Session IX - Upper Extremity

Sat., 10/12/13 Upper Extremity, PAPER #102, 3:01 pm OTA 2013

Minimally Displaced Radial Head/Neck Fractures (Mason Type I, OTA Types 21A2.2 and 21B2.1): Are We “Overtreating” Our Patients?

Brandon S. Shulman, BA; James H. Lee, BE; Frank Liporace, MD; Kenneth A. Egol, MD;
Department of Orthopaedics, Hospital for Joint Diseases, NYU Medical Center,
New York, New York, USA

Background/Purpose: Nondisplaced or minimally displaced radial head fractures (Mason Type I, OTA Types 21A2.2 and 21B2.1) are encountered frequently by orthopaedic surgeons following falls on outstretched arms. Although it is widely accepted that these fractures have excellent outcomes, there is no defined algorithm for the non-operative treatment radial head fractures. The aim of this study is to identify medical, radiographic, and demographic factors that predict full return to preinjury function for patients with Mason Type I radial head fractures treated nonoperatively.

Methods: We conducted a retrospective review of every patient who presented with a closed radial head/neck fracture seen at our tertiary care specialty institution in the past 2 years. A search of ICD-9 code 813.05, closed fracture of the radial head/neck, in our electronic record system yielded 82 consecutive patients with closed radial head/neck fractures. Initial injury radiographs were analyzed for fracture classification, displacement, size of effusion, and intra-articular fracture. Injury mechanism, additional injuries, and demographic information were recorded. For patients treated nonoperatively, follow-up intervals, physical exam scores, radiologic information, and physical therapy attendance were recorded for each outpatient visit. Statistical analysis of factors leading to full recovery was conducted.

Results: 54 patients (66%) were determined to have 56 nondisplaced or minimally displaced (2 mm or less) Mason Type I radial head fractures without additional injury to the affected limb. All patients in this cohort were treated nonoperatively and no patients in this cohort developed a complication or had any medical or surgical intervention other than physical therapy. Treating surgeons recommended a second outpatient follow-up visit with radiographs for 49 of 54 patients (91%), and of the patients who returned for a second follow-up, 16 of 27 (59%) were recommended to return for a third follow-up with radiographs. The average number of additional radiographs taken of the affected elbow after initial presentation was 4.4 (range, 0-12) for patients who returned for any follow-up. The presence of intra-articular fractures, 1 to 2 mm of displacement, and high-energy injury mechanisms was not significantly associated with recommendation for a second outpatient follow-up, third outpatient follow-up, or with the number of additional radiographs ordered beyond the initial exam. Pain with palpation of the radial head and range of motion deficits (both assessed at the second outpatient visit) were not associated with recommendation for a third outpatient follow-up or with the number of additional radiographs ordered beyond the initial exam.

Conclusion: In this study of patients with isolated, nondisplaced or minimally displaced radial head fractures, no patient developed a complication or needed subsequent surgery. Orthopaedic surgeons are likely overtreating patients with Mason Type I radial head fractures by recommending frequent follow-up without modifying treatment, leading to unnecessary patient visits, radiation exposure, and increased health-care costs.

Alphabetical Disclosure Listing

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.