Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70patients

Reasons for surgical revision after conservatively treated radial head fractures—retrospective... Original contribution 1 1 1 3 1 Obere Extremität 2018 · 13:112–120 R. Nietschke ·K. J.Burkhart ·B.Hollinger ·F.I. Dehlinger · A. Zimmerer · 1,2 https://doi.org/10.1007/s11678-018-0456-2 M. M. Schneider Received: 24 December 2017 Upper Extremity Unit, ARCUS Sportklinik, Pforzheim, Germany Accepted: 16 April 2018 University Witten/Herdecke, Witten, Germany Published online: 15 May 2018 ACURA Kliniken, Albstadt, Germany © The Author(s) 2018 Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70 patients More than 30% of all fractures are radial developed a symptomatic hypertrophic failed conservative treatment aer ft radial head fractures, making them the most plica [6]. The authors concluded that the head fractures. common bony injuries of the elbow joint. trauma mechanism is nearly the same They account for approximately 1.5–4% as in elbow dislocations. In some cases, Patients and methods of all fractures in the human body [21]. there was evidence on magnetic reso- The classification according to Mason nance imaging (MRI) or intraoperative Patients [31], later modified according to John- findings that the Mason I fracture was ac- ston, is the most commonly used classi- tually a Mason IV fracture. In addition, This retrospective, descriptive, and ex- fication system for radial head fractures Davidson et al. demonstrated, as part of plorative observational study included (. Figs. 1, 2 and 3). stress tests withradial head fractures, that patients who underwent surgery for The frequencies of the different grades all fractures had instabilities due to either fracture sequelae aer ft conservatively were published in 2010 and 2011. Ma- valgus or axial stress [9]. Itamura et al. treated radial head fractures. We identi- son I fractures accounted for about two emphasized that only 12.5% of the radial fied 70 patients (28 women and 42 men) thirds of all fractures, while only 2.5% head fractures in their case series did not treated between 2007 and 2016. Ini- were Mason IV fractures [11, 23]. have any relevant ligament injuries [19]. tial treatment was conducted outside Since Mason I fractures are generally In the case of Mason II fractures, good our hospital. Patients were referred to regarded as harmless injuries, conserva- results are achieved by conservative and our elbow center aer ft their initial pre- tive therapy is the method of choice ([6, operative measurements alike [2, 10, 15, sentation elsewhere. The average age 11, 17, 27, 31]; . Figs. 1 and 2). Con- 18, 28]. of the patients was 41.83 years (range, servative therapy includes immobiliza- Lindenhovius and coworkers did not 16–75 years). There were 40 right and tion for 5–7 days followed by early func- find better clinical long-term results fol- 30 left elbows affected. tional treatment [8, 29, 30, 33, 41, 42]. lowing operative treatment of Mason II On average, the duration of conser- The outcomes aer ft conservative treat- fractures in comparison with the long- vative therapy was 50 months (range, ment are good to very good in about term results of nonoperative manage- 5–360 months) from the time of trauma 90% of cases [17, 43, 45]. Only few data ment published by Akesson et al. [2, 28]. to surgery. exist concerning trauma sequelae of ra- The high rate of posttraumatic arthri- The study included all patients who dial head fractures that led to poor re- tis in the nonoperative group in the lat- underwent conservative treatment for at sults. Burkhart et al. reported on a case ter study is noteworthy. Although the least 5 months or longer. We also in- series of 16 patients with poor clinical authors state that these cases are asymp- cluded eight patients (11.4%) who had results following Mason I fractures. In tomatic, we believe this to be a worrisome previous surgeries, e.g., arthrolysis, else- their study, 62.5% of patients had symp- aspect of the conservative treatment of where. tomatic posttraumatic osteoarthritis with displaced radial head fractures as radio- elbow stiffness and free joint bodies. Five capitellar arthritis is known to be one of Arthroscopy of these patients had a relevant postero- the most challenging problems in elbow lateral rotation instability or a bilateral surgery—especially in the young and ac- The procedure for arthroscopy is de- instability, which had to be addressed tive patient. Therefore, the present study scribed here. We created five standard by ligament reconstruction. One patient evaluatesand describesthe sequelae of working portals: anteroradial, antero- 112 Obere Extremität 2 · 2018 Finally, we used the deep dorsoradial portal as an access to test the stability with an exchange rod inserted into the ulnohumeral joint. We distinguished between three de- grees of instability, according to the clas- sification of O’Driscoll et al. [38]: 4 Grade I: subluxation (posterolateral rotatory instability, PLRI) 4 Grade II: incomplete dislocation (PLRI II) 4 Grade III: complete dislocation Fig. 1 9 Radio- (PLRI III) graphs (two planes) of a radial head frac- The anterior joint compartment was ex- ture (Mason I) amined by using the anterolateral portal. If necessary, arthroscopic cartilage de- bridement, micro-fracturing, synovec- tomy, and/or capsulectomy was carried out aeft r creating an antero-ulnar portal. Medical files were analyzed according to the fracture sequelae, range of motion, stability, and patient complaints. Each of our patients was re-evaluated 6 weeks postoperatively. Patient data were col- lected retrospectively and postoperative evaluation was completed with the help of the available medical history. No tele- phone interview or personal examination was performed in this study. Fig. 2 8 Magnetic resonance imaging of Mason I radial head fracture and absence of soft tissue dam- age Results In 35 cases (50.0%), retrospective grad- ingaccordingto the Mason classification could not be made because radiological images at the time of the trauma were absent and there was incomplete or miss- ing data on the initial classification. In the remaining 35 patients, there were 20 type I, eight type II, five type III, and two type IV fractures. Approximately half of our patients (55.7%) were immediately immobilized with a plaster aer ft trauma. The duration Fig. 3 9 Computed tomography scans of the immobilization was 3.4 weeks of a radial head frac- (range, 1–8 weeks) on average. Five ture (Mason II) patients (7.1%) were treated with ortho- pedic devices aer ft trauma (e.g., hinged ulnar, trans-tricipital, proximal dorsora- portal. The entire dorsal elbow joint external fixator, etc.). dial, and distal dorsoradial. section was inspected with the camera In all, 98.6% of patients complained Aeft r joint insufflation through the via the high dorsoradial portal and, if of pain in the affected elbow; only one soft spot portal with 20 ml of normal necessary, treated using the trans-tricip- patient specified no pain. saline solution, an inflow cannula was ital portal. In addition, the camera was placed for the continuous supply of tilted laterally along the olecranon tip arthroscopy fluid via the anteroradial toward the deep dorsoradial portal. Obere Extremität 2 · 2018 113 Abstract · Zusammenfassung Obere Extremität 2018 · 13:112–120 https://doi.org/10.1007/s11678-018-0456-2 © The Author(s) 2018 R. Nietschke · K. J. Burkhart ·B.Hollinger · F.I.Dehlinger ·A.Zimmerer · M. M. Schneider Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70 patients Abstract In 38 cases, radial head fractures were initially and additional treatment depending on other Background. An inadequate clinical outcome treated with immobilization for 3.4 weeks injuries. The range of motion improved on av- after conservatively treated radial head (range, 1–8 weeks). Physiotherapeutic erage from preoperative flexion/extension of fractures is not uncommon. We analyzed the treatment was performed in 39 cases. In only 131–15–0° to postoperative flexion/extension subjective limitations, objective complaints, half of the cases was retrospective Mason of 135–5–0° (gain in flexion: 4.2° and and surgical procedures for radial head classification possible: 20 type I, 8 type II, extension: 10.6°). fractures initially treated conservatively. 