Introduction Epidemiology incidence 1.5-4% of all fractures radial head fractures are among the most common elbow fractures (33%) Pathophysiology mechanism of injury fall on outstretched hand elbow in extension + forearm in pronation most force transmitted from wrist to radial head Associated injuries 35% have associated soft tissue or skeletal injuries including ligamentous injury lateral collateral ligament (LCL) injury most common (up to 80% on MRI) medial collateral ligament (MCL) injury combined LCL/MCL Essex-Lopresti injury distal radioulnar joint (DRUJ) injury interosseous membrane disruption other elbow fractures coronoid fracture olecranon fracture elbow dislocation terrible triad (elbow dislocation, radial head fracture, coronoid fracture) carpal fractures scaphoid fracture Anatomy Osteology elbow joint contains two articulations ulnohumeral (hinge) radiocapitellar (pivot) 60% load transfer across elbow joint proximal radius nonarticular portion of the radial head is a ~90 degree arc from radial styloid to Lister's tubercle (safe zone for hardware placement) Ligaments lateral collateral ligament complex lateral ulnar collateral ligament (LUCL) primary stabilizer to varus and external rotation stress deficiency results in posterolateral rotatory instability radial collateral ligament (RCL) accessory lateral collateral ligament annular ligament stabilizes proximal radioulnar joint 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, dependant on radiocapitellar surface area loss of longitudinal stability occurs when radial head fracture + DRUJ injury + interosseous membrane disruption (Essex-Lopresti) radial head must be fixed or replaced to restore stability, preventing proximal migration of the radius and ulnocarpal impaction Classification 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 Presentation Symptoms pain and tenderness along lateral aspect of elbow limited elbow or forearm motion, particularly supination/pronation Physical exam range of motion evaluate for mechanical blocks to elbow motion flexion/extension and pronation/supination aspiration of joint hematoma and injection of local anesthesia aids in evaluation of mechanical block stability elbow lateral 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 may be 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 >3mm translation concerning for longitudinal forearm instability (Essex-Lopresti) Imaging Radiographs recommended views AP and lateral elbow check for fat pad sign indicating occult minimally displaced fracture 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 further delineate fragments in comminuted fractures identify associated injuries in complex fracture dislocations Treatment Nonoperative short period of immobilization followed by early ROM indications isolated minimally displaced fractures with no mechanical blocks (Mason Type I) 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 presence of other complex ipsilateral elbow injuries outcomes # fragments ORIF shown to have worse outcome with 3 or more fragments compared to 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 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 radial head arthroplasty indications comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not feasible and involves greater than 25% of the radial head elbow fracture-dislocations or 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 Approaches to Radial Head overview PIN crosses the proximal radius from anterior to posterior within the supinator muscle 4cm distal to radial head in both Kocher and Kaplan approaches, the forearm should be pronated to protect PIN pronation pulls the nerve anterior and away from the surgical field 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) cons risk of destabilizing elbow if capsule incision is too posterior and LUCL is violated, which lies below the equator of the capitellum Kaplan approach interval between EDC (PIN) and ECRB (radial n.) key steps incise mid-fibers of supinator incise capsule anterior to mid-radiopatellar plane (have access) pros less risk of disrupting LUCL and destabilizing elbow than Kocher approach (more anterior) better visualization of the coronoid cons greater risk of PIN and radial nerve injury ORIF approach Kocher or Kaplan approach plates fracture involved head and neck posterolateral plate placement safe zone (nonarticular area) consists of 90-110 degree arc from radial styloid to Lister's tubercle, 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 screws 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 Radial Head Resection approach Kocher or Kaplan approach complications after excision of the radial head include muscle weakness wrist pain valgus elbow instability heterotopic ossification arthritis proximal radial migration decreased strength cubitus valgus Radial head arthroplasty approach Kocher or Kaplan approach technique metal prostheses 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 indepedent risk factor for revision surgery complications overstuffing of joint that leads to capitellar wear problems and malalignment instability overstuffing of joint is best assessed under direct visualization Complications Displacement of fracture occurs in less than 5% of fractures; serial radiographs do not change management Posterior interosseous nerve injury (with operative management) Loss of fixation Loss of forearm rotation Elbow stiffness first-line management incluides supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period Radiocapitellar joint arthritis Infection Heterotopic ossification Hardware loosening Complex regional pain syndrome
Radial Head Replacement Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Orthobullets Team David Tuckman
QUESTIONS 1 of 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 2844 FIGURES: A B 1 Radial head resection 48% (464/966) 2 Radial head replacement 46% (442/966) 3 ORIF of the malunited fracture 3% (33/966) 4 Arthroscopic debridement 1% (14/966) 5 Total elbow replacement 0% (3/966) Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Review Topic QID: 4724 FIGURES: A B C D 1 Sling immobilization for 2 days, followed by active mobilization. 86% (3866/4518) 2 Long-arm cast immobilization for 1 week, followed by active mobilization. 7% (334/4518) 3 Long-arm cast immobilization for 1 week, followed by passive mobilization. 3% (157/4518) 4 Long-arm cast immobilization for 2 weeks 1% (36/4518) 5 Open reduction and internal fixation 2% (97/4518) Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 481 1 Excision of the radial head 7% (41/561) 2 ORIF of the radial head 4% (23/561) 3 Continued splinting, no surgery 3% (15/561) 4 Radial head arthroplasty 84% (472/561) 5 Hinged external fixation 1% (5/561) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 614 1 median nerve 1% (6/733) 2 brachial artery 1% (4/733) 3 anterior interosseous nerve 7% (48/733) 4 radial nerve 5% (40/733) 5 posterior interosseous nerve 86% (633/733) Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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