Proximal forearm fractures account for over 10% of all upper limb fractures. There
is limited epidemiological data available and much of the literature focuses on the
more complex fracture patterns, with the role of non-operative management for the
isolated proximal forearm fracture still to be defined. Prospective short and long-term
patient reported outcome data for simple isolated fractures of the radial head
and olecranon would help define the indications for the non-operative management
of these injuries. This thesis aims to test the hypothesis that non-operative
management provides a comparable outcome to operative intervention for defined
fractures of the proximal forearm.
A large prospective database of 6872 fractures collected over a one-year
period was used to define the epidemiology of proximal forearm fractures. A
separate large prospective study carried out over an eighteen-month period using a
pre-defined management protocol for all isolated radial head and neck fractures was
analysed to determine the short and long-term outcome. Additional retrospective
databases were collected and analysed to determine the short and long-term outcome
for the non-operative and operative management of olecranon fractures, as well as
the operative management of complex radial head fractures. Finally, two prospective
randomised controlled trials (PRCTs) of isolated displaced fractures of the olecranon
were carried out to compare 1) tension band wire (TBW) versus plate fixation in
younger patients (<75 years) and 2) operative versus non-operative management in
elderly patients (≥75 years). The primary outcome measure for these studies was the
upper limb specific patient reported Disabilities of the Arm, Shoulder and Hand
(DASH) score. Secondary outcome measures included surgeon reported outcome
scores, complication rates and cost.
The incidence of proximal forearm fractures was 68 per 100,000. Radial
head fractures fit a type D distribution curve (unimodal young man, bimodal woman)
and radial neck type A (unimodal young man, unimodal older woman). Proximal
ulna and olecranon fractures were both a type F (unimodal older man, unimodal
older woman), with an increasing incidence after the 6th decade. Over 90% of
proximal radial fractures were isolated stable fractures.
Prospective analysis of 201 isolated proximal radius fractures found that the
patient and surgeon reported outcome following primary non-operative management
for Mason type 1 and type 2 (n=185) fractures was excellent in the short and long-term,
with <2% of patients undergoing secondary surgical intervention. At a mean of
10 years post injury (n=100), the mean DASH score was 5.8 and 92% of patients
were satisfied. Factors associated with a poorer short and long-term patient reported
outcome included increasing fracture displacement (≥5mm) and socio-economic
deprivation. Retrospective analysis of 105 acute unstable complex radial head
fractures found that the mean short-term functional outcome was good (mean
Broberg and Morrey Score 80) following radial head replacement. In the long-term
(mean 7 years), 28% of patients required removal or revision of the prosthesis, with
younger patients and silastic implants independent risk factors (both p<0.05).
Retrospective analysis of 36 operatively managed isolated displaced
olecranon fractures found satisfactory short and long-term outcomes, with the
symptomatic metalwork removal rate 47% and the mean DASH 2.5 at a mean of
seven years post injury. In the PRCT of plate (n=34) versus TBW (n=33) fixation,
comparable functional and patient reported outcomes (DASH 8.5 vs 13.5; p=0.252)
were found at one year following injury. Complication rates were significantly
higher in the TBW group (63.3% vs 37.5%; p=0.042), predominantly due to a
significantly higher rate of symptomatic metalwork removal (50.0% vs 21.9%;
p=0.021), resulting in equivocal costs for both techniques (p=0.131). In older lower-demand
patients, short and long-term retrospective analysis found very satisfactory
outcomes following non-operative management of isolated displaced fractures of the
olecranon, with patient satisfaction 91% and no patients requiring surgery for a
symptomatic non-union. The preliminary results of the PRCT of non-operative
(n=8) versus operative (n=11) management demonstrated comparable functional and
patient reported outcomes at all points over the one-year following injury (all
p≥0.05), with a higher rate of complications (81.8% vs 14.3%; p=0.013) and cost
(p=0.01) following surgical intervention.
The association found between fragility and the epidemiology of proximal
forearm fractures highlighted the importance of considering non-operative
management for these injuries. These findings support non-operative management
for isolated stable radial head and neck fractures. For more complex injuries when
radial head replacement is indicated, there is a high rate of removal or revision, with
younger patients most at risk. In younger active patients with an isolated displaced
fracture of the olecranon, TBW and plate fixation provide comparable short-term
results, with TBW fixation as cost effective despite an increased rate of metalwork
removal. In older lower demand patients, this data provides strong evidence for the
non-operative management of isolated displaced olecranon fractures