Radial head fracture

Bahaa Kornah - Al-Azhar UN. - Cairo EGYPT
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

Objectives
• Anatomy and biomechanics
• Epidemiology & classification
• Complex patterns of injury
• Treatment algorithm
• Long term outcomes

RADIAL HEAD

EPIDEMIOLOGY
 1.5 to 4 % of all fractures in adult
 33 % of all elbow injuries
 1/3 PTASSOCIATED INJURY TO SHOULDER,HUMERUS,FOREARM,WRIST OR
HAND.
 RARE IN CHILDREN DUE TO CARTILAGENOUS NATURE OF RADIAL HEAD.
 RADIAL NECK FRACTURE MORE COMMON IN CHILDREN.

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

fractures
• Rockwood and Green-
Assume associated injuries
unless proved otherwise

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

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

Anatomy

Anatomy
Lateral
Medial

ANATOMY OF ELBOW JOINT
RADIOCAPITELLAR JOINT TRANSMIT 50-
60% LOAD ACROSS ELBOW

HEAD RADIUS SURGICAL
ANATOMY
IMPORTANT FOR
 VALGUS STABILITY
 POSTEROLATERAL ROTATORY
STABILITY
 LONGITUDINAL FOREARM
STABILITY (ALONG WITH
INTEROSSI MEMBRANE & DRUJ)

ELBOW STABILITY
PRIARY STABILIZER >>>>>> MCL & U-H
JOINT:
SECONDARY STABILIZER >>>>>>>>RADIAL
HEAD(R-C JOINT) & CAPSULE:

Ulnohumeral
articulation
AMCL LUCL
FLEXOR
tendons
EXTENSOR
tendons
Radiohumeral
articulation
Stability
(aMCL) the anterior bundle of the medial collateral ligament
(LUCL) the lateral ulnar collateral ligamentBahaa Kornah - Al-Azhar UN. - Cairo EGYPT

MUSCLE ATTACHMENT
AROUND PROXIMALRADIUS
SUPINATOR ATTACHMENT AT PROXIMAL
RADIUS.
BICEPS TENDON ATTACH TO RADIAL
TUBEROSITY.

POST.INTEROSSI NERVE AT RISK
 PIN TRAVERSES FROM ANTERIOR TO POSTERIOR
THROUGH SUPINATOR MUSCLE.
 ALWAYS CHECK PRE OPERATIVE ACTIVE FINGER
EXTENSION Bahaa Kornah - Al-Azhar UN. - Cairo EGYPT

MECHANISM OF INJURY
- Indirect injury
- Axial load thru pronated forearm
- Valgus injury
- Posterolateral rotatory load

MECHANISM OF INJURY
(1) FALL ON OUTSTRECHED HAND(MOST COMMON)
DISTAL RADIUS
INTEROSSI MEMBRANE(FOREARM) RADIAL HEAD IMPACTION
AGAINST CAPITELLUM (2)VALGUS INJURY TO ELBOW/DIRECT
INJURYMCL RUPTURE/OLECRANON FRACTURE UNSTABLE ELBOW

MECHANISM OF
INJURY
• Disruption of
interosseous
membrane due to
acute shortening
of radius producing
longitudinal
traction

ASSOCIATED INJURIES
ELBOW DISLOCATION
ESSEX LOPRESTI
CORONOID FRACTURE CAPITELLUM FRACTURE

ASSOCIATED INJURIES
MCL injury
Olecranon
fracture dislocation

DIAGNOSIS
 HISTORY: FALL ON OUTSTRETCHED HAND/DIRECT
INJURY
 EXAMINATION:
 SWELLING
 ECCHMOSIS
 ANCONEUS TRIANGLE FULLNESS
 RANGE OF MOTION RESTRICTION
 STABILITY
 ACTIVE FINGER EXTENSION
 FOREARM/INTEROSSI MEMBRANE
TENDERNESS
 WRIST TENDERNESS
ESSEX LAPROSTI INJURY

