Total Excision Of Comminuted Radial Head Fractures And Subsequent Elbow Posterolateral Rotatory Instability

Volkan Gurkan*, Haldun Orhun*, Muhsin Dursun*, Guray Altun*,  Murat Bulbul **, Mehmet Aydogan***

*Dr. Lütfi Kırdar Kartal Education and Research Hospital, Orthopaedics and Traumatology Clinic, Istanbul, Turkey.
**Vakif Gureba Education and Research Hospital, Orthopaedics and Traumatology Clinic, Istanbul, Turkey.
*** Istanbul Bilim University Medical School, Florence Nightingale Hospital, Istanbul, Turkey.
Address for Correspondence:
Volkan Gurkan
Bayar cd Sakaci sok Baytur Konutlari G Blok D:19 Kozyatagi Istanbul Turkey
Phone: +905052150181
Fax    : +902164429060
E-mail: volgur@hotmail.com

Abstract:

Background: We evaluated outcomes of radial head excisions and the subsequent elbow posterolateral rotator instability concept.

Methods: Among 27 patients who had undergone radial head excisions due to Mason type 3 radial head fractures between 1996 and 2006, 23 patients who had no ipsilateral upper extremity pathology and attended routine follow-up visits were included in the study. The mean duration of follow-up was 65.5 months (range: 23–115). At last visits, patients were assessed clinically and radiologically. The Steinberg criteria were used for clinical outcomes. Patients were also evaluated with respect to elbow posterolateral rotator instability.

Results: Clinically, 12 patients had good, 7 had fair, and 4 had poor clinical results, according to the Steinberg criteria. Eight patients had elbow posterolateral rotator instability, while 16 patients had radiologically confirmed elbow joint degeneration. Ulna plus variation was observed in 12 cases.

Conclusion: Although used frequently, total radial head excision in comminuted radial head fractures has not been found to give satisfactory results. Furthermore, patients should be subjected to intraoperative assessment for lateral ulnar collateral ligament ruptures that may lead to elbow posterolateral rotator instability.

J.Orthopaedics 2009;6(3)e6

Keywords:

radial head; fracture; total excision; posterolateral rotatory instability; lateral ulnar collateral ligament

Introduction:

Radial head fractures are commonly seen injuries in the community, representing approximately 30% of all fractures around the elbow joint⁹. In these fractures, the Mason classification is the primary categorization system used in which total radial head excision is considered to be the accepted method in type-3 comminuted fractures. Despite its relatively easy application, total excision may cause posterolateral rotator instability (PLRI) of the elbow; clinically and radiologically, it may result in positive ulnar variation, leading to clinical problems at the wrist joint, or degenerative changes in the elbow^3,6-10,14,15. The anatomical structure responsible for PLRI is the lateral ulnar collateral ligament (LUCL). In addition to the likelihood that it may be injured in the trauma itself, this ligament may also be damaged iatrogenically during surgery. For this reason, such cases should be subjected to a complete evaluation during radial head excision with respect to LUCL rupture, and the head of the radius should be preserved to avoid additional complications.  In this study, 23 patients who had undergone total radial head excision were assessed clinically and radiologically.

Materials and Methods:

Twenty-seven patients with Mason type-3 radial head fractures underwent applied radial head excisions in our clinic between 1996 and 2006. Among the 27 recruited patients undergoing radial head excision procedure, two were excluded for failing to attend follow-up visits and two further patients were excluded because of additional distal radial fractures that could interfere with the results. The remaining 23 patients (14 men and 9 women) were followed for 65.5 months on average (range: 23–115). The mean age at the time of injury was 39.1 years (range: 16–57; Table).

Reasons for the fractures included falling from a height of less than 2 m in four patients and above 2 m in two patients; high-impact trauma, such as traffic accidents, in nine patients; and minor trauma, such as falling while walking, in eight patients. Twelve patients had left extremity and 11 patients had right extremity involvement. One of the traffic accident cases had an additional knee medial collateral ligament injury, while another one had a tibia diaphysis fracture. No patient with minor trauma had any additional pathology. Additionally, none of the 23 patients had dislocation of either elbow.

