Radial head fractures

Abstract

Radial head fractures are the commonest fractures in the elbow. They are often associated with other injuries: ligamentous, cartilaginous or other fractures. Associated injuries are important determinant of the management of the radial head fracture. These should be carefully looked for, diagnosed and treated. The original Mason classification for this fracture has been modified to include the associated injuries and their treatment. CT scan is a helpful diagnostic tool and should be used if available. Radial head fractures can be treated either conservatively or operatively (by excision, open reduction and internal fixation or prosthetic replacement). Undisplaced or minimally displaced fractures should be treated non-operatively. Internal fixation by headless cannulated screws is the preferred treatment for displaced fractures. It provides satisfactory biomechanical stability, can be done through a smaller incision, has less complications and lesser requirement of later removal of screws. Small number of fractures with comminution of neck would require plate fixation. Unfixable fractures in elderly can be treated by excision while such fractures in younger population or associated with significant soft tissue or bony injuries would require prosthetic replacement.

Keywords: Excision; Fixation; Fracture; Radial head; Replacement.

Fig. 1

Demonstration of radial head as a secondary stabiliser with intact medial collateral ligament (A), and when the medial collateral ligament is divided (B) (Reproduced with permission from: Morrey's The Elbow and its Disorders, 5th edition, Morrey BE, Morrey ME, Sanchez-Sotelo J (eds), Figure 36.3, © Elsevier Inc. (2018), accessed via ScienceDirect on May 10, 2021).

Fig. 2

Bruising on the medial side of elbow.

Fig. 3

Mason classification of uncomplicated radial head fractures. The exact definition of type II fracture is often difficult to determine. (Reproduced with permission from: Morrey's The Elbow and its Disorders, 5th edition, Morrey BE, Morrey ME, Sanchez-Sotelo J (eds), Fig. 37.7, © Elsevier Inc. (2018), accessed via ScienceDirect on May 10, 2021).

Fig. 4

Type IV radial head fracture (with associated dislocation).

Fig. 5

Minimally displaced fractures of radial head suitable for non-operative treatment.

Fig. 6

Patient was able to do >50% of range of movement on day 1 so suitable for non-operative treatment.

Fig. 7

Treatment algorithm for acute radial head fractures (Reproduced with permission from: Morrey's The Elbow and its Disorders, 5th edition, Morrey BE, Morrey ME, Sanchez-Sotelo J (eds), Fig. 37.10, © Elsevier Inc. (2018), accessed via ScienceDirect on May 10, 2021).

Fig. 8

A, B Pre and post fixation of 4 fragment of radial head fracture.

Fig. 9

A, B fixation of radial head fracture by HCS in an apical fashion. (Fig. 9A (Reproduced with permission from: Morrey's The Elbow and its Disorders, 5th edition, Morrey BE, Morrey ME, Sanchez-Sotelo J (eds), Fig 38.4, © Elsevier Inc. (2018), accessed via ScienceDirect on May 10, 2021).

Fig. 10

Backing out of screws.

Fig. 11

Heterotrophic ossification following ORIF of radial head fracture.

Fig. 12

Nonunion of radial head fracture with backing out of screw.

Fig. 13

Pre and post op x-ray of comminuted fracture of radial neck treated by ORIF with a plate.

Fig. 14

Bipolar implants have additional mobile bearing between radial stem and head (Reproduced with permission from: Morrey's The Elbow and its Disorders, 5th edition, Morrey BE, Morrey ME, Sanchez-Sotelo J (eds), Fig 39.3, © Elsevier Inc. (2018), accessed via ScienceDirect on May 10, 2021).

Fig. 15

AP and lateral views of radial head prosthesis 2 years post-surgery.

Fig. 16

Intraoperative x-ray should show parallel medial ulnohumeral joint and the proximal end of the prosthesis aligned with the proximal margin of lesser sigmoid notch of the ulna.