Detecting associated injuries

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

DOCUMENT
• MCL injury
• PIN injury
• DRUJ injury
• Interosseous membrane injury

X RAY FINDINGS
 STANDARD AP AND LATERAL X RAY of elbow
 OBLIQUE(GREEN SPAN) VIEW
 FOREARM AND WRIST X RAY IF REQUIRED

Greenspan-Norman
radiocapitellar view
Imaging
45o

X RAY FINDINGS

CT scan
Imaging
45o

Patterns of Traumatic Elbow Instability With Fracture
Dislocation
Dislocation+
radial head
fracture
Terrible Triad
Dislocation Injuries
Olecranon fracture-
Dislocation
Posterior
Anterior
Disruption Injuries
Varus posteromedial
rotational instability

Classification
SIMPLE COMPLEX
- Another fracture
- Ligamentous injury

Classification Mason

Hotchkiss

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

HOTCHKISS
• TYPE 2- displaced partial radial head fracture
that blocks forearm rotation/
entire radial head fracture amenable to
fixation, treatment is ORIF

HOTCHKISS
• TYPE 3- comminuted
entire radial head
fracture not amenable to
fixation,
• Radial head excision
or
• Replacement .

Undisplaced Displaced

Type II clm
Type III lm
Mayo

TREATMENT GOAL
 CORRECTION OF ANY BLOCK TO FOREARM ROTATION
 EARLY ROM OF ELBOW AND FOREARM
 STABILITY OF ELBOW AND FOREARM
 PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW

Treatment options
 Non-operative treatment
 Fragment excision
 Radial head excision
 Internal fixation
 Allograft implantation
 Arthroplasty

 fragment number,
 displacement,
 articular surface,
 age & bone quality,
 dislocation,
 associated ligamentous injury,
 associated elbow fractures
Decision-making

Non-operative treatment
Mason type I fractures
Mason type II, without block or
articular incongruity
Fractures >1/3 of the articular
surface: later displacement

NON OPERATIVE
TREATMENT
 SLING
• PLASTER SLAB FOR 3 WEEKS
 EARLY ACTIVE MOBILIZATION OF ELBOW
 PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR
FRACTURE

- Aspiration within 6 h of injury
- Immobilization in broad arm sling for 48 h
- Active mobilization and extension stretching exercises
- Follow up at 1 week : discharged to physiotherapy
- Clinical and radiological review in 6 weeks (if no improvement)

OPERATIVE MANAGEMENT
OPEN REDUCTION & INTERNALFIXATION
INDICATION FOR ORIF:
 Mason type II with mechanical block(displaced)
 Large fragment >2 mm
 Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME)
 Mechanical block to motion (lignocaine inj in elbow joint)
 Presence of other complex ipsilateral elbow injuries(without
metaphyseal bone loss)
 FRAGMENT EXCISION LEADS TO INSTABILITY
 TRY TO PRESERVE SMALLEST FRAGMENT

Mason II & III fractures
• Lateral approach
• No more than 3 fragments Small
screws, Hebert screws Low
profile special plates
“Safe” zone
Ligament associated
injuries >>>>>repair,
Radial head fixation

Which implant to use?
 Mini fragment screw(2.4 or 2.7 mm)(counter sink must)
 Headless compression compression screw/Herbert screw
 Low profile plate/mini t plate(in safe zone/postero lateral)
 K WIRE

ORIF. implant in SAFE
ZONE

Smith and hotchkiss
90- 110o arc on the posterolateral
aspect of the radial head
With the wrist in neutral, the zone lies
between 2 longitudinal lines drawn
from Lister’s tubercle and the radial
styloid proximally.
Safe zone for fixation

Implant selection

16 patients Mason II average 22 years postop
screws (11 patients) or plates (5 patients) 2 infections
2 patients excessive screw length, 1 transient PIN palsy
second surgery (14 patients).
Mayo Index = Excellent (9), good (4), fair (2), poor (1)
The long-term results demonstrate no appreciable advantage
over the long-term results of non-operative treatment

10 patients
mean age 42 (24 to 71). Mason
type III (3) Mason type IV (7)
Mean follow-up of 28.5 months
All fractures had
9/10 plate removal
Mean Morrey score 90.7/100 1
fair result

2 Mason type-III
4 Mason type-IV
‘on-table’ reconstruction low-
profile mini-plates
mean follow-up of 112 months
Morrey score 97.0 points,
Mayo Index was 99.2
1 pt. degenerative changes,.

