- Email: [email protected]
A retrospective cohort study of displaced segmental radial head fractures: is 2 mm of articular displacement an indication for surgery?
J Shoulder Elbow Surg (2013) 22, 636-641
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A retrospective cohort study of displaced segmental radial head fractures: is 2 mm of articular displacement an indication for surgery? Matthew J. Furey, MD, MSca,*, David M. Sheps, MD, MScb, Neil J. White, MDa, Kevin A. Hildebrand, MDa a b
Section of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, AB, Canada Section of Orthopaedic Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada Hypothesis: Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. Materials and methods: We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. Results: The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm (P ¼ .8) or even 3 mm (P ¼ .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. Conclusions: This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome. Level of evidence: Level II, Retrospective Design, Prognosis Study. Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Radial head; fracture; Mason classification; 2 mm; displacement; conservative; surgical
The University of Calgary Office of Medical Bioethics Conjoint Health Research Ethics Board approved the protocol of this study (Ethics ID No. E-20762). *Reprint requests: Matthew J. Furey, MD, MSc, University of Calgary Health Sciences Centre, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail address: [email protected] (M.J. Furey).
Mason17 opened his landmark 1954 article on radial head fractures by cautioning that injuries about the elbow should be treated with trepidation and great respect. In generating his time-tested classification for radial head fractures, he stated that the treatment of the type II, or
1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.01.019
Management of displaced radial head fractures marginal sector, fractures with displacement is ‘‘unfortunately not so clearly defined.’’17 In the intervening years, a trend toward operative fixation of Mason type II radial head fractures has emerged. This is at least in part because of improvement of surgical instrumentation11 and at least in part because of increasing pessimism around radial head resection.13,19 Unfortunately, there is a lack of clear evidence on which we should base our decision making for Mason type II fractures. It is generally accepted that Mason type I fractures, fractures with minimal displacement, have good or excellent results when treated nonoperatively whereas Mason type III fractures with multiple fragments require replacement or excision.9,11,17,24 The Morrey modification of the Mason classification attempted to further define Mason type II fractures as those amenable to surgical fixation including fractures with a mechanical block or those with displacement of greater than 2 mm.10,18 Although it is a widely applied finding of the study of intra-articular fractures of the wrist by Knirk and Jupiter,15 a complete search of the Englishlanguage literature did not find any objective support for 2 mm as an acceptable limit of displacement at the radial head. There is some ex vivo evidence pointing toward 3 mm as a potential upper limit of acceptable displacement.4 The purpose of this study was to retrospectively evaluate a group of patients with isolated Mason type II radial head fractures in the Calgary Health Region between 2002 and 2005 using standardized outcome measures to record follow-up. This was done with the goal of examining the role of fracture displacement on functional and radiographic outcome. It was our hypothesis that displacement of 2 mm would not necessarily result in worse outcomes in patients treated conservatively.
Materials and methods We performed a retrospective review of all reported isolated radial head fractures in our health region for the period between 2002 and 2005. The Calgary Health Region was estimated at a population of 1.2 million during this period. One hundred six patients with Mason type II radial head fractures were identified by their presentation to either an urgent care center or acute care hospital for fracture care as per previous publication on fracture incidence.22 These patients were then reviewed for inclusion in our study. Our inclusion criteria involved skeletally mature patients with an isolated radial head fracture as shown on radiographs at the time of original injury and accessible anteroposterior and lateral radiographs of the elbow taken at the time of injury and before treatment. Patients were excluded if they were skeletally immature, had concomitant ipsilateral upper extremity injury, had previous injury to the same radial head, or were not available or agreeable to follow-up. In addition, patients who were unable to provide adequate questionnaire answers because of medical or cognitive comorbidities were excluded. After review of inclusion and exclusion criteria, we contacted patients to participate in the study. Consenting patients were asked to return for a follow-up examination in which their elbow range
