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Background: There is evidence to support primary nonoperative management of isolated stable fractures of the radial head, although minimal data exist regarding long-term outcomes. The aim of this study was to report subjective long-term outcomes of isolated stable fractures of the radial head and neck following primary nonoperative management. Methods: From a prospective database of proximal radial fractures, we identified all skeletally mature patients who sustained an isolated stable Mason type-1 or type-2 fracture of the radial head or neck during an eighteen-month period. Inclusion criteria were a confirmed isolated stable fracture of the proximal aspect of the radius, primarily managed nonoperatively. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Results: The study cohort comprised 100 patients with a mean age of forty-six years (range, seventeen to seventy-nine years). A fall from a standing height accounted for 69% of all injuries. Thirty-five percent of the patients had one or more comorbidities. There were fifty-seven Mason type-1 fractures and forty-three Mason type-2 fractures. At a mean of ten years post injury (range, 8.8 to 10.2 years), the mean DASH score was 5.8 (range, 0 to 67.2) and the mean Oxford Elbow Score (OES) was 46 (range, 14 to 48). Fourteen (14%) of the patients reported stiffness and twenty-four (24%) reported some degree of pain. A worse DASH score was associated with older age (p = 0.002), one or more comorbidities (p = 0.008), increasing socioeconomic deprivation by Index of Multiple Deprivation quintile (p = 0.026), increasing amount of fracture displacement (p = 0.041), and involvement in compensation proceedings (p = 0.006). Conclusions: Long-term patient-reported outcomes were excellent following the nonoperative management of isolated stable fractures of the radial head or neck. We suggest that routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients in our study requiring further intervention for persisting complaints. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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... 3, 21 Mason type 1 fractures, which include a fissure or marginal sector fracture without displacement, can be treated nonoperatively with early mobilization. 5,11,9,28 It is also known that patients with complete articular fractures involving the whole radial head, that is, Mason type 3 fractures, benefit from surgical treatment. These fractures should be treated either by open reduction and internal fixation or by arthroplasty in case of comminuted unreconstructable fractures. ...
... The MEPS was even significantly better in the nonoperative group compared with the operative In addition, besides a better pronation in the nonoperative group, range of motion of the elbow was comparable between both groups. Moreover, in a long-term follow-up study from a prospective database on 43 primarily nonoperatively treated Mason type 2 radial head fractures, Duckworth et al 11 found excellent patient-reported outcomes. At a mean of 10 years of follow-up, the mean DASH score was 6.1 (95% CI 2.5-9.7) and the mean OES was 45.5 (95% CI 44-47). ...
... Nonetheless, current research has shown that fracture displacement of 2 mm or even 3 mm is not necessarily an indication of poor outcome in nonoperatively treated radial head fractures. 12 Duckworth et al, 11 in 100 patients with a Mason type 1 or 2 radial head fracture, found a trend toward a significantly worse DASH score for patients whose fracture displacement was 4 mm compared with patients whose fracture displacement was <4 mm (mean DASH score 13.7 compared with 5.2; P ¼ .07). However, they concluded that no firm conclusions could be drawn from the above finding because of the small sample size and the inevitable degree of intra-and interobserver variability associated with the measurement of fracture displacement. ...
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Background The optimal treatment of isolated displaced partial articular radial head fractures remains controversial. The aim of this randomized controlled trial was to compare the functional outcome of operative treatment with non-operative treatment in adults with an isolated Mason type 2 radial head fractures. Methods In this multicenter randomized controlled trial, patients from 18 years of age with an isolated partial articular fracture of the radial head were randomly assigned to operative treatment by means of open reduction and screw fixation or non-operative treatment with a pressure bandage. The primary outcome was function assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Questionnaires and clinical follow-up was conducted at admission, and at three, six and 12 months. Results In total 45 patients were randomized, 23 patients to open reduction and screw fixation and 22 patients to non-operative treatment with a pressure bandage. At three, six, and 12 months patients treated operatively had similar functional outcomes compared to patients treated non-operatively (DASH score at 12 months: 0.0 [0.0 – 4.2] versus 1.7 [0.0 – 8.5]; p=0.076). Conclusions Non-operatively treated adults with an isolated Mason type 2 radial head fracture have similar functional results after one year compared to operatively treated patients. In addition, complication rates were low for both operative and non-operative treatment.
... Radial head fractures represent 33% of elbow fractures and 2 to 5% of all upper limb fractures [1]. Simple, isolated, non-displaced fractures do not require surgical treatment, while displaced fractures require stable osteosynthesis [2,3]. When osteosynthesis is not possible, the therapeutic alternatives are simple resection or radial head arthroplasty [4,5]. ...
... They most often result from an indirect mechanism, falling on the hand in extension with the forearm in pronation [9]. Most are the result of functional treatment (in the absence of displacement) or stable direct osteosynthesis and repair of the associated injuries, found in nearly 80% of cases [2,3]. However, faced with a very comminuted fracture with the impossibility of obtaining stable fixation, prosthetic replacement has been proposed since the 1970's [8]. ...
... A preoperative CT scan including frontal and sagittal reconstructions may be necessary to determine the size of the fragment and the existence of an overturned joint fragment or in case of doubt about an associated lesion [12]. Type I fractures require functional treatment and type II fractures require reduction and stable osteosynthesis [2,13]. Herbert's screw osteosynthesis was used in 87.5% of our patients. ...
... Radial head fractures represent 33% of elbow fractures and 2 to 5% of all upper limb fractures [1]. Simple, isolated, non-displaced fractures do not require surgical treatment, while displaced fractures require stable osteosynthesis [2,3]. When osteosynthesis is not possible, the therapeutic alternatives are simple resection or radial head arthroplasty [4,5]. ...
... They most often result from an indirect mechanism, falling on the hand in extension with the forearm in pronation [9]. Most are the result of functional treatment (in the absence of displacement) or stable direct osteosynthesis and repair of the associated injuries, found in nearly 80% of cases [2,3]. However, faced with a very comminuted fracture with the impossibility of obtaining stable fixation, prosthetic replacement has been proposed since the 1970's [8]. ...
... A preoperative CT scan including frontal and sagittal reconstructions may be necessary to determine the size of the fragment and the existence of an overturned joint fragment or in case of doubt about an associated lesion [12]. Type I fractures require functional treatment and type II fractures require reduction and stable osteosynthesis [2,13]. Herbert's screw osteosynthesis was used in 87.5% of our patients. ...
Article
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Original Research Article Objectives: To study the epidemiological, anatomopathological, diagnostic, therapeutic and evolutionary aspects of patients with a radial head fracture and compare our results with those of the literature. Introduction: Radial head fractures are articular fractures involving the head and/or neck of the radius; they are common in young persons. These fractures pose diagnostic and therapeutic problems. Osteosynthesis of the radial head allows early post-operative rehabilitation. If osteosynthesis is not possible, radial head prosthesis is discussed. Materials and methods: Our series includes 10 Men and six Women with an average age of 41 years, collected over a period of five years from 2014 to 2019 in the department of Orthopaedic Surgery and Traumatology II of the Mohamed V Military Hospital of Rabat. Most of the patients were victims of falls or road accidents. Type II fractures were the most common in 50% of cases. Seven patients had associated lesions of the homolateral upper limb. Herbert's screw osteosynthesis was used in 87.5% of our patients. Arthroplastic resection was performed in two patients. No radial head prosthesis was performed in our series. The principle of early mobilization was respected for all our patients. Results: The average decline in our series was 13 months; the evaluation of the results was based on the MAYO CLINIC score. Functional results were excellent in 37.5% of cases, good in 37.5% of cases, average in 25% of cases. Complications found were: infection in a patient, elbow stiffness in a patient and algodystrophy in a patient. Conclusion: Radial head fractures are quite common. Most are the result of functional treatment or stable direct osteosynthesis. The radial head prosthesis fits perfectly into the therapeutic strategy for multifragmentary radial head fractures that are not accessible to reliable osteosynthesis.
... Radial head fractures represent 33% of elbow fractures and 2 to 5% of all upper limb fractures [1]. Simple, isolated, non-displaced fractures do not require surgical treatment, while displaced fractures require stable osteosynthesis [2,3]. When osteosynthesis is not possible, the therapeutic alternatives are simple resection or radial head arthroplasty [4,5]. ...
... They most often result from an indirect mechanism, falling on the hand in extension with the forearm in pronation [9]. Most are the result of functional treatment (in the absence of displacement) or stable direct osteosynthesis and repair of the associated injuries, found in nearly 80% of cases [2,3]. However, faced with a very comminuted fracture with the impossibility of obtaining stable fixation, prosthetic replacement has been proposed since the 1970's [8]. ...
... A preoperative CT scan including frontal and sagittal reconstructions may be necessary to determine the size of the fragment and the existence of an overturned joint fragment or in case of doubt about an associated lesion [12]. Type I fractures require functional treatment and type II fractures require reduction and stable osteosynthesis [2,13]. Herbert's screw osteosynthesis was used in 87.5% of our patients. ...
Article
Original Research Article Objectives: To study the epidemiological, anatomopathological, diagnostic, therapeutic and evolutionary aspects of patients with a radial head fracture and compare our results with those of the literature. Introduction: Radial head fractures are articular fractures involving the head and/or neck of the radius; they are common in young persons. These fractures pose diagnostic and therapeutic problems. Osteosynthesis of the radial head allows early post-operative rehabilitation. If osteosynthesis is not possible, radial head prosthesis is discussed. Materials and methods: Our series includes 10 Men and six Women with an average age of 41 years, collected over a period of five years from 2014 to 2019 in the department of Orthopaedic Surgery and Traumatology II of the Mohamed V Military Hospital of Rabat. Most of the patients were victims of falls or road accidents. Type II fractures were the most common in 50% of cases. Seven patients had associated lesions of the homolateral upper limb. Herbert's screw osteosynthesis was used in 87.5% of our patients. Arthroplastic resection was performed in two patients. No radial head prosthesis was performed in our series. The principle of early mobilization was respected for all our patients. Results: The average decline in our series was 13 months; the evaluation of the results was based on the MAYO CLINIC score. Functional results were excellent in 37.5% of cases, good in 37.5% of cases, average in 25% of cases. Complications found were: infection in a patient, elbow stiffness in a patient and algodystrophy in a patient. Conclusion: Radial head fractures are quite common. Most are the result of functional treatment or stable direct osteosynthesis. The radial head prosthesis fits perfectly into the therapeutic strategy for multifragmentary radial head fractures that are not accessible to reliable osteosynthesis.
