Pär Herbertsson

Fractures of the Radial Head and Neck Treated with Radial Head Excision

BACKGROUND The reported long-term outcomes of the treatment of radial head and neck fractures with excision of the radial head have been mixed. The purpose of the present study was to evaluate the long-term outcomes of primary or delayed radial head excision for the treatment of these fractures. METHODS Sixty-one individuals (mean age, forty-four years) with thirty-nine Mason type-II, ten Mason type-III, and twelve Mason type-IV fractures were evaluated subjectively, objectively, and radiographically at a mean of eighteen years (range, eleven to thirty-three years) after treatment. Forty-three fractures were treated with primary radial head excision, and the remaining eighteen were treated with delayed radial head excision at a median of five months (range, one to 238 months) after the injury. RESULTS At the time of follow-up, twenty-eight individuals had no symptoms, twenty-seven had occasional elbow pain, and six had daily pain. Four individuals with daily pain had had a Mason type-IV fracture. The range of motion of the formerly injured upper extremities was slightly less than that of the uninjured upper extremities in terms of flexion (139 degrees +/- 11 degrees compared with 142 degrees +/- 8 degrees ), extension (-7 degrees +/- 12 degrees compared with -1 degrees +/- 6 degrees ), and supination (77 degrees +/- 20 degrees compared with 85 degrees +/- 10 degrees ) (all p < 0.01). A higher percentage of formerly injured elbows than uninjured elbows had cysts, sclerosis, and osteophytes (73% compared with 7%; p < 0.001), but none had a reduced joint space. No differences were found between the outcomes for individuals treated with a primary radial head excision and those for individuals treated with a delayed excision. CONCLUSIONS Following a displaced radial head or neck fracture, excision of the radial head often leads to a good or fair result. We found no differences in outcome between primary and delayed radial head excisions following a Mason type-II, III, or IV fracture. The outcomes are associated with the type of fracture, with Mason type-IV fractures having the worst results, rather than with the timing of the radial head excision (primary or delayed).

PERIPROSTHETIC BONE RESORPTION: PARTICLES VERSUS MOVEMENT

Using a rat model, we created a bone-to-titanium interface and applied phagocytosable high-density polyethylene particles between the bone and implant, either initially or when the interface had matured. No fibrous membrane developed and no bone resorption was found. If sliding movements were initiated at the interface after two weeks, there was formation of a fibrous membrane. The additional application of particles did not change the thickness of the membrane, and there were only minor qualitative changes. Creation of a membrane by movement followed by cessation of movement and the application of particles caused the membrane to persist, whereas in a particle-free control group bone-to-metal contact was re-established. Our findings suggest that mechanical stimuli are of primary importance for prosthetic loosening, and that particles may modulate the later stages of the loosening process.

Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study.

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.

Primary nonoperative treatment of moderately displaced two-part fractures of the radial head

BACKGROUND Moderately displaced two-fragment fractures of the radial head have been treated predominantly nonoperatively. Recently, however, open reduction and internal fixation has gradually gained interest, without clear evidence that initial nonoperative treatment leads to an unfavorable outcome. As a consequence, the purpose of the present study was to evaluate the long-term outcome after the initial nonoperative treatment of this type of fracture. METHODS Fifteen men and thirty-four women, with a mean age of forty-nine years at the time of the injury, were included in the study. All patients initially had been managed nonoperatively for a two-fragment fracture of the radial head that was displaced 2 to 5 mm and that included >/=30% of the joint surface (a Mason type-IIa fracture). Early mobilization had been used for twenty-seven patients, and cast immobilization for a mean of two weeks (range, one to four weeks) had been used for twenty-two. All patients were reevaluated with a questionnaire after a mean of nineteen years, and thirty-four also had a clinical and a radiographic evaluation. Six patients had had a delayed radial head excision because of an unsatisfactory primary outcome. RESULTS Forty of the forty-nine patients had no subjective complaints, eight were slightly impaired as the result of occasional elbow pain, and one had daily pain. Flexion was slightly impaired in the injured elbows as compared with the uninjured elbows (137 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). CONCLUSIONS The initial nonoperative treatment of Mason type-IIa fractures of the radial head that are displaced by 2 to 5 mm is associated with a predominantly favorable outcome, especially if a delayed radial head excision is performed in the few cases in which the early outcome is unsatisfactory. LEVEL OF EVIDENCE Therapeutic Level IV.

Mason type IV fractures of the elbow: A 14- TO 46-YEAR FOLLOW-UP STUDY

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3 degrees (sd 4) and extension by a mean of 9 degrees (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

Comminuted fractures of the radial head.

Background There have been few reports on the long-term outcome of comminuted radial head fractures in adults. Method 10 women and 9 men with a mean age of 45 (21–65) years when they sustained a comminuted fracture of the radial head were re-evaluated after 15–25 years. 6 patients had been nonoperatively (NO) treated while 13 had had a radial head excision. The uninjured elbow served as a control. Results At follow-up, 11 patients (4 NO patients) rated their fractured elbow as being without deficits, 7 (1 NO) as being slightly impaired, and 1 (NO) as being severely impaired. Range of motion and elbow strength were not impaired, and even though there were more degenerative changes such as cysts, osteophytes, and sclerosis in the injured elbows by radiography, the prevalence of joint space reduction was not higher. Interpretation Most patients with an isolated comminuted fracture of the radial head treated nonoperatively or with a radial head excision report no or only minor long-term complaints.

Long-term outcome of displaced radial neck fractures in adulthood

Background There have been no reports on the long-term outcome of radial neck Mason type IIIb fractures in adults. Methods 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. Results 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° in extension in the injured elbow. Mean deficits in elbow flexion, forearm pronation, and forearm supination were below 5° and the mean difference in cubitus valgus angle was only 2°. 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. Interpretation Mason type IIIb fracture in adults, treated with radial head excision, appears to have a favorable long-term outcome.

Displaced fractures of the neck of the radius in adults AN EXCELLENT LONG-TERM OUTCOME

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.