Radial head
fractures
Ammar Abusultan
Orthopedic surgery resident PGY1 - KFHU
Objectives:
• Anatomy of the elbow and associated clinical anatomy
• Stability of the elbow
• Mechanical description of elbow joint
• Radial head fracture approach
Elbow joint
• Two articulations
• Ulnohumeral (hinge) via trochlea
• Radiocapitellar (pivot) via capitellum
• 60% load transfer across
elbow joint
Safe zone for hardware placement
• Nonarticular portion of the radial head is a ~90 degree arc from
radial styloid to Lister's tubercle
• posterolateral in the anatomic
position of full supination
Literature speaks
• Gross observations of the nonarticulating portion of the radial head
revealed a thinner band of yellowish cartilage relative to a wider, white,
glistening cartilage of the articular portion of the radial head
Caputo, A E et al. “The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation.
” The Journal of hand surgery vol. 23,6 (1998): 1082-90. doi:10.1016/S0363-5023(98)80020-8
Interestingly
• “The average arc of the nonarticulating radial head was 113 degrees
(range, 106 degrees to 120 degrees; standard deviation, 4 degrees)”.
• This nonarticulating portion of the radial head (or safe zone for
prominent fixation) consistently encompassed a 90 degrees angle
localized by palpation of the radial styloid and Lister's tubercle.
Caputo, A E et al. “The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation.” The
Journal of hand surgery vol. 23,6 (1998): 1082-90. doi:10.1016/S0363-5023(98)80020-8
Lateral collateral ligament complex
Stabilizes proximal
radioulnar joint
Primary stabilizer to varus and external rotation stress” -
deficiency results in posterolateral rotatory instability
Medial (ulnar) collateral ligament
(MCL) - three bundles
Primary stabilizer to valgus stress
Stability of the elbow
Primary stabilizers Secondary stabilizers
Coronoid Radiocapitellar joint (radial head)
Medial (ulnar) collateral ligament (MCL) Capsule
Lateral collateral ligament complex (LCL) Origin of the flexor and extensor tendons
Dynamic stabilizers
Biceps
Triceps
Anconeus
Brichilis
Specifically speaking - radial head
• Two types of stability to the elbow:
Valgus stability: secondary restraint to valgus load at the elbow, important if
MCL deficient
Longitudinal stability: restraint to proximal migration of the radius (grip
activity)
Contributions from interosseous membrane and DRUJ
• Loss of longitudinal stability occurs when Essex-Lopresti happens:
Radial head fracture + DRUJ injury + interosseous membrane disruption
The distal humerus:
Medial and lateral supracondylar ridges
Medial and lateral condyles (epicondyles: the most prominent parts)
The condyles bear the articular surfaces of the humerus
Fossae of distal humerus
• Each fossa is filled with a fat pad
• In the presence of a haemarthrosis the fat floats out into the joint
• Perceived as a triangular filling defect on a lateral elbow radiograph
(the sail sign)
Project distally and anteriorly at 40-45°
Medial and lateral columns, separated by the ‘tie arch’ of
the articular component
Slightly angled to give around 6° of
physiological valgus at the elbow
Teardrop shaped Triangular shaped
Susceptible to shearing and torsion forces
Epidemiology:
• Represents 33% of all elbow injuries, IT’S NOT UNCOMMON
• Most injuries are isolated, minimally displaced and stable, and require
only symptomatic treatment
• However, there are unstable variants that must be actively sought
and excluded
FOOSH with pronated extended arm
• The most force is transmitted
from the wrist to the radial head in
this position
Classification – Mason
Mason Classification (Modified by Hotchkiss and Broberg-Morrey)
Type I Nondisplaced or minimally displaced (<2mm), no mechanical block to rotation
Type II Displaced >2mm or angulated, possible mechanical block to forearm rotation
Type III Comminuted and displaced, mechanical block to motion
Type IV Radial head fracture with associated elbow dislocation
Presentation
• Pain along lateral aspect of elbow
• Limited elbow or forearm motion, particularly supination and
pronation
• Sensation of elbow dislocation at the time of injury
Physical exam
• Examine the range of motion in all 4 movements
• Evaluate for mechanical blocks to elbow motion
• Aspiration of joint hematoma and injection of local anesthesia aids
in evaluation of mechanical block
• Exclude tenderness of the ulna shaft and any suggestion of pain or
tenderness at the wrist
Examining the stability
• Elbow lateral pivot shift test (tests LUCL)
• Valgus stress test (tests MCL)
• DRUJ: palpate wrist for tenderness translation in sagittal plane > 50%
• Interosseous membrane: palpate along interosseous membrane for
tenderness
• Radius pull test >3mm translation concerning for longitudinal forearm
instability (Essex-Lopresti)
• Ligamentous injuries:
(LCL): most common
(MCL):
Combined LCL/MCL
• Essex–Lopresti injury: combination of a radial head fracture and an injury
to DRUJ (usually requires surgical treatment)
• Monteggia fracture dislocation: combination of a radial head dislocation
(with or without a radial head fracture) and ulnar fracture (highly unstable)
• Terrible triad’ injury: combination of a radial head fracture, elbow
dislocation, and coronoid fracture
Radiographs
• AP view of the elbow: the elbow is held in extension with the forearm fully
supinated
• Lateral view of the elbow:
The elbow is held at 90° of flexion with the forearm fully supinated
The trochlea and capitellum are superimposed and the joint space is visible
Check for fat pad sign indicating occult minimally displaced fracture
• Radiocapitellar view (Greenspan view):
Oblique lateral view of elbow
Beam angled 45 degrees cephalad
Allows visualization of the radial head without coronoid overlap
Helps detect subtle fractures of the radial head
Radiographs
• AP and lateral views of the forearm or wrist: PLEASE NEVER FORGET
TO REQUEST THEM!
