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TraumaFurther Opinion

Mason type IV fractures of the elbow

P Herbertsson, R Hasserius, PO Josefsson, J Besjakov, F Nyquist, A Nordqvist, MK Karlsson

J Bone Joint Surg [Br] 2009;91-B:1499-504.

 

The management of radial head fractures, particularly those associated with an elbow dislocation, is controversial. There has been a vogue for radial head replacement, which does not seem to have occurred because of a great dissatisfaction with other treatments, but in some part at least because of commercial pressure. We now have an array of radial head prostheses and low profile plates that enable us to reconstruct or replace the radial head and, by restoring the secondary restraint to valgus force, we can feel more comfortable that we have restored stability to the joint. This paper reminds us, however, that we do not perhaps need to look only for better studies on the long term outcome of each implant, but also to check that we are not overusing the implants that have already become available.

The most recent papers in this journal that describe radial head replacement or reconstruction for a similar cohort of patients report average losses of extension of only 14° and 7°, respectively1,2 with no recurrent instability. However the long term results in terms of degenerative disease are not known. For radial head replacement at least these represent the best results from any centre, yet many have reported poor results with high complication rates, some prostheses having been taken off the market. It is a salutary lesson that at 14 to 46 years of follow-up the results of closed reduction of the dislocation, with or without simple excision of the radial head, are that flexion returns to normal and only 10° of extension, on average, are lost, with no recurrent instability. Furthermore the rate of clinically significant elbow arthritis is vanishingly low though X-ray changes of degenerative change are common. In keeping with other studies on elbow trauma, however, there is seldom any loss of joint space.

The disheartening aspect of reading a paper like this is that it reinforces the realisation that randomised controlled trials to determine whether modern surgical interventions are better than traditional, more conservative, treatment are all but impossible. Indeed the epidemiological power of this study is only possible because individuals have a National Identity number that is used across all government departments. With knowledge of a patient’s identity number their current whereabouts can be traced easily and contact becomes possible. Since this state of affairs is unlikely to become the norm internationally, and even if it did decades would have to pass before long-term data became available, then we have to thank the Scandinavians for  information like this that is not available from anywhere else.

However this study also reminds us that best practice does not always mean using the most talked-about technique or implant. Each case still has to be taken on its merits and, for many fracture dislocations of the elbow, radial head reconstruction or replacement has a very valid part to play. However there will remain circumstances, probably more commonly encountered than many young surgeons believe, where closed reduction alone, or in combination with simple radial head excision, could give entirely satisfactory results without a significant risk of complications.

References

1. Dotzis A, Cochu G, Mabit C, Charissoux JL, Arnaud JP. Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis. J Bone Joint Surg [Br] 2006;88-B:760-4.
2. Ikeda M, Yamashina Y, Kamimoto M, Oka Y. Open reduction and internal fixation of comminuted fractures of the radial head using low-profile mini-plates. J Bone Joint Surg [Br] 2003;85-B:1040-4.

 

Limb D

Leeds, UK

E-mail: d.limb@leeds.ac.uk