Dear Ashok

For me all articular fracture should be treated with open and anatomic reduction associated with absolute stability. In the 1st postoperative day the patient begins active movements of the elbow. I remember the AO philosophy : Life is movement and movement is life. In this case I prefer open reduction and fixation with screws (mini fragments)

Dear Nelson, I totally agree With you and That's exactly what We did, open reduction and fixation with screws. I was just wondering what would be the best position of posterior slab (Supine or Mid-prone), suppose Mason type I fracture or sometimes even Type II fracture and we choose conservative treatment ? Thank you.

Hi guys

I alsa agree with the method choice, but I am not shure what position of forearm is the best. I think it depends on fracture patern and mechanism of injury- I mean position (rotation) of forearm during accident. So it seems to be that CT scan can be helpful for assessment. But u have to ask radiologist or technician what was the psision of hand during examination ( supination, neutral or pronation).

Any comments?

Thanks

Dariusz

Dear Ashok, I really like your questions. I think in case of an impression exceeding 2-3mm I would rather choose ORIF. We recently published a metaanalysis for this topic, just in case you want to have more 'evidence' (http://www.ncbi.nlm.nih.gov/pubmed/23664241). If you are in doubt, whether a fracture is stable or not, degree of pain while movement may sometimes direct decision making. Pronation or supination for X-ray is probably more often determined by patient's pain than by order. Best regards, Hagen.

Dear Hagen,

Thank You.

I am of the opinion that this fracture must be treated operatively. The problem with conservative treatment is that you risk two complications: 1. displacement and 2. stiffness of the elbow. I will do a CT SCAN because the x-rays will not show me the extent of communition which may prove problematic during operation: I may encounter problems that I never anticipated.

If you go conservative, the position of the forearm does not reaaly matter because the position of the forearm cannot be relied on to prevent displacement. the radial head fracture is not attached to the soft tissue and therefore there are no soft tisuues to tension in order to maintain the fractures in place.

ORIF is the treatment of choice for Mason Type II radial head fractures.

Dear Nkosana and Panayot,

Thank you very much.

Dear all, this displaced radial head fracture needs open reduction and internal fixation, but that does not mean that all Mason 2 type fractures should be treated surgically. There are several recent papers in pubmed showing that nonoperative treatment gives the same result. So we should not generalize that all Mason 2 fractures should send to the OR. CT helps if displacement is unclear, or to be sure that it is not a Mason type 3.

Mason II fractures are for either conservative or operative treatment, but all depends on the "personallity" of the fracture, Displacement and stability of the medial structures is necessary to be examined and reported. This is a displaced fracture of the radial head. It will be obligatory in my books to be fixed. This will give more stability also to potential injuries of the medial collateral ligament. Due to the displacement it would be wiser to have a CT scan to investigate if there is any comminution if the lateral view is not clear enough. The further imaging will determine the type of fixation, as it will make clear the type of fracture. As you are asking about non operative management plaster can be placed at any of the two positions as the head is not attached to any soft tissue so it is not really important the supination, neutral or pronation

As many have stated before, the radiological findings of a particular fracture alone does not indicate the absolute indication of operative vs. non-operative treatment. Other factors must be considered, most important in my opinion, a good physical examination under local anesthetic in the joint + hematome drainage at the same time, which is easily done in the acute dpt. or as an outpatient procedure in the office. If the elbow is stable and there is no mechanical impingement during prono-supination of the forearm, non-operative treatment can be discussed with the patient. This implies a short period of immobilization with a slab (I don´t have any input on what degree of prono-supination), and early mobilization with the help of PT in about 7-10 days, good analgesia is needed usually with opiates during the initial PT period. I had very satisfactory results with this approach. Of course follow-up is needed after this first period to re-asses and maintain or not the initial plan. If the first assessment shows a mechanical block during prono-supination there is no doubt the recommendation will be ORIF. A CT is always a good complementary test that I also would recommend if easily available, but it should be interpreted carefully depending on your clinical experience with this type of fractures.

Thank you all.