All patients included in the study had comminuted fractures; 21 patients underwent radial head excisions and the remaining two cases were treated conservatively. However, these two patients subsequently underwent secondary excisions within the first 6 weeks due to severe persistent pain and daily function loss. Neither patient was assessed with respect to ligamentous injury intraoperatively, nor did they require soft tissue or annular ligament repair. A neck sling was used postoperatively. Physical therapy was initiated as soon as pain became tolerable. No early postoperative complication was observed.

Patients were followed-up according to clinical condition and roentgenograms. Evaluations were based on the unaffected elbow. Elbow flexion and extension angles were measured clinically. Any restriction in supination and pronation of the forearm, movement restriction at the wrist joint, differences in elbow diameters, and pain status and its influence on daily activities were assessed. Varus and valgus laxities were evaluated. Additionally, every patient underwent the lateral pivot shift test⁵, chair test⁷, push-up test⁷, and tabletop test¹⁷, each specific for PLRI. The results were based on the Steinberg criteria, adapted to children. Accordingly, cases with a complete range of motion and no pain were accepted to have good results, those with restricted movement in any direction by less than 20° were deemed to have fair results, and those with movement restricted by more than 20° and pain even during rest were recorded as having poor results¹³.

Radiologically, AP and lateral X-ray views were taken, covering both the unaffected side and wrist joints. Via these plain X-rays, degenerative signs, such as sclerosis, joint narrowing, subchondral cyst, osteophyte, heterotopic ossification in the elbow joint, and positive ulnar variation at the wrist joint, were assessed.

Results :

Clinical evaluation

Of the 23 patients, 12 had no pain while carrying out daily activities, while another 7 described slight pain, generally provoked by lifting objects. Four patients had pain even at rest, two of whom were housewives who reported loss of function during their household chores. Of the remaining two subjects, one was a bakery worker who had to change his job, and the other was a retired person with a largely sedentary lifestyle. These four patients were offered radial head arthroplasty procedures, but none of them chose to undergo this intervention. One of the patients had fallen from a height above 2 m and underwent a subsequent primary excision. Two of them had been involved in traffic accidents and the last case was a minor trauma patient who had undergone secondary excision.

When assessing elbow and wrist joint ranges of motion, only seven patients had no difference in terms of elbow extension restriction compared to the unaffected side. One patient was observed to have extension restriction by 40°, another by 30°, two patients by 20°, and 12 by 10°. Moreover, patients with 40° or 30° extension loss also had further flexion losses by 20°. Other patients had no marked flexion loss (Fig. 1). In terms of rotation movements of the forearm, 12 patients had supination restricted by 10°. Five patients had 10° extensions and two patients had 10° flexion impairment at wrist joint examination. Fifteen of the group showed valgus laxity at the elbow joint. When performing the examination for valgus laxity, all 15 of these patients had complaints.

Figure 1: Lateral view of a comminuted radial head fracture.

At final visits, 11 patients had no circumferential difference between the two elbows. Ten patients had a 1-cm-wider elbow compared to the unaffected side, and the remaining two patients had a 2‑cm-wider elbow compared to the unaffected side, both of whom underwent secondary excisions.

To establish the PLRI diagnosis clinically, patients underwent the chair test, push-up test, tabletop test, and lateral pivot shift test (see Discussion). Of the 23 patients, eight (34.7%) had groove signs secondary to radial dislocation at the elbow joint. Furthermore, they were observed to express apprehension when conducting these tests, all of which were performed by the same physician. As the lateral pivot shift test was not performed under general anesthesia, patients did exhibit over-resistance, and consequently, the test could not be performed. We routinely perform these tests, which are important for PLRI diagnosis, at follow-up visits of patients after total radial head excision.