637 of motion (ROM) and radiographs were obtained and questionnaires including our primary outcome measuredthe Disabilities of the Arm, Shoulder and Hand (DASH) questionnairedand secondary outcome measures, including the Patient-Rated Elbow Evaluation (PREE) questionnaire and a demographic survey, were completed. The demographic survey included questions assessing early ROM (defined as self-directed ROM within 2 weeks of injury) and formal physiotherapy participation. The DASH and PREE questionnaires are standardized, valid, and reliable patientbased outcome measures3 with good correlation.16 If patients were unable to return for examination, secure online versions of the surveys or mail-out versions were made available for completion. Follow-up examination consisted of ROM including flexion, extension, supination, and pronation as measured with the assistance of a goniometer, as well as a neurovascular examination. Mean follow-up was recorded as the number of weeks intervening between initial injury and follow-up examination and survey completion. Initial and follow-up radiographs were then reviewed by 3 staff orthopedic surgeons using standardized equipment and software (K-Pacs, http://www.k-pacs.de). Measurements of displacement using the x-ray projection with maximal displacement, percentage of head involvement, and number of fracture fragments were recorded on initial radiographs. Follow-up radiographs were examined for evidence of early arthritis and graded according to the system previously described by Broberg and Morrey.1,2 Mean scores for each measurement were than calculated by averaging staff observations. Our primary study question was whether conservatively treated radial head fractures in patients with fracture displacement of greater than 2 mm result in significantly worse clinical or patientreported outcomes than those in patients with less than 2 mm of fracture displacement. To this effect, patients were arranged into groups according to fracture displacement and treatment paradigms. Our groupings included nonoperatively treated patients with fracture displacement of greater versus less than 2 mm, fracture displacement of greater versus less than 3 mm, and postinjury treatment protocols including early ROM and physiotherapy. Grouped data were then assessed for statistical significance by use of a t test with a level of significance set at P ¼ .05. Along with statistical significance, we examined the score on the DASH questionnaire, our primary outcome survey, for clinical significance. A clinically significant difference in DASH score has been established as 10 of 100 by Gummesson et al.7
Results Of the initial 106 patients, 36 were included after application of exclusion criteria. Patients were excluded because of refusal to be included, inability to be contacted, or inaccessible initial radiographs. Our mean follow-up was 4.4 years. Patient demographics are outlined in Table I.
Two millimeters of displacement In our primary analysis, we compared patients treated nonoperatively with displacement of less than 2 mm and patients with displacement of greater than 2 mm. There was a statistically significant difference in fracture displacement
638 Table I
M.J. Furey et al. Demographics Data
Mean age (y) Male/female Dominant hand injured Surgery Workers Compensation Board (WCB) Early ROM Smoker
46 9 15:21 50% 22% 10% 62% 25%
between groups (1.3 0.6 mm in <2-mm group vs 2.9 0.8 mm in >2-mm group, P < .05) but no statistically or clinically significant difference in any outcome measure. This included our primary outcome measure, the DASH score (14.2 16.6 in <2-mm group vs 12.6 11.1 in >2-mm group, P ¼ .80), and secondary outcome measures, including the PREE score (7.3 16.1 in <2-mm group vs 15.9 16.7 in >2-mm group, P ¼ .86) and ROM (flexionextension arc of 137 12 in <2-mm group vs 134 8 in >2-mm group, P ¼ .62; supination-pronation arc of 162 13 in <2-mm group vs 167 16 in >2-mm group, P ¼ .52) (Fig. 1). There was no significant difference in the Broberg and Morrey arthritic grade of the radiocapitellar articulation (0.3 0.4 in <2-mm group vs 0.45 0.4 in >2-mm group, P ¼ .52).
Three millimeters of displacement We then divided patients into those with less than 3 mm of fracture displacement and those with greater than 3 mm of fracture displacement treated nonoperatively. Again, we found a significant difference in fracture displacement (1.9 0.7 mm in <3-mm group vs 3.7 0.5 mm in >3-mm group, P < .05), indicating a fundamental difference had been established between the groups, but no statistically or clinically significant difference in any outcome measure. This included DASH score (12.4 13.0 in <3-mm group vs 16.0 14.4 in >3-mm group, P ¼ .60), PREE score (13.7 13.7 in <3-mm group vs 24.4 21.5 in >3-mm group, P ¼ .20), and ROM (flexionextension arc of 135 11 in <3-mm group vs 137 5 in >3-mm group, P ¼ .85; supination-pronation arc of 163 14 in <3-mm group vs 171 13 in >3-mm group, P ¼ .49) (Fig. 2). Again, there was no significant difference in arthritic grading on follow-up radiographs (0.3 0.4 in <3-mm group vs 0.7 0.5 in >3-mm group, P ¼ .14).
