Fractures of the radial head associated with dislocation of the elbow

Fractures of the radial head associated with dislocation of the elbow constitute a pathology for which it is difficult to choose treatment, and that has a high failure rate. A retrospective study of the literature and of a series of cases was conducted: 31 patients came to our observation between 1990 amd 2001 and were analyzed by clinical (Broberg and Morrey Score and SECEC Score) and radiographic testing. Based on the Broberg and Morrey Score the results were excellent in 4 patients (13%), good in 8 (26%), fair in 12 (39%), and poor in 7 (22%) with a success rate of 39% and a failure rate of 61% principally due to secondary stiffness and instability. In an attempt to reduce the number of failures, a treatment protocol aimed at restoring a stable, mobile and painless elbow was devised.     

Simultaneous bilateral elbow dislocation with associated bilateral radial head fracture

Bilateral elbow dislocation is a rare injury, with only a small number of case reports in the literature. The majority of these reports describe associated ligamentous injuries only. Simultaneous bilateral radial head fracture in association with bilateral elbow dislocation has only been described on one occasion previously. We present the case of a 54-year-old woman who dislocated both elbows and fractured both radial heads following a fall. In the operating theatre under general anaesthesia, both elbows were reduced by closed manipulation, it was then decided to treat the radial head fractures non-operativley. There was no neurovascular deficit either pre or post reduction. The patient was placed in above elbow casts for 1 week. Both casts were then removed and intensive physiotherapy was prescribed. The patient had an excellent clinical outcome and returned to work as a florist within 6 months of her injury. The purpose of this report was to describe a very rare injury pattern, and to emphasise the importance of early mobilisation following bilateral elbow dislocation.     

Posterior dislocation of the elbow with fractures of the radial head and coronoid

BACKGROUND: Posterior dislocation of the elbow with associated fractures of the radial head and the coronoid process of the ulna has been referred to as the "terrible triad of the elbow" because of the difficulties encountered in its management. However, there are few published reports on this injury. METHODS: Eleven patients with this pattern of injury were evaluated after a minimum of two years. The radial head fracture had been repaired in five patients, and the radial head had been resected in four. None of the coronoid fractures had been repaired, and the lateral collateral ligament had been repaired in only three patients. All eleven patients returned for clinical examination, functional evaluation, and radiographs. RESULTS: Seven elbows redislocated in a splint after manipulative reduction. Five, including all four treated with resection of the radial head, redislocated after operative treatment. At the time of final follow-up, three patients were considered to have a failure of the initial treatment. One of them had recurrent instability, which was treated with a total elbow arthroplasty after multiple unsuccessful operations; one had severe arthrosis and instability resembling neuropathic arthropathy; and one had an elbow flexion contracture and proximal radioulnar synostosis requiring reconstructive surgery. The remaining eight patients, who were evaluated at an average of seven years after injury, had an average of 92 degrees (range, 40 degrees to 130 degrees ) of ulnohumeral motion and 126 degrees (range, 40 degrees to 170 degrees ) of forearm rotation. The average Broberg and Morrey functional score was 76 points (range, 34 to 98 points), with two results rated as excellent, two rated as good, three rated as fair, and one rated as poor. Overall, the result of treatment was rated as unsatisfactory for seven of the eleven patients. All four patients with a satisfactory result had retained the radial head, and two had undergone repair of the lateral collateral ligament. Seven of the ten patients who had retained the native elbow had radiographic signs of advanced ulnohumeral arthrosis. CONCLUSIONS: Elbow fracture-dislocations that involve a fracture of the coronoid process in addition to a fracture of the radial head are very unstable and prone to numerous complications. Identification of the coronoid fracture is therefore important, and computed tomography should be used if there is uncertainty. With operative treatment, the surgeon should attempt to restore stability by providing radiocapitellar contact (preserving the radial head when possible and replacing it with a prosthesis otherwise), repairing the lateral collateral ligament, and perhaps performing internal fixation of the coronoid fracture.     

Surgical management of radial head fractures

OBJECTIVE: To compare the outcome of various surgical options exercised in the management of different types of radial head fractures. METHOD: A retrospective study of 29 patients with radial head fractures managed surgically was undertaken. Case notes were retrieved, and final assessment was performed through a telephone questionnaire. The results were analysed according to the classification of Wesley et al (1983), and compared with the patients' own rating. RESULTS: The best results were obtained in Mason type II fractures, followed by type III and type IV fractures. Comparing different operations, the best outcome was observed with screw fixation, followed by excision of the radial head, Kirschner wire fixation, partial excision, silastic implant, and plating, in that order. CONCLUSION: The less comminuted a radial head fracture is, the better the outcome. Screw fixation is to be preferred, if technically possible. Our method of outcome assessment closely reflected in patient satisfaction.     

Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis

OBJECTIVES: To assess elbow function, complications, and problems of radial head fractures associated with elbow dislocation receiving surgical treatment with a floating prosthesis. DESIGN: Prospective clinical study. SETTING: University Hospital, Orthopaedic Department, Sart Tilman, Liège, Belgium. PATIENTS: Eleven consecutive adult patients were treated with a floating prosthesis for acute radial head fractures associated with elbow dislocation from January 1994 to September 1996. INTERVENTION: The floating radial head prosthesis (Tornier SA, Saint-Ismier, France) was used in all our patients. The implant is in two parts: a radial head made of high-density polyethylene enclosed in a cobalt-chrome cup, which articulates in a semiconstrained manner with the spherical end of a cemented intramedullary stem. The implants were inserted within the first week following the injury (range 2 to 7 days). Three cases also required internal fixation of the coronoid process of the ulna; in one case plate fixation of an olecranon fracture was also performed. MAIN OUTCOME MEASUREMENTS: Patients were assessed by physical examination, a functional rating index (Morrey et al.), and radiographs. The parameters evaluated were motion, stability, pain, and grip strength. Potential complications such as infection, prosthetic failure, or dislocation were investigated. RESULTS: The minimum follow-up time was two years (mean 32 months, range 24 to 56 months). Four patients were considered to have excellent results, four patients were considered to have good results, two patients had fair results, and one patient had a poor result. There were no cases of infection, prosthetic failure, or dislocation. No patient required prosthetic revision. CONCLUSION: The basic principle of maintaining anatomic and physiologic relationships applies when deciding on treatment for radial head fractures with associated elbow dislocation. The loss of lateral osseous support will render the elbow grossly unstable. We believe that a floating prosthesis may be indicated in Mason Type III radial head fractures associated with elbow dislocation, especially in the presence of associated destabilizing fractures. Well-controlled comparative randomized studies will be needed to delineate the optimal treatment for a given situation.     

Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation

PURPOSE: The purpose of this study was to evaluate the treatment of patients with Mason type III radial head fracture with and without elbow dislocation by open reduction with internal fixation, collateral ligament repair, and early mobilization. An additional purpose was to investigate whether there is any effect of elbow dislocation on the severity and functional outcome. METHODS: Twenty-five patients were treated with open reduction with internal fixation using low-profile miniplate and screws for comminuted fracture of the radial head. Eighteen fractures were Mason type III, and 7 fractures were Mason type III with elbow dislocation. There were 5 women and 20 men with a mean age of 34 years. The mean follow-up time was 27 months. Patients were reviewed for functional ability, physical examination, and radiographic assessment. RESULTS: The mean functional index in Mason type III fracture and Mason type III fracture with elbow dislocation was 87 for both groups. The mean range of motion at the elbow joint was calculated as 5 degrees extension to 136 degrees flexion for Mason type III and 7 degrees extension to 133 degrees flexion for Mason type III with elbow dislocation. The mean pronation and supination for all patients were 74 degrees and 67 degrees , respectively. CONCLUSIONS: Selected Mason III radial head fractures and fracture dislocations could be stabilized satisfactorily with internal fixation. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow after fixation of Mason type III radial head fractures with and without elbow dislocation and ligamentous injury. We believe there is still a role for prosthetic replacement in comminuted Mason III radial head fractures that cannot reliably be treated with open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

Surgical management of Mason type III radial head fractures

The evidence for optimal management of Mason type III fracture of radial head is unclear hence a systematic review of the published literature was performed in April 2012. This review includes 5 prospective studies (including 2 randomized trials), 4 retrospective studies and 9 case series. No study can be interpreted as level 1 evidence. Level 2 and 3 evidence provides some insight into the success of each modality through subjective and objective measurements of function and complication rates. Radial head replacement, open reduction internal fixation (ORIF) and radial head resection all provide satisfactory outcomes for patients in most cases. One treatment modality cannot be recommended over any other due to the small number of clinical trials and cases included in each study. Further randomized control trials are needed to evaluate the full benefits and shortcomings of each of the different surgical treatment modalities.     

Complex elbow dislocation associated with radial and ulnar diaphyseal fractures: a rare combination

We illustrate a rare complex dislocation of the elbow involving a posterior ulno-humeral dislocation associated with open diaphyseal fracture of the ulna, radial shaft fracture, Type 1 coronoid fracture and neuropraxia of the deep branch of the radial nerve. The isolated ulno-humeral dislocation without radio-capitellar involvement, and ulnar diaphyseal fracture, makes this “reverse Monteggia” type of injury pattern very unique. This patient was managed with an initial reduction of his ulno-humeral joint and stabilization of his radius and ulna fractures. He underwent a delayed medial collateral ligament reconstruction a few days later. His fractures went on to unite fully, his elbow joint remained stable, and he achieved good range of motion of his elbow.     