... alors que les fractures simples, isolées et non déplacées, ne nécessitent pas de traitement chirurgical, les fractures déplacées requièrent chaque fois que possible une réduction anatomique, une fixation stable et une réparation des lésions associées, retrouvées dans près de 80 % des cas [2][3][4]. Cependant, dans les fractures comminutives, la TR ne peut pas être reconstruite et pour éviter de déstabiliser le coude, son remplacement prothétique est alors discuté. ...
... le type iii, caractérisé par une comminution, n'est pas accessible à l'ostéosynthèse et nécessite soit une résection, soit une prothèse (tableau 7.1) [18]. en dehors de la faible reproductibilité intra-et interobservateur de ces classifications, leur principale faiblesse réside dans l'absence de prise en compte des lésions associées, pourtant retrouvées dans près de 80 % des fractures multifragmentaires (en particulier les fractures de type iii) [2][3][4]. la classification de la Mayo Clinic est exhaustive en ce sens et mérite d'être retenue (figure 7.10) [19]. elle reprend la description de la fracture de TR de Mason et lui associe une lettre correspondant à une lésion associée, représentée par une majuscule si elle est traitée. ...
... les fractures de type i relèvent d'un traitement fonctionnel et les fractures de type ii d'une réduction et ostéosynthèse stable [2,20]. la prothèse de TR ne se discute que dans les fractures de type iii non ou difficilement accessibles à une réduction anatomique avec ostéosynthèse stable permettant une mobilisation précoce de l'articulation. ...
Article
Radial head fractures are fairly common (20% of all traumatic elbow injuries). Non-operative treatment is indicated in non-displaced fractures, and direct stable internal fixation allowing early elbow mobilisation in most other cases. For severely comminuted fractures precluding stable fixation, replacement of the radial head was introduced in the 1970s as a better alternative to simple radial head resection, which can induce instability of the elbow and/or forearm, most notably in patients who have complex fractures with concomitant lesions to other structures. With contemporary implants (modular or monoblock, with or without a mobile cup), mechanical stability is close to that provided by the native radial head, although appropriate treatment of concomitant lesions remains crucial (e.g., re-attachment of the radial collateral ligament, or distal radio-ulnar stabilisation in patients with Essex-Lopresti fracture). The key technical points are selection of implant size and determination of the optimal implantation height. The two most common complications are capitellar overloading due to excessively high implantation of the prosthetic head, which causes stiffness and pain, and loosening of the stem. These complications may require removal of the implant at a distance from the injury. Studies have demonstrated satisfactory clinical outcomes in 60% to 80% of cases.
... There is agreement that for Mason I fractures, nonoperative treatment results in excellent outcomes and is the treatment of choice [1,7,11]. Successful nonoperative treatment requires early mobilization of the elbow to avoid stiffness. ...
... Elbow · Nonoperative treatment · Open fracture reduction · Radius fractures · Arthroplasty complications than with ORIF [11,13,14]. The main concern with nonoperative management is that there may be an increased risk of development of arthritic changes at the radiocapitellar joint with the over 2-mm articular step-off [1]. ...
Article
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The radial head is an important stabilizer of the elbow joint. Radial head fractures are commonly associated with additional injuries to the ligamentous structures of the elbow and can significantly compromise elbow stability. Young patients with radial head fractures are more likely to be male and present after a high-energy mechanism of injury. While not perfect, the Mason classification is the most commonly used classification system and can help to guide the management of radial head fractures. Type I fractures are nondisplaced or minimally displaced (less than 2 mm) and are treated nonoperatively with early mobilization. Type II fractures, which are displaced 2–5 mm, can be treated nonoperatively or with open reduction and internal fixation (ORIF). Type III fractures are comminuted and are most often treated with ORIF or with radial head arthroplasty (RHA). Treatment of fractures with an associated elbow dislocation (Mason type IV) is also with ORIF or RHA depending on the degree of comminution. For all of these injuries, assessment and treatment of associated ligamentous injuries are necessary in conjunction with treatment of the bony injury. Despite a significant body of literature available on radial head fractures, there is controversy regarding the optimal management of type II, III, and IV fractures, especially in young, active patients. Common complications following radial head fractures include stiffness, instability, and posttraumatic osteoarthritis; as such, these injuries can lead to significant disability in young, active patients if not managed appropriately.
... Authors found a higher incidence of x-Rayevident degenerative changes in the non-operative group but most of them remained asymptomatic. This observation has been confirmed by similar, recently published studies [12,13]. Conversely, Lindenhovius et Al reported a positive outcome in their retrospective case series of 16 surgically treat ed Mason type II fractures aft er a m ean follow-up of 22 years [14]. ...
Article
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The management of Mason type II radial head fractures is still debated. Retrospective comparative studies suggest that long-term clinical results of both operative and non-operative treatments are very good. The proper mobilization protocol is one of the most critical point of discussion. Our study aim is to establish effects of an immediate active elbow mobilization (I-RAM) on cadaveri c models of radial head fractures. We performed Mason II radial head fractures on 5 frozen intact human upper limbs. We than analyzed the effects of I-RAM on cadaveri c models using Cone-Beam Computerized-Tomography (CBCT). A statistically significant reduction in fragments diastasis after fracture reduction and after 0-30° range of motion was found. The 30-110° motion range was not able to increase fragments diastasis too. Our study shows that an extremely early mobilization after a Mason II radial head fracture does not significantly increase fragm ents displacement. Principal limitations of this study are due to the use of a cadaveric model, mainly the absence the hematoma and swelling development and fracture-associ ated soft-tissue injuries. For this reason, we are planning a perspectival study to test results of early mobilization (I-RAM) also on living models.
... The relationship between the occurrence of a complication and long-term PRWE was tested using multivariable regression analysis. Age, gender, and socioeconomic deprivation status were also entered into the model as these have previously been shown to influence functional outcomes following fractures of the upper limb [30][31][32]. The beta coefficients and 95% confidence intervals are reported. ...
Article
The aim of this study was to report the long-term functional outcomes and complication rates following early percutaneous fixation of acute fractures of the scaphoid. A trauma database was searched to identify all skeletally-mature patients with an undisplaced or minimally-displaced scaphoid waist fracture managed with early percutaneous retrograde screw fixation over a thirteen-year period from 1997-2010. Medical records were retrospectively reviewed, and complications documented. Long-term follow-up was by a questionnaire-based review. The Patient-Rated Wrist Evaluation (PRWE) was the primary outcome measure. Secondary outcomes included the Quick version of the Disability of the Arm, Shoulder and Hand score (QuickDASH), the EuroQol 5-dimensions score (EQ-5D-5 L), and complications. During the study period 114 patients underwent this procedure. The mean age was 28 years (range, 17–62) and 97 patients (85%) were male. The median time from injury to surgery was nine days (range, 1–27). Twelve patients (11%) reported a complication, all of whom required repeat surgical intervention (six revision ORIF for non-union, five elective removal of hardware, one early revision fixation due to screw impingement). Long-term outcome data was available for 77 patients (68%) at mean follow-up of 11.4 years (range, 6.4–19.8). The median PRWE was 0 (IQR 0–7.5), median QuickDASH 0 (IQR 0–4.5) and median EQ-5D-5 L 1.0 (IQR 0.837–1.0). There were 97% (n = 74) patients satisfied with their outcome. Early percutaneous fixation of acute non-displaced or minimally displaced scaphoid fractures results in good long-term patient reported outcomes and health-related quality of life. Although comparable with previous studies, the overall surgical reintervention rate is notable and can result in inferior outcomes. Level of evidence Therapeutic level III (Retrospective Cohort Study).
... Treatment options for radial head fractures vary by the extent of injury to the radial head and concomitant pathologies and comprise nonoperative management for nondisplaced or minimally displaced fractures (Mason type I) 8 and open reduction and internal fixation for displaced fractures (Mason types II and III). 35 Among the latter, there may be severely comminuted fractures that preclude reconstruction and are typically managed by radial head resection or replacement. ...
Article
Background The purposes of this study were 1) to report functional outcomes, 2) to assess complications, revisions and survival rate, and 3) to assess differences in functional outcomes between removed and retained RHAs, early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae. Methods Seventy-eight patients (mean age 59.2 years) that were at least six years postoperatively following monopolar RHA between 1994 and 2010 for unreconstructible RHFs or their sequelae and were included. The Mayo Elbow Performance Score (MEPS), Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score, the Visual Analog Scale (VAS), postoperative satisfaction (1-6, 6=highly unsatisfied), range of motion, complications and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared. Results At a median clinical follow-up of 9.5 years (range: 6.0-28.4), median MEPS was 80.0 (IQR:60.0-97.5), median QuickDASH was 22.0 (IQR:4.6-42.6), median VAS was 1 (IQR:0-4), median postoperative satisfaction was 2 (IQR:1-3), and median arc of extension/flexion was 110° (IQR:80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0). Heterotopic ossifications were seen in 14 (29.2%), moderate to severe capitellar osteopenia/abrasion in 3 (6.1%), moderate to severe ulnohumeral degeneration in 3 (6.1%) and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% CI 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of seven patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 (75.0-100) vs. Evolve: 80.0 (60.0-95.0); P=.341) and QuickDASH (Mathys: 12.5 (0-34.4) vs. Evolve: 26.7 (6.9-46.2); P=.112). Early surgery (≤3weeks) yielded significantly superior MEPS (80.0 (70.0-100.0) vs. 52.5 (30.0-83.8); P=.014) and QuickDASH (18.6 (1.5-32.6) vs. 46.2 (31.5-75.6); P=.002) compared to delayed surgery (>3weeks). Patients with retained RHAs had significantly better MEPS (80.0 (67.5-100) vs. 70.0 (32.5-82.5); P=.016) and QuickDASH (18.1 (1.7-31.9) vs. (49.1 (22.1-73.8); P=.007) compared to patients with removed RHAs. Conclusions Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year. Level of Evidence Level III; Retrospective Cohort Comparison; Treatment Study
... The excellent functional results after conservative treatment are supported by satisfactory outcome scores, which were reported for similar fractures in various other case series not included in this systematic review as they did not provide one of the demanded outcome scores. 1,8 It is also remarkable that only approximately 40% of the patients treated with ORIF but approximately 55% of the patients treated nonoperatively were female. ...
