck radial head arthroplasty. Using the Mayo Elbow Performance Index, 17 patients had good or excellent results, 5 had fair ones, and 3 had poor outcomes. The fair and poor outcomes were associated with concomitant injury in 2 patients, a history of a psychiatric disorder in 3, comorbidity in 2, a workers’ compensation claim in 2, and litigation in 1. Harrington et al18 evaluated 20 patients treated with a loose smooth spacer prosthetic radial head replacement for radial head fracture combined with dislocation of the elbow, rupture of the medial collateral ligament, fracture of the proximal ulna, and/ or fracture of the coronoid process. An average of 12 years after injury, 80% had good results based on a modified Mayo Elbow Performance Index functional rating system. Bain et al19 reported the results of press-fit, monoblock titanium radial head arthroplasty for 16 displaced fractures of the entire radial head, 12 with associated medial collateral ligament injury, 2 of which had elbow dislocations. These patients were treated with a monoblock titanium radial head prosthesis over a 5-year period. The authors reported good or excellent results in 80% of patients based on the Mayo Elbow Performance Score an average of 2.8 years after surgery. The mean flexion contracture was 15 with an average loss of 10 flexion compared with that of the contralateral elbow. Both pronation and supination decreased an average of 12 compared with that of the contralateral forearm. Popovic and colleagues20 evaluated 51 patients with comminuted fractures of the radial head (34 with r
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RADIAL HEAD FRACTURE WITH ELBOW DISLOCATION
SHORTCOMINGS OF THE EVIDENCE Most reports are retrospective case series of a single technique.11,12,14,15,17,19 Although most displaced fractures of the radial head are part of a more complex injury pattern, most studies focus on the radial head fracture alone. Associated fractures and ligament injuries were likely underdiagnosed in many of these series. This is especially true in light of studies of fractures of the radial head with more than 2 mm displacement of a fracture fragment.24 The degree of fragmentation of the radial head is uncommonly noted. This is particularly important when assessing the few studies where ORIF of displaced fractures of the entire head was successful. Perhaps the surgeons repaired only the easier fractures.
an associated posterior elbow dislocation, 11 with an isolated radial head fractures, and 6 with a proximal ulna fracture and posterior radial head dislocation) an average of 8 years after bipolar radial head prosthetic replacement. Based on the Mayo Elbow Performance Index, 14 were excellent, 25 were good, 9 were fair, and 3 were poor. A total of 37 patients (72%) demonstrated radiographic signs of osteolysis related to polyethylene wear. In a prospective, randomized study of 22 patients, Ruan and colleagues21 performed ORIF (n ¼ 8) or bipolar prosthetic head replacement (n ¼ 14) for displaced fractures of the entire head of the radius. Functional evaluation in the arthroplasty group revealed excellent results in 9 patients, good ones in 4, and fair ones in 1. In the ORIF group, the results were good in 1 patient, fair in 4, and poor in 3, with complications including nonunion in 4 patients and hardware loosening in another 4. The difference in outcomes using Broberg and Morrey functional scores between the prosthesis group (93%) and the ORIF group (12%) was statistically significant. Chen et al22 prospectively randomized 45 patients with unstable, comminuted fractures of the radial head, some of which were associated with soft tissue injuries. The authors did not provide details of the associated injuries. Patients were prospectively randomized to prosthetic replacement (n ¼ 22) or ORIF with plates and screws (n ¼ 23). Using functional Broberg and Morrey scores, patients with radial head prosthetic replacement had 91% (20 of 22) good or excellent outcomes compared with patients in the ORIF group, who had 65% (15 of 23) good or excellent results. These differences were statistically significant. Similarly, postoperative complication rates in the replacement group were significantly lower than those in the ORIF group (14% vs 48%). Flinkkila et al23 evaluated 42 patients with radial head fractures with associated acute traumatic instability of the elbow treated with modular, uncemented press-fit radial head prostheses. An average of 4 years after surgery, 25 prostheses were well-fixed and 12 implants were loose, 9 of which were removed. At the time of removal, the authors reported an average time from implantation to loosening of 11 months, with periprosthetic radiolucent lines that were mild in 3 patients, moderate in 1, and severe in 5. Elbow motion and grip strength were significantly lower in the affected elbow than those of the contralateral side; average Mayo Elbow Performance score was 86 (range, 40e100), and mean Disabilities of the Arm, Shoulder and Hand score was 23 (range, 0e81). J Hand Surg Am.
