Clinical Faceoff: Slightly Displaced, Isolated, Partial Articular Fracture of the Radial Head

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Fractures of the radial head are common. The vast majority either are isolated injuries (meaning no other fractures or ligament injuries) that cannot be seen on radiographs (occult), nondisplaced, or are displaced less than 2 millimeters. Most fractures displaced more than a few millimeters are associated with other fractures or ligament injuries. Once it is determined that the fracture is stable and isolated, the focus of treatment becomes retaining elbow range of motion. It can be counterintuitive to stretch an injured joint, but the average patient achieves normal or near-normal motion during stretching—some more quickly than others.
Fractures with 2 mm or 3 mm articular step-off at worst on radiographs are considered for surgery. Fracture displacement might block forearm rotation, but radiocapitellar and proximal radioulnar arthrosis only rarely occur following these injuries. When forearm motion is limited, it is usually related to pain and protectiveness. Confident stretching typically restores motion, and true bony blocking of ROM is uncommon in patients with nondisplaced or minimally displaced fractures. If forearm motion seems blocked, the first step is to wait a few days to allow the intra-articular pain and hematoma to dissipate. If the possibility of a bony block persists a week after the injury, injecting anesthetic into the joint can usually rule it out.
It is not clear what to do if a patient has full motion but also has crepitation. Nonunions are an occasional incidental finding; in 16 years of practice I have only seen it when we recalled patients for research purposes. There is general agreement that the vast majority of people with slightly displaced fractures do not benefit from surgery, but the occasional patient with crepitation or a bony block to motion leaves us wondering where to draw the line.
I asked George S. Athwal MD from the Hand and Upper Limb Centre at the University of Western Ontario and Neal C. Chen MD, Interim Chief of the Hand and Upper Extremity Service at Massachusetts General Hospital to debate these issues. If experts like these cannot agree on a clear path forward, then we should use decision aids and help patients discover their treatment preferences based on their values.
David C. Ring MD, PhD:The long-term outcomes of stable, slightly (2 mm to 3 mm articular step off at worst on radiographs) displaced partial articular fractures of the radial head with no associated fractures or dislocation are quite good. How can we be sure that surgery provides a benefit that outweighs the risks, discomforts, and inconveniences?
George S. Athwal MD: First off, the words “stable” and “slightly displaced” need to be defined objectively. In an ideal world with limitless resources, the best way to scientifically ensure that surgery provides a substantial clinical benefit is with a large multicenter randomized controlled trial. Unfortunately, a study of this design would demand substantial resources and require long-term followup. For such a study, a return on investment analysis would have to be done to determine if there is a net benefit to society over time. For example, a randomized controlled trial may cost USD 5 million to conduct. However, the net benefit to society could be a 50x return on investment, which would indicate a study of high societal value. Based on my assessment of the current and historical evidence, I believe, at best, surgery would demonstrate equivalence. It would be highly unlikely that surgery would be substantially better.
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