• CT:
Further delineate fragments in comminuted fractures
Identify associated injuries in complex fracture dislocations
Important lines and landmarks
• The radiocapitellar line: a line drawn through the center of the
radial neck should pass through the center of the capitellum in any
view
• The anterior humeral line: A line drawn along the anterior cortex of
the humerus in the lateral view should transect the capitellum.
• The sail sign: This indicates the likelihood of a fracture being present,
even if the fracture itself cannot be discerned on the radiograph
• The most common occult fracture is an undisplaced radial head or
neck fracture
Nonoperative management
• Short period of immobilization BY SLING followed by early ROM
• Indications:
Isolated minimally displaced fractures with no mechanical blocks Mason
Type I and possibly Mason type II
• Complications:
Elbow stiffness with prolonged immobilization
There may ultimately be some slight loss of the last 5–10° of elbow extension
Good results in 85% to 95% of patients
• Sling immobilization for 2 days followed by active mobilization is
recommended
• Immobilization for 1 week or more leads to poorer functional
outcome and pain scores
Operative management
• Management of displaced comminuted fractures of the radial head is
controversial, why is that?
• Comminuted fracture of the radial head is part of the spectrum of
elbow instability
• Optimal management of the radial head fracture should maintain
elbow stability
It is controversial, conflicting
evidence supporting:
• ORIF:
Worse outcome when > 3 fragments present
ORIF isolated radial head fractures vs complex radial head fractures
Isolated fractures have :
1. Better Patient-Rated Elbow Evaluation score
2. Lower complication rate
3. Lower rate of secondary capsular release
• Arthroplasty:
. Mason Type III with more than 3 fragments involving > 25% of the radial head
. Elbow fracture-dislocations or Essex Lopresti lesions
Resection (partial or complete):
• Delayed complications, pain, instability, proximal radial translation,
decreased strength, osteoarthrosis, and cubitus valgus
• Significant decrease in elbow stability was noted in association with
radial head excision in elbows with LCL disruption
Normal load sharing at the radiocapitellar joint no longer occurs, and
all compressive loads are transferred from the distal radius to the ulna
through the IO membrane and the distal radioulnar joint
CI: in disrupted MCL or IO membrane
Boulas HJ, Morrey BF: Biomechanical evaluation of the elbow following ra- dial head fracture: Comparison of open reduction and internal fixation vs. ex- cision, Silastic
replacement, and non- operative management. Chir Main 1998;17:314-320.
Area of controversy
• The preferential use of either ORIF or replacement continues to cause much debate and
controversy
• Unfortunately, the results of each technique have been reported separately or compared
with resection, with relatively few long-term
outcome data!
• The available literature, therefore, does not provide clear guidance as to the best
treatment option for complex radial head injuries, especially those with associated elbow
instability
Tejwani, Nirmal C, and Hemang Mehta. “Fractures of the radial head and neck: current concepts in management.” The Journal of the American
Academy of Orthopaedic Surgeons vol. 15,7 (2007): 380-7. doi:10.5435/00124635-200707000-00003
Post-op care
• Recurrent elbow instability vs early motion
• Early ROM within a safe arc should be initiated, taking into account
associated fractures and ligamentous injuries
• An extension-splinting program is begun as soon as stability improves
• Splint is worn at night for 10 to 12 weeks
• It is important to restore radiocapitellar contact through repair or
replacement of the radial head
• Interest is growing in radial head arthroplasty in:
• MCL–deficient elbow
• Comminuted radial head fracture with elbow or forearm instability
THANK YOU!