3
DIRECTIONS FOR FUTURE RESEARCH Future studies should: (1) specifically investigate and document associated fractures and ligament injuries; (2) study fractures associated with elbow dislocations separate from isolated fractures and other types of forearm and elbow traumatic instability; and (3) characterize the radial head fractures in some detail (number, size and position of fragments; metaphyseal comminution; deformation of fragments; and lost or irreparable fragments). Our understanding of the advantages and disadvantages of initial nonsurgical treatment followed by selective radial head excision, immediate excision of the radial head with or without prosthetic replacement, and ORIF would be improved by multicenter, prospective, randomized trials comparing treatments with long-term evaluation. OUR CURRENT CONCEPTS FOR THIS PATIENT Radial head excision and nonsurgical treatment are options for patients with a displaced fracture of the radial head and dislocation of the elbow, but we favor repair or replacement of the radial head. Although degenerative changes and more than a few millimeters of proximal migration of the radius are subclinical and well-tolerated in most patients in decades after excision, we favor repair or reconstruction in the younger, active patient based on the theory that restoration of radiocapitellar contact will reduce problems. Although prospective studies suggest an advantage of arthroplasty over ORIF for comminuted displaced fractures, we believe that these studies present weaker evidence owing to limitations in study design and methods of treatment. We appreciate that prosthetic replacement offers the ability to restore alignment and stability promptly while avoiding the potential for early failure of fixation, later nonunion, r
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RADIAL HEAD FRACTURE WITH ELBOW DISLOCATION
and problems with forearm rotation associated with ORIF, but we favor preservation of the native radial head in the younger, active patient because of the long-term potential for loosening or osteolysis and wear of the capitellum with a radial head prosthesis. If the fracture had two or fewer articular fragments (3 total fragments including the neck/shaft), we would attempt ORIF with a plate and screws. If the fracture had three or more articular fragments, or was thought not to be amenable to stable internal fixation at the time of surgery, we would prefer excision of the radial head and prosthetic replacement. We prefer monopolar, metallic radial head implants with modular components and a smooth neck because we believe they allow a more reproducible restoration of the native anatomy. To prevent overstuffing of the radiocapitellar joint, we choose implant sizes that are slightly smaller than the patient’s bony dimensions templated intraoperatively. As such, our implants represent a loose, smooth spacer arthroplasty. We prefer implant designs with smooth stems because of our experience with difficulties in removing implants with porous stems. After addressing the radial head fracture, we reattach the lateral collateral ligament origin to the lateral epicondyle with suture anchors. If the ulnohumeral joint dislocates after repair of the lateral soft tissues and radial head repair or replacement, we reattach the medial collateral ligament to the medial epicondyle.
8.
9.
10. 11.
12. 13.
14.
15.
16.
17.
18.
19.
REFERENCES 20.
1. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547e551. 2. Pike JM, Athwal GS, Faber KJ, King GJ. Radial head fractures—an update. J Hand Surg Am. 2009;34(3):557e565. 3. Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement—what is the evidence? Injury. 2008;39(12):1329e1337. 4. Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in management. J Am Acad Orthop Surg. 2007;15(7):380e387. 5. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987;216:109e119. 6. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res. 1989;246:126e130. 7. Akesson T, Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Karlsson MK. Primary nonoperative treatment of moderately displaced
J Hand Surg Am.
21.
22.
23.
24.
r
two-part fractures of the radial head. J Bone Joint Surg Am. 2006;88(9): 1909e1914. Goldberg I, Peylan J, Yosipovitch Z. Late results of excision of the radial head for an isolated closed fracture. J Bone Joint Surg Am. 1986;68(5):675e679. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004;86(9): 1925e1930. Steinberg EL, Golomb D, Salama R, Weintroub S. Radial head and neck fractures in children. J Pediatr Orthop. 1988;8(1):35e40. Ikeda M, Yamashina Y, Kamimoto M, Oka Y. Open reduction and internal fixation of comminuted fractures of the radial head using lowprofile mini-plates. J Bone Joint Surg Br. 2003;85(7):1040e1044. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma. 1991;5(1):21e28. Nalbantoglu U, Kocaoglu B, Gereli A, Aktas S, Guven O. Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation. J Hand Surg Am. 2007;32(10):1560e1568. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84(10): 1811e1815. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head: comparison of resection and internal fixation. J Bone Joint Surg Am. 2005;87(1):76e84. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007;89(5):1075e1080. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001;83(8): 1201e1211. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma. 2001;50(1):46e52. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason typeIII radial head fractures with a titanium prosthesis, ligament repair, and early mobilization: surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1 pt 1):136e147. Popovic N, Lemaire R, Georis P, Gillet P. Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bonecement interface. J Bone Joint Surg Am. 2007;89(11):2469e2476. Ruan HJ, Fan CY, Liu JJ, Zeng BF. A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. Int Orthop. 2009;33(1):249e253. Chen X, Wang SC, Cao LH, Yang GQ, Li M, Su JC. Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop. 35(7):1071e1076. Flinkkila T, Kaisto T, Sirnio K, Hyvonen P, Leppilahti J. Short- to midterm results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br. 2012;94(6):805e810. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical contact is associated with concomitant fracture or dislocation. J Shoulder Elbow Surg. 2010;19(1):21e25.
Vol. -, - 2015
![[Elbow dislocation with ipsilateral proximal radial shaft fracture and radial head dislocation].](/assets/img/hold.png)
