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NON UNION FRACTURE SHAFT OF RIGHT FEMUR

INTRODUCTION

Radial head fractures are one of the most common types of forearm injuries. These injuries may be uncomplicated or have complex injury patterns. The EssexLopresti lesion is an example of such an injury. The treatment options for radial head fractures are excision, open reduction with internal fixation and arthroplasty. With improved fixation devices and techniques, the role of open reduction and internal fixation is expanding. However arthroplasty is becoming more reproducible and successful with improvements in techniques and material making the role of excision of the radial head become more limited. Essex-Lopresti injuries are more complex and difficult to treat than uncomplicated radial head fractures. We shall highlight an example of a treatment option at the end of the discussion.

CASE REPORT

Mr.R is a 28 year old, Indonesian, male, was Chief Complaint admitted to hospital on May 27, 2013 with difficulty walking since approximately 4 months ago. He had motor vehicle accident. He was brought to hospital in Bulukumba but didnt assessed properly due to financial problem. Instead of having medical treatment, he went to shaman and treated with massage. The massage reduced the pain and bruised. But, he still had difficulty walking and need to use walking aid. He also complaint that his leg doesnt has symetric length. He had no previous medical illnesses. There was no history of unciousness On physical examination, his Glasgow Coma scale was 15 (Eye4 Motoric6 Verbal5) and he had a right periorbital haematoma. His right arm was tender and swollen at the elbow, the whole length of the forearm and the wrist. There was limited elbow flexion-extension as well as pronation-supination. His range of wrist motion was also markedly reduced. There was a transverse laceration wound over the palm of his right hand extending from the 1st web space, overlying the MCP joints of the

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index, middle and ring fingers up to the little finger. Fortunately there was no neurovascular deficit and function of all the flexor tendons to the fingers were intact. Plain radiographs of the hand, wrist and forearm of the patient revealed a comminuted fracture of the base of the 4th and 5th metacarpal, comminuted fracture of the radial styloid process, a disrupted DRUJ joint, an undisplaced segmental fracture of the proximal and distal 3rd of the ulna and a comminuted and separated fracture of the radial head Mason Type 3. The elbow joint was however not dislocated. The radius had migrated proximally and a diagnosis of an Essex-Lopresti lesion with disruption of the intraosseous membrane was made.

The patient was started on IV Zinacef 750 mg tds, the wound was irrigated with copious amounts of normal saline, a backslab applied and he was planned for an emergency operation under the trauma list the following day.

The following morning, the emergency operation was done under general anaesthesia. A tourniquet was applied and the forearm was cleaned and draped in the usual manner. The palm wound was explored and debrided and sutured with dafilon 4/0 sutures.

An intramedullary K-wire measuring 2.0 mm was inserted through the olecranon to stabilize the ulna under image intensifier guidance and was subsequently buried. A lateral Kocher approach was utilized to gain access to the radiocapittelar joint. There were three large radial head fragments, consisting of half the radial head and 2 quarter fragments. The half and one of the quarter fragments was excised but the other quarter piece was left in situ as it was inaccessible through the lateral wound. The fragment was not in the elbow joint. The lateral wound was closed in layers. The base of the 4th and 4th metacarpals were then reduced and fixed with 2 Kwires size 1.6 mm through a incision made at the fracture site. Attempted reduction of the DRUJ failed and it was subsequently stabilized in situ with a transverse K-wire size 2.0 mm. A backslab was applied to immobilize the forearm.

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Post-operatively the arm was elevated on a dripstand and the patient was started on Cap Indomethacin 25mg bd to prevent heterotopic ossification. Intravenous antibiotics were continued. Check radiographs noted a well fixed ulna bone. The radius however was proximally migrated as seen in preoperative radiographs and there was a positive ulnar variance of appromately 8 mm. The DRUJ was fixed in that position. There was no evidence of any nerve injuries post-op. The case was discussed during census and the decision was to maintain the current fixation as it was and mobilize the hand as soon as possible to maintain the function of the hand in view of the wound in the palm. The wound was clean and the patient was discharged at 1 week post-op.

