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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 76-78

Simultaneous bilateral Mason type IIb radial head fractures in a young female: Was an increased carrying angle the cause?


Department of Orthopaedics, Our Lady of Lourdes Hospital, County Louth, Ireland

Date of Web Publication23-Oct-2015

Correspondence Address:
Pradyumna R Raval
Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, County Louth
Ireland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-2585.167980

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  Abstract 

Radial head fracture is the most common type of elbow fracture in adults. It results from a fall on an outstretched hand. However, simultaneous bilateral radial head fractures are extremely rare. We report a case of simultaneous bilateral mason type IIb radial head fractures in a young female, which was treated nonoperatively with excellent results.

Keywords: Bilateral, Mason type IIb, nonoperative, radial head fractures, simultaneous


How to cite this article:
Raval PR, Fhoghlu CN, Mahapatra AN. Simultaneous bilateral Mason type IIb radial head fractures in a young female: Was an increased carrying angle the cause?. J Orthop Allied Sci 2015;3:76-8

How to cite this URL:
Raval PR, Fhoghlu CN, Mahapatra AN. Simultaneous bilateral Mason type IIb radial head fractures in a young female: Was an increased carrying angle the cause?. J Orthop Allied Sci [serial online] 2015 [cited 2019 Oct 21];3:76-8. Available from: http://www.joas.in/text.asp?2015/3/2/76/167980


  Introduction Top


Bilateral radial head fractures are a rare entity; of which the incidence of simultaneous bilateral fractures is <1%.[1] Elbow biomechanics plays a vital role in the nature of the injury.[2] Treatment options are largely dependent on the fracture type, with nonoperative treatment recommended for Mason type I and operative treatment recommended for Mason type II–IV radial head fractures.[1] We discuss a case of simultaneous bilateral type IIb radial head fractures treated successfully without surgery.


  Case Report Top


A 47-year-old right-handed lady presented to our clinic with a 3 weeks history of fall on outstretched hands while on vacation abroad. She tripped over a small wall and fell, supporting herself on both palms. Initially, she had pain in both elbows with limited range of movement. Radiographs revealed that she had sustained bilateral radial head fractures. She was placed in above elbow back slabs while abroad.

On clinical examination at our clinic 3 weeks later this patient had minimal tenderness on palpation over the radial head area. There was no swelling appreciated. Her movements were terminally painful, but the intensity of pain was less. She was advised to mobilize within her limits of pain, and bilateral slings were given for comfort. It was evident radiologically that she had sustained bilateral Mason type IIb radial head fractures [Figure 1] [Figure 2].
Figure 1: Initial radiograph of left elbow

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Figure 2: Initial radiograph of right elbow

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At a 6 weeks follow-up, she was much more comfortable, and it was decided to commence mobilisation under the guidance of a physiotherapist.

This patient was regularly reviewed at 3, 6, 9 months, and 1-year. On final follow-up 2 years later her radiographs revealed that the fractures had completely healed [Figure 3] [Figure 4], and she had a painless range of movement [Figure 5], [Figure 6], [Figure 7].
Figure 3: Final radiograph of left elbow

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Figure 4: Final radiograph of right elbow

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Figure 5: Clinical photograph – neutral position

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Figure 6: Clinical photograph – supination

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Figure 7: Clinical photograph – pronation

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  Discussion Top


Radial head fracture is the most common type of elbow fracture in adults and results from a fall on an outstretched hand.[3],[4] The position of the forearm and flexion at the elbow during actual impact play a significant role in the load transfer occurring at the radiocapitellar joint. Maximum forces at the radiocapitellar joint are observed in a pronated forearm with a flexion of <30° at the elbow joint.[5] Varus and valgus angulations at the elbow also play an equally vital role, with almost 97% of patients having a load transmission occurring at the radiocapitellar joint in the valgus position.[6],[7]

Radial head fractures were originally classified by Mason into four types based primarily on the displacement of the fracture fragments.[8] This classification was further modified by Johnston wherein the Essex-Lopresti injury was considered [Table 1].[9] The radial head is susceptible for a fracture because of an angulation of about 15° between the radial neck and shaft.[4],[10],[11] The frequency of radial head fractures is reported to be around 1% of all fractures.[12] A recent study has specifically reported the incidence of simultaneous bilateral fractures to be ə%.[1]
Table 1: Modified Mason classification

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Kovar et al., recommended that all patients with type II–IV radial head fractures should undergo operative fixation for a better outcome. Similarly Kutscha-Lissberg et al. recommended operative fixation for fractures of type IIb and higher.[12] However, a noteworthy point is that Kutscha-Lissberg et al. had only one patient with simultaneous bilateral Mason type IIb injury in their study population.

