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Radial Head Fracture: a Potentially Complex Injury UvA-DARE (Digital Academic Repository) Radial head fracture: a potentially complex injury Kaas, L. Publication date 2012 Document Version Final published version Link to publication Citation for published version (APA): Kaas, L. (2012). Radial head fracture: a potentially complex injury. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:05 Oct 2021 Radial head fracture: A potentially complex injury Laurens Kaas The printing of this thesis was financially supported by: Anna Fonds te Leiden, Arthrex Nederland BV, Biomet Nederland BV, Boehringer Ingelheim BV, Mathys Orthopaedics BV, Nederlandse Orthopaedische Vereniging, Synthes BV, Tornier NV, Smith & Nephew Nederland CV, and Raad van Bestuur Amphia ziekenhuis. which is gratefully acknowledged. ISBN: 978-94-6169-218-4 Layout and printing: Optima Grafische Communicatie, Rotterdam, The Netherlands Cover design and artwork: Sandra Kaas © Copyright 2012 L. Kaas. All rights reserved. No part of this publication may be repro- duced, stored in a retrieval system or transmitted in any form or by any means, without prior written permission of the author. Radial head fracture: A potentially complex injury ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. D.C. van den Boom ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op dinsdag 10 april 2012, te 14.00 uur door Laurens Kaas geboren te Heerlen PROMOTIE COMMISSIE Promotor: Prof. dr. C.N. van Dijk Co-promotor: Mevr. dr. D. Eygendaal Overige leden: Prof. dr. P.J.E. Bindels Prof. dr. P.M.M. Bossuyt Dr. M. Maas Prof. dr. F. Nollet Prof. dr. D.B.F. Saris Faculteit der Geneeskunde TAbLE OF COnTEnTS Part I: General introduction and current issues General introduction and outline of the thesis. Chapter 1: L. Kaas 9 Management of radial head fractures: current concepts. Chapter 2: L .Kaas, J.B. Jupiter, C.N. van Dijk, D. Eygendaal 23 Shoulder & Elbow 2011; 3(1): 34-40. (Invited review) Part II: Epidemiology of radial head fractures and the relation to osteoporosis Epidemiology of radial head fractures. Chapter 3: L. Kaas, R.P. van Riet, J.P.A.M. Vroemen, D. Eygendaal 41 Journal of Shoulder and Elbow Surgery 2010; 19(4): 520-523. Radial head fractures and osteoporosis: a case-control study. Chapter 4: L. Kaas, I.N. Sierevelt, J.P.A.M. Vroemen, C.N. van Dijk, D. Eygendaal 49 Submitted. Part III: Associated injuries of radial head fractures Magnetic resonance imaging findings in 46 elbows with a radial head fracture. L. Kaas, J.L. Chapter 5: Turkenburg, R.P. van Riet, J.P.A.M. Vroemen, D. Eygendaal 59 Acta Orthopaedica 2010; 81(3): 373-376. Magnetic resonance imaging in radial head fractures: Most injuries are not clinically relevant. L. Kaas, J.L. Turkenburg, R.P. van Riet, J.P.A.M. Vroemen,C.N. van Chapter 6: Dijk, D. Eygendaal 69 Journal of Shoulder and Elbow Surgery 2011;20(8): 1282-1288. Ulnar collateral ligament instability of the elbow. Chapter 7: D. Eygendaal, L. Kaas Evidence-Based Orthopedics, 1st edition. M. Bhandari (ed.) Wiley- 83 Blackwell, Oxford; 2012: Page 781-786. Part IV: Classification and treatment Intra- and interobserver reliability of the Mason-Hotchkiss classification. Chapter 8: L. Kaas, M.A. van Hooft, M.P. Somford, L.H.G.J. Elmans, C.N. van Dijk, D. Eygendaal 97 Submitted. Treatment of Mason type II radial head fractures: a systematic review. Chapter 9: L. Kaas, P.A.A. Struijs, D. Ring, C.N. van Dijk, D. Eygendaal 105 Submitted. Results of the Judet bipolar radial head prosthesis in 33 patients with a minimal follow-up of 2 years. Chapter 10: L. Kaas, I.F. Kodde, R.P. van Riet, C.N. van Dijk, D. Eygendaal 117 Submitted. Part V: General discussion, summary and conclusions Discussion and summary Chapter 11: L. Kaas 131 Conclusions and recommendations for future research Chapter 12: L. Kaas 141 nederlandstalige algemene discussie, samenvatting, 147 conclusies en aanbevelingen voor toekomstig onderzoek Dankwoord 156 bibliography 161 Curriculum Vitae 163 Part I General introduction and current issues Chapter 1 General introduction Laurens Kaas “The fracture of the head of the radius is a serious injury, and whilst the prognosis is good for recovery of a useful elbow, rarely it is a normal elbow.” Jones SG. Fractures of the head and neck of the radius - seperation of the upper radial epiphysis. New England Journal of Medicine 1935;212:914-7. 