Radial Head Fractures

Author: Tracy Jones

Topic updated on 05/29/13 10:04pm

Introduction

Epidemiology
- radial head fractures are among the most common elbow fractures occurring in up to 20% of all elbow injuries
  - 30% have associated soft tissue or skeletal injuries
Mechanism of injury
- fall on outstretched hand
- forearm in pronated position
- axial load created across elbow
Associated injuries
- most radial head fractures are associated with other soft tissue or skeletal injuries further compromising elbow stability
  - distal radioulnar joint (DRUJ) injuries
  - interosseous membrane disruption
  - coronoid fractures
  - MCL/LCL injuries
  - Essex-Lopresti lesion (DRUJ) injury plus radial head fracture
  - elbow dislocation
  - terrible triad (elbow dislocation, radial head fx, coronoid fx)
  - carpal ractures
Prognosis
- radial head fractures requiring replacement have shown good clinical outcomes with metallic implants

Anatomy

Osteology
- radial head acts as secondary restraint to valgus force at the elbow

Classification

Mason classification
Type I	Minimally displaced fx
Type II	Displaced fx
Type III	Comminuted and displaced fx
Type IV	Radial head fx with elbow dislocation

Presentation

Symptoms
- pain and tenderness along lateral aspect of elbow
- limited elbow or forearm motion
Physical exam
- ROM & instability
  - evaluate for mechanical blocks to flexion /extension at elbow and rotaion of forearm
    - aspiration of joint hematoma and injection of local anesthesia aids in evaluation of mechanical block
  - examine varus and valgus stability at elbow
- DRUJ stability
  - palpate wrist for pain and DRUJ stability
- palpate interosseous membrane for tenderness/pain

Imaging

Radiographs
- recommended views
  - AP and Lateral of the elbow
  - check for fat pad sign indicating nondisplaced fracture
- additional view
  - radiocapitellar view (oblique lateral)
  - lateral view of elbow with tube angled at 45 degrees toward shoulder
  - helps detect subtle fractures of the radial head
CT
- useful for comminuted fractures to further delineate fracture fragments

Treatment

Nonoperative
- short period of immobilization followed by early ROM
  - indications
    - isolated nondisplaced or minimally displaced (less than 3mm) fxs with no mechanical blocks
  - outcomes
    - elbow stiffness with prolonged immobilization
    - good results in 85% to 95% of patients
Operative
- ORIF
  - indications
    - Mason Type II with mechanical block
    - Mason Type III where ORIF feasible
    - mechanical block to motion
    - presence of other complex injuries
- fragment excision (partial excision)
  - indications
    - fragments less than 25% of the surface area of the radial head or 25%-33% of capitellar surface area
- radial head replacement
  - indications
    - relative indication for comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not feasible
      - ORIF shown to have worse outcome with 3 or more fragments compared to ORIF with < 3 fragments
    - Elbow fracture-dislocations or Essex Lopresti lesions, as radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement
- radial head resection
  - indications
    - low demand, sedentary patients
    - in a delayed setting for continued pain of an isolated radial head fracture
  - contraindications
    - presence of destabilizing injuries
    - forearm ligament injury (identify with radius pull test)
    - coronoid fracture
    - MCL deficiency

Techniques

ORIF
- approach
  - varies based on pathology of fracture
  - forearm should be held in pronation during a Kocher posterolateral approach to protect PIN
- plates
  - place plate posterolateral (safe zone consists of 90-110 arc from radial styloid to Lister's tubercle) with arm in neutral rotation to avoid impingement of ulna with forearm rotation
  - countersink implants on articular surface
- screws
  - Herbert screws
Fragment excision (partial excision)
- complications
  - even small fragment excision may lead to instability
Radial head replacement
- approaches
  - Kaplan direct lateral approach
    - interval between EDC and ECRB (radial wrist extensors)
    - keep forearm pronated to protect PIN
    - pros
      - will not disrupt LUCL, as approach is anterior and splits the lateral annular ligament complex
    - cons
      - since this is a more anterior approach may put PIN at risk and this is not an extensile approach
  - Kocher posterolateral approach
    - interval between ECU and anconeus
    - keep forearm pronated to protect PIN
    - pros
      - is an extensile approach that can be extended distally (Thompson approach to forearm) and proximally
    - cons
      - may destabilize the elbow if the LUCL is violated, which lies below the equator of the capitellum
- technique
  - two types of metal prostheses are in use
    - loose stemmed prosthesis
      - that acts as a stiff spacer
    - bipolar prosthesis
      - that is cemented into the neck of the radius
    - silicon replacements are no longer used
- complications
  - overstuffing of joint that leads to capitellar wear problems and malalignment instability
Radial head resection
- approaches
  - same as radial head replacement
- complications after excision of the radial head include
  - muscle weakness
  - wrist pain
  - valgus elbow instability
  - heterotopic ossification
  - arthritis

Complications

Displacement of fracture
- occurs in less than 5% of fractures
Posterior Interoseous nerve injury (with operative mangement)
Loss of fixation
Loss of forearm rotation
Elbow stiffness
Radiocapitellar joint arthritis
Infection

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Qbank (3 Questions)