Surgical approach for ORIF:
Kaplan direct lateral
approach
 Interval between EDC and ECRB
 Keep forearm pronated to protect PIN
 PIN present approx. 2 cm below radial head
 Do not extend exposure below annular ligament
 Gentle retraction
 ADVANTAGE:
 No disruption LATERAL LIGAMENT
COMPLEX(LUCL)
 DISADVANTAGE:  PIN at risk

KOCHER POSTEROLATERAL
APPROACH
 Interval between ECU and anconeus
 Keep forearm pronated to protect PIN
 Advantage:
 Less of a risk of PIN injury than the kaplan
 Disadvantage:
 LATERAL LIGAMENT COMPLEX may injured
 Leads to instability
 HOTCHKISS APPROACH
 DIRECTLY THROUGH EDC
 PROTECT LATERAL LIGAMENT COMPLEX

PRONATE FOREARM WHILE FIXATION

SAFE ZONE OF RADIUS HEAD FIXATION
 LONGITUDINAL LINE B/W LISTER TUBERCLE AND RADIUS STYLOIDPROCESS
 NO ARTICULATION WITH ULNA
 SAFE FOR IMPLANT INSERTION:NO IMPINGMENT IN ROTATION
POSTERO-LATERAL ZONE IN FULL SUPINATION(CAPUTOA)
IN NEUTRAL(MID PRONE)POSITION : ANTEROLATERALZONE

Early
• inadequate fixation,
• hardware malposition,
• injury to the PIN
• Head misshapen
• Delayed healing - non union
Osteonecrosis
Late
• hardware prominence
• elbow stiffness
• Need for plate removal (~ 6
months) LCL repair NO
supination for 4-6 weeks
• Loss of terminal extension
Complications

RADIAL HEAD REPLACEMENT
 To prevent proximal migration of the radius
 Indication:
 Extensive communition of radial head/excess bone loss
 Elbow instability:
 essex lapresti lesion,
 coronoid fracture,
 elbow dislocation,
 collateral ligament injury,
 olecranon fracture

Radial head arthroplasty
Mason III, IV
> one third of the head not
amenable to fixation
associated ligamentous injury
coronoid or olecranon fractures
Late reconstruction nonunion,
fixation failure, loss of forearm
rotation

• Silicone prosthesis
• Instability
• Destructive synovitis
• Discarded
• Metal prosthesis
- Press fit / cemented
- Smooth stem
- Unipolar or modular bipolar head

Silicone rubber prostheses are no
longer used
not sufficiently rigid prone to
fragmentation
late inflammatory synovitis

Modern implants unipolar or bipolar,
Monoblock or modular,
anatomical or non-anatomical,
cemented or press-fit
Correct diameter, height, medial offset
and cervico-cephalic angle
Bipolarity permits
positioning of the
an ‘‘automatic’’
radial head with
respect to the neck and the opposite
articular surfaces

RADIAL HEAD REPLACEMENT
PROSTHESIS
 LOOSE STEMMED PROSTHESIS
 THAT ACTS AS ASTIFF SPACER

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

• 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

12 fresh & two old cases
Mason type III radial head fracture
Cement stem and bipolar prosthesis
Control group: 8 cases ORIF with screws
Good or excellent
92.9% of prosthesis
12.5% in ORIF

Systematic review & meta-analysis
67 patients with 67 cases
Mason type III radial head fractures
Complication rate
13.9 % RHR
58.1 % ORIF
Satisfactory rate 91.7 % / 51.6

