Decision-making in the treatment of radial head fractures: Delphi methodology

The treatment of partial, displaced radial head fractures is determined not only by the type of fracture, but also by patient characteristics such as age, occupation, hand dominance, mechanism of injury, and concomitant injuries and comorbidities. The goal of this study was to employ the Delphi method to achieve consensus on the management of patients with radial head fractures, utilizing the experience of the ASES elbow fracture-dislocation multicenter study group and Mayo Elbow Club surgeons.The initial survey was sent to participants, which included consent to participate in the study and questions about their experience, knowledge, and interest in participating in the Delphi method.We used both open-ended and category-based questions. The second questionnaire generated 76 variables, and individual questions with mean Likert ratings of2.0 or4.0 were deemed significant and merged to form multifactorial clinical scenarios relating to both nonoperative and operative management, respectively.Of surgeons who responded to the questionnaire; 64% were from the United States, while the remainder were from overseas practices. Years in practice on average were 12.4 years (range, 1-40). Seven of the 76 factors met the criteria of a mean Likert score of2.0 or4.0. These factors were; age, block to the range of motion (ROM) after aspiration/injection, crepitation with ROM, tenderness over the distal radioulnar joint (DRUJ) and/or interosseous membrane (dorsal forearm), gap and/or displacement2mm on imaging, complete loss of contact of the head with rest of radius on imaging, fracture head involvement 30% on imaging. 22 (46%) of the 96 clinical scenarios gained90% consensus in favor of surgical treatment, whereas 8 (17%) reached90% consensus in favor of non-operative treatment.Obtaining expert consensus on the treatment of radial head fractures remains challenging. Certain factors such as gap/displacement ≥ 2mm without complete loss of contact, ≥ 30% head involvement with a block to a range of motion regardless of tenderness over DRUJ or interosseous membrane (dorsal forearm) or crepitation when the patient was80 years of age led to a recommendation of operative treatment in 100% of the surveyed surgeons. Patients greater than 80 years of age with no block to ROM after aspiration/injection, no crepitation with ROM, and no tenderness on DRUJ/interosseous membrane (dorsal forearm) were recommended for non-operative treatment regardless of the size of the radial head involvement on imaging.