Physiotherapy versus no physiotherapy Next, we examined whether patients underwent any physiotherapy as part of their postinjury treatment regimen and whether there was any discernible difference in outcome measures. There was no significant difference in fracture displacement between the two groups (2.2 1.3 mm in physiotherapy group vs 1.9 0.9 mm in no-physiotherapy group, P ¼ .49). No significant difference was found in any
outcome measure including the DASH score (8.8 10.5 in physiotherapy group vs 13.5 15.2 in no-physiotherapy group, P ¼ .36), PREE score (12.0 15.2 in physiotherapy group vs 16.6 16.1 in no-physiotherapy group, P ¼ .48), or ROM arcs (flexion-extension arc of 137 8 in physiotherapy group vs 133 15 in no-physiotherapy group, P ¼ .59; supination-pronation arc of 163 15 in physiotherapy group vs 159 14 in no-physiotherapy group, P ¼ .59).
Early ROM versus immobilization Early ROMddefined as ROM within the first 2 weeks and self reported on the general surveydwas examined. No statistically significant difference was found in displacement (2.3 1.1 mm for early ROM vs 1.5 1.2 mm for no early ROM, P ¼ .14) or any outcome measure (DASH score of 8.8 10.6 for early ROM vs 17.9 16.2 for no early ROM, P ¼ .12; PREE score of 11.1 13.7 for early ROM vs 20.0 19.2 for no early ROM, P ¼ .14; flexion-extension arc of 137 10 for early ROM vs 134 14 for no early ROM, P ¼ .62; supination-pronation arc of 166 13 for early ROM vs 155 19 for no early ROM, P ¼ .17).
Dominant versus nondominant hand injury In examining nondominant and dominant hand injury, we found that patients with a dominant hand injury were more likely to have decreased ROM (flexion-extension arc of 145 8 in nondominant group vs 131 8 in dominant group, P < .05; supination-pronation arc of 171 17 in nondominant group vs 159 10 in dominant group, P ¼ .06), but there was no difference in self-reported outcomes as measured by the DASH score (7.3 8.2 in nondominant group vs 14.0 14.2 in dominant group, P ¼ .15) and PREE score (9.4 13.4 in nondominant group vs 16.9 15.7 in dominant group, P ¼ .20). In addition, there was no significant difference in displacement (2.2 0.9 mm in nondominant group vs 2.0 1.4 mm in dominant group, P ¼.69) or arthritic changes (0.42 0.4 in nondominant group vs 0.46 0.4 in dominant group, P ¼ .78) between these groups.
Discussion A systematic review of the literature was performed for any literature to support 2 mm as a cutoff for conservative versus surgical treatment. No objective evidence was found. In one interesting abstract, in a cadaveric model, Druschel et al4 showed 3 mm of displacement causing kinematic deficits; however, no peer-reviewed published studies were available. Next, a systematic review of the literature was performed to examine treatment of Mason type II fractures overall. This yielded only one direct comparison of surgical versus conservative treatment of Mason type II fractures,14 although there were a number of single–treatment arm studies.5,6,9,11,12,19,21,24
Management of displaced radial head fractures
639
Figure 1 Outcome measures in patients with less than 2 mm (n ¼ 8) or greater than 2 mm (n ¼ 14) of displacement. Flex/Ex, Flexionextension arc; Sup/Pron, supination-pronation arc.
Figure 2 Outcome measures in patients with less than 3 mm (n ¼ 17) or greater than 3 mm (n ¼ 5) of displacement. Flex/Ex, Flexionextension arc; Sup/Pron, supination-pronation arc.
