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  • summary
    • Radial Head Fractures are common intra-articular elbow fractures that can be associated with an episode of elbow instability, a mechanical block to elbow motion, an injury to the distal radioulnar joint and/or to the interosseous membrane (Essex-Lopresti).
    • Diagnosis can be made with plain radiographs of the elbow. CT studies can be helpful for surgical planning. 
    • Treatment may be nonoperative for non-displaced fractures without a mechanical block to motion but  operative management is indicated for displaced fractures, or fractures associated with mechanical block to motion or elbow/forearm instability. 
  • Epidemiology
    • Incidence
      • very common fracture
        • makes up 1-4% of all fractures in adults
        • makes up 20-30% of all elbow fractures
    • Demographics
      • 85% occur between the ages of 30-60
      • mean age is ~ 45 years
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall on an outstretched hand
          • elbow in extension and forearm in pronation
            • leads to most force transmitted from wrist to radial head
    • Associated conditions
      • incidence
        • 30% have associated soft tissue or skeletal injuries
      • types
        • ligamentous/ interosseous injuries
          • lateral collateral ligament (LCL) injury
            • most common (up to 80% on MRI)
          • medial collateral ligament (MCL) injury
          • Essex-Lopresti injury
            • radial head fracture
            • distal radioulnar joint (DRUJ) injury
            • interosseus membrane injury
        • elbow fractures & dislocations
          • coronoid fracture
          • olecranon fracture
          • Monteggia fracture/dislocation
          • terrible triad
            • posterolateral elbow dislocation
            • radial head fracture
            • coronoid fracture
        • carpal fractures
          • scaphoid fracture
  • Anatomy
    • Osteology
      • proximal radius consists of
        • radial head
        • radial neck
        • radial tuberosity
        • radial shaft
      • radial head
        • head-neck osteology
          • the radial head is 15º offset from the neck (not collinear)
          • anterolateral third of radial head lacks subchondral bone
            • easily fractured in this area
        • articular surface
          • has 40º oval-shaped concavity that articulates with capitellum
        • nonarticular portion
          • 90-110º of radial head defined by the projections of the radial styloid and Lister's tubercle 
            • considered a safe zone for hardware placement
    • Arthrology
      • radiocapitellar joint
        • a pivot joint
        • 60% load transfer across elbow joint
          • fracture or resection of the radial head decreases surface area available for load transfer and decreases stability
      • proximal radial ulnar joint (PRUJ)
        • ulnar portion of radial head that articulates with the lesser sigmoid notch of the ulna
        • important for forearm pronation and supination
    • Ligaments
      • lateral collateral ligament complex
        • lateral ulnar collateral ligament (LUCL)
          • inserts onto supinator crest of ulna.
          • primary stabilizer to varus and external rotation (hypersupination) stress
            • more important stabilizer near elbow extension
          • deficiency results in posterolateral rotatory instability
        • radial collateral ligament (RCL)
          • inserts into annular ligament
        • annular ligament
          • originates and inserts on the anterior and posterior aspects of the lesser sigmoid notch, respectively
          • stabilizes the proximal radioulnar joint by maintaining the radial head in contact with the ulna
        • accessory lateral collateral ligament
      • medial (ulnar) collateral ligament (MCL)
        • three bundles
          • anterior bundle
            • primary stabilizer to valgus stress (radial head is second)
          • posterior bundle
          • transverse bundle
    • Biomechanics
      • radial head confers two types of stability to the elbow
        • valgus stability
          • secondary restraint to valgus load at the elbow, important if MCL deficient
        • longitudinal stability
          • restraint to proximal migration of the radius
          • contributions from interosseous membrane and DRUJ
          • load-sharing from wrist to radiocapitellar joint is dependent on radiocapitellar surface area
          • loss of longitudinal stability occurs with Essex-Lopresti injury pattern
            • radial head fracture + DRUJ injury + interosseous membrane disruption 
              • radial head must be fixed or replaced to restore stability, preventing proximal migration of the radius and ulnocarpal impaction
  • Classification
    • Common
      • Mason Classification
        (Modified by Hotchkiss and Broberg-Morrey)
      • Type I
      • Nondisplaced or minimally displaced (<2mm), no mechanical block to rotation
      • Type II
      • Displaced >2mm or angulated, possible mechanical block to forearm rotation
      • Type III
      • Comminuted and displaced, mechanical block to motion
      • Type IV
      • Radial head fracture with associated elbow dislocation
    • Advanced
      • OTA Classification 
      • 2R1A
      • Extra-articular pattern
      • 2R1B
      • Partial articular pattern
      • 2R1C