5 type III, and 2 type IV. Of the 70 patients, Conclusion. Conservative treatment of radial Patients and method. Between 2007 and 53 had posttraumatic elbow stiffness; 34 had head fractures does not always yield good 2016, 70 patients (42 men, 28 women) isolated lateral and four patients isolated results. Reasons for a poor outcome include who suffered from fracture sequelae after medial ligament instability. There were eight chronic instability, cartilage damage, stiffness, conservatively treated radial head fractures cases with a combination of lateral and medial or a combination thereof. Improved outcomes were examined. Demographic (age, 41.8 years, ligament instability and 27 cases of elbow can be achieved via arthroscopic arthrolysis. range, 16–75 years) and clinical data stiffness combined with instability. An average (pain, range of motion, instability) were of 1.2 (range, 1–4) surgical procedures per Keywords retrospectively evaluated. patient were performed. In all, 64 patients Radius fractures · Elbow · Joint instability · Results. The average time to surgery after underwent elbow arthroscopy with arthrolysis Osteoarthritis · Surgery trauma was 50 months (range, 5–360 months). Revisionsgründe nach konservativ behandelten Radiuskopffrakturen – Retrospektive Analyse von 70 Patienten Zusammenfassung In 38 Fällen wurden Radiuskopffrakturen Behandlungen je nach Begleitverletzungen Hintergrund. Patienten mit unzureichendem zunächst für 3,4 (Spanne: 1–8) Wochen mittels durchgeführt. Der Bewegungsumfang klinischem Ergebnis nach konservativ Immobilisation behandelt. Eine physiothe- verbesserte sich im Durchschnitt von behandelten Radiuskopffrakturen sind nicht rapeutische Behandlung wurde in 39 Fällen Flexion/Extension (präoperativ) 131–15–0° zu selten. Ziel der vorliegenden Studie war eine durchgeführt. In nur der Hälfte der Fälle war Flexion/Extension (postoperativ) 135–5–0° Analyse von subjektiven Einschränkungen, eine retrospektive Klassifizierung nach der (Zugewinn: Flexion: 4,2°; Extension: 10,6°). objektiven Beschwerden und chirurgischen Mason-Klassifikationmöglich: 20 Typ I, 8 Typ II, Schlussfolgerung. Die konservative Eingriffen nach anfänglich konservativ 5Typ III und2Typ IV. Bei53der 70 Patienten Behandlung von Radiuskopffrakturen zeigt behandelten Radiuskopffrakturen. lag eine posttraumatische Ellenbogensteife nicht immer gute Ergebnisse. Gründe Patienten und Methode. Zwischen 2007 vor, bei 34 eine isolierte laterale und bei hierfür können chronische Instabilitäten, und 2016 wurden 70 Patienten (42 Männer, 28 Frauen) untersucht, die an Frakturfolgen 4 Patienten eine isolierte mediale Seitenband- Knorpelschäden, Steife oder eine Kombination nach konservativ behandelten Radiuskopf- instabilität. Eine Kombination aus lateraler davon sein. Eine Verbesserung des Ergebnisses frakturen litten. Demographische (Alter im und medialer Seitenbandinstabilität bestand kann über eine arthroskopische Arthrolyse in 8 Fällen, Ellenbogensteife kombiniert mit erzielt werden. Mittel: 41,8 Jahre; Spanne: 16–75 Jahre) und einer Instabilität in 27 Fällen. Pro Person . klinische Daten (einschließlich Schmerzen, waren 1,2 (Spanne: 1–4) chirurgische Eingriffe Bewegungsumfang, Instabilität) wurden notwendig. Bei 64 Patienten wurden jeweils Schlüsselwörter retrospektiv ausgewertet. eine Arthroskopie (52-mal kombiniert mit Radiusfrakturen · Ellenbogen · Gelenk- Ergebnisse. Im Durchschnitt betrug die Zeit einer Arthrolyse) und weitere notwendige instabilität · Ellenbogensteife · Operation nach dem Trauma 50 (Spanne: 5–360) Monate. In all, 53 patients (75.7%) had symp- the range of motion was improved to Ligament instability and elbow tomatic elbow stiffness with a restricted flexion/extension of 135–5–0° as well stiffness range of motion (. Fig. 5a, b). Of as pronation/supination of 73–0–76°. In 35 patients (50%), clinical examina- these patients, 91% needed arthroscopic Extension was improved by 10.6° and tion revealed ulnar (n=3), radial (n=5), arthrolysis including capsulectomy. In flexion by 4.2°, which corresponds to or bilateral lateral (n= 30) ligament in- addition to the arthroscopic arthrolysis, a total gain in range of motion of 14.8°. stability of the elbow joint (. Fig. 4a). a total of two open arthrolysis procedures Usually, the arthrolysis treatment was A combination of elbow instability with had to be performed. The preoperative planned for cases of considerable elbow concomitant posttraumatic elbow stiff- range of motion was flexion/extension stiffness to improve range of motion and ness was found in 27 patients (38.6%). of 131–15–0° and pronation/supination to prepare for a second ulnar or radial of 67–0–71°. At the 6-week follow-up, ligament reconstruction, if necessary. 114 Obere Extremität 2 · 2018 Fig. 4 8 Gaping joint gap (arrow in a) during arthroscopy and advanced cartilage damage on the radial head and the capitu- lum humeri (arrows in b, c) Via arthroscopic stability testing with the exchange rod, 18 cases (25.7%) of PLRI II or more and 12 cases (17.1%) of ulnar instability were detected. There was bilateral lateral ligament instability in eight patients (11.4%). All the other patients had either no PLRI or had lateral instabilities of a grade less than PLRI II; 24 patients exhibited no instability at all (34.3%). In five cases (7.1%), radial ligament reconstruction had to be carried out in asecond surgery (eitherplanned ordue to recurrent instability). Fig. 5 8 Distinct soft-parted bridle strands (arrows) Four patients (5.7%) required either aradial(n=2) or ulnar (n=2) liga- ment reconstruction without previous III° II-III° arthroscopy (. Fig. 6). In one case, ulnar 4% 3% ligament reconstruction was performed in a second surgery. II° In total, 1.2 surgeries per patient 17% (range, 1–4) were necessary to improve clinical outcome in the 70 patients in our study (57 patients needed only one op- N/A eration, 12 patients had two operations, 41% and one patient had four operations). When comparing the findings of clin- ical and arthroscopic stability testing, we found that 35 patients (50%) had a medial Fig. 6 9 Distribu- I-II° or lateral ligament instability in the pre- tion of postero- 28% lateral rotatory operative clinical examination. In 94% of instability (PLRI)in these cases, the instability was confirmed the study series: intraoperatively (25 cases of PLRI, five I° 24% of the instabil- 7% cases of ulnar instability, and three cases ities were graded as PLRI II or greater. of combined instability). Finally, only N/A no PLRI 16 patients (45.7%) underwent ligament reconstruction: 4 In all, 12 cases of lateral ulnar collat- eral ligament reconstruction (see case report in . Fig. 7): Obere Extremität 2 · 2018 115 Original contribution Fig. 7 8 Case report: A 50-year-old patient with a radial head fracture (Mason I) after a fall had persistent symptoms after initial conservative treatment for more than 1 year.Radiography and computed tomography images show no step formation (arrows) at the radial head (a–e). Magnetic resonance imaging confirms the diagnosis of a Mason I fracture, but no soft tissue