A recently published systematic review completed by Struijs et al23 showed residual pain present in 42% of the conservatively treated patients compared with 32% of the surgically treated patients with Mason type II fractures. Overall, their conclusion was ‘‘insufficient evidence due to
lack of randomised trials and heterogeneity of retrospective studies.’’ As discussed earlier, efforts have been made to furthe define fractures that fall into the Mason type II classification with the Morrey modification of the Mason classification,
640 along with treatment protocols as recommended by Hotchkiss.10,11,18 Unfortunately, this is largely based on expert opinion rather than objective high-quality studies. Our study, though not solving the over-riding clinical equipoise of Mason type II treatment, adds to the information currently available to make evidence-based clinical judgment. Current expert opinion redefines Mason type II fractures as fractures with greater than 2 mm of displacement and/or mechanical block in fractures lending themselves to surgical reconstruction. Our data would suggest that displacement of 2 mm or even 3 mm is not necessarily an indication of poor outcome when fractures are treated conservatively. In addition, although the generally accepted expert opinion is that early ROM and physiotherapy in conservatively treated Mason type I and II fractures are beneficial, our data indicate that this may not be the case for conservatively treated Mason type II fractures. A review of the literature supports our data, including a recent Cochrane review that found no evidence to support early ROM.8 Certainly, our study has limitations. First, from the onset, a retrospective design has inherent limitations including its non-blinded, non-randomized nature. In addition, we relied on patient recall of postinjury treatment (ie, early ROM and physiotherapy). Most importantly, we had low follow-up. The average follow-up in a North American retrospective orthopedic trauma study is difficult to pinpoint. There is evidence that in prospective orthopedic studies, patients lost to follow-up may be different from patients who attend follow-up.20 There is no current evidence to suggest that this applies to retrospective trials. Though largely anecdotal, it has been suggested that post-traumatic arthritis develops 2 to 6 years after injury.25 We believe that our mean follow-up of 4.4 years is adequate to capture any difference in early arthritic development.
Conclusion The Mason classification is the most common classification scheme in use today for radial head fractures. The Morrey and Hotchkiss modifications have attempted to make treatment based on this classification more precise. However, the most appropriate definition and treatment of a Mason type II fracture remain undecided. We believe that our study adds to the literature base and suggest that a future definition of Mason type II fractures requiring operative fixation need not include 2 mm or even 3 mm of articular displacement.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not
M.J. Furey et al. received any financial payments or other benefits from any commercial entity related to the subject of this article. Funding was provided by the Calgary Surgical Research and Development Fund.
References 1. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 1987;216:109-19. 2. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986;68:669-74. 3. Dowrick AS, Gabbe BJ, Williamson OD, Cameron PA. Outcome instruments for the assessment of the upper extremity following trauma: a review. Injury 2005;36:468-76. http://dx.doi.org/10.1016/ j.injury.2004.06.014 4. Druschel M, Palmer G, Baratz ME, Miller MC. Mason II fractures with three millimeters displacement require reduction. Presented at the American Society of Biomechanics 2010 Conference; August 18-21, 2010; Providence, RI. 5. Duckworth AD, Watson BS, Will EM, Petrisor BA, Walmsley PJ, CourtBrown CM, et al. Radial head and neck fractures: functional results and predictors of outcome. J Trauma 2011;71:643-8. http://dx.doi.org/ 10.1097/TA.0b013e3181f8fa5f 6. Geel CW, Palmer AK, Ruedi T, Leutenegger AF. Internal fixation of proximal radial head fractures. J Orthop Trauma 1990;4:270-4. 7. Gummesson C, Atroshi I, Ekdahl C. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after hand surgery. BMC Musculoskelet Disord 2003;4:11. http://dx.doi.org/ 10.1186/1471-2474-4-11 8. Harding P, Rasekaba T, Smirneos L, Holland AE. Early mobilisation for elbow fractures in adults. Cochrane Database Syst Rev 2011;6: CD008130. http://dx.doi.org/10.1002/14651858.CD008130.pub2 9. Herbertson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karllson MK. Displaced Mason type I fractures of the radial head and neck in adults: A fifteen to thirty-three-year follow-up study. J Shoulder Elbow Surg 2003;14:73-7. http://dx.doi.org/10.1016/j.jse. 2004.07.001 10. Hotchkiss R. Longitudinal instability of the forearm. Presented at the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons; March 15-19, 2000; Orlando, FL. 11. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10. 12. Iacobellis C, Visentin A, Aldegheri R. Open reduction and internal fixation of radial head fractures. Musculoskelet Surg 2012;96(Suppl 1):S81-6. http://dx.doi.org/10.1007/s12306-012-0186-3 13. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. J Bone Joint Surg Am 2005;87:76-84. http://dx.doi.org/10.2106/JBJS.C.01323 14. Khalfayan EE, Culp RW, Alexander AH. Mason type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma 1992;6:283-9. 15. Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68: 647-59. 16. Liem IS, Kolling C, Marks M, Nelissen RG, Goldhahn J. Development of a score set to measure function and quality of life in patients suffering from elbow pathology. J Orthop Trauma 2012;26:229-35. http://dx.doi.org/10.1007/s00402-012-1472-0 17. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123-32.