Article
Background: Fractures of the radial head represent the most common bony injury of the elbow in adults. Radial head fractures are classified according to Mason or one of its classification modifications. Current literature does not indicate consensus on whether to treat isolated stable type II radial head fracture patterns with open reduction and internal fixation (ORIF) or nonoperatively, especially, when there is no mechanical block to motion. Methods: We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and Embase for studies published between 2011 and 2020. Primary objective was to contrast the outcome scores of these two different study groups and the pitfalls accompanied with the two different approaches. The PRISMA guidelines were applied. Results: The literature search left 11 studies for inclusion, all but one retrospective in design, comprising 319 patients. 218 patients (68.3%) were treated with ORIF and 101 patients (31.7%) were treated nonoperatively. Our findings indicate that ORIF does not provide better results when compared to nonoperatively treated patients concerning functional outcome parameters. Treatment success, defined as excellent or good results according to the MEPS or the Broberg and Morrey Score, among the patients treated with ORIF was 90.9%, 7.1% were in need of subsequent surgery, 5.2% had radiologic osteoarthritic changes of the radial column. 95.1% of the nonoperative cohort was treated successfully, osteoarthritis was present in 11.9%. Mean follow-up period of the ORIF and the nonoperative cohort was 73 and 39 months, respectively. Conclusion: ORIF and nonoperative treatment of isolated Mason type II radial head fractures provide comparably satisfactory functional outcomes, without significant differences. Consideration of age, activity level and potential risks is recommendable for treatment decision. Subsequent surgery rates were higher for patients treated with ORIF than for those treated nonoperatively and should be discussed. However, development of osteoarthritis of the radial column appears to be more likely after nonoperative treatment. The study pool remains limited and implications of this review should be handled with caution. Level of evidence: Level IV; Systematic Review. Keywords: Mason type II; ORIF; Radial head fractures; isolated; nonoperatively; outcome; systematic review.
... Neben der operativen Versorgung der Mason-II-Fraktur zeigen einzelne Fallserien auch bei konservativem Therapieregime gute Ergebnisse und im Vergleich zur operativen Versorgung oftmals keine Unterschiede im klinischen Outcome [1]. Die konservative Therapie bietet sich bei Mason-II-Frakturen an, die keinen Rotationsblock zeigen [4]. Einige Studien belegen allerdings eine erhöhte Rate posttraumatischer Arthrosen bei dislozierten Frakturen und konservativem Vorgehen, sodass die operative Wiederherstellung der Gelenkkongruenz insbesondere beim jungen und aktiven Patienten im eigenen Vorgehen bevorzugt wird [14,17]. ...
... Fowler et al. reported a systematic review of 11 articles on patients over 50 years of age that had undergone a radial head arthroplasty with a mean MEPS score of 88.6/100 and an extension deficit of 15.9 • [28]. They also reported an overall median pain score of 0 (range 0 to 8) [29]. This differs from our own results (3.4/10) and could be attributed to the more complex nature of the associated injuries in the current series and explain the discrepancy with the literature. ...
Article
Background: The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. Materials and methods: This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). Results: Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11°, p=0.004) and total ROM (-14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (-9.00°, p=0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically. Discussion: We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries. Level of evidence: IV, Retrospective study.
... Internal bracing · Arthroscopy · Fracture fixation · Fracture osteosynthesis · Olecranon 2 mm ist aktuell in der Diskussion. Erste Studien konnten gute klinische Langzeitergebnisse nach konservativer Therapie nachweisen [26,27]. Dennoch sind nach operativer Therapie zuverlässigere klinische und funktionelle Ergebnisse mit geringeren Arthroseraten zu beobachten [28]. ...
Article
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Eine Vielzahl von Implantaten und Operationstechniken hat die Versorgungsqualität von Ellenbogenverletzungen in den letzten Jahren verbessert. „Low-profile“-Doppelplatten am Olekranon scheinen mechanische Weichteilirritationen reduzieren und winkelstabile Koronoidplatten die Versorgung der anteromedialen Facette erleichtern zu können. Ausgewählte Radiuskopf- und Koronoidfrakturen können zudem arthroskopisch assistiert versorgt werden, wodurch Begleitpathologien detektiert werden können. Neue Repositionstechniken am distalen Humerus erleichtern die Versorgung komplexer intraartikulärer Frakturen. Verletzungen des „lateral ulnar collateral ligament“ (LUCL) nach Ellenbogenluxation können zudem mithilfe des „Internal Bracing“ stabilisiert werden, wodurch eine sofortige frühfunktionelle Nachbehandlung aufgrund der hohen Primärstabilität ermöglicht wird.
... Die 10-Jahres-Ergebnisse von 100 Patienten, die mit einer Radiuskopf-bzw. Radiushalsfrakturen entsprechend Mason I und II konservativ therapiert wurden, wurde von Duckworth et al. [16] publiziert. Insgesamt 92 % der Patienten waren mit dem Langzeitverlauf zufrieden und erreichten im DASH-Score ("disability of shoulder, arms and hand questionnaire") durchschnittlich 5,8 (0-67,2) und im "Oxford Elbow Score" 46 (14-48) Punkte. ...
Article
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Der Spielraum für die konservative Therapie ist bei Gelenkverletzungen bekanntermaßen eng. Gelenkfrakturen mit einer Stufenbildung >2 mm bergen ein hohes Risiko einer posttraumatischen Arthrose. Gerade beim jüngeren Patienten gilt daher die anatomische Rekonstruktion als Therapie der Wahl. Dennoch lässt sich eine Vielzahl an Ellenbogenverletzungen mit gutem Erfolg konservativ therapieren. Ziel der Therapie muss die Gewährleistung eines stabilen (knöchern wie ligamentär), belastbaren Ellenbogens sein mit einer Beweglichkeit, die dem individuellen Profil des Patienten entsprechen sollte. In diesem Artikel werden die konservativen Möglichkeiten bei der Ellenbogenluxation sowie der Radiuskopf‑, Olecranon- und distalen Humerusfraktur diskutiert.
... Radial neck fractures in adults can be classified according to Broberg-Morrey [10], which is a modification of the Mason classification [11]. A majority of isolated radial neck fractures, especially types 1 and 2 according to the Broberg-Morrey classification, can be treated by functional exercises alone, achieving excellent or good results in most patients [8,[12][13][14]. In comminuted and dislocated fractures of the radial neck, operative treatment with open reduction and internal fixation with screws or plate osteosynthesis is common [15][16][17]. ...
Article
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Background: The aim of this study is to determine the functional long-term outcome after non-operative and operative treatment of radial neck fractures in adults. Methods: Thirty-four consecutive patients with a mean age of 46.4 (18.0 to 63.0) years with a fracture of the radial neck who were treated between 2000 and 2014 were examined regarding the clinical and radiological outcome. Twenty patients were treated non-operatively, and 14 patients underwent surgery. Results: After a mean follow-up of 5.7 (2.0 to 15.7) years, the clinical scores showed good results in both groups. The Disabilities of Arm, Shoulder and Hand score was 16.1 (0 to 71.6) in the non-operative group and 8.8 (0 to 50.8) in the operative group, respectively. The Mayo Elbow Performance Score was 80.0 (30 to 95) in the non-operative group and 82.5 (35 to 95) in the non-operative group, respectively. The initial angle of the radial head towards the shaft (RHSA) was significantly higher in the operative group in the anterior-posterior plane (12.8° [2 to 23] vs. 26.3° [1 to 90], p = 0.015). In the follow-up radiographs, the RHSA was significantly lower in the operative group (15.1° [3 to 30] vs. 10.9° [3 to 18], p = 0.043). Five patients developed 7 complications in the non-operative group, and 7 patients developed 12 complications in the operative group. Revision rates were higher in the operative groups as 1 patient received radial head resection in the non-operative (5%) group while 7 patients in the operative group (50%) needed revision surgery. Conclusion: A good functional long-term outcome can be expected after operative and non-operative treatment of radial neck fractures in adults. If needed due to major displacement, open reduction is associated with a higher risk of complications and the need for revision surgery but can achieve similar clinical results. Trial registration: DRKS DRKS00012836 (retrospectively registered).
... Radial head fracture is a common injury, with an incidence of 30 per 100,000 persons per year [1]. Open reduction and internal fixation is an important method of treatment for Mason III, IV and some Mason II fractures, although controversy exists regarding this procedure [2][3][4][5][6][7][8][9][10][11][12][13][14]. As a landmark during ORIF procedures, the "safe zone" should always considered by the surgeon. ...
Article
Purpose: Direct location of a "safe zone" on a CT axial view is inadequate because the radial head is circular in shape. Previous "safe zone" location methods are not appropriate if the physician is unable to visualize the actual radial head. This study aims to introduce a new method to locate the "safe zone" on CT. Methods: CT scans were performed on 20 intact cadaveric upper limbs from 20 different corpses in full pronation and supination. The DICOM-format raw data were then re-sliced and analyzed in Mimics 17.0 (Materialise, Belgium). The radial interosseous border (IB) is shaped like a droplet on the axial view; its axis was selected as our reference line (RL). A parallel line in the radial head axial slice was created, and its position relative to the "safe zone" was studied. Deviation in RL direction was evaluated. Results: Safe-zone scope was 114.41°±11.99. The rotation angle from the RL to the safe-zone's anterior and posterior border was 215.03°±5.99 and 100.62°±8.12, respectively. Rotation direction (clockwise or anti-clockwise) depended on relative radius-ulna position. The safe zone was located by determining these two borders. The reference line's direction was stable in the upper half of the IB; its distance to the radial head fovea was 77.33 mm±6.24. Conclusions: The radial head "safe zone" can be located on CT axial view based on the upper half of the IB using this new method. The method is clinically applicable to determine whether postoperative elbow malrotation results from plate impingement.
... Mason III-IV are treated in several ways, both open reduction internal fixation (ORIF) and arthroplasty are used as well as resection of the radial head. [7][8][9][10][11][12][13][14][15] As described above, the treatment of radial head fractures is segmented. A few previous reviews have investigated the functional outcome after radial head fractures. ...