Clinical outcomes were assessed according to the Steinberg criteria, revealing good results in 12 patients (52%), fair results in seven (30%), and poor results in four (18%). The 12 patients with good results had all suffered low-impact traumatic injury, such as simple falling or falling from a height below 1 m, and underwent primary excision, while those with fair or poor outcomes were observed to have had an increased severity of trauma (Table).

Radiological evaluation

At radiological evaluation, the excised site was observed to possess more degenerative changes compared to the unaffected elbow. Of the 23 patients, 16 had radiological degenerative changes. Sclerosis was the most frequently observed finding (all 16 cases), followed by elbow joint narrowing (approx. 1 mm) in 10 patients, formation of articular heterotopic ossification in five patients (Fig. 2), and subchondral cyst formation in two patients. All patients developing heterotopic ossification had restricted movement at the elbow joint.

Figure 2: Postoperative second-year plane X-rays of the same patient. The presence of severe heterotopic ossification is remarkable.

Ulna plus variation (positive ulnar variance) was demonstrated by comparative wrist roentgenograms. While 11 of 23 patients had no ulna plus deformity, the remaining 12 patients exhibited 2–24 mm (4.52 mm on average) positive ulnar variance. One patient was detected to have a 15-mm and another to have a 24-mm ulna plus deformity (Fig. 3); a severe radial deviation deformity was also observed at the wrist joint, resulting in loss of function and pain, which led to an avoidance of daily activities (Table).

Figure 3: Wrist radiographs of a patient with a 24-mm ulnar plus variant. Remarkable osteoarthrosis is present.

Discussion :

Fractures of the radial head are frequently seen injuries, comprising 1.5–4.0% of all fractures. Representing about 30% of the fractures around the elbow, they usually result from falling in a position that makes the palmar surface hit the ground⁹. The Mason classification is generally used in categorizing fractures of the head of the radius. While Mason type 1 fractures can be treated conservatively, Mason type 2 fractures are often treated by open reduction and internal fixation. For Mason type 3 fractures that we focus on here, no consensus exists as to the best treatment modality. However, one of the most commonly applied techniques for many years has been total excision of the radial head⁹.

Total excision is preferred in comminuted fractures, usually because sufficiently sized fragments for internal fixation are lacking, when the consistency of the coronoid process and the condition of the ligamentous structures of the elbow gain importance with respect to elbow stability^6,8,9. In a recent cadaveric study, the effect of the radial head on elbow stability was demonstrated to be approximately 28–30%⁸. In cases with additional coronoid process fractures and/or ligament injury, excision of the radial head may lead to chronic instability at the elbow joint^5,6. In such cases, the treatment of choice could be directed to fixation of coronoid process, soft tissue repair, or prosthetic replacement of the radial head^6,9. In a recent study, however, prosthetic radial head replacement without ligament repair failed to provide sufficient elbow stability¹¹. Thus, we believe that performing a prosthetic replacement to increase elbow stability and to achieve radius length is an appropriate approach in cases with total radial head excision.

Outcomes of total excision of the head of the radius after isolated radial head fractures are satisfactory according to many studies^1,3. The type of fracture, presence of additional pathologies, and time of operation are also factors affecting clinical outcomes. Herbertsson et al. performed either primary or late total excision in 61 patients with Mason types 2, 3, or 4 fractures, and obtained satisfactory results, except for type-4 fracture cases; no difference was detected between primary and late phase cases¹.

In Sanchez-Sotelo’s study of 10 cases, patients were followed for a mean duration of 4.6 years. Early results of the total excision were reported to be satisfactory, but long-term results of the intervention were not discussed³.