Management of displaced radial head fractures 18. Morrey BF. The elbow and its disorders. 3rd ed. Philadelphia: Saunders; 2000. 19. Miller KG, Dreman D, Maylahan D. Treatment of segmental radialhead fractures. J Bone Joint Surg Am 1981;63:712-7. 20. Murnaghan ML, Buckley RE. Lost but not forgotten: patients lost to follow-up in a trauma database. Can J Surg 2002;45:191-5. 21. Pearce MS, Gallannough SC. Mason type II radial head fractures with Herbert bone screws. J R Soc Med 1996;89:340-4. 22. Sheps D, Kemp K, Hildebrand K. Population-based incidence of proximal radius and ulnar fractures among adults in a Canadian
641 metropolitan area. Curr Orthop Pract 2012;23:364-8. http://dx.doi.org/ 10.1097/BCO.0b013e31825a2881 23. Struijs PA, Smit G, Steller EP. Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review. Arch Orthop Trauma Surg 2007;127:125-30. http://dx.doi.org/ 10.1007/s00402-006-0240-4 24. Weseley MS, Barenfeld PA, Eisenstein AL. Closed treatment of isolated radial head fractures. J Trauma 1983;23:36-9. 25. Wright V. Post-traumatic osteoarthritisda medico-legal minefield. Br J Rheumatol 1990;29:474-8.
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A retrospective cohort study of displaced segmental radial head fractures: is 2 mm of articular displacement an indication for surgery? Matthew J. Furey, MD, MSca,*, David M. Sheps, MD, MScb, Neil J. White, MDa, Kevin A. Hildebrand, MDa a b
Section of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, AB, Canada Section of Orthopaedic Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada Hypothesis: Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. Materials and methods: We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. Results: The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm (P ¼ .8) or even 3 mm (P ¼ .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. Conclusions: This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome. Level of evidence: Level II, Retrospective Design, Prognosis Study. Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Radial head; fracture; Mason classification; 2 mm; displacement; conservative; surgical
The University of Calgary Office of Medical Bioethics Conjoint Health Research Ethics Board approved the protocol of this study (Ethics ID No. E-20762). *Reprint requests: Matthew J. Furey, MD, MSc, University of Calgary Health Sciences Centre, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail address: [email protected] (M.J. Furey).
Mason17 opened his landmark 1954 article on radial head fractures by cautioning that injuries about the elbow should be treated with trepidation and great respect. In generating his time-tested classification for radial head fractures, he stated that the treatment of the type II, or
1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.01.019
Management of displaced radial head fractures marginal sector, fractures with displacement is ‘‘unfortunately not so clearly defined.’’17 In the intervening years, a trend toward operative fixation of Mason type II radial head fractures has emerged. This is at least in part because of improvement of surgical instrumentation11 and at least in part because of increasing pessimism around radial head resection.13,19 Unfortunately, there is a lack of clear evidence on which we should base our decision making for Mason type II fractures. It is generally accepted that Mason type I fractures, fractures with minimal displacement, have good or excellent results when treated nonoperatively whereas Mason type III fractures with multiple fragments require replacement or excision.9,11,17,24 The Morrey modification of the Mason classification attempted to further define Mason type II fractures as those amenable to surgical fixation including fractures with a mechanical block or those with displacement of greater than 2 mm.10,18 Although it is a widely applied finding of the study of intra-articular fractures of the wrist by Knirk and Jupiter,15 a complete search of the Englishlanguage literature did not find any objective support for 2 mm as an acceptable limit of displacement at the radial head. There is some ex vivo evidence pointing toward 3 mm as a potential upper limit of acceptable displacement.4 The purpose of this study was to retrospectively evaluate a group of patients with isolated Mason type II radial head fractures in the Calgary Health Region between 2002 and 2005 using standardized outcome measures to record follow-up. This was done with the goal of examining the role of fracture displacement on functional and radiographic outcome. It was our hypothesis that displacement of 2 mm would not necessarily result in worse outcomes in patients treated conservatively.
