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Lack of cortical contact in fragments of radial head fractures indicative of complex injury

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SAN FRANCISCO — Complete loss of cortical contact of at least one fracture fragment is strongly predictive of a complex injury pattern in Broberg and Morrey Modified Mason type 2 fractures, according to a study presented here.

Thierry Guitton, MD, of Boston, Mass., and his colleagues aimed to test the hypothesis that, among partial radial head fractures displaced more than 2 mm, separation of at least one radial head fracture fragment is predictive of a complex injury pattern.

“Radial head fractures are usually classified according to the size and displacement of the fracture fragments, but stability is not considered,” Guitton said at the Combined Annual Meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapies, here. “Therefore, we propose a radiographic definition of stability: complete loss of cortical contact between the fracture fragment and the rest of the proximal radius.”

Trauma database

The investigators used a prospective trauma database and billing records to identify 296 consecutive skeletally mature patients with radial head fractures treated over a 6-year period.

Researchers investigated whether or not there was a complete lack of cortical contact between a fracture fragment and the rest of the proximal radius and used this information to classify 121 consecutive fractures of part of the radial head displaced by more than 2 mm.

Study parameters included predictors of an isolated vs. a complex injury pattern in bivariate and multivariable analyses.

Guitton reported that 30 of the 121 fractures (25%) were classified as having cortical contact, with the remaining 91 displaying no cortical contact. Ten of 30 fractures with cortical contact were part of a complex elbow injury, while 83 of 91 fractures (91%) without cortical contact were reported to be part of a complex elbow injury with an odds ratio of 21.

“Lack of cortical contact with at least one radial head fracture fragment has fair reliability, but the diagnostic performance characteristics suggest that this concept may be useful and it deserves further study,” Guitton said.

Influence on decision making

Moderator Jesse B. Jupiter, MD, praised the study but had numerous questions.

“It's clear that a pure radiographic interpretation without clinical correlation — without accurate imaging on a standard reference — can only be speculative in some cases and cannot be consistent in every case,” he said. “So the question is: How does it influence decision making if you have a split fragment with no contact but no block to motion and no other findings? Will you go and do surgery on that based just on an X-ray evaluation?”

“The study definitely has some limitations,” Guitton conceded. “But I think the take-home message should be that there is a 21-to-1 chance of having a more complex injury with a lack of cortical contact. … Future research would definitely be worthwhile.”

Reference:

• Guitton T, Rineer CA, Ring DC, et al. Unstable radial head fractures. Paper HS-41. Presented at the Combined Annual Meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapies. Sept. 3-5, 2009. San Francisco.