The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Uncomplicated Mason Type-II and III Fractures of the Radial Head and Neck in Adults: A Long-Term Follow-up Study"
by Pär Herbertsson, MD, et al.

Commentary & Perspective by
Robin R. Richards, MD, FRCSC*,
Sunnybrook and Women's College Health Sciences Centre and the University of Toronto, Toronto, Ontario

The authors of this study had access to an enviably comprehensive case documentation system in Malmo, Sweden, where fewer than 3% of patients within the city received care outside of the local hospital system. The study is all the more remarkable in that all radiographs and reports had been archived at the local hospital for the past half century, allowing re-evaluation and retrospective reclassification of the fractures with the use of the primary radiographs. Accordingly their study, with a mean follow-up of nineteen years, represents a unique contribution to the literature.

The authors were able to identify 100 individuals who had been 16.5 years of age or older at the time of the fracture and who were still living in the city. Of these 100 individuals, seventy-five were examined clinically and radiographically. The other twenty-five were evaluated with a questionnaire. Most of the injuries (seventy-seven of 100) were the result of low-energy trauma. Most patients (seventy-six of 100) had Mason type-II fractures, and twenty-three of these fractures involved the radial neck. Forty-four patients were not immobilized, whereas thirty-four were treated with cast immobilization for a median of two weeks. A minority of patients (twenty-two) had operative treatment initially, whereas nine of seventy-eight patients had secondary surgical treatment in the form of radial-head excision a mean of thirteen months after the initial injury. Seventy-five patients were examined clinically with goniometric assessment of the range of motion, measurement of grip strength, and determination of forearm circumference.

At follow-up, most patients (seventy-seven of 100) had no subjective symptoms in the previously injured elbow. Only twelve of 100 subjectively reported stiffness, and five of 100 reported weakness and numbness in the hand. The mean range of motion was from −4° to 138° of flexion, with a mean reduction in supination of 3°. According to the Steinberg classification, 84% of the outcomes were classified as good; 11%, as fair; and 5%, as poor.

Radiographic analysis found cyst formation in forty-six elbows and osteophytes in forty-two. Only eight elbows had a reduction in the joint space of >1 mm compared with the opposite elbow, and there were no cases of nonunion, avascular necrosis, proximal radioulnar synostosis, or periarticular ossification. A reduction in the joint space was seen in only eight previously fractured elbows, whereas a reduction in the joint space was seen in six of the uninjured elbows with no history of previous fracture.

The authors acknowledged that they were not able to identify with certainty each and every fracture within the defined population, although they did note that their follow-up period was one of the longest published to date and the sample was larger than in most previous studies. They noted that the treatment provided for their patients was not randomized or even standardized. The paucity of symptoms in the authors' series at follow-up was remarkable as was the mobility of the elbow, with mean residual deficits of only 2° in elbow flexion, 3° in elbow extension, and 3° in supination compared with the ranges of the uninjured elbow.

The authors noted that there was a tendency for patients with secondary excision of the radial head to have an inferior outcome in terms of subsequent minor complaints compared with those who had primary excision of the radial head and speculated whether this difference was due to the severity of injury, but they could not verify this hypothesis. The authors also noted that, even though degenerative change was very frequent, there was no correlation between the degenerative changes and pain or loss of motion, which occurred in only a minority of patients. They suggested that additional long-term studies of larger samples of patients should be performed to compare the outcome of primary and secondary radial head excision.

The authors concluded that isolated and closed Mason type-II or III fractures of the radial head or neck in adults usually have a favorable long-term outcome. Their contribution is timely in view of the frequency with which open reduction and internal fixation and primary radial head replacement of the radius have has been performed in recent years. The authors' practice environment is ideally suited to a prospective study, and it is hoped that either they or others will develop a prospective randomized trial that compares closed management, radial-head excision, open reduction and internal fixation, and radial-head replacement of equivalent types of radial-head fractures. Like any good study, that of Herbertsson et al. raises important questions that need to be answered by additional study. We are thankful to the authors for increasing our understanding of the long-term outcome of uncomplicated displaced fractures of the radial head and neck in adults.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.