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Introduction Fractures of the radial head and neck are the most common fractures of the elbow, and account for approximately one-third of all elbow fractures. Depending on the fracture type the treatment is either conservative or surgical. There is no absolute consensus regarding optimal treatment for different fracture types. The aim of this protocol is to present the method that will be used to collect, describe and analyse the current evidence regarding the treatment of Mason II–III radial head and neck fractures. Method and analysis We will conduct a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines statement. We will search a number of databases with a predefined search strategy to collect both randomised and non-randomised studies. The articles will be summarised with descriptive statistics. If applicable a meta-analysis will be conducted. Ethics and dissemination Ethical approval is not required since this is a protocol for a systematic review and no primary data will be collected. The authors will publish findings from this review in a peer-reviewed scientific journal. Trial registration number CRD42016037627.
Chapter
Radial head arthroplasty (RHA) is a valuable addition to the surgeon’s armamentarium for treatment of complex, comminuted radial head fractures with associated elbow instability. The major goal of radial head arthroplasty is to replicate the length of the native radial head and to avoid “overstuffing” or “understuffing” the radiocapitellar joint. It is important to assess for ligamentous injuries as well and repair these as necessary to restore elbow stability and allow joint range of motion. The goal of all rehabilitation protocols for the elbow is early, safe mobilization. We present our technique as well as tips and tricks for successful radial head implant arthroplasty.
Chapter
Fractures of the radial head are the most common elbow injuries. These injuries can range from simple nondisplaced fractures to those associated with complex elbow instability. Because the radial head is an important stabilizer of the elbow, displaced fractures, particularly when associated with ligamentous injuries, may lead to elbow dysfunction. Management of these injuries, whether nonoperative or operative, is aimed at maintaining radial head alignment while elbow joint motion is encouraged as rapidly as the stability of the fracture affords.
Chapter
This chapter presents a case scenario of a 36-year-old woman who arrives at the Emergency Department with elbow pain after a fall onto her outstretched left hand while skating. Aspiration of the hemarthrosis and injection of local anesthesia might help determine if some radial head fractures are hindering forearm rotation, and thus change the treatment strategy to follow. The patient’s radiographs reveal a minimally displaced partial articular radial head fracture. Nonoperative treatment of displaced partial articular fractures of the radial head without elbow dislocation or associated fractures is associated with good recovery. There are no randomized trials comparing operative and nonoperative management of displaced partial articular radial head fractures. Fractures that were once treated with excision are now often treated with open reduction internal fixation or prosthetic replacement, particularly in a complex injury that includes an associated coronoid fracture. The chapter also provides recommendations for implementing evidence-based practice in the clinical setting.
Article
Radial head fractures account for the majority of bony injuries to the elbow. The usual clinical signs include hemarthrosis, pain and limitations in movement. The standard diagnostic tool is radiological imaging using X‑rays and for more complex fractures, computed tomography (CT). Concomitant ligamentous injuries occur more frequently than expected and must be reliably excluded. The classification is based on the modified Mason classification. Mason type I fractures are usually treated conservatively with immobilization and early functional aftercare. Mason type II fractures can be well-addressed by screw osteosynthesis but higher grade fractures (Mason types III–IV) can necessitate a prosthetic radial head replacement. In this case, prosthesis implantation is to be preferred to a radial head resection. The outcome after treatment of radial head fractures can be described as good to very good if all accompanying injuries are adequately addressed.
Article
Résumé Introduction/Hypothèse L’objectif de cette étude était d’évaluer les facteurs qui affectent l’amplitude de mouvement (ROM) et la fonction dans les cas de fractures partielles de la tête radiale. L’hypothèse proposée est qu’un traitement conservateur donnera de meilleurs résultats. Matériel et méthode Cette étude de cohorte rétrospective comparative incluait 43 volontaires adultes ayant subi une fracture partielle de la tête radiale avec un suivi minimum d’un an, qui ont été divisés en deux groupes : le groupe chirurgical et le groupe non-chirurgical. Les facteurs de risques étaient : blessure associée, ossification hétérotopique, prestations d’indemnisation au travailleur et l’implication de l’articulation ulno-radiale proximale (ARUP). Les résultats évalués incluaient la mesure du ROM radiographique, les données démographiques et les questionnaires de qualité de vie (PREE, Q-DASH, MEPS). Résultats Le suivi moyen était de 3.5 ans (1–7 ans). Trente patients (70 %) avaient des blessures associées avec une diminution de l’extension du coude (− 11°, p = 0.004) et du ROM total (− 14°, p = 0.002) comparativement à l’autre groupe. L’ossification hétérotopique était associée à une diminution de flexion du coude (− 9.00°, p = 0.001) et l’ARUP était impliquée chez 88 % des patients. Seules les prestations d’indemnisation pour invalidité étaient associées avec de moins bons scores. Il n’y avait pas de différences en termes de fonction et de résultats entre les patients traités chirurgicalement et non-chirurgicalement. Conclusion Nous avons trouvé que les blessures associées, les prestations d’indemnisation et la présence d’ossification hétérotopique étaient les seuls facteurs corrélés avec un moins bon pronostic dans cette cohorte de patient. Étant donné ces résultats, les auteurs réitèrent l’importance d’être vigilant en ce qui concerne les blessures associées. Niveau d’évidence IV, étude rétrospective.
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Objectives: To evaluate the utility of follow-up radiographs in patients with isolated partial articular radial head fractures (OTA/AO 2R1B1 or 2R1B3). Design: Retrospective cohort study. Setting: Academic Level 1 Trauma Center. Patients: Adult patients (≥18 years) with isolated partial articular radial head fractures indicated for initial nonoperative treatment. Intervention: Analysis of elbow radiographs at initial presentation and at postinjury follow-up of 3-8 weeks. Variables measured: Articular gap and step-off. Main outcome measure: Radiographic articular displacement between initial and follow-up radiographs. Results: For 72 included patients, initial radiographs were obtained on average 2.6 days after injury and follow-up radiographs 33.7 days thereafter. Equivalence tests evaluating gap and step-off thresholds of <1 mm were both significant, indicating that the cohort displaced <1 mm for both parameters between initial and follow-up radiographs. No patients proceeded to surgical treatment following the repeat radiographs. Conclusions: These fractures do not displace in the early postinjury period, as defined as a <1 mm of change in both intra-articular gap and step-off, as compared to initial radiographs. Routine follow-up radiographs for these injuries is a source of cost, but with limited utility in detecting interval displacement or leading to a change in management. Selective use of radiographs to evaluate specific clinical concerns may lead to cost savings. Level of evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
Der Radiuskopf ist ein wichtiger Stabilisator des Ellenbogengelenks. Verletzungen des Radiuskopfes sind nicht selten mit weiteren destabilisierenden Begleitverletzungen vergesellschaftet und können zu relevanten funktionellen Einschränkungen des Ellenbogengelenks führen. Abhängig von der Verletzungsmorphologie muss eine differenzierte Therapie erfolgen. Nicht- oder gering dislozierte Frakturen können in den meisten Fällen konservativ behandelt werden. Dislozierte Frakturen werden in der Regel operativ versorgt. Die Rekonstruktion des Radiuskopfes erfolgt mittels Schrauben- und/oder Plattenosteosynthese. Zuletzt hat die technische Weiterentwicklung der Implantate das Indikationsspektrum für die Radiuskopfosteosynthese erweitert. Bei den nicht rekonstruierbaren Frakturen ist die Implantation einer Radiuskopfprothese die Therapie der Wahl. Gerade bei höhergradigen Verletzungen ist die Mitversorgung von osteoligamentären Begleitverletzungen essentiell, um ein gutes Therapieergebnis zu erzielen. Insgesamt ist die Evidenzlage zur Versorgung der Radiuskopffrakturen weiterhin unzureichend. Dies betrifft insbesondere die dislozierten und mehrfragmentären Brüche. Geringe Fallzahlen und ein meist retrospektives Studiendesign sind hierfür maßgeblich verantwortlich. Hinsichtlich eines im Durchschnitt jungen Patientenkollektivs stehen Langzeitergebnisse insbesondere zur Radiuskopfprothese noch aus. Entscheidend für eine erfolgreiche Behandlung der Radiuskopffrakturen ist die Wiederherstellung einer stabilen, stufenfreien Gelenkführung am humeroradialen Gelenk, sodass eine frühfunktionelle Beübung erfolgen kann und das Risiko für sekundäre degenerative Veränderungen minimiert wird.
Chapter
Radial head fractures are the commonest fracture of the elbow occurring at all ages. The treating surgeon should be diligent to distinguish isolated from combined injuries with concomitant fractures and/or ligament disruption. A thorough understanding of the mechanism of injury and pathoanatomy allows the treating physician a better understanding of the potential structures involved. Careful assessment of elbow stability in all planes of motion facilitates the selection of appropriate treatment options. Various treatment protocols exist ranging from non-operative care, radial head resection, open reduction and internal fixation to arthroplasty of the radial head. Unfortunately, an optimal management algorithm for radial head fractures has not yet been elucidated given the lack of evidence to support decision making. Further longer term follow-up and clinical studies will help guide future management of these injuries.
Article
Radial head and neck fractures are one of the most common elbow fractures, comprising 2% to 5% of all fractures, and 30% of elbow fractures. Although uncomplicated Mason type I fractures can be managed nonsurgically, Mason type II-IV fractures require additional intervention. Mason type II-III fractures with 3 or fewer fragments are typically treated with open reduction and internal fixation using 2 to 3 lag screws. Transverse radial neck involvement or axial instability with screw-only fixation has historically required the additional use of a mini fragment T-plate or locking proximal radius plate. More recently, less invasive techniques such as the cross-screw and tripod techniques have been proposed. The purpose of this paper is to detail and demonstrate the proper implementation of the tripod technique using headless compression screws.