Materials and methods We performed a retrospective review of all reported isolated radial head fractures in our health region for the period between 2002 and 2005. The Calgary Health Region was estimated at a population of 1.2 million during this period. One hundred six patients with Mason type II radial head fractures were identified by their presentation to either an urgent care center or acute care hospital for fracture care as per previous publication on fracture incidence.22 These patients were then reviewed for inclusion in our study. Our inclusion criteria involved skeletally mature patients with an isolated radial head fracture as shown on radiographs at the time of original injury and accessible anteroposterior and lateral radiographs of the elbow taken at the time of injury and before treatment. Patients were excluded if they were skeletally immature, had concomitant ipsilateral upper extremity injury, had previous injury to the same radial head, or were not available or agreeable to follow-up. In addition, patients who were unable to provide adequate questionnaire answers because of medical or cognitive comorbidities were excluded. After review of inclusion and exclusion criteria, we contacted patients to participate in the study. Consenting patients were asked to return for a follow-up examination in which their elbow range
637 of motion (ROM) and radiographs were obtained and questionnaires including our primary outcome measuredthe Disabilities of the Arm, Shoulder and Hand (DASH) questionnairedand secondary outcome measures, including the Patient-Rated Elbow Evaluation (PREE) questionnaire and a demographic survey, were completed. The demographic survey included questions assessing early ROM (defined as self-directed ROM within 2 weeks of injury) and formal physiotherapy participation. The DASH and PREE questionnaires are standardized, valid, and reliable patientbased outcome measures3 with good correlation.16 If patients were unable to return for examination, secure online versions of the surveys or mail-out versions were made available for completion. Follow-up examination consisted of ROM including flexion, extension, supination, and pronation as measured with the assistance of a goniometer, as well as a neurovascular examination. Mean follow-up was recorded as the number of weeks intervening between initial injury and follow-up examination and survey completion. Initial and follow-up radiographs were then reviewed by 3 staff orthopedic surgeons using standardized equipment and software (K-Pacs, http://www.k-pacs.de). Measurements of displacement using the x-ray projection with maximal displacement, percentage of head involvement, and number of fracture fragments were recorded on initial radiographs. Follow-up radiographs were examined for evidence of early arthritis and graded according to the system previously described by Broberg and Morrey.1,2 Mean scores for each measurement were than calculated by averaging staff observations. Our primary study question was whether conservatively treated radial head fractures in patients with fracture displacement of greater than 2 mm result in significantly worse clinical or patientreported outcomes than those in patients with less than 2 mm of fracture displacement. To this effect, patients were arranged into groups according to fracture displacement and treatment paradigms. Our groupings included nonoperatively treated patients with fracture displacement of greater versus less than 2 mm, fracture displacement of greater versus less than 3 mm, and postinjury treatment protocols including early ROM and physiotherapy. Grouped data were then assessed for statistical significance by use of a t test with a level of significance set at P ¼ .05. Along with statistical significance, we examined the score on the DASH questionnaire, our primary outcome survey, for clinical significance. A clinically significant difference in DASH score has been established as 10 of 100 by Gummesson et al.7
Results Of the initial 106 patients, 36 were included after application of exclusion criteria. Patients were excluded because of refusal to be included, inability to be contacted, or inaccessible initial radiographs. Our mean follow-up was 4.4 years. Patient demographics are outlined in Table I.
