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Three Part Question

In [patients with minimally displaced isolated radial head fractures] does [early mobilisation or conventional immobilisation] lead to [superior functional outcome]?

Clinical Scenario

A thirty year-old lady has fallen onto her outstretched hand and sustained a radial head fracture, which is virtually undisplaced. Knowing that prolonged immobilisation is likely to lead to poor functional outcome, you wonder whether there is any evidence for immediate mobilisation.

Search Strategy

OVID Medline 1966 - 2005 July Week 2
OVID Embase 1980 - 2005 Week 29
The Cochrane Library 2005 Issue 2
Medline and Embase:
(((exp Elbow/ OR exp Radius/ OR exp Elbow Joint/) AND (exp Fractures, Closed/ OR exp Fractures/)) OR radial head.mp. OR exp Radius Fractures/) AND (exp Early Ambulation/ OR mobilis$ OR mobiliz$ OR exp Immobilization/ OR splint$.mp.)
Cochrane:
radial head

Search Outcome

Altogether, 132 papers were identified using Medline, 56 using Embase and 49 using Cochrane. One paper, identified in all three databases, was relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Liow et al 2002 United Kingdom	60 consecutive patients referred to fracture clinic with minimally displaced radial head fractures. Two groups of 30 patients, starting supervised exercise programmes 24 hours and 5 days after injury, respectively. The delayed mobilisation group were treated with broad arm sling for the first five days. Assessments by an independent, blinded observer.	Prospective comparative clinical trial	Pain (visual analogue scale)	Significantly less in mobilisation group at 1 week (p=0.002). Similar pain scores at 4 and 12 weeks	Not truly randomised: 'random' allocation to different fracture clinics only (treated according to consultant preference). More Mason II (displaced) fractures in delayed mobilisation group (57% vs. 37%, p=0.12). Discrepancy between text and tables for p values regarding Morrey score
			Range of motion (Morrey scale, measured with goniometer)	Better flexion (112 v. 98 degrees, p=0.0004) and supination (58 v 47 degrees, p=0.0022) in mobilisation group at 1 week. Similar at 4 and 12 weeks
			Elbow strength (measured with dynamometer)	Stronger in mobilisation group at 1 week (p=0.035); no difference at 4 and 12 weeks
			Morrey score of elbow function	Higher in mobilisation group at week 1 (54.4 v. 43.5, p<0.05). Similar at 4 and 12 weeks
			Radiographic assessment	All fractures united, no displacements observed

Comment(s)

Only one study has compared early mobilisation with conventional immobilisation with broad arm sling or collar and cuff for radial head fractures. This study included patients with both displaced and undisplaced radial head fractures. The findings suggest that both approaches lead to similar long term outcomes but that early mobilisation may enable patients to obtain better function early after injury with quicker resolution of pain.

Clinical Bottom Line

Treatment of isolated undisplaced radial head fractures by early mobilisation is safe and may lead to quicker functional recovery.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Liow RYL; Creagn A; Nanda R; Montgomery RJ Early mobilisation for minimally displaced radial head fractures is desirable: A prospective randomised study of two protocols Injury 2002; 33: 801-806