damagecanbedetected(f,g). Theintraoperativeresults1yearposttraumashowtheformerfracture(arrow)attheradialhead (rh) and a gaping humeroradial joint gap (arrow) as an indication of lateral instability (ch capitulum humeri,ct coronoid tip; h–k). Postoperative radiograph after treatment with lateral ulnar collateral ligament repair (l, m) j Two cases without arthroscopic 4 Four cases of ulnar reconstruction: besides arthroscopic arthrolysis was not treatment j Two cases without arthroscopic necessary (52 cases, 74.3%). j Five cases in combination with an treatment The patients with nonstabilized frac- arthroscopic procedure j Two cases in a planned second tures were nevertheless satisfied with the j Four cases in a planned second surgery postoperative outcome, so that not all surgery instabilities had clinical relevance in our j One case due to recurrent instabil- In most cases, however, additional treat- series. ity ment (e.g., neutralizing the instabilities) 116 Obere Extremität 2 · 2018 nine of 14 patients with Mason I frac- ulno-humeral radio-humeral tures using MRI [16]. Kaas et al. sup- ported these findings, detecting accom- panying injuries in Mason I–III fractures including lateral collateral ligament rup- tures (n = 28) and humeroradial cartilage damage (n=8) in 35 of 46 cases [22–24]. Whether concomitant injuries increase the necessity for surgical treatment re- mains controversial. Kaas et al. stated that most of the additional lesions in pa- tients with radial head fractures are either not symptomatic or not of clinical impor- tance. However, in their follow-up exam- ination at least 12 months aeft r trauma, flexion and extension deficits occurred in N/A I° I-II° II° II-III° III° III-IV° IV° 45 and 43% of their patients, respectively. In addition, 13 of 40 patients described Fig. 8 8 Cartilage damage according to joint section. A dramatic increase in cartilage damage occurs crepitus and one patient had locking due on the radial side of the elbow joint.N/A no cartilage damages to a loose body. The authors claimed that no patient needed delayed surgery since patients including recurrent elbow stiff- symptoms were mild and without ma- Cartilage defect ness and one recurrent lateral instability. jor restrictions [23]. In our case series, Depending on the intraoperative find- Therefore, arthroscopic and open revi- most of the patients were initially treated ings, accompanying pathologies such as sion arthrolysis as well as one revision of elsewhere and did not undergo MRI as cartilage damage or hypertrophic plicae a lateral ligament reconstruction had to they suffered from mainly Mason I and were addressed in the same surgery. be performed. Mason II fractures (28/35 cases). In only four cases (5.7%) were neither Conservative treatment for Mason I humero-ulnar nor humeroradial carti- fractures is regarded the gold standard Discussion lagedefectsfound. AccordingtotheOut- and yields good to excellent results with erbridge classification [39], the humero- Radial head fractures tend to be un- temporary immobilization for 5–7 days ulnar joint itself showed at least grade II derestimated by clinicians, in particu- followed by early functional treatment or higher cartilage damage in approxi- lar because of the lack of evidence of [17, 43, 45]. However, Burkhart et al. re- mately one out of six patients (15.7%). In displacement on plain radiographs and ported on 16 patients with poor outcome the humeroradial joint (radial head and the good results achieved with conserva- aer ft Mason I fractures due to fracture capitulum humeri), 90% of the patients tive treatment. However, these injuries sequelae such as instability, loose bodies, already had grade II or higher cartilage may oeft n be accompanied by a high de- and posttraumatic arthrosis. The trauma lesions. Furthermore, 62.5% of all pa- gree of ligamentous and soft tissue as mechanism in radial head fractures is tients already had at least grade II–III well as intra-articular cartilaginous dam- similar to that of elbow dislocations. An cartilage lesions at the radial head it- age, which cannot be displayed on radio- enhanced clinical and radiological evalu- self, and every third patient (35.7%) had graphs [4]. Therefore, a thorough assess- ation(typicallyMRI)is required fortype I an advanced grade IV cartilage defect ment of radial head fractures is necessary Mason radial head fractures in order to (. Figs. 4b, c and 8). in order to determine the true severity detect soft tissue and ligamentous dam- and extent of these lesions and to mini- age and to initiate adequate treatment mize the risk of delayed surgical therapy. [6]. MRI frequently reveals evidence of Reoperation The correlation between an osseous le- elbow dislocation in Mason type I frac- In total, 13 patients needed 15 reop- sion of the radial head and ligamentous tures with severe soft tissue injuries. It erations: two arthroscopic arthrolysis, injuries is well known. Itamura et al. de- remains unknown which of these soft tis- four open arthrolysis, five lateral liga- scribed medial collateral ligament rup- sue injuries might benefit from surgery. ment reconstructions (one time due to tures in 54%, lateral collateral ligament However, a study by Adolfsson et al. sup- recurrent instability), two ulnar ligament ruptures in 80%, and bilateral ruptures in ports the assumption that the severity of reconstructions, one hinged external fix- 50% of all cases classified as Mason II and soft tissue injuries correlates with com- ator, one mobilization under anesthe- III fractures, while Mason IV fractures plications. The authors reported on a co- sia. However, nine of these operations were excluded [19]. hort of patients who experience redislo- were plannedsecondinterventions. Six Hausmann et al. found a partial le- cation despite receiving proper conser- complications were encountered in five sion of the interosseous membrane in vative management for a simple elbow Obere Extremität 2 · 2018 117 Original contribution dislocation. During surgery they found Owing to the lower rate of degenera- The difficulty of treating radiocapitellar complete avulsions of the medial and/or tive changes, especially in young patients, arthritis especially in young patients is lateral collateral ligaments and muscle werecommendsurgeryforMasonIIfrac- a frequent topic of discussion in the lit- origins [1]. For this reason, the use of tures. However, the operative approach erature. Therefore, prevention of radio- MRI to visualize the extent of soft tissue (screws, plate osteosynthesis, pins etc.) capitellar arthritis seems logical. ORIF of injuries is reasonable. This conclusion has to be assessed individually. Mason II fractures is a simple procedure is supported by our study. In particular, By contrast, in Mason type III and IV with a very high rate of good results and subjective elbow instability, pre-arthrotic fractures, a surgical approach is the gold low complication rates. deformities, and restriction in elbow mo- standard. The method to be followed, On the basis of our patient popula- bility frequently occuraeft rMason Iand however, is still under discussion since tion, we cannot recommend primarysur- II fractures with a negative effect on the ORIF, as the preferred therapy, and im- gical treatment for Mason I or Mason II clinical outcome. Our approach always plantation of a radial head prosthesis or fractures since we did not compare out- includes MRI in selected cases of insuffi- radial head replacement represent suit- comes. Instead, appropriate and exten- cient clinical improvement during early able treatment options [3, 20, 25, 26, 37, sive diagnostics are necessary to detect follow-up even in non-dislocated Ma- 40, 43]. Allthesestrategiesexhibitadvan- concomitant