841 clinical studies with 1264 pt.
Mason II best treatment option = ORIF (overall success rate 98%)
Mason III 92% success of ORIF (better than resection and
replacement)
Mason IV best results after ORIF followed by resection and
implantation of a prosthesis
primary implantation showed better outcomes in type III (87%) and
IV (82%) compared to secondary implantation

BIPOLAR PROSTHESIS
 That is cemented into
the neck of the radius
COMPLICATIONS:
 Overstuffing of joint
 capitellar wear problems

 Malalignment instability

COMPLICATION OF
REPLACEMENT
 Post operative infection of implant
* Over stuffing with opening up
 Ulnar nerve/PIN injury
 Immediate post operative dislocation
 Recurrent instability
 Heterotrophic ossification
 Contracture /stiffness
 Crps type 1

Over stuffing with
opening up

Tips
Radius pull test
change in Ulnar variance > 3 mm: rupture of the IM
> than 6 mm, both TFCC and IM are disrupted
.
RH should be in line with the
proximal edge of the lesser sigmoid
notch to avoid overstuffing

Allograft reconstruction

Fragment excision
mechanical block
(RH fragments or cartilaginous pieces)
Not always visible in plain x-rays
Fragments < 1/3 of the radial head
Fragments 1/4 to 1/3 of the capitellum
Caputo AE, Burton KJ, Cohen MS, et al: Articulator cartilage injuries
of the capitellum interposed in radial head fractures: A report of
ten cases. J Shoulder Elbow Surg 15:716-720, 2006

RADIAL HEAD EXCISION
 INDICATION:
 Low demand, sedentary patients
 In a delayed setting for continued pain of an isolated radial head fracture
 CONTRAINDICATION:
 In children
 Presence of destabilizing injuries (Essex-lopresti lesion, fracture dislocation
elbow(mason type 4),monteggia)
 Terrible triad of elbow(coronoid fracture, MCL deficiency)

Radial head excision
• Avoidacuteexcision
• Noinligamentousinjury
• 3ormorefragments
• ComminutionoftheRHneck Elderly,
• lowdemandpatients
• Assalvageprocedure
Maintenance of radial head height is
important in allowing ligamentous
healing at the correct length

Radial head excision
Disadvantage
• Chronic ulnar wrist pain,
• Instability,
• Elbow stiffness,
• Loss of strength,
• Degenerative arthritis
• Cubitus valgus,
• Heterotopic calcification,
• Myositis ossificans,

17 years fup51 RH excisions
27 pt (20 m, 7 f)
• mean age 37 (18-61)
• 5 type II, 16 type III, and 6 type IV. mean
follow-up 17 years (10-24) Mayo & DASH
scores
• 22 patients excellent (81%)
• 4 patients good (15%)
• 1 patient fair (4%)

COMPLICATION OF EXCISION
 PROXIMAL MIGRATION OF RADIUS
 INFERIOR RADIO ULNAR JOINT DISTURBANCE
 PAIN & WEAKNESS OF WRIST
 Joint instability
 Decreased strength
 Cubitus valgus
 EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR
SYNOSTOSIS.

• Force transmission
- 60% of load applied to hand
• Stability
– 30% resistance to valgus stress
– Secondary stabilizer in MCL deficiency
• Rotational motion of the forearm
Biomechanics

Biomechanics
- RH resection overloads the coronoid process
- the elbow then depends on the MCL to
prevent valgus deformity
- if interosseous membrane is disrupted the
radius is proximally migrate
- for each mm of radial shortening, the distal
ulnar load increases by approximately 10%.

With modern implants and techniques,
fragment excision, ORIF, and arthroplasty all
offer good results
Radial head excision has become a less
favorable treatment option
Individualized treatment in complex cases
with ligamentous injuries or associated
fractures
Conclusion

‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬
Good Luck
and Thank
You for Your
Attention
bkornah@gmail.com
Bahaa Kornah. AlAzhar Un. Cairo EGYPT

Radial head fracture

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