Article
Die arthroskopisch assistierte Osteosynthese von ausgewählten Frakturen des Ellenbogengelenks stellt eine potentielle Alternative zum offenen Vorgehen dar. Die Arthroskopie bietet die Vorteile einer minimal-invasiven Operation mit geringerer Zugangsmorbidität bei gleichzeitig detaillierterer Beurteilbarkeit der Frakturreposition und der bestehenden Begleitpathologien. Dislozierte Two-part-Frakturen ohne Trümmerzone eignen sich für eine arthroskopisch gestützte Versorgung. Hierzu zählen Mason-2-Frakturen des Radiuskopfes, transverse Koronoidfrakturen und koronare Abscherfrakturen des distalen Humerus Typ 1/2 A nach Dubberley. Nach temporärer Reposition mit Kirschner-Drähten erfolgt die definitive Osteosynthese mit kopflosen und kanülierten Kompressionsschrauben. Koronoidspitzenfrakturen können alternativ indirekt durch Anschlingen der am Fragment anhaftenden ventralen Kapsel in Form einer Suture-lasso-Technik versorgt werden. Relevante Begleitverletzungen müssen im Rahmen einer systematischen diagnostischen Arthroskopie erfasst und sollten, sofern nötig, mitversorgt werden. Die bisher publizierten Fallserien und Einzelfallberichte zur arthroskopisch gestützten Frakturversorgung am Ellenbogen schildern vielversprechende Ergebnisse, die verfügbaren klinischen Daten sind jedoch noch begrenzt.
Article
Objectives: To compare physical impairments and patient reported outcomes in patients following simple and complex elbow injuries who were treated with a radial head arthroplasty. Design: Patients with isolated elbow trauma and no prior injury to the elbow were prospectively enrolled following radial head arthroplasty for an acute unreconstructable fracture. Injury patterns were classified as simple or complex based on the presence or absence of associated elbow fractures and/or dislocation. Setting: Quaternary Upper Extremity referral HospitalPatients/Participants: Patients (n= 148) were subgrouped into 67 simple and 81 associated fracture/dislocation injury patterns. Intervention: Radial Head Arthroplasty MAIN OUTCOME MEASUREMENTS:: PREE, QuickDASH, Range of Motion and Biodex measurements RESULTS:: At a minimum 1 year follow-up PREE and QuickDASH, and ROM and strength values were similar. Fourty-four patients evaluated at a mean of 7 years demonstrated no effect of injury pattern on clinical outcomes at any time point. Continued statistical improvements in PREE, supination ROM, and flexion ROM at medium term compared to earlier follow up was observed. Eight patients required secondary surgery, 2 in the simple injury group and 6 complex injury patients. Conclusions: Concomitant elbow injuries do not affect the longer term outcomes of patients with unreconstructable radial head fractures requiring radial head arthroplasty. Patient outcomes continued to improve beyond two years of follow-up. Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Article
Objective: Study purposes were to 1) identify outcome measures used in studies of persons with traumatic upper limb injury and/or amputation and 2) evaluate focus, content and psychometric properties of each measure. Data sources: Searches of PubMed and CINAHL for terms including upper extremity, function, activities of daily living, outcome assessment, amputation and traumatic injuries. Study selection: Included articles had a sample of ≥10 adults with limb trauma or amputation, and were in English. Measures containing a majority of items assessing impairment of body function or activity limitation were eligible. Data extraction: Two hundred sixty papers containing 55 measures were included. Data on internal consistency; test-retest, inter-rater, and intra-rater reliability; content, structural, construct, concurrent, and predictive validity; responsiveness; and floor/ceiling effects were extracted and confirmed by a second investigator. Data synthesisresults: The mostly highly rated performance measures included 2 amputation specific measures: Activities Measure for Upper Limb Amputees, University of New Brunswick Test of Prosthetic Skill and Spontaneity, and 2 non-amputation specific measures: Box and Block Test, and modified Jebsen-Taylor Hand Function test light and heavy cans tests. Most highly rated self-report measures were DASH, Patient Rated Wrist Evaluation, QuickDASH and Hand Assessment Tool (HAT), International Osteoporosis Foundation Quality of Life Questionnaire and Patient Rated Wrist Evaluation Functional Recovery subscale. None were amputation specific. Conclusion: Few performance measures were recommended for patients with limb trauma and amputation. All top rated self-report measures were suitable for use in both groups. These results will inform choice of outcome measures for these patients.
Chapter
Radial head fractures constitute 3 % of all fractures and the mean age of patients is 43 years. These fractures are famous for its associated injuries; in each case, a careful assessment and classification of the associated injuries have to be done to make a proper treatment plan. Outcome is dictated by the fracture type and the extent of the associated injuries. Nondisplaced fractures are routinely treated conservatively with a favorable long-term outcome. Partial displaced fractures can be treated conservatively or surgically. Fractures with more than three fragments are, in general, treated with a radial head prosthesis in the elderly. In younger patients, preservation of the radial head should be tried, even in very comminuted fractures.
Article
We examined the impact of fragility fractures on the work outcomes of employed patients. The majority successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore the fast recovery rates of working fragility fracture patients. IntroductionThe purpose of this study is to describe the impact of fragility fractures on the work outcomes of patients who were employed at the time of their fracture. MethodsA self-report anonymous survey was mailed to fragility fracture patients over 50 who were screened as part of the quality assurance programs of fracture clinics across 35 hospitals in Ontario, Canada. Measures of return to work (RTW), at-work productivity loss (Work Limitations Questionnaire), and sociodemographic, fracture-related, and job characteristics were included in the survey. Kaplan-Meier estimates of the cumulative proportion of patients still off work were computed. Factors associated with RTW time following a fragility fracture were examined using Cox proportional hazards modeling. ResultsOf 275 participants, 242 (88 %) returned to work. Of these, the median RTW time was 20.5 days. About 86 % returned to the same job, duties, and hours as before their injury. Among full-time workers, the median number of lost hours due to presenteeism was 2.9 h (Q1–Q3 0.4–8.1 h). The median cost of presenteeism was $75.30 based on the month prior to survey completion. In multivariable analyses, female gender, needing surgery, and medium/heavy work requirements were associated with longer RTW time. Earlier RTW time was associated with elbow fracture and feeling completely better at time of survey completion. Conclusions The majority of fragility fracture patients successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore their fast recovery rates and give reason for optimism regarding the resilience of this population.
Article
Objectives: After diagnosis of an isolated radial head or neck fracture and selection of nonoperative treatment, the value of subsequent radiographs is uncertain. This study tested the null hypothesis that there are no patient, surgeon, or injury factors associated with alteration in patient management based on subsequent radiographs. Secondarily, we tested the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics. Methods: We identified 415 adult patients with nonoperative treatment for isolated Broberg and Morrey modified Mason type 1 or 2 fractures at a large urban hospital system during years 2013 and 2014. Patient demographics, fracture characteristics, provider characteristics, and treatment details were obtained from a hospital database. Bivariate analysis and multivariable logistic regression modeling were performed. Results: One of 255 patients with 262 fractures that had subsequent radiographs (0.4%) was offered surgery but declined. In multivariable analysis, displaced fractures were more likely to have subsequent radiographs, but surgeon-to-surgeon variation was a far more influential factor. Conclusions: Radiographs subsequent to diagnosis do not alter treatment of radial head fractures with no associated ligament injuries or fractures. The substantial surgeon-to-surgeon variation in the use of subsequent radiographs suggests that this may be a good focus for quality improvement initiatives.
Article
Radial head fractures are the most common fractures around the elbow. Because they are often accompanied by ligamentous injuries, we recommend considering them to be osteoligamentous injuries rather than simple fractures, even in undisplaced or minimally displaced fractures. Surgeons should always suspect and actively exclude concomitant ligament tears. The incidence of these associated injuries increases with greater severity of the radial head fracture. However, the standard Mason classification system does not adequately address this problem, and all attempts to establish a new classification system that provides concise treatment algorithms have failed. This article discusses the current treatment options and the current controversies in nonsurgical therapy, open reduction and internal fixation (ORIF) and radial head replacement.
Article
The annual meeting of the Orthopaedic Trauma Association (OTA) continues to stand out as the foremost global meeting focussed on the practice and science of orthopaedic trauma surgery. All of the global opinion leaders in orthopaedic trauma regularly present their work, alongside instructional elements, and it remains the meeting at which one will find most of the United Kingdom’s leading trauma surgeons. The UK Orthopaedic Trauma Society (OTS) is steadily bringing practice-changing meetings of this kind to the UK and, given time, it seems likely that the OTS meetings should be part of UK trauma and orthopaedic (T&O) surgeons’ calendars. The 30th anniversary 2014 OTA Annual Meeting was held between 15 and 18 October 2014 in Tampa, Florida, hosted by the irrepressible Roy Sanders, of the calcaneal fracture classification. Nearby, the white sands of Clearwater Beach and the turquoise warm water of the Gulf of Mexico posed stiff competition for the extensive educational programme which offered a combination of a large collection of instructional course lectures, symposia, and scientific exhibits representing a wide range of trauma subspecialties. The programme committee presented 150 podium presentations from over 800 submitted, along with 170 posters, for the 1340 attendees. Prior to the annual meeting, on the Wednesday afternoon and Thursday morning there was a number of pre-meeting events, which cater for the variety of trauma surgeons attending. There is a guest nation each year, which this year was Brazil; 2016 will be the UK’s turn as guest nation in Vancouver, Canada. The extensive OTA meeting includes a number of ‘pre-meeting’ events such as the pelvic surgeons’ forum hosted by Adam Starr each year, and the basic science focus forum. A standout paper from …
Article
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Background: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits. Methods/design: The RAMBO trial (Radial Head - Amsterdam - Amphia - Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the 'Disabilities of Arm, Shoulder and Hand (DASH) score' twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the 'Numeric Rating Scale', range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year. Discussion: The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head. Trial registration: The trial is registered at the Dutch Trial Register: NTR3413.
Article
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This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario).Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plants for validity and reliability testing. © 1996 Wiley-Liss, Inc.
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This is the first study to use the English Indices of Multiple Deprivation 2007, the Government’s official measure of multiple deprivation, to analyse the effect of socioeconomic status on the incidence of fractures of the hip and their outcome and mortality. Our sample consisted of all patients admitted to hospital with a fracture of the hip (n = 7511) in Nottingham between 1999 and 2009. The incidence was 1.3 times higher (p = 0.038) in the most deprived populations than in the least deprived; the most deprived suffered a fracture, on average, 1.1 years earlier (82.0 years versus 83.1 years, p < 0.001). The mortality rate proved to be significantly higher in the most deprived population (log-rank test, p = 0.033), who also had a higher number of comorbidities (p = 0.001). This study has shown an increase in the incidence of fracture of the hip in the most deprived population, but no association between socioeconomic status and mortality at 30 days. Preventative programmes aimed at reducing the risk of hip fracture should be targeted towards the more deprived if they are to make a substantial impact.