DISCUSSION

In 1951, Essex-Lopresti described a combination of radial head fractures, interosseous membrane disruption, and triangular fibrocartilage complex injury with subsequent longitudinal forearm instability. [5] Fractures of the radial head are relatively common injuries, accounting up to 5% of all fractures and over 30% of all elbow fractures. [1]

Longitudinal forearm stability is maintained through the interaction of several anatomic structures including the interosseous membrane, a fibrous tissue with an oblique orientation form the radius to the ulna. The interosseous membranes load transferring ability reduces the forces placed on the radiocapitellar articulation, thereby protecting this joint. Large sustained loads occur after radial head resection with concurrent interosseous membrane tears resulting in the proximal migration of the radius and disruption of the distal radioulnar joint. There are three specific types of injuries related to proximal migration of the radius. These are the Essex-Lopresti lesions, Galleazi fractures, and distal radius fractures. [5]

The elbow joint is a trochoginglymoid providing arcs of motion in two axes, flexion-extension and pronation-supination. The radial head has various functions. Firstly, it articulates with the ulna forming the proximal radio-ulnar joint. This

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articulation consists of a 260-degree arc that is covered by articular cartilage. The safe zone was introduced by Smith and Hotchkiss to determine the arc of the radial head that tolerates prominent hardware without limiting prono-supination. The safe zone is an arc of approximately 110 of the outer radius of the radial head that does not articulate with the proximal ulna. Intraoperatively, this zone is defined roughly as 65 anterior and 45 posterior to the line bisecting the anterior and posterior head with the forearm in neutral rotation. [1]

The second function of the radial head to articulate with the capitellum at the radiocapitellar joint. It transmits up to 60% of the axial load from the forearm through the radiocapitellar joint. In complex injuries such as Essex-Lopresti lesions as seen in this patient, the intact radial head becomes important in preventing proximal migration of the radius with resultant wrist pain and disability. [1]

Thirdly, it transmits axial loads to the capitellum at this joint; and fourthly the radial head acts as a secondary stabilizer to valgus stress in the intact elbow. [1]

The antebrachial interosseous membrane is a fibrous structure located in the midsubstance of the forearm. It lies between the radius and ulna and possesses distinct orientation and direction. All the fiber bundles except the proximal band are directed in an oblique direction from the radius to the ulna at an average angle of 20. The proximal band is directed at an angle of -20. The average length of the radial origin and ulnar insertion is 10.6 cm. The functions of the membrane include forearm stability, a tendon for deep extensor and flexor muscle attachment, reduction of bone separation, and force transfer. [5] When a force is applied to the wrist, the distal radius carries 68% of the load and the distal ulna carried 32%. Proximally, the radius maintained 51% of the force whereas the proximal ulna 49%. With subsequent sectioning of the interosseous membrane, the forces measured at the proximal and distal radius and ulna were equal. [5]

In radial head fractures, the detection of a combined injury is the first step in its treatment. Approximately 5% of radial head fractures is complicated by distal

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ligamentous disruption. There must be a high index of suspicion to avoid missing this injury because it is very difficult to treat when not properly treated inititally. [6] Mason in 1954 classified radial head fractures into three types: Type I nondisplaced fractures; Type II displaced fractures; and Type III comminuted fractures. Johnston in 1962 further classified a radial head fracture and concurrent elbow dislocation as Type IV. The concomitant ligament injury is not addressed by the classification system. [4]

Treatment options for radial head fractures include, i) nonoperative treatment; ii) excision; iii) open reduction and internal fixation; and iv) excision with arthroplasty.

In the past, the radial head was once considered a surplus, or expendable part of the skeleton. [7] Historically, the primary surgical treatment for radial head fractures was simple excision. [2] It is now recognized that the radial head is an important stabilizer of the elbow and forearm articulations. [7]

Non-operative treatment is generally recommended for the treatment of nonor minimally displaced Mason type 1 radial head fractures. The mainstay is early, active range of motion of the elbow both in flexion-extension and prono-supination arcs. A posterior splint may be provided for comfort but should be removed for active range of motion. [1]

The indications for excision of the radial head for displaced radial head fractures have dwindled with advances in the operative reconstruction of the radial head. [Carroll 1998] Primary excision is most commonly recommended for unreconstructable, displaced radial head fractures in an otherwise stable elbow. Sanchez-Sotelo et al. concluded in a small study of 10 patients that acute radial head excision provides satisfactory short-term clinical results and a high rate of patient satisfaction in the treatment of elbow fracture-dislocations when there is comminuted nonsalvageable radial head fractures with no other associated intraarticular fractures.

