American Shoulder and Elbow Surgeons
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Average 4.4 of 61 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 38-year-old concert violinist presents after falling onto a pronated, outstretched hand this morning. She complains of lateral elbow pain. Examination reveals lateral elbow tenderness, and an 80 degree arc of flexion-extension and 60 degree arc of prono-supination, with extremes of motion limited by pain. There is no bony block to motion. Radiographs of her injury are seen in Figures A through D. The most appropriate treatment plan that would allow her to return to her occupation would be
Sling immobilization for 2 days, followed by active mobilization.
Long-arm cast immobilization for 1 week, followed by active mobilization.
Long-arm cast immobilization for 1 week, followed by passive mobilization.
Long-arm cast immobilization for 2 weeks
Open reduction and internal fixation
Select Answer to see Preferred Response
This patient has a Mason Type I radial head fracture (minimally displaced, no mechanical block, intra-articular displacement <2mm). Non-operative treatment is recommended. Sling immobilization for 2 days followed by active mobilization is recommended.
Radial head fractures occur after axial loading/fall onto a pronated, outstretched hand as the most force is transmitted from the wrist to the radial head in this position. For Type II and III fractures, open reduction and internal fixation is indicated. For Type III fractures with more than 3 fragments, radial head replacement is advocated. Radial head excision in the acute setting is generally not recommended to prevent late proximal radial migration and ulnocarpal impingement, as an easily missed Essex-Lopresti injury is possible; any patient with a painful DRUJ or mid forearm in the face of a radial head fracture should not undergo excision.
Paschos et al. compared (1) immediate active mobilization vs (2) sling immobilization for 2 days, followed by active mobilization vs (3) immobilization in a cast for 7 days followed by active mobilization. Early mobilization (Groups 1 and 2) had better ROM and less pain at 4 wks. Group 2 had better pain relief than Group 1 in the first 3 days, and the best functional scores at 12wks. They recommend early mobilization after a delay of 48 hours.
Tejwani et al. reviewed current management of radial head and neck fractures. Most fractures can be managed nonoperatively with early motion if there is no instability or block to elbow motion. Complex fractures require ORIF or arthroplasty (fragment >1/3 of the radial head, ORIF not possible).
Figures A through D are radiographs showing an undisplaced simple (AO/OTA 21-B2.1) radial head fracture.
Answers 2, 3, 4: Immobilization for 1 week or more leads to poorer functional outcome and pain scores. Early mobilization is important at the elbow joint.
Answer 5: ORIF is only indicated if there is a displaced fragment or mechanical block to motion.
Paschos NK, Mitsionis GI, Vasiliadis HS, Georgoulis AD
J Orthop Trauma. 2013 Mar;27(3):134-9. PMID: 22576643 (Link to Abstract)
Paschos, JOT 2013
Tejwani NC, Mehta H.
J Am Acad Orthop Surg. 2007 Jul;15(7):380-7. PMID: 17602027 (Link to Abstract)
Tejwani, JAAOS 2007
Please rate question.
Average 3.0 of 13 Ratings
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?
Radial head resection
Radial head replacement
ORIF of the malunited fracture
Total elbow replacement
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 ligamentous 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.
Finally, Antuna et al in their study conclude "Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment".
Bone Joint Surg Am. 2004 Mar;86-A(3):569-74. [PMID]14996884[/PMID]
, JBJS 2004
Jackson JD, Steinmann SP.
Hand Clin. 2007 May;23(2):185-93, vi. PMID: 17548010 (Link to Abstract)
Jackson, HANDC 2007
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 Abstract)
Herbertsson, JBJS 2004
Antuña SA, Sánchez-Márquez JM, Barco R.
J Bone Joint Surg Am. 2010 Mar;92(3):558-66. PMID: 20194313 (Link to Abstract)
Antuña, JBJS 2010
Average 1.0 of 115 Ratings
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?
Excision of the radial head
ORIF of the radial head
Continued splinting, no surgery
Radial head arthroplasty
Hinged external fixation
In the context of elbow instability, optimal treatment of a comminuted radial head fracture with greater than three fragments is with a radial head replacement.
Radial head fractures are often seen in conjunction with injuries such as elbow dislocations and DRUJ instability. Although minimally displaced injuries can be treated non-operatively, an ORIF can be utilized when there is limited comminution of the radial head. Improved outcomes are demonstrated when radial head arthroplasty is used in the setting of greater than 3 fracture fragments.
Ring et al. reviewed 56 patients who had been treated with an ORIF of the radial head at 48 months after injury. They found that patients had unsatisfactory outcomes for patients who had an ORIF of radial fractures with greater than 3 articular fragments. They recommend ORIF of radial head fractures with 3 or few fragments.
Moro et al. reviewed functional outcomes of patients treated with radial head arthroplasty for un-reconstructible fractures. They found that patients treated with metal radial head implants had mild physical impairment. Short term follow-up indicates that radial head arthroplasty is a reasonable option for severely comminuted radial head fractures.
Illustration A shows a 3D reconstruction of a radial head fracture with a coronal and sagittal split. The presence of 3 fragments portends good outcomes with an ORIF procedure.
Answer 1: Resection is not indicated in this patient to improve her function and optimize outcome
Answer 2: With greater than 3 fragments, better outcomes have been reported with radial head replacement.
Answer 3: Non operative management will likely lead to loss of motion and radiocapitellar arthritis
Answer 5: Hinged external fixation is not indicated in this patient
Ring D, Quintero J, Jupiter JB.
J Bone Joint Surg Am. 2002 Oct;84-A(10):1811-5. PMID: 12377912 (Link to Abstract)
Ring, JBJS 2002
Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ.
J Bone Joint Surg Am. 2001 Aug;83-A(8):1201-11. PMID: 11507129 (Link to Abstract)
Moro, JBJS 2001
Average 4.0 of 19 Ratings
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?
anterior interosseous nerve
posterior interosseous nerve
Dilberti et al quantified the dimensions of a surgical 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.
Diliberti T, Botte MJ, Abrams RA
J Bone Joint Surg Am. 2000 Jun;82(6):809-13. PMID: 10859100 (Link to Abstract)
Diliberti, JBJS 2000
Average 4.0 of 43 Ratings
Title: Radial Head Replacement: When and How? Presenter: Mark Baratz, MdColumbia...
Title: Case Controversies, Radial Head and Instability Author: Jorge L. Orbay, M...
ORIF of Radial Head Fracture with Kocher approach, scews, Bio-suture Tak anchor,...
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