Mr Christopher Hill Mr Matija Krkovic The Management Of Comminuted Mason Type 3 Radial Head Fractures With Open Reduction And Internal Fixation: A Case Series Mr Christopher Hill Mr Matija Krkovic

Introduction Methods and Operative Technique Results Discussion Limitations References

Introduction Fractures of the radial head are common, estimated to be present in 17-44% of all elbow injuries (1-3) Traditionally management of these fractures is based on fracture type and the presence or absence of any other associated injury (3) Classification most commonly by the Mason System (4) which describes fractures from Type 1 to Type 3, dependent on their degree of comminution Undisplaced or minimally displaced radial head fractures can be managed by non-operative means with a high chance of a favourable outcome (5) Limited number of management options for comminuted radial head fractures: Conservative (non-operative) management Radial head excision Radial head arthroplasty Open reduction and internal fixation (ORIF) of the fractured radial head Fractures common - They usually occur following a fall onto an outstretched arm (4) Undisplaced - It is now relatively accepted that undisplaced or minimally displaced radial head fractures can be managed by non-operative means with a high chance of a favourable outcome (7). However, the management of the more comminuted Mason Type 2 and 3 fractures remains an area of controversy Limited No. - However, there is conflicting evidence supporting the surgical options,

Introduction (2) Stabilisers of the elbow: Primary: ulno-humeral articulation, the MCL and the LCL Secondary: the radial head, joint capsule and the common flexor and extensor origins (6,7) The radial head plays an important biomechanical role in the stability of the elbow Contributes to force transmission from the hand to the humerus across a variety of positions with as much as 60% of a load applied to the hand being transmitted up through the radio-capittellar articulation (8,9) Provides an important role in resisting posterior dislocation (7) Given the key role the radial head has biomechanically in maintaining the stability of the elbow, preservation by either open reduction and internal fixation or prosthetic replacement has been advocated by many authors (10-13) Anatomically studies have shown that the stabilisers of the elbow can be broadly divided into two groups: Primary, including the ulnohumeral articulation, the MCL and the LCL; and Secondary, including the radial head, joint capsule and the common flexor and extensor origins (13,14). Although only a secondary stabiliser the radial head itself plays an important role biomechanically in the stability of the elbow Contributing to force transmission from the hand to the humerus across a variety of positions, with as much as 60% of a load applied to the hand being transmitted up through the radiocapittellar articulation Also Provides an important role in resisting posterior dislocation acting alongside the coronoid process as an anterior buttress (14). Given the key role the radial head has biomechanically in maintaining the stability of the elbow, preservation by either open reduction and internal fixation or prosthetic replacement has been advocated by many authors

Aim The purpose of this study was: to assess the outcomes of patients with Mason 3 comminuted radial head fractures treated with ORIF evaluating the effectiveness of the chosen management technique To highlight operative technique for ORIF of these fractures

Methods Between 2008 and 2012, 12 consecutive patients presenting with a Mason Type 3 comminuted radial head fracture were treated with ORIF Single surgeon at UHCW, a major trauma centre in the United Kingdom Identified retrospectively from theatre logbooks and notes coding Study population consisted of: 12 subjects (9 male, 3 female) Mean average age of 45 years (range 28-72) All fractures were classified as Mason Type 3 as per the Mason radial head classification system (4) Patient outcomes assessed using the standardised Broberg and Morrey rating system(11) with patients assessed in follow-up clinics Between 2008 and 2012, 12 consecutive patients presenting with a Mason Type 3 comminuted radial head fracture were treated with ORIF using either Herbert screw or low profile radial head plating system (Depuy, radial head plate) by a single surgeon Patients with Mason Type 1 or 2 injuries were excluded as this paper focuses specifically on comminuted Mason Type 3 radial head fracture management. In order to assess patient outcomes using a standardised technique the Broberg and Morrey rating system was used for each patient (17). This is a 100-point system that assesses range of motion, strength, stability and pain at the affected elbow. The generated score then reflects the overall patient outcome, with 95-100 being excellent, 80-94 being good, 60-79 being fair and less than 60 representing a poor outcome. Patients were assessed in the appropriate criteria in follow-up clinics.

