deals with fractures of isolated radial head with evaluation , management and postoperative protocol

1. Isolated radial head
fractures

2. ISOLATED RADIAL HEAD
FRACTURES
Kc gopalakrishnan

3. 1.5 to 4 % of all fractures in adult
33 % of all elbow injuries

4. Isolated Radial head
fractures
• Davidson et al- all 111 patients
with entire radial head fractures
had associated wrist or elbow
ligamentous injury( clin orthop
1993)
• 30 – 70% associated injuries in
various studies

5. Isolated Radial head
fractures
• Rockwood and Green- assume
associated injuries unless
proved otherwise

6. Isolated Radial head
fractures
• Possible to get isolated
radial head fractures in
elderly but rare -Rockwood
and Green

7. Isolated Radial head
fractures
• “Entire radial head fracture or
displaced partial radial head
fracture always associated with
ligamentous injury-” Rockwood and
Green

8. ISOLATED RADIAL
HEAD FRACTURE

9. APPLIED ANATOMY

10. APPLIED ANATOMY
• Radial head act as secondary
stabilizer to valgus stress, primary
being MCL
• Radial head resection in presence
of intact MCL does not alter valgus
instability much

11. APPLIED
ANATOMY
• PROXIMAL RADIO
ULNAR JOINT
»260* arc
covered with
articular
cartilage
»100* arc safe
zone
»Pronation-
supination

12. APPLIED ANATOMY
• RADIO
CAPITELLAR
JOINT
• Radial head transmits
60% of axial load of
forearm to capitellum
(Morrey JBJS 1988)

13. APPLIED ANATOMY
• RADIO
CAPITELLARJOINT
This load is greatest
with forearm in
pronation and b/w
0-30* elbow
flexion

14. MECHANISM OF
INJURY
– Indierect injury
– Axial load thru pronated forearm
– Valgus injury
– Posterolateral rotatory load

15. MECHANISM OF
INJURY

16. MECHANISM OF
INJURY
• Disruption of
interroseous
membrane due to
acute shortening
of radius
producing
longitudinal
traction

17. ASSOCIATED INJURIES
ELBOW DISLOCATION
ESSEX LOPRESTI
CAPITELLUM FRACTURECORONOID FRACTURE

18. ASSOCIATED INJURIES
MCL injury Olecranon
fraccture dislocation

19. Detecting associated
associated injuries
• Clinical examination
• X-ray evaluation
• CT
• Intraoperative evaluation

20. Detecting associated
associated injuries

21. CLINICAL
EVALUATION
• Even minor fractures are painful due
to haemarthrosis
• Document forearm rotation after LA
injection to joint to rule out
mechanical block

22. DOCUMENT
• MCL injury
• PIN injury
• DRUJ injury
Interroseous membrane injury

23. DOCUMENT
•
•
•
•

24. BROBERG MORREY MODIFICATION OF
MASON CLASSIFICATION 1
• Marginal/ segmental fracture
• < 2mm displacement
• No block to forearm rotation

25. BROBERG MORREY MODIFICATION
OF MASON CLASSIFICATION 2
• Displaced segmental fracture
• > 2mm/ >30* angulation
• Mechanical block to forearm rotation

26. BROBERG MORREY
MODIFICATION OF MASON
CLASSIFICATION 3
• Communited entire radial head
fracture

27. BROBERG MORREY
MODIFICATION OF MASON
CLASSIFICATION 4
• Radial head fracture associated
with elbow dislocation

28. HOTCHKISS
MODIFICATION OF MASON
CLASSIFICATION
• TYPE 1- minimally displaced radial head
fracture , no block to forearm rotation,
can be treated non operatively

29. HOTCHKISS
MODIFICATION OF MASON
CLASSIFICATION
• TYPE 2- displaced partial radial head
fracture that blocks forearm rotation/
entire radial head fracture amenable to
fixation, treatment is ORIF

30. HOTCHKISS
MODIFICATION OF MASON
CLASSIFICATION
• TYPE 3- communited entire radial head
fracture not amenable to fixation, radial
head excision or replacement .

