The Role of Prosthetic Replacement in the Management of Comminuted Radial Head Fractures

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A displaced and badly comminuted fracture of the radial head is part of a complex instability injury of 3 joints namely elbow, radio-ulnar and wrist joints. If it is associated with Mason type IV and Essex Lopresti injury to forearm, simple
excision of the radial head may lead to instability of the elbow joint and painfully restricted movements of the wrist.
Management should be aimed at achieving the normal anatomy so that the function of elbow, radio-ulnar and wrist
joints will be restored to a satisfactory level. We report the medium term result of a patient who had prosthetic replacement of radial head. Our patient in this case report was informed, that the details of the management would be
submitted for publication.

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The Role of Prosthetic Replacement in the Management of Comminuted Radial Head Fractures

  1. 1. The Role of Prosthetic Replacement in the Management of Comminuted Radial Head Fractures
  2. 2. Apollo Medicine 2012 December Volume 9, Number 4; pp. 336e338 Case Report The role of prosthetic replacement in the management of comminuted radial head fractures A. Mohan Krishnaa, N. Somasekhar Reddyb,* ABSTRACT A displaced and badly comminuted fracture of the radial head is part of a complex instability injury of 3 joints namely elbow, radio-ulnar and wrist joints. If it is associated with Mason type IV and Essex Lopresti injury to forearm, simple excision of the radial head may lead to instability of the elbow joint and painfully restricted movements of the wrist. Management should be aimed at achieving the normal anatomy so that the function of elbow, radio-ulnar and wrist joints will be restored to a satisfactory level. We report the medium term result of a patient who had prosthetic replacement of radial head. Our patient in this case report was informed, that the details of the management would be submitted for publication. Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Keywords: Radial head fracture, Radial head prosthesis, Fracture dislocation of elbow, Radial head replacement, Radial head fracture with DRUJ instability CASE REPORT A 30-year-old gentleman was admitted following a road traffic accident with injury to his right upper limb. He had an elbow deformity with pain over forearm down to the wrist. He has mild fullness over volar aspect of the forearm with tenderness over the dorsum of the distal radioulnar joint and wrist joints with limitation of movements. X-rays confirmed dislocation of the elbow joint with a comminuted, displaced fracture of the radial head and fracture of the tip of the coronoid process. There was no gross dislocation at the distal radio-ulnar joint on the X-ray (Fig. 1). Surgery was done under brachial block. Dislocation was first reduced. Radial head was exposed through a postero lateral approach. It was found to be too comminuted to fix and was excised. There was about 3e5 mm of linear translatory movement between the radius and ulna confirming the axial forearm instability. Then the radial head was a recreated using the excised fragments. It is very important for two reasons. One is to make sure that all the broken pieces were removed. The second reason is to size the appropriate prosthetic component. Radial neck was prepared to get a uniform cut and the medullary canal was prepared with a gouge and a narrow pointed rasp. Sometimes a high-speed burr is necessary to shape the medullary canal to accept the stem of the trial component. The preparation of the medullary canal can be tedious as one cannot hammer the prosthesis in to the canal due to the high risk of fracture of radial neck and shaft. I used chrome cobalt uncemented prosthesis (Corin) (Fig. 2). This implant comes in three diameters and each diameter comes with a thick and a thin head, making a total of 6 sizes. When the natural radial head diameter falls in between the prosthetic sizes it is advisable to go for the smaller prosthetic head. This is to prevent over stuffing the proximal radio-ulnar joint. But the thickness of the head should be maintained as close to the natural as Consultant Orthopaedic Surgeon, bSenior Consultant Orthopaedic Surgeon, Apollo Hospitals, Hyderabad, India. Corresponding author. Room No. 957, Apollo Hospitals, Jubilee Hills, Hyderabad 500 033, India. Tel.: þ91 98480 25355, email: nreddy12@ yahoo.com Received: 4.7.2012; Accepted: 4.8.2012; Available online 21.8.2012 Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. * http://dx.doi.org/10.1016/j.apme.2012.08.002