injuries, which might influ- son I fractures. Conservative treatment tages and disadvantages and are mainly ence the decision on whether the patient is aimed for, but concomitant injuries dependent on the expertise of the sur- will benefit from surgery or not. Further- might call for surgery. geon. more, continuous clinical examinations In the literature, conservative treat- Our study involved only patients un- are highly recommended so as to change ment is still regarded the method of dergoing surgery for fracture sequelae conservative treatment when required. choice for Mason II fractures. In a long- such as instability, restricted range of mo- We tend to recommend operative ther- term follow-up study, Akesson et al. tion (stiffness), or painful weight-bear- apy for Mason II fractures in cases of reported good to excellent results in ing. Elbow stiffness described in the lit- concomitant lesions, since degenerative about 82% of cases aeft r conservative erature, which is significantly correlated lesions mostly prevailed in our patient management of Mason II fractures. The with the duration of immobilization, is group with Mason II fractures. rate of degenerative changes reached a serious complication aer ft radial head u Th s, measurements that possibly 82% for the injured and 21% for the un- fractures [8, 29, 30, 33–35, 41, 42]. This promote complications, such as lengthy injured elbow [2]. Surgical treatment led was also found in the present study. In immobilization or patients with suspi- to similar clinical results (82% good to most cases, a relevant restriction of elbow cious injuries who refuse MRI, should be excellent) 22 years aer ft open reduction movement was one of the main reasons avoided. Although not applicable to all and internal fixation (ORIF) in a study by for delayed surgery aeft r initial conser- patients and all clinics, we recommend Lindenhovius and colleagues. However, vative treatment of non- or only slightly acquiring radiographs in two planes arthrosis was only detected in one of displaced radial head fractures. Regard- and performing MRI independent of the 16 cases in their study [28]. To date, there ing the soft tissue damage, some patients Masson classification of the fracture. The is no prospective study comparing ORIF with Mason I radial head fractures likely necessity for surgical treatment has to be with conservative treatment in Mason II had an injury mechanism similar to an evaluated individually in every patient fractures. Yoon et al. compared non- elbow dislocation. Furthermore, the ra- with consideration of age, occupation, surgical treatment with ORIF in partial dialheadisanimportantstabilizeragainst sports, and handedness [4, 7, 16, 19, 22, articular radial head fractures, but the valgus stress in combination with the me- 23, 32]. study was compromised by several biases dial collateral ligament, which was con- Especially the treatment of intraoper- and the conclusion is therefore limited firmed by several biomechanical studies atively detected instabilities by means of [44]. The RAMBO trial was initiated in [12–14, 25, 36]. stabilization surgery (ligament repair or 2014 and aimed to address the question Soft tissue damage, especially in Ma- ligament reconstruction) should be as- of whether Mason II fractures should be son I fractures, can lead to the classifi- sessed individually. In our study, not ev- treated conservatively or surgically [5]. cation being adapted aeft r surgical inter- ery arthroscopically detected instability Unfortunately, no results from the trial vention, thereby resulting in a Mason IV needed surgical stabilization. Even with- have been published yet. A systematic fracture. out stabilization, adequate clinical results review by Zwingmann et al. favored In contrast to reports in the literature, could be achieved, similar to the findings ORIF with screws in Mason type II in which cartilage lesions are described as of Kaas and coworkers [22–24]. fractures over osteosynthesis with pins either asymptomatic or clinically not rel- The lack of a classification system that or K-wires and over conservative treat- evant, our patients suffered remarkably combines bony and ligamentous lesions ment because of better outcomes with from cartilage damage, which is mostly as well as the lack of prospective stud- the former approach. However, the se- detected as crepitus during clinical exam- ies comparing surgical with conservative lection of conservative studies included ination. In our series, all complications treatment does not allow for a general in the review, dated from 1981 to 1992, and all pathologies represented surgical therapy algorithm. It is important to pay represents a possible bias [46]. indications due to restricting symptoms. attention to so-called red flags like re- 118 Obere Extremität 2 · 2018 dislocation of the elbow joint. Relationship striction of movement, unchanging high Compliance with ethical to medial instability. J Bone Joint Surg Am pain level, or simply unambiguous elbow guidelines 82(4):555–560 instabilities in stress testing a few days 14. Fornalski S, Gupta R, Lee TQ (2003) Anatomy and biomechanics of the elbow joint. Tech Hand Up after trauma. Conflict of interest. R. Nietschke, K.J. Burkhart, ExtremSurg7(4):168–178 B.Hollinger,F.I.Dehlinger,A.Zimmerer,and 15. Guzzini M, Vadalà A, Agrò A, Di Sanzo V, Pironi M.M. Schneider declare that they have no competing D, Redler A, Serlorenzi P, Proietti L, Civitenga C, Practical conclusion interests. MazzaD,LanzettiRM,FerrettiA(2016)Nonsurgical treatment of Mason type II radial head fractures 4 Mason I fractures are associated This article does not contain any studies with human in athletes. A retrospective study. G Chir participants or animals performed by any of the au- with soft tissue injuries that might 37(5):200–205 thors. 16. Hausmann JT, Vekszler G, Breitenseher M et al benefit from surgical treatment in (2009) Mason type-I radial head fractures and select patients. Therefore, we tend Open Access This article is distributedunder the terms interosseous membrane lesions—a prospective of the Creative Commons Attribution 4.0 International to regard radial head fractures as study. JTrauma66:457–461 License (http://creativecommons.org/licenses/by/ 17. 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Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Pöll RG, Rozing PM (2000) Posterolateral Obere Extremität 2 · 2018 119 Original contribution 32. McKee MD et al (2003) The pathoanatomy of lateral ligamentous disruption in complex elbow instability. JShoulderElbowSurg12(6):391–396 33. Mehlhoff TL, Noble PC, Benett JB, Tullos HS (1988) Simple dislocationof the elbowinthe adult. Results after closed treatment. J Bone Joint Surg Am70(2):244–249 34. Mellema JJ, Lindenhovius ALC, Jupiter JB (2016) The posttraumaticstiff elbow: an update. Curr Rev MusculoskeletMed9(2):190–198 35. Mittal R (2017) Posttraumatic stiff elbow. Indian J Orthop51(1):4–13 36. Morrey BF, Tanaka S, An KN (1991) Valgus stability oftheelbow. Adefinitionofprimaryandsecondary constraints. ClinOrthopRelatRes256:187–195 37. Nestorson J, Josefsson PO, Adolfsson L (2017) A radial head prosthesis appears to be unnecessary in Mason IV fracture dislocation. Acta Orthop 88(3):315–219 38. O’Driscoll SW, Bell DF, Morrey BF (1991) Posterolat- eral rotatory instability of the elbow. J Bone Joint SurgAm73(3):440–446 39. Outerbridge RE (1961) The etiology of chon- dromalacia patellae. J Bone Joint Surg Br 43- B:752–757 40.Pomianowski S, Morrey BF,Neale PG,Park MJ, O’Driscoll SW, An KN (2001) Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Surg Am 83-A(12):1829–1834 41. Rafai M, Largab A, Cohen D, Trafeh M (1999) Pure posterior luxation of the elbow in adults: immobilization or early mobilization. A random- ized prospective study of 50 cases. Chir Main 18(4):272–278 42. Schippinger G, Seibert FJ, Steinbock J et al (1999) Management of simple elbow dislocations. Does the period of immobilization affect the eventual results? LangenbecksArchSurg384(3):294–297 43. Struijs PA, Smit G, Steller EP (2007) Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review. ArchOrthopTraumaSurg127:125–130 44. Yoon A, King GJ, Grewal R (2014) Is ORIF superior to nonoperative treatment in isolated displaced partial articular fractures of the radial head? Clin OrthopRelatRes472(7):2105–2112 45. Weseley MS, Barenfeld PA, Eistenstein AL (1983) Closed treatment of isolated radial head fractures. JTrauma23:36–39 46. Zwingmann J, Welzel M, Dovi-Akue D, Schmal H, Südkamp NP, Strohm PC (2013) Clinical results after different operative treatment methods of radialheadandneckfractures: asystematicreview and meta-analysis of clinical outcome. Injury 44(11):1540–1550 120 Obere Extremität 2 · 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Obere Extremität Springer Journals

Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70patients

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Medicine & Public Health; Orthopedics; Surgical Orthopedics; Medicine/Public Health, general
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Original contribution 1 1 1 3 1 Obere Extremität 2018 · 13:112–120 R. Nietschke ·K. J.Burkhart ·B.Hollinger ·F.I. Dehlinger · A. Zimmerer · 1,2 https://doi.org/10.1007/s11678-018-0456-2 M. M. Schneider Received: 24 December 2017 Upper Extremity Unit, ARCUS Sportklinik, Pforzheim, Germany Accepted: 16 April 2018 University Witten/Herdecke, Witten, Germany Published online: 15 May 2018 ACURA Kliniken, Albstadt, Germany © The Author(s) 2018 Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70 patients More than 30% of all fractures are radial developed a symptomatic hypertrophic failed conservative treatment aer ft radial head fractures, making them the most plica [6]. The authors concluded that the head fractures. common bony injuries of the elbow joint. trauma mechanism is nearly the same They account for approximately 1.5–4% as in elbow dislocations. In some cases, Patients and methods of all fractures in the human body [21]. there was evidence on magnetic reso- The classification according to Mason nance imaging (MRI) or intraoperative Patients [31], later modified according to John- findings that the Mason I fracture was ac- ston, is the most commonly used classi- tually a Mason IV fracture. In addition, This retrospective, descriptive, and ex- fication system for radial head fractures Davidson et al. demonstrated, as part of plorative observational study included (. Figs. 1, 2 and 3). stress tests withradial head fractures, that patients who underwent surgery for The frequencies of the different grades all fractures had instabilities due to either fracture sequelae aer ft conservatively were published in 2010 and 2011. Ma- valgus or axial stress [9]. Itamura et al. treated radial head fractures. We identi- son I fractures accounted for about two emphasized that only 12.5% of the radial fied 70 patients (28 women and 42 men) thirds of all fractures, while only 2.5% head fractures in their case series did not treated between 2007 and 2016. Ini- were Mason IV fractures [11, 23]. have any relevant ligament injuries [19]. tial treatment was conducted outside Since Mason I fractures are generally In the case of Mason II fractures, good our hospital. Patients were referred to regarded as harmless injuries, conserva- results are achieved by conservative and our elbow center aer ft their initial pre- tive therapy is the method of choice ([6, operative measurements alike [2, 10, 15, sentation elsewhere. The average age 11, 17, 27, 31]; . Figs. 1 and 2). Con- 18, 28]. of the patients was 41.83 years (range, servative therapy includes immobiliza- Lindenhovius and coworkers did not 16–75 years). There were 40 right and tion for 5–7 days followed by early func- find better clinical long-term results fol- 30 left elbows affected. tional treatment [8, 29, 30, 33, 41, 42]. lowing operative treatment of Mason II On average, the duration of conser- The outcomes aer ft conservative treat- fractures in comparison with the long- vative therapy was 50 months (range, ment are good to very good in about term results of nonoperative manage- 5–360 months) from the time of trauma 90% of cases [17, 43, 45]. Only few data ment published by Akesson et al. [2, 28]. to surgery. exist concerning trauma sequelae of ra- The high rate of posttraumatic arthri- The study included all patients who dial head fractures that led to poor re- tis in the nonoperative group in the lat- underwent conservative treatment for at sults. Burkhart et al. reported on a case ter study is noteworthy. Although the least 5 months or longer. We also in- series of 16 patients with poor clinical authors state that these cases are asymp- cluded eight patients (11.4%) who had results following Mason I fractures. In tomatic, we believe this to be a worrisome previous surgeries, e.g., arthrolysis, else- their study, 62.5% of patients had symp- aspect of the conservative treatment of where. tomatic posttraumatic osteoarthritis with displaced radial head fractures as radio- elbow stiffness and free joint bodies. Five capitellar arthritis is known to be one of Arthroscopy of these patients had a relevant postero- the most challenging problems in elbow lateral rotation instability or a bilateral surgery—especially in the young and ac- The procedure for arthroscopy is de- instability, which had to be addressed tive patient. Therefore, the present study scribed here. We created five standard by ligament reconstruction. One patient evaluatesand describesthe sequelae of working portals: anteroradial, antero- 112 Obere Extremität 2 · 2018 Finally, we used the deep dorsoradial portal as an access to test the stability with an exchange rod inserted into the ulnohumeral joint. We distinguished between three de- grees of instability, according to the clas- sification of O’Driscoll et al. [38]: 4 Grade I: subluxation (posterolateral rotatory instability, PLRI) 4 Grade II: incomplete dislocation (PLRI II) 4 Grade III: complete dislocation Fig. 1 9 Radio- (PLRI III) graphs (two planes) of a radial head frac- The anterior joint compartment was ex- ture (Mason I) amined by using the anterolateral portal. If necessary, arthroscopic cartilage de- bridement, micro-fracturing, synovec- tomy, and/or capsulectomy was carried out aeft r creating an antero-ulnar portal. Medical files were analyzed according to the fracture sequelae, range of motion, stability, and patient complaints. Each of our patients was re-evaluated 6 weeks postoperatively. Patient data were col- lected retrospectively and postoperative evaluation was completed with the help of the available medical history. No tele- phone interview or personal examination was performed in this study. Fig. 2 8 Magnetic resonance imaging of Mason I radial head fracture and absence of soft tissue dam- age Results In 35 cases (50.0%), retrospective grad- ingaccordingto the Mason classification could not be made because radiological images at the time of the trauma were absent and there was incomplete or miss- ing data on the initial classification. In the remaining 35 patients, there were 20 type I, eight type II, five type III, and two type IV fractures. Approximately half of our patients (55.7%) were immediately immobilized with a plaster aer ft trauma. The duration Fig. 3 9 Computed tomography scans of the immobilization was 3.4 weeks of a radial head frac- (range, 1–8 weeks) on