      • Complete articular pattern
  • Presentation
    • Symptoms
      • common symptoms
        • pain
          • pain and tenderness along lateral aspect of elbow
        • limited elbow or forearm motion
          • particularly supination/pronation
    • Physical exam
      • inspection
        • ecchymosis/swelling possible
        • tenderness over lateral elbow
        • deformity possible in setting of associated dislocation
      • motion
        • important to evaluate for mechanical blocks to elbow motion
          • flexion/extension
            • normal = 0-150º 
          • pronation/supination
            • normal pronation = 85º, supination = 75º
          • aspiration of joint hematoma and injection of local anesthesia aids in evaluation of mechanical block
      • stability testing
        • elbow
          • posterolateral drawer test and posterolateral pivot shift test (tests LUCL)  
          • valgus stress test (tests MCL)
        • DRUJ
          • palpate wrist for tenderness
          • translation in sagittal plane > 50% compare to contralateral side is abnormal
            • if difficult to determine on exam, can get dynamic CT scan in neutral, pronation and supination for subtle injury
        • interosseous membrane
          • palpate along interosseous membrane for tenderness
          • radius pull test (performed at the time of surgery)
            • >3mm translation concerning for longitudinal forearm instability (Essex-Lopresti)
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral elbow 
        • AP and lateral forearm/wrist
      • findings
        • fracture with or without displacement/intra-articular involvement
        • may see anterior/posterior fat pad sign indicating occult minimally displaced fracture
          • demonstrates intra-articular hemarthrosis
          • posterior fat pad sign more sensitive for fracture
        • must rule out concomitant involvement of forearm/wrist
      • additional views
        • radiocapitellar view (Greenspan view)
          • oblique lateral view of elbow
          • beam angled 45 degrees cephalad
          • allows visualization of the radial head without coronoid overlap
          • helps detect subtle fractures of the radial head
    • CT
      • indications
        • comminuted fractures
          • further delineate fragments
        • complex fracture dislocations
      • findings
        • may be helpful in planning surgical technique/approaches
  • Treatment
    • Nonoperative
      • short period of immobilization (3-7 days) followed by early ROM
        • indications
          • isolated minimally displaced fractures with no mechanical blocks (Mason Type I)
        • outcomes
          • good results in 85% to 95% of patients
          • beware elbow stiffness with prolonged immobilization
    • Operative
      • open reduction internal fixation (ORIF)  
        • indications
          • Mason Type II with mechanical block
          • Mason Type III where ORIF feasible
          • presence of other complex ipsilateral elbow injuries
        • techniques
          • screw(s) only
          • plate + screw(s)
        • outcomes
          • >90% good-excellent outcomes in Mason II fractures, with variable outcomes in Mason III fractures
          • # fragments
            • ORIF shown to have worse outcome when more than 3 fragments present compared to ORIF with 3 or less fragments
              • >50% rate of unsatisfactory outcomes after ORIF with > 3 fragments
          • isolated vs. complex
            • ORIF isolated radial head fractures versus complex radial head fractures (other associated fracture/dislocation) show no significant difference in outcomes at 4 years
            • isolated fractures trended towards better Patient-Rated Elbow Evaluation score, lower complication rate and lower rate of secondary capsular release
      • fragment excision (partial excision)
        • indications
          • older, lower demand adults with complex fractures but no associated instability
          • fragments less than 25% of the surface area of the radial head or 25%-33% of capitellar surface area
        • outcomes
          • even small fragment excision may lead to instability
      • radial head resection (complete excision)
        • indications
          • low demand, sedentary patients
          • in a delayed setting for continued pain of an isolated radial head fracture
        • contraindications
          • presence of destabilizing injuries
            • forearm interosseous ligament injury (>3mm translation with radius pull test)
            • coronoid fracture
            • MCL deficiency
        • outcomes
          • worse outcomes with regards to strength, function and motion compared to ORIF
          • higher percentage of arthritis (73%) compared to contralateral uninjured elbow after excision
      • radial head arthroplasty
        • indications
          • comminuted fractures (Mason Type III) with more than 3 fragments 
          • severe plastic deformity of radial head
          • nonunion/malunion
          • elbow fracture-dislocations 
            • terrible triad or Monteggia variants
            • with involvement of >30% of articular surface of radial head
          • Essex-Lopresti lesions
            • radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement
        • outcomes
          • radial head fractures requiring replacement have shown good clinical outcomes with metallic implants
          • compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasty results in greater stability, lower complication rate and higher patient satisfaction
      • retrograde titanium nail reduction and stabilization
        • indications
          • not yet considered mainstream treatment as it is in the pediatric population
        • outcomes
          • small powered case studies show good outcomes
  • Techniques
    • Nonoperative management
      • Sling (preferred) or posterior long arm splint
        • 3-7 days only to prevent stiffness
    • ORIF
      • approaches
        • Kocher approach
          • interval
            • between ECU (PIN) and anconeus (radial n.)
          • key steps
            • incise posterior fibers of the supinator
            • incise capsule in mid-radiocapitellar plane
              • anterior to crista supinatoris to avoid damaging LUCL
          • pros
            • less risk of PIN injury than Kaplan approach (more posterior)
              • PIN crosses the proximal radius from anterior to posterior within the supinator muscle 4 cm distal to radial head
              • in both Kocher and Kaplan approaches, the forearm should be pronated to protect PIN
                • PIN originates approximately 1.2mm from radiocapitellar joint
                • pronation pulls the nerve anterior and away from the surgical field
            • more extensile  
          • cons
            • risk of destabilizing elbow if capsule incision is too posterior and LUCL is violated, which lies below the equator of the capitellum
              • recommended when LCL is already disrupted (i.e., associated dislocation)  
        • Kaplan approach
          • interval
            • between EDC (PIN) and ECRB (radial n.)
          • key steps
            • incise mid-fibers of supinator
            • incise capsule anterior to mid-radiocapitellar plane (have access)
          • pros
            • less risk of disrupting LUCL and destabilizing elbow than Kocher approach (more anterior)
            • improved exposure of anterior fractured fragments when screw fixation is performed
          • cons
            • greater risk of PIN and radial nerve injury
            • less extensile
        • extensor digitorum communis (EDC) split
          • interval
            • incision made longitudinally through middle of EDC to origin on lateral epicondyle
          • pros
            • improved access to anterior half of radial head 
            • reduced risk of iatrogenic injury to lateral collateral ligament complex
        • posterior approach
          •  interval
            • no true intermuscular interval
            • raising a large lateral skin flap
          • indications
            • associated olecranon or Monteggia fracture
          • pros
            • access to both medial and lateral sides of elbow 
              • utilitarian approach when the medial aspect of the elbow is planned to be exposed using the same posterior midline skin incision
          • cons
            • less popular currently due to skin flap related complications
      • technique
        • screw(s)
          • best utilized alone in simple partial articular patterns
          • headless compression screws (Hebert) if placed in articular surface
          • better elbow range of motion and functional outcome scores at 1 year compared to plate fixation
        • plate(s) + screws
          • fractures involving head and neck
          • mini-fragment (1.5 - 2.0 mm) plates and screws utilized
          • posterolateral plate placement
            • safe zone (non-articular area) consists of 90-110º arc defined by the projections of the radial styloid and Lister's tubercle
              • this zone is straight lateral with arm in neutral rotation to avoid impingement of ulna with forearm rotation  
          • bicipital tuberosity is the distal limit of plate placement
            • anything distal to that will endanger PIN
          • countersink implants on articular surface
          • plate removal relatively common in order to restore forearm rotation
      • complications
        • PIN injury
        • destabilization of lateral ligament complex
        • articular surface penetration with screws 
        • mechanical block to motion by hardware
    • Fragment Excision
      • approach
        • Kocher or Kaplan approach as described
      • technique
        • if fracture is <25% of surface area of radial head and does not compromise elbow stability, fragment can be excised
      • complications
        • elbow instability if fragment excised is too large
    • Radial Head Resection
      • approach
        • Kocher or Kaplan approach 
      • technique
        • remove enough head to fully remove comminuted aspects of radial head
        • attempt to keep annular ligament intact
      • complications 
        • muscle weakness
        • wrist pain
        • valgus elbow instability
        • heterotopic ossification
        • elbow arthritis
        • proximal radial migration
        • decreased strength
        • cubitus valgus
    • Radial head arthroplasty
      • approach
        • Kocher
        • Kaplan
        • EDC split
      • technique
        • metal prostheses
          • loose stemmed prosthesis
            • acts as a stiff spacer
            • thought to "settle in" to anatomic position throughout arc of motion
          • press-fit prosthesis