TAG

(OBQ09.31) A 51-year-old right-hand-dominant male fell onto his left arm and sustained the isolated injury shown in Figures A and B approximately 6 months prior to presentation. Examination of the wrist is notable for a stable DRUJ and no tenderness. The elbow shows no ligamentous laxity, and the patient reports isolated elbow pain during attempted pronation/supination Current radiographs reveal a malunited radial head fracture. Treatment should now consist of? Topic

Review Topic

FIGURES: A

1. Radial head resection
2. Radial head replacement
3. ORIF of the malunited fracture
4. Arthroscopic debridement
5. Total elbow replacement

PREFERRED RESPONSE ▶

DISCUSSION: The injury films represent a highly comminuted radial head fracture, which when treated with ORIF, is likely to have a poor outcome especially in the delayed setting. In the absence of DRUJ and elbow instability, and no wrist tenderness, radial head resection is the best treatment option. While a radial head prosthesis may theoretically prevent proximal radial head migration that can occur with radial head excision, this is unlikely in an isolated radial head fracture without other ligmentous injury (elbow ligaments, interosseous membrane or DRUJ).

Herbertsson et al (March, 2004) reported on 100 patients with Mason II and III radial head fractures. Nine of those initially treated nonoperatively had continued pain and underwent late radial head excision with good results.

In another report by Herbertsson et al (September, 2004) the authors report on radial head excision in both an acute and delayed setting and found fair-good results for most patients in both subgroups.

Jackson et al present a review article on radial head fractures where management and operative technique are discussed.

REFERENCES:

1. Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karlsson M. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg Am. 2004 Mar;86-A(3):569-74. PMID:14996884 (Link to Abstract)

2. Jackson JD, Steinmann SP. Radial head fractures. Hand Clin. 2007 May;23(2):185-93, vi. PMID:17548010 (Link to Abstract)

3. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004 Sep;86-A(9):1925-30. PMID:15342754 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Michael Hughes MD, John Badylak MD,

Please Rate Educational Value!

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TAG

(OBQ08.95) A 51-year-old female sustained a comminuted radial head fracture with 4 fragments and an associated elbow dislocation. She was initially closed reduced and splinted with the elbow joint in a reduced position and presents to the orthopedists office 10 days later. In response to the patient's question of what treatment offers the best chance for a good outcome, the surgeon should recommend? Topic

Review Topic

1. excision of the radial head
2. ORIF of the radial head
3. continued splinting, no surgery
4. radial head arthroplasty
5. hinged external fixation

PREFERRED RESPONSE ▶

DISCUSSION: In a classic article, Ring et al reported that ORIF of radial head fractures with more than 3 fragments has poor results and recommend radial head replacement for these fractures. Metallic implants are the material of choice for radial head replacement. Silicone implants were often used in the past, have many well-documented complications including prosthesis failure, adverse tissue reaction, and poor load transfer . Excision is not appropriate in the setting of a radial head fracture associated with elbow instability.

REFERENCES:

1. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002 Oct;84-A(10):1811-5. PMID:12377912 (Link to Abstract)

2. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001 Aug;83-A(8):1201-11. PMID:11507129 (Link to Abstract)

Question Authors:

Doug Nowak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

TAG

(OBQ08.228) When performing a Kocher approach to the radial head for open reduction internal fixation the forearm is held in pronation. What structure is this maneuver attempting to protect? Topic

Review Topic

1. median nerve
2. brachial artery
3. anterior interosseous nerve
4. radial nerve
5. posterior interosseous nerve

PREFERRED RESPONSE ▶

DISCUSSION: Dilberti et al quantified the dimensions of a surgically safe zone (with respect to the posterior interosseous nerve) when using the posterolateral approach to the radial head between the anconeus and the extensor carpi ulnaris. They found that the safe zone increased with pronation and decreased with supination.

REFERENCES:

1. Dilberti T, Botte MJ, Abrams RA: Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am 2000;82:809-813. PMID:10859100 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 19 Ratings

Cases

	Radial Head Fracture (C1487) Trauma - Treatment Consult - Radial Head Fractures HPI - Fall at home. Injury to left elbow.(non dominant arm) operativre or conservative.	4/20/2013 423 responses 3
$http://upload.orthobullets.com/cases/1327/radiakl head frace.jpg$ $http://upload.orthobullets.com/cases/1327/radial hd fracw.jpg$	radial head fracture with elbow dislocation (C1327) General - Treatment Consult - Radial Head Fractures HPI - patient had a fall 3 weeks back had an elbow dislocation with radial head farctu... radial head orif or excision	11/20/2012 295 responses

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Fractures of the radial head and neck treated with radial head excision. Includes Poll

Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK
J Bone Joint Surg Am. 2004 Sep;86-A(9):1925-30. PMID: 15342754 (Link to Pubmed)

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004 Sep;86-A(9):1925-30. PMID:15342754 (Link to Abstract)
Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karlsson M. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg Am. 2004 Mar;86-A(3):569-74. PMID:14996884 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Jackson JD, Steinmann SP. Radial head fractures. Hand Clin. 2007 May;23(2):185-93, vi. PMID:17548010 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Dilberti T, Botte MJ, Abrams RA: Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am 2000;82:809-813. PMID:10859100 (Link to Abstract)
Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001 Aug;83-A(8):1201-11. PMID:11507129 (Link to Abstract)
Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002 Oct;84-A(10):1811-5. PMID:12377912 (Link to Abstract)

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Radial Head Fractures

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