average. Five ture (Mason II) patients (7.1%) were treated with ortho- pedic devices aer ft trauma (e.g., hinged ulnar, trans-tricipital, proximal dorsora- portal. The entire dorsal elbow joint external fixator, etc.). dial, and distal dorsoradial. section was inspected with the camera In all, 98.6% of patients complained Aeft r joint insufflation through the via the high dorsoradial portal and, if of pain in the affected elbow; only one soft spot portal with 20 ml of normal necessary, treated using the trans-tricip- patient specified no pain. saline solution, an inflow cannula was ital portal. In addition, the camera was placed for the continuous supply of tilted laterally along the olecranon tip arthroscopy fluid via the anteroradial toward the deep dorsoradial portal. Obere Extremität 2 · 2018 113 Abstract · Zusammenfassung Obere Extremität 2018 · 13:112–120 https://doi.org/10.1007/s11678-018-0456-2 © The Author(s) 2018 R. Nietschke · K. J. Burkhart ·B.Hollinger · F.I.Dehlinger ·A.Zimmerer · M. M. Schneider Reasons for surgical revision after conservatively treated radial head fractures—retrospective study of 70 patients Abstract In 38 cases, radial head fractures were initially and additional treatment depending on other Background. An inadequate clinical outcome treated with immobilization for 3.4 weeks injuries. The range of motion improved on av- after conservatively treated radial head (range, 1–8 weeks). Physiotherapeutic erage from preoperative flexion/extension of fractures is not uncommon. We analyzed the treatment was performed in 39 cases. In only 131–15–0° to postoperative flexion/extension subjective limitations, objective complaints, half of the cases was retrospective Mason of 135–5–0° (gain in flexion: 4.2° and and surgical procedures for radial head classification possible: 20 type I, 8 type II, extension: 10.6°). fractures initially treated conservatively. 5 type III, and 2 type IV. Of the 70 patients, Conclusion. Conservative treatment of radial Patients and method. Between 2007 and 53 had posttraumatic elbow stiffness; 34 had head fractures does not always yield good 2016, 70 patients (42 men, 28 women) isolated lateral and four patients isolated results. Reasons for a poor outcome include who suffered from fracture sequelae after medial ligament instability. There were eight chronic instability, cartilage damage, stiffness, conservatively treated radial head fractures cases with a combination of lateral and medial or a combination thereof. Improved outcomes were examined. Demographic (age, 41.8 years, ligament instability and 27 cases of elbow can be achieved via arthroscopic arthrolysis. range, 16–75 years) and clinical data stiffness combined with instability. An average (pain, range of motion, instability) were of 1.2 (range, 1–4) surgical procedures per Keywords retrospectively evaluated. patient were performed. In all, 64 patients Radius fractures · Elbow · Joint instability · Results. The average time to surgery after underwent elbow arthroscopy with arthrolysis Osteoarthritis · Surgery trauma was 50 months (range, 5–360 months). Revisionsgründe nach konservativ behandelten Radiuskopffrakturen – Retrospektive Analyse von 70 Patienten Zusammenfassung In 38 Fällen wurden Radiuskopffrakturen Behandlungen je nach Begleitverletzungen Hintergrund. Patienten mit unzureichendem zunächst für 3,4 (Spanne: 1–8) Wochen mittels durchgeführt. Der Bewegungsumfang klinischem Ergebnis nach konservativ Immobilisation behandelt. Eine physiothe- verbesserte sich im Durchschnitt von behandelten Radiuskopffrakturen sind nicht rapeutische Behandlung wurde in 39 Fällen Flexion/Extension (präoperativ) 131–15–0° zu selten. Ziel der vorliegenden Studie war eine durchgeführt. In nur der Hälfte der Fälle war Flexion/Extension (postoperativ) 135–5–0° Analyse von subjektiven Einschränkungen, eine retrospektive Klassifizierung nach der (Zugewinn: Flexion: 4,2°; Extension: 10,6°). objektiven Beschwerden und chirurgischen Mason-Klassifikationmöglich: 20 Typ I, 8 Typ II, Schlussfolgerung. Die konservative Eingriffen nach anfänglich konservativ 5Typ III und2Typ IV. Bei53der 70 Patienten Behandlung von Radiuskopffrakturen zeigt behandelten Radiuskopffrakturen. lag eine posttraumatische Ellenbogensteife nicht immer gute Ergebnisse. Gründe Patienten und Methode. Zwischen 2007 vor, bei 34 eine isolierte laterale und bei hierfür können chronische Instabilitäten, und 2016 wurden 70 Patienten (42 Männer, 28 Frauen) untersucht, die an Frakturfolgen 4 Patienten eine isolierte mediale Seitenband- Knorpelschäden, Steife oder eine Kombination nach konservativ behandelten Radiuskopf- instabilität. Eine Kombination aus lateraler davon sein. Eine Verbesserung des Ergebnisses frakturen litten. Demographische (Alter im und medialer Seitenbandinstabilität bestand kann über eine arthroskopische Arthrolyse in 8 Fällen, Ellenbogensteife kombiniert mit erzielt werden. Mittel: 41,8 Jahre; Spanne: 16–75 Jahre) und einer Instabilität in 27 Fällen. Pro Person . klinische Daten (einschließlich Schmerzen, waren 1,2 (Spanne: 1–4) chirurgische Eingriffe Bewegungsumfang, Instabilität) wurden notwendig. Bei 64 Patienten wurden jeweils Schlüsselwörter retrospektiv ausgewertet. eine Arthroskopie (52-mal kombiniert mit Radiusfrakturen · Ellenbogen · Gelenk- Ergebnisse. Im Durchschnitt betrug die Zeit einer Arthrolyse) und weitere notwendige instabilität · Ellenbogensteife · Operation nach dem Trauma 50 (Spanne: 5–360) Monate. In all, 53 patients (75.7%) had symp- the range of motion was improved to Ligament instability and elbow tomatic elbow stiffness with a restricted flexion/extension of 135–5–0° as well stiffness range of motion (. Fig. 5a, b). Of as pronation/supination of 73–0–76°. In 35 patients (50%), clinical examina- these patients, 91% needed arthroscopic Extension was improved by 10.6° and tion revealed ulnar (n=3), radial (n=5), arthrolysis including capsulectomy. In flexion by 4.2°, which corresponds to or bilateral lateral (n= 30) ligament in- addition to the arthroscopic arthrolysis, a total gain in range of motion of 14.8°. stability of the elbow joint (. Fig. 4a). a total of two open arthrolysis procedures Usually, the arthrolysis treatment was A combination of elbow instability with had to be performed. The preoperative planned for cases of considerable elbow concomitant posttraumatic elbow stiff- range of motion was flexion/extension stiffness to improve range of motion and ness was found in 27 patients (38.6%). of 131–15–0° and pronation/supination to prepare for a second ulnar or radial of 67–0–71°. At the 6-week follow-up, ligament reconstruction, if necessary. 