The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Posteriorly Displaced Radial Head Fractures May Represent the Footprint of an Elbow Dislocation or Subluxation as a Variant of Modified Mason Type 4

Document Type : RESEARCH PAPER

Authors
Monica M. Shoji 1
Magdalena Hartwich Garcen 2
Alberto A. Fernandez Dell’Oca 2
Jesse B. Jupiter 3
1 Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
2 Orthopedics and Traumatology Department, British Hospital, Montevideo, Uruguay
3 Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
10.22038/abjs.2021.55486.2764
Abstract
Background: The purpose of this case series is to describe surgical decision making and clinical outcomes in posteriorly 
displaced radial head fractures with a major fragment (more than 50% of the head) located behind the humeral condyle. 
We also document the outcome of open reduction and internal fixation of completely displaced radial head fractures.
Methods: A retrospective review of the ICUC® (Integrated Comprehensive Unchanged Complete) database was 
performed between 2012 and 2020. Patients were included if preoperative radiographs demonstrated a major radial 
head fracture fragment located posterior to the humeral condyle and a minimum of 2-year follow-up data was available. 
Results: Ten patients met inclusion criteria. Two patients had an associated elbow dislocation whereas 8 patients did 
not. All patients were found to have disruption of the lateral collateral ligament complex intraoperatively. Nine radial 
head fractures were successfully fixed with interfragmentary screws. One multi-fragmented radial head fracture could 
not be successfully stabilized with interfragmentary screw fixation and was resected. The average time to final followup was 4.8 years (range 2.2-8.1). At final follow-up, 6 patients demonstrated radiographic evidence of a healed radial 
head, 1 patient had avascular necrosis, and 2 had post-traumatic arthritis. None demonstrated radiographic instability. 
The average functional score was 0.64 (SD 0.81) and pain score was 0.45 (SD 0.93). The average elbow extension 
was 8 degrees (SD 11), elbow flexion was 139 degrees (SD 6), forearm supination was 60 degrees (SD 27), and 
forearm pronation was 69 degrees (SD 3).
Conclusion: Recognition of a posteriorly displaced radial head fracture is essential, as it may be an indirect sign of 
elbow instability. This instability should be addressed during surgical intervention. 
Level of evidence: IV
Keywords
Elbow
Elbow dislocation
Trauma
Radial head fracture
  1. Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJW. The effect of radial head fracture size on elbow kinematics and stability. J Orthop Res off Publ Orthop Res Soc. 2005; 23(1):210–7.
  2. Capo JT, Shamian B, Francisco R, Tan V, Preston JS, Uko L, et al. Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis. J Orthop Traumatol. 2015; 16(2):125–31.
  3. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical contact is associated with concomitant fracture or dislocation. J Shoulder Elbow Surg. 2010; 19(1):21–5.
  4. Regazzoni P, Giannoudis PV, Lambert S, Fernandez A, Perren SM. The ICUC® app: Can it pave the way for quality control and transparency in medicine? Injury. 2017;48(6):1101–3.
  5. Regazzoni P, Südkamp N, Fernandez A, Perren SM. A new way to learn and analyze surgical interventions. Orthopedics and Trauma Surgery messages and news. 2016.
  6. Blonna D, Zarkadas PC, Fitzsimmons JS, O’Driscoll SW. Validation of a photography-based goniometry method for measuring joint range of motion. J Shoulder Elbow Surg. 2012;21(1):29–35.
  7. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872–7.
  8. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440–6.
  9. Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch T, Shean C. Radial head fractures: MRI evaluation of associated injuries. J Shoulder Elbow Surg. 2005;14(4):421–4.
  10. Kaas L, van Riet RP, Turkenburg JL, Vroemen JPAM, van Dijk CN, Eygendaal D. Magnetic resonance imaging in radial head fractures: most associated injuries are not clinically relevant. J Shoulder Elbow Surg. 2011;20(8):1282–8.
  11. Tarallo L, Porcellini G, Merolla G, Pellegrini A, Giorgini A, Catani F. Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear. J Shoulder Elbow Surg. 2020;29(1):132–8.
  12. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJW. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg Am. 2006;88(10):2192–200.
  13. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001;83(8):1201–11.
  14. Clembosky G, Boretto JG. Open Reduction and Internal Fixation Versus Prosthetic Replacement for Complex Fractures of the Radial Head. J Hand Surg. 2009;34(6):1120–3.
  15. Koslowsky TC, Mader K, Gausepohl T, Pennig D. Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years. Acta Orthop. 2007;78(1):151–6.
  16. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84(10):1811–5.
  17. Duckworth AD, Wickramasinghe NR, Clement ND, Court-Brown CM, McQueen MM. Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal? Clin Orthop. 2014;472(7):2136–43.
  18. Vannabouathong C, Akhter S, Athwal GS, Moro J, Bhandari M. Interventions for displaced radial head fractures: network meta-analysis of randomized trials. J Shoulder Elbow Surg. 2019;28(3):578–86.
  19. Chen X, Wang S, Cao L, Yang G, Li M, Su J. Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop. 2011;35(7):1071–6.
  20. Kachooei AR, Baradaran A, Ebrahimzadeh MH, Dijk CN van, Chen N. The Rate of Radial Head Prosthesis Removal or Revision: A Systematic Review and Meta-Analysis. J Hand Surg. 2018;43(1):39-53.e1.
  21. Al-Burdeni S, Abuodeh Y, Ibrahim T, Ahmed G. Open reduction and internal fixation versus radial head arthroplasty in the treatment of adult closed comminuted radial head fractures (modified Mason type III and IV). Int Orthop. 2015;39(8):1659–64.
  22. Sun H, Duan J, Li F. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Eur J Orthop Surg Traumatol Orthop Traumatol. 2016;26(3):283–91.
The Archives of Bone and Joint Surgery
Volume 10, Issue 6
June 2022
Pages 501-506

  • Receive Date 07 February 2021
  • Revise Date 18 September 2021
  • Accept Date 06 October 2021