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[8] Conversely, there are many potential complications associated with radial head excision. These include pain, instability, new bone formation around the resection site, and cubitus valgus. [2] Other published late findings include minor losses in elbow motion, loss of strength, radiographic evidence of osteoarthritis, and some degree of proximal radial migration (average 2 mm). [1] The radial head of this patient was excised as the surgeon believed that the radial head would undergo avascular necrosis as there was no soft tissue attachment whatsoever. The radius had already migrated approximately 8 mm at the time of injury in view of the interosseous membrane rupture hence the diagnosis of an Essex-Lopresti lesion.

The indications for open reduction and internal fixation include mechanical block of motion, greater than 1/3 of the articular surface involved, 2 to 3 mm displacement, and 2 to 3 mm articular depression. Other indications include lesions of the capitellum cartilage, a proximal ulnar fracture, an injury to the ulnar collateral ligament and an injury to the DRUJ. Contraindications include older age of patients, underlying osteoarthritis and injury to the capitellum [2]

Ring et al in 2002 retrospectively analyzed the functional results following open reduction and internal fixation of 56 patients with radial head fractures (Mason type II 30 patients; Mason type III 26 patients). The authors noted that 13 of the 14 patients with Mason Type III comminuted fracture with more than 3 articular fragments had unsatisfactory results. In contrast, all 15 patients with an isolated, noncomminuted type II fracture had a satisfactory result. There were no early failures, only one nonunion, and the arc of forearm rotation was 100 in twelve patients with type III fracture with 2 or 3 simple fragments. They concluded that open reduction and internal fixation is best reserved for minimally comminuted fractures with 3 or fewer articular fragments. [7]

Schuind in 1999 observed some major complications after osteosynthesis not found after resection. These include radial head osteonecrosis, nonunion, intermittent locking and secondary displacement justifying a reoperation in 32%. However, at final follow-up, the results were significantly better after osteosynthesis (excellent or

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good in 80% versus 59% after resection. The complications after radial head resection included ulnocarpal abutment in 15%, cubitus valgus in 85%, elbow instability in 37%, and ulnohumeral ostoearthrosis in 2%. The author concluded that the tendency is now to internally fix displaced radial head fractures. However, serious complications and poor results sometimes occur after this procedure. Radial resection remains a valuable alternative, especial when it is impossible to obtain an anatomical and stable reduction allowing early mobilization. [9]

Replacement arthroplasty was first described in 1941 by Speed using ferrule capsules. Since then there has been multiple designs and materials used for prosthetic reconstruction of the radial head. [1] These include acrylic, stainless steel, silastic, and articulating CoCr prosthesis. [2] Open reduction and internal fixation has been advocated by numerous authors, however there are fractures that are not amenable to successful internal fixation, such as severely comminuted fractures that are difficult to fix because of poor bone quality or inadequate fixation of very small fragments. Such fractures are probably better treated with arthroplasty, especially if there is concomitant elbow or wrist instability. Replacement provides temporary or permanent lateral instability for associated ulnar collateral ligament healing and axial stability for interosseous membrane and distal radioulnar joint healing. [2]

The silicone prosthesis has the worst outcome as a result of its poor wear characterisitics in the elbow and its tendency to induce an aggressive synovitis. [1] Silicone implants have an overall increased failure rate as compared with metallic implants, including reactive synovitis, inflammatory arthritis, and fractures of silastic implants. The amount of axial stability is also questionable. [2] This implant has been all but abandoned in the United States. [6] Use of the metal radial-head have been described from the 1950s with reports of satisfactory outcome. Metallic implants have better force transmission and less tendency to failure. [2] Knight et al. in 1993 published their results using Vitallium prosthesis in Mason III and IV injuries. Twenty-four out of 31 patients had negligible elbow pain and only 2 required removal for painful loosening. Minimum problems

