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Radial Head Fractures

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Topic updated on 06/11/16 2:58pm
Introduction
  • Epidemiology
    • incidence
      • radial head fractures are among the most common elbow fractures
      • occur in up to 20% of all elbow injuries
  • Pathophysiology
    • mechanism of injury
      • fall on outstretched hand
      • forearm in pronated position
      • axial load created across elbow
  • Associated injuries
    • 30% have associated soft tissue or skeletal injuries including
      • 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 fractures
Anatomy
  • Osteology
    • radial head acts as secondary restraint to valgus force at the elbow
    • non-articular portion is roughly between radial styloid and listers tubercle
Classification

Mason classification
Type I Minimally displaced fx, no mechanical block to rotation, intra-articular displacement <2mm
Type II Displaced fx >2mm or angulated, possible mechanical block to forearm rotation
Type III Comminuted and displaced fx, mechanical block to motion
Type IV (Hotchkiss modification) Radial head fx with elbow dislocation

Presentation
  • Symptoms
    • pain and tenderness along lateral aspect of elbow
    • limited elbow or forearm motion, particularly supination/pronation
  • Physical exam
    • ROM & instability
      • evaluate for mechanical blocks to flexion /extension at elbow and rotation 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, compare to contralateral side
    • palpate interosseous membrane for tenderness/pain
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of the elbow
        • check for fat pad sign indicating possible minimally displaced 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 minimally displaced (less than 2mm) 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 ipsilateral elbow injuries
      • outcomes
        • ORIF shown to have worse outcome with 3 or more fragments compared to ORIF with < 3 fragments 
    • 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 replacement 
      • indications
        • comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not feasible
        • 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
    • 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 interosseous ligament injury (identify with radius pull test)
        • coronoid fracture
        • MCL deficiency
      • complications
        • pain
        • joint instability
        • proximal radial migration
        • decreased strength
        • cubitus valgus
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
        • if plate small (<2.0) will likely not affect supination/pronation if placed on radial neck
      • countersink implants on articular surface
    • screws
      • Herbert screws if placed in articular surface
  • 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
          • is an extensile approach that can be extended distally (Thompson approach to forearm) and proximally
        • cons
          • since this is a more anterior approach may put PIN at risk
      • Kocher posterolateral approach
        • interval between ECU and anconeus
        • keep forearm pronated to protect PIN
        • pros
          • less of a risk of PIN injury than the Kaplan
        • 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 
      • overstuffing of joint is best assessed under direct visualization 
  • 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 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

 

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Qbank (10 Questions)

TAG
(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 Topic Review Topic
FIGURES: A   B   C   D    

1. Sling immobilization for 2 days, followed by active mobilization.
2. Long-arm cast immobilization for 1 week, followed by active mobilization.
3. Long-arm cast immobilization for 1 week, followed by passive mobilization.
4. Long-arm cast immobilization for 2 weeks
5. Open reduction and internal fixation

PREFERRED RESPONSE ▶
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   B        

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

PREFERRED RESPONSE ▶
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 ▶
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 ▶
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