Which radial head fractures are best treated surgically?

Abstract

Despite the common occurrence of radial head fractures, there is still a lack of consensus on which radial head fractures should be treated surgically. The radial head is an important secondary stabilizer in almost all directions. An insufficient radial head can lead to increased instability in varus-valgus and posterolateral rotatory directions, especially in a ligament-deficient elbow. The decision to perform surgery is often not dictated by the fracture pattern alone but also by the presence of associated injury. Comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. Displacement (>2 mm) of fragments in radial head fractures without a mechanical block to pronation/supination is not a clear indication for surgery. Mechanical block to pronation/supination and comminution of the fracture are indications for surgery. The following paper reviews the current literature and provides state-of-the-art guidance on which radial head fractures should be treated surgically.

Keywords: arthroplasty; open reduction internal fixation; radial head excision; radial head fractures.

Figure 1

Mason classification of radial head fractures (13). Fissures (non-displaced) or peripheral rim fractures (A) are classified as Mason type I fractures. Type II fractures are marginal sector fractures with displacement (B). Type III fractures are comminuted, displaced fractures involving the whole radial head (C). Radial head fractures accompanied by dislocation (D) were added as type IV fractures by Johnston (14).

Figure 2

Surgical treatment options for radial head fractures. Headless screw fixation for partial radial head fractures (A). Fixation of radial head fractures by plate and screw fixation (B), the plate should be placed in the safe zone of the proximal radius (C) to limit the risk of impingement of the plate in de proximal radioulnar joint. Fixation of the radial head with crossing headless screws (tripod technique) (D) as alternative for plate fixation. Radial head arthroplasty (E) and radial head excision (F).

Figure 3

Plain radiograph (A) and CT scan (B) showing loosening of a radial head arthroplasty in a 32-year-old male, with extensive erosion of the capitellum and joint space narrowing in the ulnohumeral compartment. After removal of the implant, a large defect marked by * is seen in the capitellum (C). Postoperative plain radiograph (D) shows the destruction of the capitellum and ulnohumeral joint space narrowing.

Figure 4

Plain radiographs of a very comminuted radial head fracture showing fragments (marked by *) proximal to the anterior fossa (A) and on the medial side of the proximal ulna (B). All fragments were retrieved and an on-table reconstruction of the five fragments was performed (C). Fixation of the radial head to the shaft was performed with plate osteosynthesis in de safe zone (D).

Figure 5

Treatment algorithm for radial head fractures.