Two millimeters of displacement In our primary analysis, we compared patients treated nonoperatively with displacement of less than 2 mm and patients with displacement of greater than 2 mm. There was a statistically significant difference in fracture displacement
638 Table I
M.J. Furey et al. Demographics Data
Mean age (y) Male/female Dominant hand injured Surgery Workers Compensation Board (WCB) Early ROM Smoker
46 9 15:21 50% 22% 10% 62% 25%
between groups (1.3 0.6 mm in <2-mm group vs 2.9 0.8 mm in >2-mm group, P < .05) but no statistically or clinically significant difference in any outcome measure. This included our primary outcome measure, the DASH score (14.2 16.6 in <2-mm group vs 12.6 11.1 in >2-mm group, P ¼ .80), and secondary outcome measures, including the PREE score (7.3 16.1 in <2-mm group vs 15.9 16.7 in >2-mm group, P ¼ .86) and ROM (flexionextension arc of 137 12 in <2-mm group vs 134 8 in >2-mm group, P ¼ .62; supination-pronation arc of 162 13 in <2-mm group vs 167 16 in >2-mm group, P ¼ .52) (Fig. 1). There was no significant difference in the Broberg and Morrey arthritic grade of the radiocapitellar articulation (0.3 0.4 in <2-mm group vs 0.45 0.4 in >2-mm group, P ¼ .52).
Three millimeters of displacement We then divided patients into those with less than 3 mm of fracture displacement and those with greater than 3 mm of fracture displacement treated nonoperatively. Again, we found a significant difference in fracture displacement (1.9 0.7 mm in <3-mm group vs 3.7 0.5 mm in >3-mm group, P < .05), indicating a fundamental difference had been established between the groups, but no statistically or clinically significant difference in any outcome measure. This included DASH score (12.4 13.0 in <3-mm group vs 16.0 14.4 in >3-mm group, P ¼ .60), PREE score (13.7 13.7 in <3-mm group vs 24.4 21.5 in >3-mm group, P ¼ .20), and ROM (flexionextension arc of 135 11 in <3-mm group vs 137 5 in >3-mm group, P ¼ .85; supination-pronation arc of 163 14 in <3-mm group vs 171 13 in >3-mm group, P ¼ .49) (Fig. 2). Again, there was no significant difference in arthritic grading on follow-up radiographs (0.3 0.4 in <3-mm group vs 0.7 0.5 in >3-mm group, P ¼ .14).
Physiotherapy versus no physiotherapy Next, we examined whether patients underwent any physiotherapy as part of their postinjury treatment regimen and whether there was any discernible difference in outcome measures. There was no significant difference in fracture displacement between the two groups (2.2 1.3 mm in physiotherapy group vs 1.9 0.9 mm in no-physiotherapy group, P ¼ .49). No significant difference was found in any
outcome measure including the DASH score (8.8 10.5 in physiotherapy group vs 13.5 15.2 in no-physiotherapy group, P ¼ .36), PREE score (12.0 15.2 in physiotherapy group vs 16.6 16.1 in no-physiotherapy group, P ¼ .48), or ROM arcs (flexion-extension arc of 137 8 in physiotherapy group vs 133 15 in no-physiotherapy group, P ¼ .59; supination-pronation arc of 163 15 in physiotherapy group vs 159 14 in no-physiotherapy group, P ¼ .59).
Early ROM versus immobilization Early ROMddefined as ROM within the first 2 weeks and self reported on the general surveydwas examined. No statistically significant difference was found in displacement (2.3 1.1 mm for early ROM vs 1.5 1.2 mm for no early ROM, P ¼ .14) or any outcome measure (DASH score of 8.8 10.6 for early ROM vs 17.9 16.2 for no early ROM, P ¼ .12; PREE score of 11.1 13.7 for early ROM vs 20.0 19.2 for no early ROM, P ¼ .14; flexion-extension arc of 137 10 for early ROM vs 134 14 for no early ROM, P ¼ .62; supination-pronation arc of 166 13 for early ROM vs 155 19 for no early ROM, P ¼ .17).