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Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. PATIENTS AND METhods: 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.
Article
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There have been no reports on the long-term outcome of radial neck Mason type IIIb fractures in adults. 3 women and 2 men, aged 46 (22-69) years when they sustained a radial neck Mason type IIIb fracture, were evaluated after an average of 18 (16-21) years. All had been treated with radial head excision. 3 individuals had no subjective elbow complaints while 2 reported occasional weakness. None had severe elbow complaints. The maximum elbow-to-elbow difference in range of motion was a deficit of mean 10 degrees in extension in the injured elbow. Mean deficits in elbow flexion, forearm pronation, and forearm supination were below 5 degrees and the mean difference in cubitus valgus angle was only 2 degrees. There was no instability and no recurrent elbow dislocations. Radiographically, there were cysts, sclerosis, and osteophytes in all formerly injured elbows but none in the uninjured elbows. We found reduced joint space in 1 elbow that had been formerly injured. Mason type IIIb fracture in adults, treated with radial head excision, appears to have a favorable long-term outcome.
Article
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The purpose of this study was to evaluate the incidence of combined osteochondral and ligamentous injuries by magnetic resonance imaging (MRI) in 24 patients with an acute radial head fracture (Mason type II and III) without documented dislocation or tenderness at the distal radioulnar joint. Elbow radiographs (anteroposterior and lateral views) were obtained on all patients as well as magnetic resonance images in the 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 in 13 of 24 (54.16%), lateral ulnar collateral ligament not intact in 18 of 24 (80.1%), both collateral ligaments not intact in 12 of 24 (50%), capitellar osteochondral defects in 7 of 24 (29.1%), capitellar bone bruises in 23 of 24 (95.83%), and loose bodies in 22 of 24 (91.67%). A high level of suspicion should be used when one is treating displaced or comminuted radial head fractures, because concurrent osteochondral injuries and/or ligamentous injuries may be present.
Article
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We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space. Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.
Article
We present a retrospective study of 125 patients with an impacted valgus fracture (B1.1) of the proximal humerus. This fracture rarely occurs in young patients and is much more common in elderly fit subjects. All patients were documented prospectively and followed for one year. None was treated surgically. At one year, 80.6% of the patients had a good or excellent result, the quality of which depended on the age of the patient and the degree of displacement of the fracture. Mean outcome scores based on these two parameters are presented. A comparison with data from other studies suggests that operative fixation of these fractures is not necessary.
Article
Background This prospective cohort study tested the hypothesis that agreement with the idea that ‘stretching of the elbow beyond the point where it becomes painful is important in recovery’ leads to greater elbow range of motion, 1 month after injury. Methods Seventy-one patients with an isolated partial articular radial head fracture seen within 14 days after injury completed measures of depression and catastrophic thinking and rated their agreement with a statement regarding pain and recovery from their injury on a five-point Likert scale. One month later, patients completed the Disabilities of the Arm, Shoulder, and Hand questionnaire and elbow and forearm motion were measured. Results Nine patients (12.6%) disagreed with the role of pain in recovery, six (8%) were neutral and 56 (78.9%) agreed. Patients that disagreed with the role of stretch pain in recovery were older (p = 0.031), had more depressive symptoms (Center for the Epidemiological Study of Depression Instrument;p = 0.047), and achieved less elbow extension (p = 0.050) and forearm rotation (p = 0.017) 1 month after injury. Conclusions A protective attitude towards stretch pain during recovery from fracture of the radial head is associated with less elbow motion 1 month after injury. Level of evidence Prognostic study, Level 1 (prospectively).
Article
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 degrees +/- 8 degrees compared with 140 degrees +/- 7 degrees ) as well as a small extension deficit (mean and standard deviation, -4 degrees +/- 8 degrees compared with -1 degrees +/- 6 degrees ) (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.
Article
Hypothesis: Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. Materials and methods: We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. Results: The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm (P = .8) or even 3 mm (P = .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. Conclusions: This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome.
Article
Social deprivation is associated with many diseases. To our knowledge, there has been no previous investigation of its role in the epidemiology and incidence of fractures in adults. We analyzed 6872 consecutive fractures in patients fifteen years of age or older over a one-year period. Social deprivation was analyzed using the Carstairs score, which is derived from patients' postal codes and accurately defines social deprivation in our population. Social deprivation is associated with an increasing fracture incidence. The effect is not linear, and the most deprived 10% of society are affected. The odds ratios of the most deprived 10% of society having an increased incidence of fractures are 3.7 in males and 3.1 in females. Social deprivation is associated with a significant increase in the incidence of fractures in the most deprived 10% of the population. Most fracture types are affected. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Article
Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence. Cite this article: Bone Joint J 2013;95-B:151–9.
Article
There is no consensus as to the best treatment of Mason type II fractures without concomitant elbow fractures or dislocation. The aim of this systematic review was to compare the results of operative and nonoperative treatment of these injuries. We systematically screened the databases of PubMed, EMBASE, and Cochrane Library until September 2011 for studies on nonoperative or operative treatment of Mason type II fractures. We defined successful treatment as an excellent or good result according to the Broberg and Morrey score, Mayo Elbow Performance Score, or Radin score. Exclusion criteria were duration of follow-up of less than 6 months, an improperly described therapy or combination of therapies, skeletal immaturity, and articles written in languages other than English. Among 717 studies, 9 retrospective case series (level IV) describing 224 patients satisfied our inclusion criteria. Nonoperative treatment was successful in 114 of 142 patients (80%) pooled from the studies (42% to 96% success in individual studies). Open reduction and internal fixation was successful in 76 of 82 patients (93%) (81% to 100% success in individual studies). Only a few studies with a low level of evidence address the treatment of isolated, displaced, partial articular fractures. There is a need for sufficiently powered randomized, controlled trials. There is insufficient evidence to draw firm conclusions on the optimal treatment of isolated, displaced, partial articular Mason type II fractures.
Article
The aim of this study was to define the epidemiological characteristics of proximal radial fractures. Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed. We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13-94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity. Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended. Prognostic IV.
Article
The most common location of a displaced fracture of part of the radial head is often described as the anterior lateral aspect of the radial head with the forearm in neutral position, based on observation rather than precise measurements. The purpose of our study was to measure the exact location of fractures involving part of the radial head using quantitative 3-dimensional computed tomography (CT). We measured the fracture lines with respect to the biceps tuberosity in 24 patients with a displaced articular fracture of part of the radial head (Mason type 2). Two observers preformed each measurement twice. Reliability was measured using the concordance correlation coefficient according to Lin. The average start of the fracture was 97° (standard deviation [SD]) 48.3°; range 31°-254°) clockwise from the biceps tuberosity, the average end of the fracture was 241.6° (SD, 61.0; range 19°-330°), and the average fracture subtends was 170° (SD, 32.8°; range 99°-252°). The fracture was through the anterolateral quadrant of the radial head in 22 of the 24 patients and through the posteromedial quadrant in 2 patients. This quantitative analysis of CT scans of displaced articular fractures of part of the radial head (Mason type 2) confirms that the most common location is the anterolateral quadrant with the forearm in neutral rotation. Given the important role of the radial head in elbow stability, more accurate characterization of incomplete radial head fractures may improve our understanding of treatment and outcome of these fractures.
Article
To compare the outcomes of two different surgical treatments for the management of isolated closed Mason Type 2 radial head fractures. Retrospective study. The Student t test and McPearson chi-square test were used to evaluate whether there was a significance difference between the groups. Fifty-nine patients with isolated Mason Type 2 radial head fractures. Twenty-four patients treated with radial head excision (Group I) and 35 treated with open reduction and internal fixation (Group II). Clinical outcomes were assessed using the Broberg and Morrey functional rating scores and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Orthogonal radiographs were performed on both the elbow and the wrist; these were assessed for the presence of arthritis, heterotopic ossification, and the degree of proximal radial migration. The length of postoperative follow-up was 157 ± 61.84 months (Group I) and 125 ± 39.09 months (Group II). The Broberg and Morrey functional rating score was 86.21 ± 6.10 points and 95.09 ± 4.78 points, respectively. The DASH score was 21.82 ± 6.01 points and 2.81 ± 2.73 points, respectively. Radiologically moderate or severe osteoarthritis was present in the elbows of nine patients in Group I and only two patients in Group II. Patients with isolated Mason Type 2 radial head fractures treated by open reduction and internal fixation (Group II) had less residual pain, greater range of motion, and better strength than patients treated by radial head excision (Group I). Additionally, Group II had a lower incidence of severe posttraumatic arthritis, which contributed to improved DASH and Broberg and Morrey functional scores. These results support open reduction and internal fixation as the treatment of choice for these fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
Recent studies report that magnetic resonance imaging (MRI) shows a high incidence of associated injuries in patients with a radial head fracture. This retrospective study describes the clinical relevance of these injuries. Forty patients with 42 radial head fractures underwent a MRI scan after a mean of 7.0 days after trauma and were reviewed after a mean of 13.3 months. MRI showed 24 of 42 elbows had a lateral collateral ligament (LCL) lesion, 1 had a medial collateral ligament (MCL) and LCL lesion, 16 had an injury of the capitellum, 1 had a coronoid fracture, and 2 had loose osteochondral fragments. Clinical evaluation after a mean of 13.3 months showed that 3 elbows had clinical MCL or LCL laxity, of which 2 elbows had no ligamentous injuries diagnosed with MRI. One elbow with a loose osteochondral fragment showed infrequent elbow locking. The mean Mayo Elbow Performance Scale was 97.5 (range, 80-100) after a mean of 13.3 months after trauma, with no significant difference between patients with and without associated injuries (P = .8). Most injuries found with MRI in patients with radial head fractures are not symptomatic or of clinical importance in short-term follow-up.