            • depend on osteointegration and tight canal fit
            • may be more prone to incorrect intramedullary positioning given tight fit
          • bipolar prosthesis
            • has an articulation in the head-neck junction
            • thought to allow better articulation of radial head to capitellum throughout arc of motion
            • may facilitate elbow instability when the radial head angles in reference to the radial stem
        • pyrocarbon prostheses
          • pyrocarbon implant thought to better approximate modulus of cartilage and decrease risk of capitellar wear from metallic radial head implant
          • currently still under investigation
        • silicon replacements (Sylastic)
          • no longer used
          • independent risk factor for revision surgery
            • implant fracture
            • reactive synovitis
      • implant design
        • monoblock
          • head and stem are a single connected piece implanted together
        • modular 
          • head and stem are 2 distinct pieces that are attached upon implantation
      • complications
        • overstuffing of joint that leads to capitellar wear problems and malalignment instability
          • excessive length produces abnormal loads through the capitellum and is associated with pain, stiffness and progressive capitellar erosion  
          • incorrect diameter radial head prosthesis has cam effect which produces abnormal loads through the lateral aspect of the trochlea and the lesser sigmoid notch
          • best assessed by direct visualization and fluoroscopy
            • proximal implant should align with proximal lesser sigmoid notch
            • deepest point of the radial head dish should be at same height as lateral coronoid facet
            • range of motion should be assessed in flexion and extension and should be smooth
            • the radial head should remain properly aligned with the capitellum with elbow flexion and extension as well as with forearm pronation and supination
        • loosening 
          • higher likelihood in press-fit prosthesis, with potential need for revision surgery
          • any implant may be fixed with bone cement if needed
        • implant dissociation
          • bipolar prosthesis
            • modular prosthesis with defective locking mechanism of the head on the stem, leading to metalosis and pain
  • Complications
    • Surgical Site Infection
      • treatment
        • incision and drainage
        • consider radial head excision if osteomyelitis present
        • consider hardware/implant removal when infection complicates ORIF or radial head replacement
        • six weeks of intravenous antibiotics, possibly followed by oral antibiotics if hardware/prosthesis retained
    • Secondary displacement of fracture
      • incidence
        • occurs in < 5% of fractures initially treated nonoperatively
      • treatment
        • fixation may be necessary
        • serial radiographs do not change management
    • Posterior interosseous nerve injury (with operative management)
      • risk factors
        • dissection distal to biceps tuberosity in ORIF
        • overaggressive retraction at radial neck
      • treatment
        • if neuropraxia suspected, begin conservatively
          • cock-up wrist splint, therapy
          • may order EMG after several months of conservative management if not improving
          • may need tendon transfer if permanent
    • Elbow stiffness & loss of forearm rotation
      • incidence
        • 3-20% 
      • risk factors
        • prolonged immobilization
        • intra-articular fracture involvement
        • malunion/nonunion
        • heterotopic ossification
      • treatment
        • nonoperative
          • first-line management includes supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period
            • primary goal is to achieve "functional" elbow range of motion
              • 100º flexion arc (30º-130º) and 100º of rotation (50º pronation & 50º supination)
        • operative
          • contracture release with or without radial head removal or replacement
          • anconeus or Achilles allograft interposition arthroplasty
    • Radiocapitellar joint arthritis
      • risk factors
        • fracture with intra-articular displacement
        • use of metallic radial head replacement
          • worse with overstuffing
      • treatment
        • nonoperative
          • activity modification
          • anti-inflammatories
          • injections
        • operative
          • radial head resection
          • anconeus or Achilles allograft interposition arthroplasty
          • radiocapitellar hemiarthroplasty
            • limited outcome data present
            • no implants currently available
    • Heterotopic ossification (HO)
      • risk factors
        • CNS injury
        • burns
        • elbow fracture/dislocation with significant soft tissue injury
      • treatment
        • prevention
          • consider 6-week course of indomethacin to minimize risk after fracture/dislocation
          • post-operative radiation 
            • controversial
        • operative removal
          • ensure HO is mature before resection
          • most have satisfactory outcome despite residual flexion contracture
          • ~10% have recurrence 
    • Loss of hardware fixation
      • treatment
        • revision fixation
        • radial head replacement
        • radial head removal

