Review Question - QID 216386

Radial head excision is contraindicated for the treatment of radial head fractures with associated distal radioulnar joint (DRUJ) injury and interosseous membrane disruption (Essex-Lopresti injuries).

Radial head fractures with concomitant DRUJ injury and interosseous membrane disruption (Essex-Lopresti injuries) are caused by a longitudinal compression force transmitted from the wrist to the elbow. Delayed diagnosis can lead to chronic instability from proximal migration of the radius and persistent dislocation of the DRUJ. Wrist tenderness can be an early indication that an Essex-Lopresti injury is present, which can be further characterized by MRI. In patients with Essex-Lopresti injuries, fixation or replacement of the radial head is indicated to maintain the secondary stabilizer and prevent proximal migration of the radius.

Ring et al. analyzed functional results of fifty-six patients following ORIF of radial head fractures to determine which fracture patterns are most amenable to this treatment. The authors found that ORIF is best reserved for minimally comminuted fractures with three or fewer articular fragments. They also note that an associated fracture-dislocation of the elbow or forearm may compromise the long-term result of radial head repair, especially with regard to forearm rotation.

Grassman et al. reviewed the outcomes of 295 patients with radial head fractures, 12 of which were diagnosed with an Essex-Lopresti injury confirmed by MRI. The authors recommend early MRI and K-wire stabilization of the DRUJ in cases where disruption of the interosseous membrane and interosseous ligament are suspected. In addition, the surgeon should preserve the radial head if at all possible or proceed with arthroplasty if not.

Figures A, B, and C demonstrate a comminuted radial head fracture. Figure D demonstrates positive ulnar variance, consistent with disruption of the interosseous membrane and subsequent proximal migration of the radius in a patient with an Essex-Lopresti injury.

Illustration A is the Mason classification for radial head fractures.

Incorrect Answers
Answer 1: ORIF should be considered if the fracture pattern is amenable.
Answer 2: Radial head arthroplasty should be considered if the fracture is not amenable to ORIF.
Answer 3: Closed reduction and percutaneous pinning of the DRUJ should be considered in patients with suspected Essex-Lopresti injuries.
Answer 5: Initiation of early motion after elbow surgery is encouraged to help improve outcomes by reducing stiffness.