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with dislocation or prosthetic failure were encountered. They concluded that metallic prosthesis have a role in the treatment of comminuted fractures of the radial head in complex elbow injuries. [3] A review of the literature by Furry however does not show consistently better results with radial head arthroplasty versus open reduction and internal fixation. Generally, the radial head should be preserved when technically feasible and replaced when necessary. [2] With continued improvement in techniques and materials, radial head arthroplasty may become the procedure of choice for all non-reconstructable radial head fractures. [1]

The extent of the problem concerning this patient has not been fully addressed. As stated earlier, this patient sustained a complex Essex-Lopresti lesion and not just an isolated radial head fracture. McGinley in 2001 reported a similar case of a 30year-old left-hand dominant man who fell 25 feet from scaffolding resulting in a comminuted fracture of the radial head and DRUJ disruption of his left upper limb. Initial treatment consisted of an attempted open reduction and internal fixation of the radial head fracture and Kirschner wire cross pinning of the DRUJ. Unfortunately the radial head was highly comminuted and irreparable and a silicone radial head replacement was inserted. The K wires were removed 6 weeks after surgery and ROM was instituted. The radial head prosthesis was removed 3 months after surgery to prevent silicon breakdown and synovitis. Three months later progressive ulnar sided wrist pain had ensued and an 8 mm positive ulna variance was noted on radiographs. The patient was managed with a rigidly fixed distal radioulnar arthrodesis and creation of an ulnar pseudoarthrosis to allow early forearm rotation and wrist motion. Nine months after injury, the patient complained of persistent elbow pain with flexion and extension, and pronation and supination. Radiographs revealed loss of radiocapitellar space and abutment between the radius and capitellum. Without any viable technique to restore forearm stability, a single-bone forearm was recommended and performed with transposition of the distal radius onto the proximal ulna with plate fixation. [5]

CONCLUSION

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Essex-Lopresti lesions are complex injuries that involve fractures of the radial head with loss of the longitudinal forearm stability as a result of interosseous membrane disruption leading to proximal migration of the radius and DRUJ disruption. The radial head in uncomplicated radial head injuries should in general be preserved as far a possible, however radial head replacement is a viable alternative to excision in non-reconstructable radial head fractures. In Essex-Lopresti injuries, the radial head should be preserved. If immediate excision is indicated or unavoidable, a prosthesis should be used to maintain the length of the radius while the interosseous membrane heals. The Essex-Lopresti lesion remains a difficult injury to manage and ultimately, the treatment option for severe membrane disruption combined with proximal migration of the radius is the creation of a single bone forearm.

REFERENCE

1.

Carroll RM, Osgood G, Blaine TA. Radial Head Fractures: Repair, Excise, or Replace? Curr Opin Orthop 2002; 13: 315-22.

2.

Furry KL, Clinkscales CM. Comminuted Fractures of the Radial Head: Arthroplasty Versus Internal Fixation. Clin Orthop 1998; 353: 40-52.

3.

Knight DJ, Rymaszewski LA, Amis AA. Primary Replacement of the Fractured Radial Head with a Metal Prosthesis. J Bone Joint Surg 1993; 75-B: 572-6.

4.

Kupersmith LM, Hausman MR. Fracture-dislocations of the Elbow. Curr Opin Orthop 2001; 12: 356-63.

5.

McGinley JC, Kozin SH. Interosseous Membrane Anatomy and Functional Mechanics. Clin Orthop 2001; 382: 108-22.

6.

Morrey BF. Instructional Course Lectures, the American Academy of Orthopaedic Surgeons. Current Concepts in the Treatment of Fractures of the Radial Head, the Olecranon, and the Coronoid. J Bone Joint Surg 1995; 77A(2): 316-27.

7.

Ring D, Quintero J, Jupiter J. Open Reduction and Internal Fixation of Fractures of the Radial Head. J Bone Joint Surg 2002; 84-A(10): 1811-5.

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8.

Sanchez-Sotelo J, Romanillos O, Garay EG. Results of Acute Excision of the Radial Head in Elbow radial Head Fracture-Dislocations. J Orthop Trauma 2000; 14(5): 354-8.

9.

Schuind F. Displaced Radial Head Fractures: Resection or Osteosynthesis? J Bone Joint Surg 1999; 81-B Suppl II: 191.