114 Obere Extremität 2 · 2018 Fig. 4 8 Gaping joint gap (arrow in a) during arthroscopy and advanced cartilage damage on the radial head and the capitu- lum humeri (arrows in b, c) Via arthroscopic stability testing with the exchange rod, 18 cases (25.7%) of PLRI II or more and 12 cases (17.1%) of ulnar instability were detected. There was bilateral lateral ligament instability in eight patients (11.4%). All the other patients had either no PLRI or had lateral instabilities of a grade less than PLRI II; 24 patients exhibited no instability at all (34.3%). In five cases (7.1%), radial ligament reconstruction had to be carried out in asecond surgery (eitherplanned ordue to recurrent instability). Fig. 5 8 Distinct soft-parted bridle strands (arrows) Four patients (5.7%) required either aradial(n=2) or ulnar (n=2) liga- ment reconstruction without previous III° II-III° arthroscopy (. Fig. 6). In one case, ulnar 4% 3% ligament reconstruction was performed in a second surgery. II° In total, 1.2 surgeries per patient 17% (range, 1–4) were necessary to improve clinical outcome in the 70 patients in our study (57 patients needed only one op- N/A eration, 12 patients had two operations, 41% and one patient had four operations). When comparing the findings of clin- ical and arthroscopic stability testing, we found that 35 patients (50%) had a medial Fig. 6 9 Distribu- I-II° or lateral ligament instability in the pre- tion of postero- 28% lateral rotatory operative clinical examination. In 94% of instability (PLRI)in these cases, the instability was confirmed the study series: intraoperatively (25 cases of PLRI, five I° 24% of the instabil- 7% cases of ulnar instability, and three cases ities were graded as PLRI II or greater. of combined instability). Finally, only N/A no PLRI 16 patients (45.7%) underwent ligament reconstruction: 4 In all, 12 cases of lateral ulnar collat- eral ligament reconstruction (see case report in . Fig. 7): Obere Extremität 2 · 2018 115 Original contribution Fig. 7 8 Case report: A 50-year-old patient with a radial head fracture (Mason I) after a fall had persistent symptoms after initial conservative treatment for more than 1 year.Radiography and computed tomography images show no step formation (arrows) at the radial head (a–e). Magnetic resonance imaging confirms the diagnosis of a Mason I fracture, but no soft tissue damagecanbedetected(f,g). Theintraoperativeresults1yearposttraumashowtheformerfracture(arrow)attheradialhead (rh) and a gaping humeroradial joint gap (arrow) as an indication of lateral instability (ch capitulum humeri,ct coronoid tip; h–k). Postoperative radiograph after treatment with lateral ulnar collateral ligament repair (l, m) j Two cases without arthroscopic 4 Four cases of ulnar reconstruction: besides arthroscopic arthrolysis was not treatment j Two cases without arthroscopic necessary (52 cases, 74.3%). j Five cases in combination with an treatment The patients with nonstabilized frac- arthroscopic procedure j Two cases in a planned second tures were nevertheless satisfied with the j Four cases in a planned second surgery postoperative outcome, so that not all surgery instabilities had clinical relevance in our j One case due to recurrent instabil- In most cases, however, additional treat- series. ity ment (e.g., neutralizing the instabilities) 116 Obere Extremität 2 · 2018 nine of 14 patients with Mason I frac- ulno-humeral radio-humeral tures using MRI [16]. Kaas et al. sup- ported these findings, detecting accom- panying injuries in Mason I–III fractures including lateral collateral ligament rup- tures (n = 28) and humeroradial cartilage damage (n=8) in 35 of 46 cases [22–24]. Whether concomitant injuries increase the necessity for surgical treatment re- mains controversial. Kaas et al. stated that most of the additional lesions in pa- tients with radial head fractures are either not symptomatic or not of clinical impor- tance. However, in their follow-up exam- ination at least 12 months aeft r trauma, flexion and extension deficits occurred in N/A I° I-II° II° II-III° III° III-IV° IV° 45 and 43% of their patients, respectively. In addition, 13 of 40 patients described Fig. 8 8 Cartilage damage according to joint section. A dramatic increase in cartilage damage occurs crepitus and one patient had locking due on the radial side of the elbow joint.N/A no cartilage damages to a loose body. The authors claimed that no patient needed delayed surgery since patients including recurrent elbow stiff- symptoms were mild and without ma- Cartilage defect ness and one recurrent lateral instability. jor restrictions [23]. In our case series, Depending on the intraoperative find- Therefore, arthroscopic and open revi- most of the patients were initially treated ings, accompanying pathologies such as sion arthrolysis as well as one revision of elsewhere and did not undergo MRI as cartilage damage or hypertrophic plicae a lateral ligament reconstruction had to they suffered from mainly Mason I and were addressed in the same surgery. be performed. Mason II fractures (28/35 cases). In only four cases (5.7%) were neither Conservative treatment for Mason I humero-ulnar nor humeroradial carti- fractures is regarded the gold standard Discussion lagedefectsfound. AccordingtotheOut- and yields good to excellent results with erbridge classification [39], the humero- Radial head fractures tend to be un- temporary immobilization for 5–7 days ulnar joint itself showed at least grade II derestimated by clinicians, in particu- followed by early functional treatment or higher cartilage damage in approxi- lar because of the lack of evidence of [17, 43, 45]. However, Burkhart et al. re- mately one out of six patients (15.7%). In displacement on plain radiographs and ported on 16 patients with poor outcome the humeroradial joint (radial head and the good results achieved with conserva- aer ft Mason I fractures due to fracture capitulum humeri), 90% of the patients tive treatment. However, these injuries sequelae such as instability, loose bodies, already had grade II or higher cartilage may oeft n be accompanied by a high de- and posttraumatic arthrosis. The trauma lesions. Furthermore, 62.5% of all pa- gree of ligamentous and soft tissue as mechanism in radial head fractures is tients already had at least grade II–III well as intra-articular cartilaginous dam- similar to that of elbow dislocations. An cartilage lesions at the radial head it- age, which cannot be displayed on radio- enhanced clinical and radiological evalu- self, and every third patient (35.7%) had graphs [4]. Therefore, a thorough assess- ation(typicallyMRI)is required fortype I an advanced grade IV cartilage defect ment of radial head fractures is necessary Mason radial head fractures in order to (. Figs. 4b, c and 8). in order to determine the true severity detect soft tissue and ligamentous dam- and extent of these lesions and to mini- age and to initiate adequate treatment mize the risk of delayed surgical therapy. [6]. MRI frequently reveals evidence of Reoperation The correlation between an osseous le- elbow dislocation in Mason type I frac- In total, 13 patients needed 15 reop- sion of the radial head and ligamentous tures with severe soft tissue injuries. It erations: two arthroscopic arthrolysis, injuries is well known. Itamura et al. de- remains unknown which of these soft tis- four open arthrolysis, five lateral liga- scribed medial collateral ligament rup- sue injuries might benefit from surgery. ment reconstructions (one time due to tures in 54%, lateral collateral ligament However, a study by Adolfsson et al. sup- recurrent instability), two ulnar ligament ruptures in 80%, and bilateral ruptures in ports the assumption that the severity of reconstructions, one hinged external fix- 50% of all cases classified as Mason II and soft tissue injuries correlates with com- ator, one mobilization under anesthe- III fractures, while Mason IV fractures plications. The authors reported on a co- sia. However, nine of these operations were excluded [19]. hort of patients who experience redislo- were plannedsecondinterventions. Six Hausmann et al. found a partial le- cation despite receiving proper conser- complications were encountered in five sion of the interosseous membrane in vative management for a simple elbow Obere Extremität 2 · 2018 117 Original contribution dislocation. During surgery they found Owing to the lower rate of degenera- The difficulty of treating radiocapitellar complete avulsions of the medial and/or tive changes, especially in young patients, arthritis especially in young patients is lateral collateral ligaments and muscle werecommendsurgeryforMasonIIfrac- a frequent topic of discussion in the lit- origins [1]. For this reason, the use of tures. However, the operative approach erature. Therefore, prevention