31. Goals of treatment
• Correcton of block to free forearm
rotation
• Stable elbow
• Prevent late arthrosis
• Early mobilisation

32. Non operative treatment
• Modified mason 1 fractures
• No associated lig injuries
• No bony block to ROM

33. Non operative treatment
• Early(3-4d) ROM
• Large undisplaced fragments need to be
monitored with x-ray
• Loss of elbow extension
• Redisplacement
• Non union
• Various studies have reported 90% favourable
results in mason 1 injury

34. Non operative treatment
• 80% favourable result with MASON
2&3 fractures treated
nonoperatively and added with
delayed radial head excision when
required for pain(JBJS (Am) :86-
A; 3, 570.)

35. Non Operative Rx

36. More than 2 wks POP

37. Retain/Regain

39. Safe Zone
• Smith and hotchkiss
• 65* ant and 45* pos to line bisecting
anterior and pos head with arm in
neutral rotation

40. Safe Zone

41. ORIF. implant in SAFE
ZONE

42. CONSIDER ORIF
• Displaced MASON 2(>2mm) partial
radial head fractures which block
forearm rotations
• Entire radial head fractures with
unstable elbow if
– Less than three articular fragments
– Sufficient size and bone quality ti accept screws
– No metaphyseal bone loss

43. Partial radial head
fracture

44. Entire radial head
fracture

45. • Better understanding of anatomy and safezones
for implant and current implants have improved
clinical results of internal fixation
• King et al have repoted 100% excellent results
with internal fixation for Mason 2 fractures
• They have reported only 33%good results with
Mason 3 fractures treated by internal fixation

46. • Due to inadequate fixation or
selection of fracture pattern-
include
• Nonunion
• Restriction of forearm motion
• Implant failure
• Infection
• PIN injury

47. Inadequate fixation

48. Extending the indication

49. Primary Radial head
excision

50. Primary Radial head
excision
Modified mason 3 fractures with
» Intact MCL
» No injury to DRUJ
» Coronoid and olecranon
intact
• Partial radial head fractures hindering
forearm rotation not amenable to
reconstruction

51. 15 yr follow up studies
• Antuna et al- 81 % painfree ,
radigraphic OA did not produce
clinical symptoms
• Hebertson et al- 90% excellent
results, OA changes in 50%

52. COMPLICATIONS
• LOSS OF ELBOW MOTION
• LOSS OF STRENGTH
• ELBOW OA CHANGES
• PROXIMAL MIGRATION OF
RADIUS( up to 2 mm assymptomatic)
• WRIST PAIN
• VALGUS INSTABILITY OF ELBOW

53. EVOLVING
?

54. Radal head arthroplasty
• Silicone prosthesis
• Insabilty
• Destructive synovitis
• Discarded
• Metal prosthesis
– Press fit / cemented
– Smooth stem
– Unipolar or modular bipolar head

55. • Smooth stem
• Act like spacer
• Produce
radiolucencies but
asymptomatic
• No overstuffing of
radiocapitellar joint

56. • Fixed stem
• Overstuffing if radiocapitellar joint if
prosthesis more than 1 mm proximal to
coronoid process
• Open up elbow on lateral side
• Capitellar wear and synovitis
• So exact sizing must
• No significant diff b/w monopolar or bipolar
heads

57. Over stuffing with
opening up

58. TAKE HOME MESSAGE
• Isolated radial head fracture do occur
but is rare
• Always look for wrist or elbow
ligamentous injury
• Document forearm rotation
• Nonoperative treatment involves
supervised mobilization NOT
immobilization

59. TAKE HOME MESSAGE
• Selection of type of fracture
amenable to fixation crucial
• Follow safe zones for implants
• Radial head arthroplasty is still
evolving

60. DIDN’T MEAN TO
CONFUSE!!!!!!!!!!