Intra-articular Radial Head Fractures: A Deceptive Type of Injury

Abstract

Background: Isolated intra-articular radial head (IARH) fractures in skeletally immature patients represent a rare injury. Despite their initial benign radiologic appearance, these fractures are at risk for progressive radial head subluxation and may end with degenerative irreversible changes of the radiocapitellar joint. The aim of this study is to highlight the seriousness of these injuries and the importance of early diagnosis and a proper follow-up to achieve optimal outcomes. Methods: We retrospectively reviewed 6 patients with IARH fractures treated at our institution between 2011 and 2016. All patients presented with Salter-Harris types III or IV fracture. Five of 6 fractures were initially undisplaced. Treatment, clinical, and radiographic results were analyzed. Patients were divided into 2 groups according to treatment: patients included in group A were treated conservatively, whereas patients of group B were treated with early surgery. The final functional outcome was assessed using the Oxford Elbow Score (OES). The Broberg-Morrey classification was used for the radiographic results. Results: Group A included 3 patients (average age, 11±2 y). They developed an initially missed posterior subluxation of the radiocapitellar joint that caused to all of them a painful elbow and limited range of motion (ROM). Despite rescue surgery, they all presented with limited ROM at the final follow-up, although no functional limitations (OES, 46.3±2.9). The radiographs showed early degenerative changes. Group B included 3 patients (average age, 11±1 y) all treated surgically within 1 week from the injury. They showed no limitation of ROM and good functional (OES, 47.7) and radiologic outcomes. Conclusions: IARH fractures in skeletally immature children are deceptive injuries which are often underestimated. Surgeons should be aware of these fractures, especially when a discrepancy between the clinical signs and symptoms, and the radiologic appearance exists, as this may be the only red flag that allows their identification in the acute setting. An early and accurate diagnosis followed by prompt and more aggressive treatment when necessary is mandatory for successful results. Level of Evidence: Level IV—case series.

Clinical and radiological outcome of Mason-Johnston types III and IV radial head fractures treated by an on-table reconstruction

“…Radiographs were evaluated for nonunions, in-congruencies, loss of reduction, radial head necrosis (dissolving of the radial head), heterotopic ossifications classified according to Hastings and Graham [ 19 ], sings of posttraumatic osteoarthritis, implant failure or loosening. Radiographic sings of posttraumatic osteoarthritis were rated according to the Broberg and Morrey classification [ 20 ] as grade 0 (normal joint), grade I (minimal joint space narrowing and osteophyte formation), grade II (moderate joint space narrowing and osteophyte formation) and grade III (severe joint space narrowing and osteophyte formation).…”

Corrective Osteotomy for Symptomatic Radial Head and Neck Malunions in the Skeletally Immature

“…Furthermore, the importance of radiocapitellar joint congruency has been underemphasized in commonly used references, despite certain literature highlighting its importance 7,11,12,21–24. Providers should be encouraged to inspect all radiographic views 3,4,17,25–29. In cases where the joint is not congruent, acute intervention should be considered regardless of measured angulation due to the risk of progressive radiocapitellar instability, impingement, and eventual arthrosis 7,11,12…”

“…1,2,7,12 Functional outcomes were assessed using the Broberg and Morrey Elbow Scale (Table 1). 16,17 Pain was assessed as a binary variable (yes/no). Acceptable follow-up was defined as ≥ 6 months upon confirmed radiographic healing or upon clinic discharge.…”

“…7,11,12,[21][22][23][24] Providers should be encouraged to inspect all radiographic views. 3,4,17,[25][26][27][28][29] In cases where the joint is not congruent, acute intervention should be considered regardless of measured angulation due to the risk of progressive The scale ranges from 0 to 100, with higher scores indicated better outcome. Raw scores are assigned categorical ranks: poor (0 to 59), fair (60 to 79), good (80 to 94), excellent (95 to 100).…”

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture

“…Dragoni et al . [59] used the OES to evaluate the functional outcome of two groups of skeletally immature patients treated for isolated intra-articular radial head fracture. The two groups showed similar OES scores, although the sample size was reduced in size ( n = 6) and follow-up was short.…”