Operative Technique Under general anaesthesia, without a tourniquet The posterolateral approach between anconeus muscle and extensor carpi ulnaris muscle was explored The annular ligament was often completely disrupted but if not, a transverse incision through the ligament in the middle third was performed The posterolateral approach between anconeus muscle and extensor carpi ulnaris muscle was explored, although this Kocher´s interval was often difficult to identify. Any torn collateral ligaments were identified. The annular ligament was often completely disrupted but if not, a transverse incision through the ligament in the middle third was performed keeping in mind reconstruction of ligament at the end of the procedure.

Three main fracture fragments present: Largest fragment represented just over half or the radial head circumference A medium fragment sized approximately one quarter of the radial head A smaller fragment with additional small comminuted parts representing the remaining radial head We found in all cases in this series that there were three main fracture fragments present. The largest fragment represented just over half or the radial head circumference, a medium fragment sized approximately one quarter of the radial head and a smaller fragment with additional small comminuted parts representing the remaining radial head.

All fracture fragments were identified and left viable by not dissecting them from soft tissue attachments The proximal radial shaft was carefully dislocated for better exposure by use of a bone hook Osteosynthesis was performed with K-wires, later replaced by Herbert screws or a pre-contoured plate with screws and use of fibrin glue for smaller fragments where needed to restore full congruity All fracture fragments were identified and left viable by not dissecting them from any soft tissue they were connected to (usually joint capsule from the radius). The proximal radial shaft was carefully dislocated for better exposure by use of a bone hook. Osteosynthesis was performed with K-wires later replaced by Herbert screws or a pre-contoured plate with screws and use of fibrin glue for smaller fragments where needed to restore full congruity Careful attention was used not to use Hohmann type retractors in the region where the posterior interosseus nerve could be compressed.

The radial head was repositioned after osteosynthesis and the collateral ligaments reconstructed if needed The annular ligament was repaired and the lateral collateral ligamentous complex were repaired with re-absorbable sutures The radial head was repositioned after osteosynthesis was completed and the collateral ligaments reconstructed if needed. The annular ligament was repaired with a re-absorbable suture as well as the lateral collateral ligamentous complex, both with interrupted sutures. The rest of the wound was closed in layers.

Results The 12 patients were evaluated at a mean average of 32 months (range 12-47) post-operatively No loss to follow-up The mean average overall arc of movement was 106.8° (range 35° - 135°) Mean average of flexion was 120.8° (range 80° - 135°) Mean average of flexion contracture of 14.1° (range 0° - 45°) Mean average of supination was 63.8° (range 20° - 70°) Mean average of pronation was 54.6° (range 20°-60°)   The mean average Broberg and Morrey score was 89.2 (range 65 – 100) 6pts = excellent, 4pts = good, 2pts = fair, 0pts = poor As part of the Broberg and Morrey scoring patients were assessed for pain. 5 of the 12 stated they had continued pain, although all rated it as only mild 2 patients required later removal of metalwork due to migration If remove pt with range 35 Av improves to 115. No patients had a result rating poor. 2 of the patients (with fair rating) had an unsatisfactory result as per the Broberg and Morrey rating system. Regarding complications, 2 patients required later removal of metalwork due to migration; their overall Broberg and Morrey ratings were excellent and fair respectively. No infections