10 Chapter 1 FunCTIOnAL AnATOMy The elbow plays an important role in the flexion-extension of the arm and supination- pronation of the forearm. It consists of three bones: the distal part of the humerus and the proximal parts of the ulna and the radius. These three bones articulate in the elbow in three separate joints: the radiohumeral (or radiocapitellar) joint, radioulnar joint and the ulnohumeral (or ulnotrochlear) joint. The radial head is an oval-shaped, concave dish that articulates with the spherical capitellum.1 It makes no contact with the capitellum during extension, but during flexion the radial head moves proximally and contact with the distal humerus increases. Supination decreases radiocapitellar contact and pronation increases the contact.2 The majority of the load from the forearm through the elbow is transferred by the radial head, especially in full extension. About 57% of the load applied to the hand crosses the radiocapitellar joint. The other 43% passes the ulnohumeral joint. However, this is highly dependent on the position of the elbow and muscle loading.3 The three elbow joints are surrounded by a joint capsule. It covers the tip of the olecra- non, the coronoid process and radial fossa, but not the humeral epicondyles. The capsule is most lax at 80 degrees of flexion and holds a capacity of 25-30 mL in this position.1, 4 Patients with acute elbow injury therefore find this position more comfortable.1 The me- dial ligament complex consists of three parts: anterior, posterior and transverse segments (Fig. 1). The anterior and posterior ligaments originate at the medial epicondyle and insert to respectively the distal end of the coronoid process and medial margin of the semilunar notch of the olecranon. They contribute to valgus stability. The transverse part contributes little or nothing to elbow stability. The lateral collateral ligament complex contributes to 1 2 3 Figure 1: Anatomy of the medial collateral ligament complex. 1 = anterior, 2 = posterior, 3 = transverse ligament. General introducti on 11 1 2 1 3 Figure 2: Anatomy of the lateral collateral complex. 1 = annular ligament, 2 = radial collateral ligament, 3 = lateral ulnar collateral ligament varus stability and consists of two parts: the radial collateral ligament and the annular ligament. The radial collateral ligament originates from the lateral epicondyle and inserts at the base of the coronoid process. The annular ligament originates and inserts on the lesser sigmoid notch and maintains contact between the radial head and ulna (Fig. 2).5 Elbow stability results from the interplay of the arti cular surfaces, ligaments and muscles. The radial head plays an important role in maintaining elbow stability. The three primary stati c stabilizers of the elbow are the ulnohumeral arti culati on and the medial and lateral collateral ligaments. Secondary constraints include the radial head, capsule and the common fl exor and extensor origins. The muscles around the elbow, especially the anconeus, triceps and biceps, functi on as dynamic stabilizers. If the coronoid process or medial collateral ligament (MCL) are injured, the radial head becomes a criti cal stabilizer.6 The radiocapitellar joint is the primary restraint to proximal migrati on of the radius. The interosseus membrane, a fi brous membrane between radius and ulna, and the triangular fi brocarti lage complex (TFCC) at the distal radioulnar joint also contribute to longitudinal stability of the forearm.7 Normal range of moti on (ROM) is from full extension of 0° to 145° of fl exion. Some hyperextension can be normal. Pronati on and supinati on show large normal variati ons, but usually are 85° of pronati on and 80° of supinati on. Interindividual variati on is wide.3 Full ROM is not necessary for normal acti viti es of daily living. Morrey et al. showed that for most acti viti es in daily life fl exion-extension of 130° to -30° and a pro-supinati on arc of 100° would be suffi cient.8 12 Chapter 1 RADIAL HEAD FRACTuRE Fracture of the radial head is common and accounts for up to one third of all elbow fractures.9 The incidence in the general population is estimated at 2.5 to 2.9 per 10,000 inhabitants per year.10, 11 Fracture of the radial head was probably first described by Paul of Aegina (AD: 625-690)12: “The ulna and radius are sometimes fractured together and sometimes one of them only, either in the middle or at one end as the elbow or the wrist.” In the first decades of the 20th century it was stated that fracture of the radial head was caused by direct trauma, Flemming found that 75% of the cases were caused by direct injury.13 14 However, it is now generally agreed that the radial head fracture is the result of a fall on the outstretched hand with the elbow partially flexed and pronated.9, 15 (Fig.
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