Introduction. The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?. Material and methods. In an amount of 35 consecutive patients who were taken in charge for an elbow dislocation 26 were included in this retrospective study, 13 of them had the association of a dislocation and a fracture of the radial head. In all 13 cases the radial head was considered as inadequate with a conservative treatment and was resected. The patients were assessed clinically according to the American Shoulder and Elbow Surgeons score (ASES) and the Mayo elbow performance index with a mean follow-up of 13 years (ranging from 5 to 15). The degenerative changes were assessed on plan × rays and an additional axial view according to the 4 stages described by Morrey. Results. No redislocation occurred. According to the Broberg/Morrey index 92% of the patients were considered as having a good result. They returned to work with no hindering. Signs of osteoarthritis grade 1 or 2 were observed and were clinically well tolerated. There was no difference for this item between the patients who conserved their radial head and those who sustained a resection. All patients were satisfied although they were protecting their joint against overuse while working. Discussion. The studies about the use of prosthesis of the radial head offer similar functional results. Degenerative changes on the trochleo ulnar joint are identical in all type of treatment. In order to prevent stiffness in the elbow joint an early post operative rehabilitation is recommended, it justifies a surgical stabilization associated with the use of an adapted dynamic splint. Conclusion. In case of elbow dislocation with a fracture of the radial head when its preservation is impossible, the resection without any prosthetic replacement remains a reasonable option if associated with a repair of the medial collateral ligament. At long term the functional results are still good with mild signs of osteoarthritis eliminating ipso facto the problem of an implant survivorship

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence. Cite this article: Bone Joint J 2013;95-B:151–9

Background. Chronic acquired radial head dislocations pose a complex problem in terms of surgical decision making, especially if surgery has already previously failed. There are several underlying causes that should be investigated, including previous trauma resulting in a missed Monteggia fracture. Aim. To review the clinical and radiological outcomes for children up to 18 years of age, with a radial head dislocation treated with circular frame surgery. Method. A retrospective study was designed to identify patients from our departmental database who had undergone circular frame surgery to reduce the radial head during the past 6 years. Results. 20 patients were identified with a mean age of 11 years (3 – 17). Fourteen patients had a diagnosis of missed Monteggia fracture, three patients had Hereditary Multiple Exostoses, one had Nail Patella syndrome, one had Osteogenesis Imperfecta and one had rickets. The average delay between trauma and frame surgery was three years (0 – 7). All patients achieved union of their ulnar or radial osteotomy. The average frame duration was 167 days (61 – 325) and complications included delayed union and residual radial head subluxation. Thirteen patients achieved at least 40 degrees of supination, and 10 patients achieved at least 40 degrees of pronation. Eighteen patients achieved an arc of movement from full extension to at least 110 degrees of flexion. Eleven patients reported their pain level at final follow-up, of which 9 had no pain at all. Conclusion and Discussion. Circular frame surgery was a reliable and consistent method of reducing chronic radial head dislocations and improving function. Radiological appearances of mild residual subluxation of the radial head were clinically well tolerated and generally required no further treatment

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18). The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison. The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction. Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment

The aim of this study was to report the outcome of radial head replacement for complex fractures of the radial head, and determine any risk factors for prosthesis removal or revision. We identified 119 patients who were managed acutely using primary radial head replacement for an unstable fracture of the radial head over a 15-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded following retrospective clinical record review. There were 105 (88%) patients with a mean age of 50 yrs (16–93) and 54% (n=57) were female. There were 95 (91%) radial head fractures and 96% were a Mason type 3 or 4 injury. There were 98 associated injuries in 70 patients (67%), with an associated coronoid fracture (n=29, 28%) most frequent. All implants were uncemented monopolar prostheses, with 86% metallic and 14% silastic. At a mean short-term follow-up of 1 year (range, 0.1–5.5; n=87) the mean Broberg and Morrey score was 80 (range, 40–99), with 49.5% achieving an excellent or good outcome. At a final mean review of 6.7 yrs (1.8–17.8), 29 (27%) patients had undergone revision (n=3) or removal (n=26) of the prosthesis. Independent risk factors of prosthesis removal or revision were silastic implant type (p=0.010) and younger age (p=0.015). This is the largest series in the literature documenting the outcome following radial head replacement for complex fractures of the radial head. We have demonstrated a high rate of removal or revision for all implants, with younger patients and silastic implants independent risk factors