Article
The purpose of this study was to determine the functional outcomes and predictive factors of radial head and neck fractures. Over an 18-month period, we performed a prospective study of 237 consecutive patients with a radiographically confirmed proximal radial fracture (156 radial head and 81 radial neck). Follow-up was carried out over a 1-year period using clinical and radiologic assessment, including the Mayo Elbow Score (MES). Multivariate regression analysis was used to determine significant predictors of outcome according to the MES. Of the 237 patients enrolled in the study, 201 (84.8%) attended for review, with a mean age of 44 years (range, 16-83 years; standard deviation, 17.3). One hundred eighty-seven (93%) patients achieved excellent or good MESs. The mean MES for Mason type-I (n = 103) and type-II (n = 82) fractures was excellent, with only two patients undergoing surgical intervention. For Mason type-III (n = 11) and type-IV (n = 5) fractures, the flexion arc, forearm rotation arc, and MES in the nonoperatively treated patients were not significantly different (all p ≥ 0.05) from those managed operatively. Regression analysis revealed that increasing age, increasing fracture complexity according to the AO-OTA classification, increasing radiographic comminution, and operative treatment choice were independently significant predictors of a poorer outcome (all p < 0.05). A majority of radial head and neck fractures can be treated nonoperatively, achieving excellent or good results. Age, fracture classification, radiographic comminution, and treatment choice are important factors that determine recovery.
Article
Radiographic arthrosis is a common sequela of elbow trauma. Few studies have addressed risk factors for radiographic arthrosis after elbow injury, especially in the long term. Data from multiple long-term follow-up studies of patients with surgically treated elbow fractures provided us with an opportunity to assess risk factors for long-term radiographic arthrosis after elbow injury. During a 5-year period, we obtained radiographs during a research-specific evaluation of 139 patients (81 men and 58 women) 10 or more years (median, 19.5 y; range, 10-34 y) after surgical treatment of an elbow fracture as part of multiple retrospective studies. Radiographic arthrosis was graded according to the system of Broberg and Morrey. Bivariate and multivariable analyses evaluated risk factors for radiographic arthrosis. Of 139 patients, 75 had radiographic evidence of arthrosis at final evaluation and 32 had moderate or severe radiographic arthrosis. Mechanism of injury, age, gender, follow-up time, occupation, and limb dominance were not associated with radiographic arthrosis. Multiple logistic regression analysis identified the type of injury as the only independent predictor of moderate to severe radiographic arthrosis. Patients with a bicolumnar fracture of the distal humerus, a capitellum/trochlear fracture, or an elbow fracture-dislocation were 8.0, 7.3, and 5.2 times more likely (odds ratio), respectively, to develop radiographic evidence of moderate or severe radiographic arthrosis than the average patient in this cohort. Distal humerus fractures (both columnar and capitellum/trochlea) and elbow fracture-dislocations are more likely than fractures of the olecranon and radial head to develop moderate or severe radiographic arthrosis in the long term. Prognostic IV.
Article
This study investigates the relationship between the epidemiology of hand fractures and social deprivation. Data were collected prospectively in a single trauma unit serving a well-defined population. The 1382 patients treated for 1569 fractures of the metacarpals or phalanges represented an incidence of hand fracture of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women. Deprivation was not directly associated with the incidence of hand fracture. Common mechanisms of injury are gender specific. Fractures of the little finger metacarpal were common (27% of the total) and were associated with social deprivation in men (P = 0.017). For women, fractures where the mechanism of injury was unclear or the patient was intoxicated and could not recall the mechanism showed a clear association with deprivation. Affluent patients were more likely to receive operative treatment. Social deprivation influences both the pattern and management of hand fractures.
Article
Unlabelled: Socioeconomic inequality through deprivation and access to healthcare is an aetiological factor in many disease processes. It is associated with the development of osteoarthritis, the need for joint arthroplasty and poorer access to secondary healthcare. Few studies have investigated the influence of deprivation on the function of patients undergoing total hip arthroplasty. The aim of this study was to investigate the association between deprivation and function in these patients before their operation and at 18 months. The secondary aim was to investigate if deprivation was associated with comorbidity or adverse outcomes. A prospectively database of functional scores of 1865 patients undergoing total hip arthroplasty over seven years was used. Deprivation was categorized using the Scottish Index of Multiple Deprivation (SIMD) government rating. The most deprived quintiles had lower absolute functional scores at time of operation. At 18 months the least deprived quintile had a greater SF36 physical function score and relative improvement. Deprivation was not linked with length of stay or BMI. There was a higher proportion of ASA (American Society of Anesthesiologists) category 1 patients in the least deprived group signifying less comorbidity. Smoking was more prevalent in patients from areas of greater deprivation. There was no observed difference in mortality, infection, dislocation or thromboembolism. This study demonstrates a socioeconomic gradient in the function of patients undergoing total hip arthroplasty. Further investigation is required to elucidate the biological and social mechanisms driving these outcomes, and to determine whether these gradients persist at longer term follow-up. Level of evidence: II (Prognostic Studies--Investigating the effect of a patient characteristic on the outcome of disease).
Article
The relationship between fall-related fractures and social deprivation was studied in 3,843 patients. The incidence of fractures correlated with deprivation in all age groups although the spectrum of fractures was not affected by deprivation. The average age and the prevalence of hip fractures decreased with increasing deprivation. This study examines the relationship between social deprivation and fall-related fractures. Social deprivation has been shown to be a predisposing factor in a number of diseases. There is evidence that it is implicated in fractures in children and young adults, but the evidence that it is associated with fragility fractures in older adults is weak. As fragility fractures are becoming progressively more common and increasingly expensive to treat, the association between social deprivation and fractures is important to define. All out-patient and in-patient fractures presenting to the Royal Infirmary of Edinburgh over a 1-year period were prospectively recorded. The fractures caused by falls from a standing height were analysed in all patients of at least 15 years of age. Social deprivation was assessed using the Carstairs score and social deprivation deciles, and the 2001 census was used to calculate fracture incidence. The data were used to analyse the relationship between social deprivation and fall-related fractures in all age groups. The incidence of fall-related fractures correlated with social deprivation in all age groups including fragility fractures in the elderly. The overall spectrum of fractures was not affected by social deprivation although the prevalence of proximal femoral fractures decreased with increasing deprivation. The average age of patients with fall-related fractures also decreased with increasing social deprivation as did the requirement for in-patient treatment. This is the first study to show the relationship between fall-related fractures and social deprivation in older patients. We believe that the decreased incidence of proximal femoral fractures, and the lower average age of patients with fall-related fractures, in the socially deprived relates to the relative life expectancies in the different deprivation deciles.
Article
Ethnic disparities have been demonstrated in the treatment of chronic diseases, such as diabetes and heart disease. It is unclear if similar ethnic disparities appear with respect to recovery following fracture care. We retrospectively reviewed 496 individuals (253 whites, 100 blacks, and 143 Latinos) with a fracture of the distal part of the radius. Assessment of physical function and pain was conducted at three, six, and twelve months following treatment. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess physical function, and a visual analog scale was used to assess pain. Multiple linear regression was used to model physical function and pain across ethnicity while controlling for age, sex, mechanism of injury, level of education, type of fracture, type of treatment (operative or nonoperative), and Workers' Compensation status. Both blacks and Latinos exhibited poorer physical function and greater pain than whites did at most follow-up points. Latinos reported more pain at each follow-up point in comparison with blacks and whites (p < 0.001 at three, six, and twelve months). These significant differences remained after controlling for Workers' Compensation status, which was also strongly associated with both pain and function. These findings suggest that recovery is different between ethnic groups following a fracture of the distal part of the radius. These ethnic disparities may result from multifactorial sociodemographic factors that are present both before and after fracture treatment.
Article
Excellent long-term results have been reported for nonoperative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head, suggesting that the role of operative treatment can be questioned. This investigation reports the long-term outcome of operatively treated Mason 2 radial head fractures. Sixteen patients with stable displaced partial articular (Mason 2) fractures of the radial head not associated with fracture or dislocation of the proximal forearm were evaluated an average of 22 years (range, 14-30 years) after open reduction and internal fixation with screws (11 patients) or a plate and screws (5 patients). Complications included two infections (1 deep and 1 superficial), two patients with restriction of motion because of screws of excessive length, and one transient posterior interosseous nerve palsy. A second surgery for implant removal was routine (14 of 16 patients). The average flexion arc was 129 degrees (range, 110-145 degrees) and the average forearm rotation arc was 166 degrees (range, 120-180 degrees). According to the Mayo Elbow Performance Index, elbow function was excellent in nine patients, good in four, fair in two, and poor in one patient. According to the classification system of Steinberg et al., there were three good, eight fair, and five poor results. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 12 points (range, 0-52). The long-term results of operative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head demonstrate no appreciable advantage over the long-term results of nonoperative treatment of these fractures published in prior reports. Moreover, the appeal of operative treatment is diminished by the potential complications.
Article
Radial head fractures are the most common fractures occurring around the elbow. Although radial head fractures can occur in isolation, associated fractures and ligament injuries are common. Assembling the clinical presentation, physical examination, and imaging into an effective treatment plan can be challenging. The characteristics of the radial head fracture influence the technique used to optimize the outcome. Fragment number, displacement, impaction, and bone quality are considered when deciding between early motion, fragment excision, and radial head excision, repair, or replacement. Isolated, minimally displaced fractures without evidence of mechanical block can be treated nonsurgically with early active range of motion (ROM). Partial, displaced radial head fractures without evidence of mechanical block can be treated either nonsurgically or with open reduction internal fixation (ORIF), as current evidence does not prove superiority of either strategy. For displaced fractures with greater than 3 fragments, radial head replacement is recommended. Radial head arthroplasty may be preferred over tenuous fracture fixation in the setting of associated ligament injuries when maintenance of joint stability could be compromised by ineffective fracture fixation.
Article
Two patients with high-energy elbow injuries were diagnosed with minimally displaced partial fractures of the radial head that subsequently displaced and were noted to be Essex-Lopresti injuries. The true complexity and instability of the fractures were not immediately obvious. High-energy partial radial head fractures may merit closer observation and evaluation for associated forearm ligament injury. (J Hand Surg 2009;34A:436-438. (C) 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)
Article
To assess the responsiveness and minimal change for the Oxford Elbow Score (OES) using anchor- and distribution-based approaches. A prospective observational study of 104 patients undergoing elbow surgery at a specialist orthopaedic hospital was carried out. Patients completed the OES and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires (both scored on a 0 to 100 scale) pre- and 6 months post-surgery. Transition items (used as anchors) assessed perceived changes following surgery. Indicators of responsiveness were the effect size; the anchor-based minimal clinically important difference (MCID) and best cut-point on the receiver operator characteristic (ROC) curve; and the distribution-based minimal detectable change (MDC). The three elbow-specific OES scales (Function, Pain, Social-Psychological) produced generally larger effect sizes (0.79, 1.14 and 1.18, respectively) than the upper-limb-specific DASH scale (0.76). Clear associations were observed between transition items and all OES and DASH scores (all r > |0.35|). The MCIDs for the OES Function scale and the DASH were similar (approximately 10), but were larger for the OES Pain and Social-Psychological scales (approximately 18), reflecting their lower (i.e. poorer) baseline scores and larger effect sizes. The MCIDs were, however, only consistently larger than the MDCs for the OES Pain domain. The OES Function scale and the DASH performed similarly on ROC analysis, but with the OES Pain and Social-Psychological scales demonstrating superior efficiency. For elbow surgery, the 12-item three-scale OES is highly responsive to 6-month post-operative outcomes, with its performance being generally better than that of the 30-item one-scale DASH. Study estimates of minimal change for the OES may be useful for informing sample size calculations and interpreting outcomes in future clinical trials.