of radio- MRI to visualize the extent of soft tissue (screws, plate osteosynthesis, pins etc.) capitellar arthritis seems logical. ORIF of injuries is reasonable. This conclusion has to be assessed individually. Mason II fractures is a simple procedure is supported by our study. In particular, By contrast, in Mason type III and IV with a very high rate of good results and subjective elbow instability, pre-arthrotic fractures, a surgical approach is the gold low complication rates. deformities, and restriction in elbow mo- standard. The method to be followed, On the basis of our patient popula- bility frequently occuraeft rMason Iand however, is still under discussion since tion, we cannot recommend primarysur- II fractures with a negative effect on the ORIF, as the preferred therapy, and im- gical treatment for Mason I or Mason II clinical outcome. Our approach always plantation of a radial head prosthesis or fractures since we did not compare out- includes MRI in selected cases of insuffi- radial head replacement represent suit- comes. Instead, appropriate and exten- cient clinical improvement during early able treatment options [3, 20, 25, 26, 37, sive diagnostics are necessary to detect follow-up even in non-dislocated Ma- 40, 43]. Allthesestrategiesexhibitadvan- concomitant injuries, which might influ- son I fractures. Conservative treatment tages and disadvantages and are mainly ence the decision on whether the patient is aimed for, but concomitant injuries dependent on the expertise of the sur- will benefit from surgery or not. Further- might call for surgery. geon. more, continuous clinical examinations In the literature, conservative treat- Our study involved only patients un- are highly recommended so as to change ment is still regarded the method of dergoing surgery for fracture sequelae conservative treatment when required. choice for Mason II fractures. In a long- such as instability, restricted range of mo- We tend to recommend operative ther- term follow-up study, Akesson et al. tion (stiffness), or painful weight-bear- apy for Mason II fractures in cases of reported good to excellent results in ing. Elbow stiffness described in the lit- concomitant lesions, since degenerative about 82% of cases aeft r conservative erature, which is significantly correlated lesions mostly prevailed in our patient management of Mason II fractures. The with the duration of immobilization, is group with Mason II fractures. rate of degenerative changes reached a serious complication aer ft radial head u Th s, measurements that possibly 82% for the injured and 21% for the un- fractures [8, 29, 30, 33–35, 41, 42]. This promote complications, such as lengthy injured elbow [2]. Surgical treatment led was also found in the present study. In immobilization or patients with suspi- to similar clinical results (82% good to most cases, a relevant restriction of elbow cious injuries who refuse MRI, should be excellent) 22 years aer ft open reduction movement was one of the main reasons avoided. Although not applicable to all and internal fixation (ORIF) in a study by for delayed surgery aeft r initial conser- patients and all clinics, we recommend Lindenhovius and colleagues. However, vative treatment of non- or only slightly acquiring radiographs in two planes arthrosis was only detected in one of displaced radial head fractures. Regard- and performing MRI independent of the 16 cases in their study [28]. To date, there ing the soft tissue damage, some patients Masson classification of the fracture. The is no prospective study comparing ORIF with Mason I radial head fractures likely necessity for surgical treatment has to be with conservative treatment in Mason II had an injury mechanism similar to an evaluated individually in every patient fractures. Yoon et al. compared non- elbow dislocation. Furthermore, the ra- with consideration of age, occupation, surgical treatment with ORIF in partial dialheadisanimportantstabilizeragainst sports, and handedness [4, 7, 16, 19, 22, articular radial head fractures, but the valgus stress in combination with the me- 23, 32]. study was compromised by several biases dial collateral ligament, which was con- Especially the treatment of intraoper- and the conclusion is therefore limited firmed by several biomechanical studies atively detected instabilities by means of [44]. The RAMBO trial was initiated in [12–14, 25, 36]. stabilization surgery (ligament repair or 2014 and aimed to address the question Soft tissue damage, especially in Ma- ligament reconstruction) should be as- of whether Mason II fractures should be son I fractures, can lead to the classifi- sessed individually. In our study, not ev- treated conservatively or surgically [5]. cation being adapted aeft r surgical inter- ery arthroscopically detected instability Unfortunately, no results from the trial vention, thereby resulting in a Mason IV needed surgical stabilization. Even with- have been published yet. A systematic fracture. out stabilization, adequate clinical results review by Zwingmann et al. favored In contrast to reports in the literature, could be achieved, similar to the findings ORIF with screws in Mason type II in which cartilage lesions are described as of Kaas and coworkers [22–24]. fractures over osteosynthesis with pins either asymptomatic or clinically not rel- The lack of a classification system that or K-wires and over conservative treat- evant, our patients suffered remarkably combines bony and ligamentous lesions ment because of better outcomes with from cartilage damage, which is mostly as well as the lack of prospective stud- the former approach. However, the se- detected as crepitus during clinical exam- ies comparing surgical with conservative lection of conservative studies included ination. In our series, all complications treatment does not allow for a general in the review, dated from 1981 to 1992, and all pathologies represented surgical therapy algorithm. It is important to pay represents a possible bias [46]. indications due to restricting symptoms. attention to so-called red flags like re- 118 Obere Extremität 2 · 2018 dislocation of the elbow joint. Relationship striction of movement, unchanging high Compliance with ethical to medial instability. J Bone Joint Surg Am pain level, or simply unambiguous elbow guidelines 82(4):555–560 instabilities in stress testing a few days 14. Fornalski S, Gupta R, Lee TQ (2003) Anatomy and biomechanics of the elbow joint. Tech Hand Up after trauma. Conflict of interest. R. Nietschke, K.J. Burkhart, ExtremSurg7(4):168–178 B.Hollinger,F.I.Dehlinger,A.Zimmerer,and 15. Guzzini M, Vadalà A, Agrò A, Di Sanzo V, Pironi M.M. Schneider declare that they have no competing D, Redler A, Serlorenzi P, Proietti L, Civitenga C, Practical conclusion interests. MazzaD,LanzettiRM,FerrettiA(2016)Nonsurgical treatment of Mason type II radial head fractures 4 Mason I fractures are associated This article does not contain any studies with human in athletes. A retrospective study. G Chir participants or animals performed by any of the au- with soft tissue injuries that might 37(5):200–205 thors. 16. Hausmann JT, Vekszler G, Breitenseher M et al benefit from surgical treatment in (2009) Mason type-I radial head fractures and select patients. Therefore, we tend Open Access This article is distributedunder the terms interosseous membrane lesions—a prospective of the Creative Commons Attribution 4.0 International to regard radial head fractures as study. JTrauma66:457–461 License (http://creativecommons.org/licenses/by/ 17. 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Obere ExtremitätSpringer Journals

Published: May 15, 2018

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