Introduction. This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation. Patients and Methods. From a prospective database we identified and analysed all patients who had sustained a fracture of the radial head or neck over a one year period. The degree of social deprivation was assessed using the Carstairs and Morris index. The relationship between demographic data, fracture characteristics and deprivation categories was determined using statistical analysis. Results. Two hundred and ninety radial head (n=203) and neck (n=87) fractures were diagnosed with a mean age of 44.3years (13–94). There was no significant difference with regards age or gender predominance when comparing radial head and neck fractures directly. The mean age of males was significantly younger when compared to females for radial head (p<0.001) and neck (p<0.001) fractures, but with no gender predominance seen. Associated injuries (n=25) were related to increasing age (p=0.006), radial head fractures (p=0.003) and increasing fracture complexity according to the Mason classification (p<0.001). Social deprivation was related to the mean age at the time of fracture and the mechanism of injury (p<0.05 for both). Conclusions. Proximal radial fractures are frequently fragility fractures affecting older females and assessment for osteoporosis is recommended. Complex radial head fractures require thorough investigation for the presence of associated injuries

Introduction. Chronic radial head dislocation in children after trauma is a serious condition. Often the dislocation is overseen initially and is a part of the Monteggia fracture complex with anterior bowing of the ulna. Typical complaints are pain, decreased ROM and cubitus valgus. Radial head dysplasia often occurs. The treatment of this condition is debated. Only few series of patients treated with open reduction and ulnar osteotomy exists with long-term follow up. We present a group of rare patients with long-time follow-up treated by only two surgeons through a period of 16 years. Materials and Methods. All 16 patients had anterior radial head dislocation (Bado type 1). Mean age at the time of traumatic dislocation was 6 years ranging from 2 to 9. We found a mean delay of 17 (range 1–83) months before open reduction and ulnar open wedge osteotomy. In 8 cases reconstruction of the annular ligament was performed and in 6 patients temporary transarticular fixation of the radial head with a k-wire was performed. Follow-up time was 8 (range 3–17) years postoperatively. Patients were investigated with bilateral x-ray, arthrosis status, congruency of the radiocapitellar joint, Oxford Elbow Score, force measurements and range of motion. Results. There were no major complications to surgery such as infection, nerve palsies or pseudarthrosis. Radiological results showed 9/16 with reduction of the radial head and with no arthrosis, 4/16 with arthrosis or subluxation, and 2/16 with a dislocated radial head. We found a significant correlation between radiological outcome and delay to ulnar osteotomy (p = 0.03). At follow up the mean Function score was 92 (SD 9), Social/psychological score 83 (SD 14) and Pain score was 88 (SD 15). None of the patients with fully reduced radial head had progressed in increased valgus deformity. In contrast, one of two patients with postoperative secondary dislocation of the radial head had an increase in carrying angle on 25 degrees. Typical clinical findings were a small but significant extension deficit and median loss of supination on 10 grades ranging from 0–90 (p = 0.008). Five patients had subsequent surgery, of which one had an excision of the radial head 8 years after primary surgery. Ligament reconstruction or transfixation of the radial head did not influence the radiological or clinical outcome. Discussion and Conclusion. Case reports of similar patients treated conservatively demonstrate high morbidity and therefore open reduction and ulnar osteotomy is justified given the good clinical longterm outcome in the present study. However, this study underlines the importance of minimising the delay between trauma and open reduction. If surgery is performed before 40 months after trauma good to fair longterm radiological results can be obtained. After 40 months there is a high risk of recurrent luxation of the radial head

There is a high rate of forearm deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients acquire a dislocated radial head due to disproportionate ulnar shortening. One-hundred and six patients with HME aged 15 years or older were identified from a prospective database. Flexion and extension of the elbow and wrist, and supination and pronation of the forearm was measured. The number of exostoses affecting the proximal and distal radius and ulna were recorded. Proportional ulna length was calculated as a percentage of the patients measured height ([ulna length/height] × 100). More than 70% of patients were affected by exostoses of the forearm, of which the distal radius was the commonest site to be affected (73%). One in seven patients had a dislocated radial head, which was associated with proportional ulna shortening (p<0.001). Both radial head dislocation (p<0.001) and proportional ulna shortening (p<0.001) were confirmed to be independent predictors of forearm motion on multivariable regression analysis. In conjunction with other predictors these could be used to calculate ROM of the forearm. In addition proportional ulna length was also an independent predictor of radial head dislocation (p<0.001). Proportional ulna length could be used as a tool to identify patients at risk of diminished forearm motion and radial head dislocation during childhood, who could be monitored clinically and radiographically, and surgical intervention could be offered before deterioration in function and dislocation of the radial head occurs

