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

Author(s): Herbertsson, P., Josefsson, P.O., Hasserius, R., et. al.

Source: J Bone Joint Surg 86A(9): 1925-1930, 2004

Summary:

This study is a retrospective review of 61 patients treated with radial head and neck fractures that were sustained over a 20-year period in Sweden.  The mean age was 44 years.  There were 39 Mason Type II fractures, 10 Mason Type III fracture and 12 Mason Type IV fractures.  Forty-three fractures were treated with primary radial head excision and 18 were treated with delayed radial head excision in a median of five months (range, 1 to 238 months) after the injury.  Thirty-seven individuals had sustained a low energy injury and 21 individuals had sustained a high-energy injury.  There were no postoperative complications.  Twenty-eight patients had no symptoms in elbow, although 27 had occasional pain and six had daily pain that was present at rest.  Of the patients with daily pain, four had had a primary radial head excision and two a delayed radial head excision; four had a Mason Type IV fracture and two a Mason Type II fracture, although the two Mason Type II fracture patients had chronic elbow pain prior to the fracture.  Four of the 12 Mason Type IV fractures had severe pain at the time of final follow-up compared with two of the 49 in the Mason Type II or III fracture group.  Flexion in the previously injured elbows was 139 degrees + 11 degrees compared to 142 degrees + 8 degrees in the uninjured elbow.  Extension of the elbow was –7 degrees + 12 degrees in the injured elbows compared to –1 degree + 6 degrees in the uninjured elbows.  Supination of the forearm was 77 degrees + 20 degrees in the injured elbows compared to 85 degrees + 10 degrees in the uninjured elbows.  According to the classification of Steinberg, 25 elbows were rated as good; 26 as fair; and 10 as poor.  The formerly injured elbows had more degenerative changes than the uninjured elbows with cysts in 42 compared with only three in the contralateral side.  However, none of the formerly fractured elbows had a reduced joint space.  Sixteen injured upper extremities had a greater than 2 mm ulnar positive variance, although the range was not noted.  Of the 43 former patients treated with a primary radial head excision, 22 had no symptoms in comparison with six of the 18 who had a delayed excision.

This review study confirmed that there was no significant difference between patients treated with primary radial head excision and delayed radial head excision with respect to symptomatology or degenerative radiographic changes.  Overall, the greatest correlation with a poor outcome was the severity of the initial fracture with Mason Type IV fractures having the highest percentage of poor outcomes.  Currently, radial head excision is thought contraindicated in elbow fracture-dislocations due to associated soft-tissue injury. Limitations include the retrospective nature of the study over a prolonged period of time with multiple different surgeons.  In addition, the true incidence of an Essex-Lopresti lesion (longitudinal forearm instability) is uncertain, although no patient in this study developed this sequella.

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