Review Question - QID 211243

Patients with radial head fractures consisting of 3 or more fragments are not considered candidates for ORIF, and are best treated with radial head arthroplasty.

The combination of an elbow dislocation, radial head fracture and coronoid fracture is commonly known as a “terrible triad” injury to the elbow. Treatment of the radial head is an important aspect to the overall treatment of these patients. Radial head arthroplasty is recommended for fracture patterns in which there are 3 or more fragments that consist of >25% of the radial head. ORIF is considered not feasible for these injuries, and radial head arthroplasty provides good outcomes in this subset of patients. Furthermore, radial head excision is not recommended, given the secondary stabilization of the ligamentous injury provided by the radial head.

Mathew et al. reviewed the current concepts in terrible triad injuries of the elbow. They report that the combination of an elbow dislocation, radial head fracture and coronoid process fracture consistently have poor outcomes when treated non-operatively. They concluded that the primary goal of surgical fixation is to stabilize the elbow and allow early range of motion.

Steinmann reviewed the treatment of coronoid processes fractures. In discussing coronoid tip fractures as it relates to terrible triad injuries they review that this injury is commonly the result of a valgus and supination moment to the forearm. The radial head is fractured as it is forced up against and then under the capitellum. Progressive valgus force drives the coronoid under the trochlea resulting in the commonly seen coronoid tip fracture. They conclude that treatment of coronoid tip fractures can be performed through either a posterior or lateral incision, with the authors preference being posterior because of the versatility in exposure of the medial and lateral aspects of the elbow.

Ring reviewed open reduction and internal fixation of fractures of the radial head. He reported that complex fractures of the radial head are prone to early failure, nonunion, and poor forearm rotation after operative fixation. He concluded that improved outcomes seen with metal radial head arthroplasties have redefined radial head treatment.

Figure A is the lateral radiograph of the elbow demonstrating a posterior elbow dislocation with concomitant coronoid and comminuted radial head fracture.

Incorrect Answers:
Answer 1: Age >40-years-old is not a contraindication to ORIF.
Answer 2: Simple fractures in the sagittal plan can be treated with ORIF.
Answer 4: Ligamentous repair, not replacement of the radial head should be performed if there is instability following radial head ORIF.
Answer 5: Preoperative PIN palsy is not an indication for radial head arthroplasty.