Discussion Traditional teaching dictates that for comminuted Mason Type 3 fractures of the radial head the appropriate course of management should be excision or replacement More recently with the advent of better implants for small fracture fixation, ORIF of these fractures has become increasingly possible (14,15) All joint replacements are known to be temporally limited thus we propose that if a fracture can be adequately reduced and unite, and produce a good functional result, then this is likely to be more beneficial for the patient in the long term This series demonstrates that ORIF of comminuted Mason Type 3 radial head fractures can be a successful treatment method, with good patient-based outcomes, and therefore should be considered A review article by Charalambos et al. (2011) (16) concluded: Management of these injuries remains controversial Fixation of comminuted radial head fractures was associated with a high rate hardware removal and a risk of nonunion Recommended that in young patients with comminuted radial head fractures every attempt of fixation should be undertaken, whilst appreciating that further surgery for hardware removal may be needed Traditional teaching dictates that for comminuted Mason Type 3 fractures of the radial head the appropriate course of management should be excision or replacement However, given the key role the radial head has biomechanically in maintaining the stability of the elbow, preservation of the radial head important aim and with the advent of better implants for small fracture fixation, open reduction and internal fixation of these fractures has become increasingly possible (4,20), All joint reps - Although there still remains some controversy as to whether arthroplasty or internal fixation is the better option.

Limitations Retrospective, experimental design Small sample size Lack of a control group or comparative arthroplasty group However: Presents potential avenues for further research Highlights operative technique and form of successful management often overlooked We appreciate that there are a number of limitations to this study: retrospective design Experimental rather than pragmatic , small sample size lack of a control group or comparative arthroplasty group are limitations to our study, although given the relative rarity of the injury a case series is appropt But it does present potential avenues for further research Series Highlights operative technique and form of successful management that is often overlooked

Any Questions? The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest

References 1 Morrey B F. The elbow and its disorders. 2nd ed.W.B. Saunders, Philadelphia 1993. 2 Pelto K, Hirvensalo E, Bostman O, et al. Treatment of radial head fractures with absorbable polyglycolide pins: a study on the security of the fixation in 38 cases. Journal of Orthopaedic Trauma 1994; 8(2): 94-8. 3 Ruan H-J, Fan C-Y, Liu J-J et al. A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. International Orthopaedics 2009 Feb; 33(1): 249-53. 4 Mason M.L. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954; 42: 123–132. 5 Mezera K, Hotchkiss R N. Radial head fractures. In: Rockwood and Green’s fractures in adults (5th ed.) Vol. 1 (Ed. Bucholz R W & Heckman J D). Lippincott Williams & Wilkins, Philadelphia, 2001; 940–952. 6 O’Driscoll S W, Jupiter J B, King G J, et al. The unstable elbow. Instr Course Lect 2001; 50: 89-102. 7 Mathew P K, Athwal G S & King G J W. Terrible Triad Injury of the Elbow: Current Concepts. J Am Acad Orthop Surg 2009; 17: 137-151. 8 Halls A A & Travill A. Transmission of pressures across the elbow joint. Anat. Rec 1964; 150: 243-247. 9 Morrey B F, An K N & Stormont T J. Force transmission through the radial head. J. Bone and Joint Surg 1988; 70-A: 250-256. 10 Nalbantoglu U, Kocaoglu B, Gereli A, et al. Open Reduction and Internal Fixation of Mason Type III Radial Head Fractures With and Without an Associated Elbow Dislocation. The Journal of Hand Surgery. 2007; 32(10): 1560–1568. 11 Broberg M A & Morrey B F. Results of delayed excision of the radial head after fracture. J Bone Joint Surg (Am) 1986; 68A: 669-674. 12 Ring D, Quintero J & Jupiter, J. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg 2002; 84A: 1811–1815. 13 Ikeda M, Yamashina M, Kamimoto M, et al. Open reduction and internal fixation of comminuated fractures of the radial head using low profile mini plates. J Bone Joint Surg 2003; 85B: 1040–1044. 14 Ring D & Jupiter J B. Current Concepts Review - Fracture-Dislocation of the Elbow. J Bone Joint Surg (Am) 1998; 80: 566-80. 15 Heim U & Pfeiffer K M. Internal Fixation of Small Fractures. Technique Recommended by the AO-ASIF Group. Ed. 3. New York, Springer 1988. 16 Charalambous C P, Stanley J K, Mills S P, et al. Comminuted radial head fractures: aspects of current management. Journal of Shoulder and Elbow Surgery 2011; 20(6): 996-1007.