Our patient had simultaneous bilateral Mason type IIb radial head fractures, which is extremely rare. The senior author is of the opinion that an increased carrying angle in this female patient of 18°could well have caused something like the “nutcracker effect” leading to these fractures. In a classic case of “nutcracker effect,” the medial portion of the radial head is compressed between the capitulum and the radial shaft and lateral part of the radial head.[13] Our patient, however, had bilateral radial head fractures with a minimal lateral displacement of the radial head fragment, hence though not exactly identical, but the mechanism could be similar to that of the “nutcracker” effect. In our opinion, an increased valgus angulation at the elbow and classical position of forearms in pronation during impact compounded the loading forces at the elbow joint resulting in simultaneous bilateral fractures.


  Conclusion Top


Although operative treatment is recommended for Mason type II fractures, we firmly believe that each case is unique and must be treated on its individual merit. A detailed history, specifically of the attitude of the extremity on initial impact and individual anatomic variations should also be considered. The excellent outcome noted in this particular case of late presentation justifies our approach of treating this injury without any operative intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kovar FM, Jaindl M, Thalhammer G, Rupert S, Platzer P, Endler G, et al. Incidence and analysis of radial head and neck fractures. World J Orthop 2013;4:80-4.  Back to cited text no. 1
    
2.
de Haan J, Schep NW, Eygendaal D, Kleinrensink GJ, Tuinebreijer WE, den Hartog D. Stability of the elbow joint: Relevant anatomy and clinical implications of in vitro biomechanical studies. Open Orthop J 2011;5:168-76.  Back to cited text no. 2
    
3.
Muzaffar N, Bashir N, Baba A, Ahmad A, Ahmad N. A case study in bilateral radial head fractures in apparently trivial trauma: A subtle diagnosis. Ortop Traumatol Rehabil 2011;13:601-6.  Back to cited text no. 3
    
4.
Shariff Z, Patel KJ, Elbo A, Guisasola I. Bilateral radial head fractures in a woman with trivial trauma. Med Gen Med 2005;7:8.  Back to cited text no. 4
    
5.
Morrey BF, An KN, Stormont TJ. Force transmission through the radial head. J Bone Joint Surg Am 1988;70:250-6.  Back to cited text no. 5
    
6.
Amis AA, Miller JH. The mechanisms of elbow fractures: An investigation using impact tests in vitro. Injury 1995;26:163-8.  Back to cited text no. 6
    
7.
Markolf KL, Lamey D, Yang S, Meals R, Hotchkiss R. Radioulnar load-sharing in the forearm. A study in cadavera. J Bone Joint Surg Am 1998;80:879-88.  Back to cited text no. 7
    
8.
Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123-32.  Back to cited text no. 8
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9.
Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J 1962;31:51-6.  Back to cited text no. 9
[PUBMED]    
10.
Deshmukh NV, Shah MS. Bilateral radial head fractures in a martial arts athlete. Br J Sports Med 2003;37:270-1.  Back to cited text no. 10
    
11.
Hodge JC. Bilateral radial head and neck fractures. J Emerg Med 1999;17:877-81.  Back to cited text no. 11
    
12.
Kutscha-Lissberg F, Platzer P, Thalhammer G, Krumböck A, Vécsei V, Braunsteiner T. Incidence and analysis of simultaneous bilateral radial head and neck fractures at a level I trauma center. J Trauma 2010;69:907-12.  Back to cited text no. 12
    
13.
Muzaffar N, Bhat A, Shah N. Excision of radial head fractures with medially displaced fragments using 2 incisions: The nutcracker effect. Orthopedics 2012;35:e1488-91.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1]



 

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Case Report
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