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(OBQ13.89) 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

QID: 4724

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



L 2 B

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(SBQ12TR.86) Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?

QID: 4001

Early range of motion



Hinged elbow brace for 4 weeks



Repair lateral collateral ligament



Remove and upsize implant



Remove and downsize implant



L 1 B

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(SBQ11UE.28.1) A 35-year-old right-hand dominant male construction worker sustained the injury demonstrated in figures A, B, and C after a fall. On exam, he has wrist and forearm tenderness in addition to edema, ecchymosis, and tenderness about the elbow. An ipsilateral wrist radiograph is shown in figure D, while contralateral wrist radiographs demonstrate neutral ulnar variance. Which of the following is likely contraindicated in this patient?

QID: 216386

Open Reduction Internal Fixation (ORIF)



Radial head arthroplasty



Percutaneous pinning of the Distal Radioulnar joint



Radial head excision



Initiation of early motion



L 2 C

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(SBQ11UE.28) A 30-year-old female falls onto her outstretched arm and sustains the injury shown in Figures A and B. After intra-articular lidocaine injection, her elbow range of motion is 30°-95° extension/flexion, 45° supination, 65° pronation. There is no wrist tenderness and the radius pull test is symmetric to the contralateral forearm. What is the most appropriate treatment?

QID: 4263

Fragment excision via the extensor carpi ulnaris / anconeus approach



Internal fixation with headless compression screws via the brachialis / pronator teres approach



Internal fixation with a periarticular plate via the extensor carpi ulnaris / anconeus approach



Radial head arthroplasty via the brachialis / pronator teres approach



Sling and early elbow range of motion



L 4 A

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(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?

QID: 2844

Radial head resection



Radial head replacement



ORIF of the malunited fracture



Arthroscopic debridement



Total elbow replacement



L 4 D

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(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?

QID: 481

Excision of the radial head



ORIF of the radial head



Continued splinting, no surgery



Radial head arthroplasty



Hinged external fixation



L 1 B

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(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?

QID: 614

median nerve



brachial artery



anterior interosseous nerve



radial nerve



posterior interosseous nerve



L 1 C

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