Article
The most appropriate treatment of Mason type II radial head fractures remains controversial. Recommended treatment has included closed reduction and immobilization, resection, or open reduction and internal fixation. The cases of 29 Mason type II radial head fractures treated at Naval Hospital Oakland from 1983 to 1989 were identified. Twenty-six or 90% were available for detailed follow-up. All cases underwent standardized elbow evaluations and results were compared using an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function in activities of daily living. In addition, injury and follow-up radiographs were analyzed. Mean follow-up was 18 months. There were 10 cases treated by open reduction and internal fixation and 16 cases treated by closed means. At final follow-up, the operatively treated group had a mean elbow score of 92 and 90% good/excellent results. The nonoperatively treated group had a mean elbow score of 77 and 44% good/excellent results. This difference was statistically significant (p less than 0.01). Radiographic analysis revealed a higher incidence of articular depression, displacement, and joint narrowing in the nonoperatively treated group. We conclude that displaced radial head fractures treated nonoperatively have a higher incidence of pain, functional limitations, loss of strength, and radiographic evidence of arthritis when compared to those treated by open reduction and internal fixation.
Article
The treatment of choice for proximal radial head fractures remains controversial. The goal of any treatment for an intra-articular fracture must be the complete restoration of the joint and its function. Nonoperative treatment leads to full motion in cases of less than 1-2 mm of fracture displacement. Resection of the radial head can be recommended only for very comminuted fractures. All other fracture types should be treated by open reduction and internal fixation. Our own personal follow-up observation of 19 patients who had surgical intervention demonstrated restoration of elbow function after an average follow-up time of 11.7 months. Five patients had a slightly restricted range of motion of less than 10 degrees extension and flexion as well as less than 8 degrees pronation and supination, without signs of arthritis. Because complications were minimal, we recommend internal fixation of displaced proximal radial head fractures to restore the anatomic function of the elbow. This is especially true in cases with accompanying proximal ulna fractures and/or ruptured collateral ligaments of the elbow joint and/or disruption of the distal radio-ulnar joint.
Article
Twenty-four patients with ulnohumeral dislocation associated with radial head fracture were studied two to 35 years after injury. On the basis of an objective functional grading score that included elements of pain, motion, strength, and stability, results were excellent in three (12%), good in 15 (62%), and fair in six (25%). The best results were obtained in patients with Mason Type 2 injuries treated by closed reduction without fracture excision and with early complete radial head excision for a Type 3 fracture. Late instability was not observed in any of the 24 patients. Prolonged immobilization (greater than four weeks) was associated with poor results. Ectopic ossification occurred in only one patient who had surgical treatment at eight days after injury; the grading score was only fair. These observations demonstrate that the injury should be treated with early reduction of the ulnohumeral joint and treatment of the radial head fracture according to its type. Immobilization for more than four weeks should be avoided. The prognosis is better than what has been thought previously.
Article
Three hundred eighty-seven cases of isolated fractures of the radial head are reviewed, that were treated over a 20-year period by the authors without operative intervention. Mason types I, II, and III were all included in this group. Excellent and good results were usually obtained. Seventeen radial head fractures were excised during the same 20 years because of severely displaced and/or loose fracture fragments. Roentgenographic and physical examination were the criteria for surgery rather than any specific classifications. The cooperation of the patient with early range of motion exercises was the major factor in obtaining excellent or good results with this injury.
Article
Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using one's arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.
Article
The management of radial head fractures remains controversial. Accurate classification of the fracture (Mason) may necessitate the use of special X-ray views (45 degrees arterior oblique or radio-capitellar). We present the results of 19 cases of Mason type II fractures treated operatively by open reduction and internal fixation with the Herbert bone screw. All patients achieved 'good-to-excellent' outcome at follow-up. Our results compare favourably with other forms of treatment for this injury.
Article
Displaced fractures of the radial head in the young active patient should no longer be routinely treated with excision of the radial head. Better techniques of imaging, surgical exposure, and implant placement have improved the likelihood of preserving the head. Associated injuries may make preservation of the radial head important for both acute and long-term stability. In patients with suspected injury to the interosseous ligament of the forearm, saving the radial head may prevent pathologic proximal migration. Rigid internal fixation, permitting early mobilization, can be applied to the radial head and neck in a "safe zone" that does not impede motion. Radial-head excision should be performed in patients with grossly comminuted fractures and in those with low demand on their upper extremities.
Article
The influence of socio-economic status on the prevalence of Type 1 and Type 2 diabetes mellitus, and on obesity, was explored using routinely collected healthcare data for the population of Tayside, Scotland. Among 366,849 Tayside residents, 792 and 5,474 patients with Type 1 and Type 2 diabetes, respectively, were identified from a diabetes register. The Carstairs Score was used as a proxy for socio-economic status. This is a material deprivation measure derived from the UK census, using postcode data for four key variables. Odds ratios for diabetes prevalence, adjusted for age, were determined for each of six deprivation categories (1 - least deprived, 6/7 - most deprived). The mean body mass index (BMI) in each group was also determined, and the effect of deprivation category explored by analysis of covariance, adjusting for age and sex. The prevalence of Type 2 diabetes, but not Type 1 diabetes, varied by deprivation. People in deprivation category 6 and 7 were 1.6-times (95% confidence interval 1.4-1.8) more likely to have Type 2 diabetes than those least deprived. There was no relationship between deprivation and BMI in Type 1 diabetes (P = 0.36), but there was an increase in BMI with increasing deprivation in Type 2 diabetes (P < 0.001; test of linearity P < 0.001). The study confirms the relationship between deprivation and the prevalence of Type 2 diabetes. There are more obese, diabetic patients in deprived areas. They require more targeted resources and more primary prevention.
Article
Previous studies have demonstrated that socioeconomic deprivation is associated with poorer survival in patients with colorectal cancer. These differences have been attributed to more advanced disease at presentation. A total of 2269 patients undergoing resection for colorectal cancer in hospitals in central Scotland between 1991 and 1994 were studied. Socioeconomic status was defined using the Carstairs deprivation index. The impact of deprivation on case mix, treatment and outcome was analysed. There were no significant differences in mode of presentation, extent of disease at presentation, type of resection and postoperative mortality rate among the socioeconomic groups. Following curative resection, the overall survival rate at 5 years was 47.0 per cent in deprived patients, compared with 55.4 per cent in affluent patients (P = 0.05); the cancer-specific survival rate was 62.6 per cent in the deprived and 68.1 per cent in the affluent (P = 0.05). Compared with the affluent, the adjusted hazard ratios for the deprived were 1.36 (95 per cent confidence interval (c.i.) 1.09 to 1.69) for overall mortality and 1.26 (95 per cent c.i. 0.95 to 1.67) for cancer-specific mortality. Following palliative resection, there was no difference in survival between the affluent and deprived for either overall (P = 0.27) or cancer-specific (P = 0.89) mortality. These findings confirm that the cancer-specific survival rate following surgery for colorectal cancer is lower in deprived patients. Stage of disease at presentation and type of operation did not account for this difference. The excess mortality was confined to patients undergoing apparently curative resection.
Article
We present a retrospective study of 125 patients with an impacted valgus fracture (B1.1) of the proximal humerus. This fracture rarely occurs in young patients and is much more common in elderly fit subjects. All patients were documented prospectively and followed for one year. None was treated surgically. At one year, 80.6% of the patients had a good or excellent result, the quality of which depended on the age of the patient and the degree of displacement of the fracture. Mean outcome scores based on these two parameters are presented. A comparison with data from other studies suggests that operative fixation of these fractures is not necessary.
Article
The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees. Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.
Article
Undisplaced radial head and neck fractures are consistently described with no long-term deficits. The aim of this study was to evaluate specifically the long-term outcome of displaced Mason type I fractures, which have not previously described. Twenty women and twelve men, with a mean age of 46 years (range, 22-69 years) when they sustained a displaced Mason type I fracture, were reexamined at a mean of 21 years (range, 15-33 years) after injury. All were treated nonoperatively. Twenty-nine individuals had no subjective complaints, whereas three had occasional elbow pain. There was no objective impairment, and none had elbow osteoarthritis, defined as reduced joint space, whereas there was more radiographic degeneration in the formerly fractured elbow than in the uninjured elbow (85% vs 4%, P < .001). We conclude that the long-term results of nonoperatively treated displaced Mason type I fractures of the radial head and neck are predominantly favorable.
Article
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. 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. 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 degrees +/- 8 degrees compared with 139 degrees +/- 7 degrees ), as was extension (-3 degrees +/- 7 degrees compared with 1 degrees +/- 5 degrees ) and supination (86 degrees +/- 7 degrees compared with 88 degrees +/- 4 degrees ) (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). 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. Therapeutic Level IV.
Article
Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. As of yet, there is no consensus on optimal treatment strategy for Mason II-IV fractures. The aim of this study was to compare the results of conservative treatment with different surgical strategies for radial head fractures. Electronic databases from 1966 to 2004 were screened. Based on our inclusion criteria, 24 studies, describing 825 patients, were included. For Mason type II fractures, residual pain was present in 42% of the conservatively treated of the patients compared to 32% of the surgically treated patients. Good/excellent results for Broberg score were 52 and 88%, respectively. For Mason type III and IV fractures, no conservatively treated patients were described. There is insufficient evidence to be able to draw definitive conclusions on optimal treatment of type II-IV radial head fractures. Evidence is currently limited to a maximum level II evidence. There is great need for sufficiently powered randomized controlled trials.