Some studies, however, have reported poor results on performing total excisions. In Leppilathi’s paper, 23 subjects underwent total radial head excisions; elbow and wrist joints were checked after 5 years on average and showed apparently restricted movement in 17 elbow and 14 wrist joints. This study concluded that this finding originated primarily from shortening of the radius². In the study of Ikeda et al., 15 patients with Mason type-2 and -3 fractures underwent total radial head excisions, and only five cases demonstrated good results. Subjects were followed for 10 years on average, and pain was shown to have persisted in 10 subjects, accompanied by loss of movement and function. This study recommended that total excision in comminuted radial head fractures not be performed for patients doing physical work⁴.

In our study, 11 of 23 patients had fair or poor clinical outcomes, which we consider unsatisfactory, leading us to evaluate this technique with suspicion. As demonstrated, although readily applicable, total excision is a method with an outcome that may not be as innocent as it appears. In recent studies, the PLRI context is frequently encountered, which led us to assess the technique in detail.

PLRI is the most commonly seen pattern of elbow instability, as first described by O’Driscoll in 1991,^5,14 in which abnormal external rotation of the ulna over the humerus and subsequent valgus displacement in the trochlea of the humerus was the underlying mechanism¹⁵. The lateral ulnar collateral ligament (LUCL) is the anatomical structure responsible for posterolateral rotator instability¹⁴. Clinical findings may consist of a history of recurrent elbow dislocation, the presence of painful clicks, and a feeling of elbow dislocation during daily activities, followed by an apprehensive state. If PLRI is symptomatic, LUCL repair or reconstruction of the ligament by tendon graft should be considered¹⁵.

While PLRI could result iatrogenically from lateral approaches to the elbow, as in a radial head excision or tennis elbow operation, it may also arise secondary to elbow trauma, such as an elbow dislocation or comminuted fracture of the head of the radius. Using MRI, Itamura et al. showed that 18 of 24 cases (80.1%) with Mason type-2 and -3 fractures had concurrent development of LUCL rupture¹².

LUCL is one of the four parts of the lateral collateral ligament (LCL); the others are the radial collateral ligament, the annular ligament, and the accessory lateral collateral ligament. These components can exhibit individual variations. LUCL attaches at the anteroinferior aspect of the lateral condyle proximally and attaches at the ulnar supinator crest distally. In this way, it not only contributes to the formation of valgus resistance, but also prevents posterior dislocation of the radial head via a supportive effect. Moreover, it prevents abnormal external rotation of the ulna over the humerus. In our opinion, however, intraoperative assessment of LUCL is important for elbow stability, and if it is torn, repair or reconstruction of the ligament subsequent to the total radial head excision is an appropriate approach. If, however, the ligament cannot be repaired, we believe that performing a prosthetic replacement to increase elbow stability and restore radius length is the approach of choice.

Clinical demonstration of PLRI is not always easy⁷. Several specific tests are used to diagnose this condition, all of which are based on same rationale: they eventually result in an “apprehensive” state in patients, as observed in anterior shoulder instability and form a “groove sign” at the elbow, accompanied by subluxation of the proximal radius. Nevertheless, patients sometimes develop dramatic apprehension and resistance, an unpleasant condition.

One such test is the “Lateral Pivot-Shift Test” described by O’Driscoll in 1991⁵. In this test, the arm is made to extend while the patient is in a supine position. Concurrent with axial loading, the elbow is forced to the valgus position. However, this maneuver is difficult to perform while the patient is awake, so it is recommended that it be carried out under general anesthesia⁵. Another test is the “push-up test” described by Regan et al. in 2006⁷. The patient is first asked to assume the push-up position. If fear ensues when the elbow is extended from flexion and subluxation appears at the radial head, the test outcome is deemed to be positive. In the same article, the chair test was also described in which the patient is seated on a chair. If the same signs appear when the patient puts a load on his/her arm to stand up, the test is considered positive.

The last test for diagnosing PLRI is the “tabletop test” described by Arvind et al. in 2006¹⁰. Similar to the other tests, it consists of enduring a load while the elbow is extended, with the patient staying near the table¹⁷. In our study, all of these tests were performed by the same physician and showed no significant difference that could have influenced the outcome. The tabletop and chair tests are likely to be more practical compared to the other tests.