Posterolateral elbow dislocation with sub flexor displacement of radial head fragment

Elbow joints are the second most common joints to dislocate, second only to shoulder joints with most of the dislocations occurring in the posterolateral direction. The dislocations can be simple involving capsuloligamentous structures around the joint or complex involving associated bony injuries. The dislocations can be disabling for the patients with the sequelae involving decreased range of movement, valgus instability due to ruptured medial collateral ligament complex, ectopic calcification, degenerative changes and neurologic deficits. The terrible triad is a type of complex elbow dislocation involving fracture of radial head along with coronoid process fracture. This injury is highly unstable and most of the time requires surgical intervention. We present 2 cases of terrible triad injuries that needed surgical intervention. The radial head fractures in both the cases could be classified as Mason type 2 injuries and the coronoid fractures could be classified as type 1 fracture according to Regan and Morrey classification. The aim of this report is to highlight the medial and distal migration of the fractured fragment of the radial head to the anterior aspect of ulna underneath flexor digitorum profundus, at the junction of proximal third and distal two thirds of the shaft of ulna. On radiographs, this could be mistaken for fractured fragment of coronoid process of ulna, which could mislead the surgeon pre and intra operatively causing delay and confusion in the surgery.     

桡骨头骨折的手术治疗

目的:探讨桡骨头骨折手术治疗的疗效。方法:1998-2004年治疗26例,男20例,女6例;平均年龄31岁(20~68岁)。按改良的Mason和Johnston分型:Ⅰ型4例,Ⅱ型6例,Ⅲ型16例,分别采用石膏固定,克氏针或螺丝钉固定,桡骨头置换,并修复相关内侧副韧带、冠状突等损伤。结果:本组平均随访28.6个月(3个月~6年)。按Morrey和Broberg标准评分平均85分(40~100分):优8例,良10例,中6例,差2例。结论:既要重视桡骨头的复位固定,又要重视合并周围韧带及冠状突的损伤,桡骨头骨折的治疗才可能取得较好的结果。     

Surgical management of neural injuries associated with elbow fractures in children.

Twenty-two patients with 25 neural injuries at the elbow joint were reviewed. Follow-up lasted 2 years after surgery. Mean age was 9.4 years. Findings at surgery revealed discontinuity of the affected nerve trunk in eight cases; 17 cases showed a constrictive lesion with the nerve trunk in continuity. Surgical technique involved repair by interfascicular grafting in six lesions, two by epineural suture, and 17 by neurolysis. The mean interval between injury and surgery was 10.1 months (range, 1-40). Motor and sensory function assessment was according to the Nerve Injuries Committee of the British Medical Research Council (preoperatively and at the final follow-up). Excellent results were found in nearly 80% of the continuous lesions treated by neurolysis. In discontinuous lesions, we found 66% with excellent results with grafting. The prognosis after neurolysis in continuous lesions is excellent. In discontinuous lesions after surgery, the rate of recovery is high. There is a poor prognosis for surgery performed > or = 1 year after the injury.     

Surgical treatment for chronic radial head dislocation

BACKGROUND: The treatment of chronic radial head dislocation remains controversial. High rates of redislocation and complications have been reported after surgery. In our view, correction of malalignment with ulnar osteotomy is the key to a good surgical result. METHODS: Since 1975, twenty-two patients were treated surgically for chronic radial head dislocation at our hospital. The procedure consisted of open reduction of a dislocated radial head followed by radial and/or ulnar osteotomy, with or without reconstruction of the annular ligament or by reconstruction of the annular ligament alone. The ages of the patients ranged from four to twenty years. In 1991, we modified the surgical technique by performing an oblique ulnar osteotomy with angulation and elongation and rigid plate fixation. Bone-grafting at the osteotomy site was also performed if necessary. A cast was applied with the forearm in neutral rotation and was worn for two to four weeks. Nine patients were treated with this modified technique. RESULTS: The mean interval between the initial injury and the reconstructive surgery was ten months. There were no serious surgical complications. Of the thirteen patients treated before 1991, four had a good reduction and seven had redislocation. Seven patients had restricted forearm rotation postoperatively. Of the nine patients treated with the modified osteotomy since 1991, seven had a good reduction. Two patients, who had had slight radial head deformity preoperatively, had subluxation postoperatively. Two patients had restricted forearm rotation. CONCLUSIONS: Since we modified our technique for ulnar osteotomy, good reduction of the radial head has been achieved without causing serious contracture. Both angulation and elongation of the ulna are required to allow the radial head to reduce.     

陈旧性桡骨头脱位的手术治疗进展

陈旧性桡骨头脱位的治疗,目前主要是手术切开复位,保守疗效欠佳。手术治疗一般采用尺骨延长、桡骨短缩、桡骨头复位术。环状韧带的修复或重建问题是当前研究的热点。功能障碍十分明显者,桡骨头切除可作为最后的选择。早期诊断是陈旧性桡骨头脱位治疗的关键,尺、桡骨截骨,不重建环状韧带的综合治疗是当今的主要趋势。     

Open reduction and internal fixation of radial head fractures associated with olecranon fracture or dislocation

Six fracture dislocations or dislocations of the olecranon associated with radial head fractures were treated with open reduction and internal fixation of the radial head. The olecranon was reduced and if fractured (three cases) was internally fixed. Postoperatively, early active range of motion was achieved in all cases. Twelve to 48 months after surgery, there was an average loss of 18 degrees of elbow extension and 56 degrees of forearm rotation. An average of 132 degrees of flexion was maintained. There was no elbow instability or wrist pain.