There is an increasing trend towards radial head replacement (RHR) or fixation for complex radial head fractures. These injuries are identified by grossly displaced fragments or elbow instability. The aim of this study was to examine the outcome of a surgical protocol that emphasised delayed radial-head excision (RHE) as the procedure of choice. When the humero-ulnar joint was congruent, intervention was delayed 10 to 14 days to allow time for ligamentous healing. RHR was performed if instability was demonstrated on-table. A retrospective study was performed to identify the outcome of patients undergoing surgery for a radial head fracture between 2008 and 2014. There were 18 Mason Type III and 18 Mason Type IV injuries. There was an associated coronoid fracture in 17 patients. RHE was performed in 28 patients, of which the reoperation rate was 2 (7.1%). RHR was performed in 15 patients, of whom 4 (27%) had reintervention. RHR was most common in the Type III coronoid fractures. The cumulative reoperation rate was 9.3% at six months and 15.4% at two years. The median Oxford Elbow Score (OES) was 85.4 (IQR 73.4 to 99.5). Time from injury was the only predictor of the Oxford Elbow Score (p=0.04). This surgical protocol resulted in a reduced need for RHR, a low reintervention rate, and satisfactory function. RHR should be reserved for cases where stability cannot be achieved on-table. Stability can be maximised by delaying RHE until early ligamentous healing occurs

Purpose. Evaluation of our experience on the treatment of comminuted, radial head fractures, and of the outcomes of pyrocarbon prosthetic replacement in such cases. Materials and Methods. We evaluated 47 cases of prosthetic replacement, performed from May 2003 to July 2008. There were 18 males and 29 females with an average follow-up of 48 months (12 to 60). The Hotchkiss classification was used to characterize the fractures. The indicators for the procedure were type III fractures in 27 cases, type IV fractures in 10 cases, comminuted radial head fractures (associated with disruption in medial collateral ligament) in 3 cases, Monteggia variant in 5 cases, and Essex Lopresti in 2 cases. Functional outcomes were assessed using the Mayo Elbow Performance Index and the Visual Analog Scales (VAS) of pain, joint motion, and stability. Results. The mean VAS score for elbow pain was 1 (0.5–2.1). Patients showed an average arch of motion from 6 degrees to 140, with 75 degrees of pronation, and 67 of supination. By the Mayo Elbow Performance Index, 42 patients had good to excellent results, 3 fair, and 2 poor. The complications that we have encountered were: implant dislocations (2 cases), elbow stiffness (1), implant dissociation (1), stem rupture (1), and transient PIN palsy (2 cases with complete recovery of nervous function at 5 and 8 weeks). There was no persistent instability, infection, synosthosis, severe degenerative changes, or impingement. Conclusion. The pyrocarbon implants are a good treatment option in complicated, radial head fractures, but the outcome depends on the severity of the initial fracture and the associated lesions. We have also encountered a tendency towards overestimating the prosthesis size, causing restriction of motion, impingement, overstuffing, or dislocation. For these results we are now using the non-modular prosthesis in our center, but further studies are required

Between 1996 and 2000, we treated ten patients with severely comminuted fractures of the radial head using low-profile mini-plates. Their mean age was 42 years (24 to 71). Three fractures were Mason type III and seven were Mason-Johnston type IV. At a mean follow-up of 28.5 months (15 to 44), all fractures had united. The plates were removed in nine patients. No patient had difficulty with daily activities or symptoms of instability of the elbow. The mean range of flexion of the elbow was from 7° to 135°, with 74° of supination and 85° of pronation. According to the Broberg and Morrey functional elbow index, the mean score was 90.7 points (73 to 100), and the outcome was excellent in three patients, good in six and fair in one. These results compare favourably with those reported previously. The technique is applicable to severely comminuted fractures of the radial head which otherwise would require excision

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome. . The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results. . From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment. Cite this article: Bone Joint J 2014;96-B:1385–91

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR. From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD). The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05). This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures

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° (. sd. 4) and extension by a mean of 9° (. 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

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100 000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age

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

We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow. We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months. All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head

Aims

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.