Today, studies are successfully assessing LUCR using MRI¹². From a radiological point of view, ulna plus deformity at the wrist joint may attract attention (Fig. 3). The underlying mechanism for this deformity is the relative lengthening of ulna, secondary to the shortening of radial length after excision. Whereas the distal articular surface of ulna is in line with the distal ulnar articular surface of the radius under normal conditions, the ulna appears in a position as if it descended distally. In ulna plus deformity, inspection of the wrist joint may exhibit an apparent deformity that may also be painful.

In our study, 12 patients had positive ulnar variation, four of whom had severe deformities of 10, 10, 15, and 24 mm, which led to clinical complaints. This severity of radius shortening can be related to the size of the excised radial head. Thus, appropriate choice of an osteotomy level that avoids unnecessary distal involvement or prosthetic replacement of the radial head is a good solution.

Conclusions :

Comminuted radial head fracture is a frequently seen condition in which the degree of energy causing the trauma has a net effect on the outcome. Total radial head excision is the most commonly used treatment modality. Note, however, despite its relatively easy application, this intervention can be associated with complications such as posterolateral rotator instability, chronic elbow pain, loss of function at the elbow joint, and ulna plus deformity at the wrist joint. For this reason, total excision of the radial head should be avoided; if this is not possible, integrity of LUCL should be evaluated intraoperatively. If a LUCL tear is present, it should be repaired; if this is not possible, a radial head prosthesis should be applied. The proximal portion of the radius should never be left uncontrolled.

Reference :

1. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004 Sep;86-A(9):1925-30.

2. Leppilahti J, Jalovaara P. Early excision of the radial head for fracture. Int Orthop. 2000;24(3):160-2.

3. Sanchez-Sotelo J, Romanillos O, Garay EG. Results of acute excision of the radial head in elbow radial head fracture-dislocations. J Orthop Trauma. 2000 Jun-Jul;14(5):354-8.

4. Ikeda M, Oka Y. Function after early radial head resection for fracture: a retrospective evaluation of 15 patients followed for 3-18 years. Acta Orthop Scand. 2000 Apr;71(2):191-4.

5. O'Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000 Jan;(370):34-43.

6. Hall JA, McKee MD. Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am. 2005 Jul;87(7):1571-9.

7. Regan W, Lapner P. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow. J Shoulder Elbow Surg. 2006 May-Jun;15(3):344-6.

8. Jensen SL, Olsen BS, Sojbjerg JO. Elbow joint kinematics after excision of the radial head. J Shoulder Elbow Surg. 1999 May-Jun;8(3):238-41.

9. Jensen SL, Olsen BS, Tyrdal S, Sojbjerg JO, Sneppen O. Elbow joint laxity after experimental radial head excision and lateral collateral ligament rupture: efficacy of prosthetic replacement and ligament repair. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1):78-84.

10. Arvind CH, Hargreaves DG. Tabletop relocation test: a new clinical test for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):707-8. Epub 2006 Aug 7.

11. Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJ. The effect of radial head excision and arthroplasty on elbow kinematics and stability. J Bone Joint Surg Am. 2004 Aug;86-A(8):1730-9.

12. 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 Jul-Aug;14(4):421-4.

13. Steinberg EL, Golomb D, Salama R, Wientroub S. Radial head and neck fractures in children. J Pediatr Orthop. 1988 Jan-Feb;8(1):35-40.

14. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6.

15. Mehta JA, Bain GI. Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):405-15.

This is a peer reviewed paper 

Please cite as: Volkan Gurkan: Total Excision Of Comminuted Radial Head Fractures And Subsequent Elbow Posterolateral Rotatory Instability.

J.Orthopaedics 2009;6(3)e6

URL: http://www.jortho.org/2009/6/3/e6

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