  3. 3. The role of prosthetic replacement in the management of comminuted radial head fractures Case Report 337 DRUJ or wrist joint. At his next visit at 18 months following surgery he has full pronation with marginal improvement in flexion and extension. X-ray of the elbow did not show any evidence of prosthesis loosening or erosion of the capitellum. DISCUSSION Fig. 1 Pre-operative X-ray showing fracture dislocation of elbow joint. possible by inserting less or more of the prosthetic stem in to the medullary canal to appropriately support the capitellum. There was no valgus instability after reducing the radial head suggesting the integrity of medial collateral ligament. At 90 of flexion elbow joint was stable and hence no attempt was made to fix the small fragment of coronoid process. Elbow was immobilised at about 100 of flexion and forearm in full supination to maintain maximum interosseous space. Active and active assisted movements were started after 3 weeks. Four months following the procedure, patient regained 15 short of full extension with terminal restriction of flexion. There was terminal restriction of both supination and pronation. Elbow joint was stable and he has no pain at Resection of the radial head for simple fractures has been shown to give satisfactory long term results.1,2 However unrecognised complex injuries with elbow or axial forearm instability may be responsible for unstable elbow, proximal migration of radius, with or without chronic wrist pain.3 This instability is a major concern in young and active people whereas in a relatively sedentary and elderly people it may not cause any significant problem for the day to day activities. Silicon radial head prosthesis did not offer rigid stability. Proximal migration of the radius progressed with break-up of the implant and subsequent synovitis.4,5 Metallic radial head offered better stability against valgus forces at elbow and axial forearm instability.6e8 However over stuffing of the radio capitellar joint must be avoided, as it may produce capitellar erosion especially when done as a late reconstructive procedure for chronic wrist pain.9 We recommend this procedure strongly in young people to avoid long term consequences of elbow, radio-ulnar and wrist joint instabilities. Loosening of the stem as a major complication was not reported in the literature when the procedure was done in young people. We believe that for any reason if the prosthesis has to be explanted after a period of 6e12 months it may not lead to any instabilities mentioned above as the interosseous membrane and other soft tissues would have got stabilised by then to a large extent preventing proximal migration of radial shaft. Even though the role of radial head prosthesis in stabilising the elbow and axial forearm instability seems well proven, it is being used less often mainly because of lack of awareness of secondary instability and non-availability of radial head prosthesis. CONFLICTS OF INTEREST All authors have none to declare. REFERENCES Fig. 2 Post-operative X-ray showing radial head replacement. 1. Goldberg I, Peylan J, Yosipovitch Z. Late results of excision of the radial head for an isolated closed fracture. J Bone Joint Surg Am. 1986;68:675e679.
  4. 4. 338 Apollo Medicine 2012 December; Vol. 9, No. 4 2. Morrey BF, Chao EY, Hui FC. Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am. 1979;61:63e68. 3. Sowa DT, Hotchkiss RN, Welland AJ. Symptomatic proximal translation of the radius following radial head resection. Clin Orthop. 1995;317:106e113. 4. Morrey BF, Askew L, Chao EY. Silastic prosthesis replacement for the radial head. J Bone Joint Surg Am. 1981;63:454e458. 5. Valderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflammatory arthritis after failure of silicon rubber replacement of the radial head. J Bone Joint Surg Br. 1994;76:78e81. 6. Moro JK, Werler J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructable Mohan Krishna and Somasekhar Reddy fractures of the radial head. J Bone Joint Surg Am. 2001;83: 1201e1211. 7. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason type III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg Am. 2005;87:65e76. 8. Grewal Ruby, Dermid Joy C, Faber Kenneth J, Drosdowech Darren S, King Graham JW. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. J Bone Joint Surg Am. 2006;88:2192e2200. 9. Van Riet Roger P, Van Glabbeek Francis, Verborgt Olivier, Gielen Jan. Capitellar erosion caused by metal radial head prosthesis. J Bone Joint Surg Am. 2004;86:1061e1064. Erratum to “Colour Doppler ultrasound in controlled ovarian stimulation with intrauterine insemination” [Apollo Med 9 (3) (2012) 252e263] Kavita Bhadauriaa,*, Reeti Sahnib, Sohani Vermab, Payal Q. Khatric The above mentioned article published in the September issue is an Original Article, but was published as a Case Report by mistake. The journal regrets for this error. DOI of original article: 10.1016/j.apme.2012.07.014. a Resident, bSenior Consultant, cAssociate Consultant, Department of Radiodiagnosis and AARU, Indraprashta Apollo Hospitals, New Delhi 110076, India. * Corresponding author. Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.11.001
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