Dominant versus nondominant hand injury In examining nondominant and dominant hand injury, we found that patients with a dominant hand injury were more likely to have decreased ROM (flexion-extension arc of 145 8 in nondominant group vs 131 8 in dominant group, P < .05; supination-pronation arc of 171 17 in nondominant group vs 159 10 in dominant group, P ¼ .06), but there was no difference in self-reported outcomes as measured by the DASH score (7.3 8.2 in nondominant group vs 14.0 14.2 in dominant group, P ¼ .15) and PREE score (9.4 13.4 in nondominant group vs 16.9 15.7 in dominant group, P ¼ .20). In addition, there was no significant difference in displacement (2.2 0.9 mm in nondominant group vs 2.0 1.4 mm in dominant group, P ¼.69) or arthritic changes (0.42 0.4 in nondominant group vs 0.46 0.4 in dominant group, P ¼ .78) between these groups.
Discussion A systematic review of the literature was performed for any literature to support 2 mm as a cutoff for conservative versus surgical treatment. No objective evidence was found. In one interesting abstract, in a cadaveric model, Druschel et al4 showed 3 mm of displacement causing kinematic deficits; however, no peer-reviewed published studies were available. Next, a systematic review of the literature was performed to examine treatment of Mason type II fractures overall. This yielded only one direct comparison of surgical versus conservative treatment of Mason type II fractures,14 although there were a number of single–treatment arm studies.5,6,9,11,12,19,21,24
Management of displaced radial head fractures
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Figure 1 Outcome measures in patients with less than 2 mm (n ¼ 8) or greater than 2 mm (n ¼ 14) of displacement. Flex/Ex, Flexionextension arc; Sup/Pron, supination-pronation arc.
Figure 2 Outcome measures in patients with less than 3 mm (n ¼ 17) or greater than 3 mm (n ¼ 5) of displacement. Flex/Ex, Flexionextension arc; Sup/Pron, supination-pronation arc.
A recently published systematic review completed by Struijs et al23 showed residual pain present in 42% of the conservatively treated patients compared with 32% of the surgically treated patients with Mason type II fractures. Overall, their conclusion was ‘‘insufficient evidence due to
lack of randomised trials and heterogeneity of retrospective studies.’’ As discussed earlier, efforts have been made to furthe define fractures that fall into the Mason type II classification with the Morrey modification of the Mason classification,
640 along with treatment protocols as recommended by Hotchkiss.10,11,18 Unfortunately, this is largely based on expert opinion rather than objective high-quality studies. Our study, though not solving the over-riding clinical equipoise of Mason type II treatment, adds to the information currently available to make evidence-based clinical judgment. Current expert opinion redefines Mason type II fractures as fractures with greater than 2 mm of displacement and/or mechanical block in fractures lending themselves to surgical reconstruction. Our data would suggest that displacement of 2 mm or even 3 mm is not necessarily an indication of poor outcome when fractures are treated conservatively. In addition, although the generally accepted expert opinion is that early ROM and physiotherapy in conservatively treated Mason type I and II fractures are beneficial, our data indicate that this may not be the case for conservatively treated Mason type II fractures. A review of the literature supports our data, including a recent Cochrane review that found no evidence to support early ROM.8 Certainly, our study has limitations. First, from the onset, a retrospective design has inherent limitations including its non-blinded, non-randomized nature. In addition, we relied on patient recall of postinjury treatment (ie, early ROM and physiotherapy). Most importantly, we had low follow-up. The average follow-up in a North American retrospective orthopedic trauma study is difficult to pinpoint. There is evidence that in prospective orthopedic studies, patients lost to follow-up may be different from patients who attend follow-up.20 There is no current evidence to suggest that this applies to retrospective trials. Though largely anecdotal, it has been suggested that post-traumatic arthritis develops 2 to 6 years after injury.25 We believe that our mean follow-up of 4.4 years is adequate to capture any difference in early arthritic development.
Conclusion The Mason classification is the most common classification scheme in use today for radial head fractures. The Morrey and Hotchkiss modifications have attempted to make treatment based on this classification more precise. However, the most appropriate definition and treatment of a Mason type II fracture remain undecided. We believe that our study adds to the literature base and suggest that a future definition of Mason type II fractures requiring operative fixation need not include 2 mm or even 3 mm of articular displacement.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not
M.J. Furey et al. received any financial payments or other benefits from any commercial entity related to the subject of this article. Funding was provided by the Calgary Surgical Research and Development Fund.
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