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Radial Head Fractures

Definition

  • Fracture of the Radial Head

Incidence

  • Common, up to 30% of injuries around the elbow.
  • Can be isolated or in conjunction with interosseous ligament injuries & DRUJ lesions (Essex-Lopresti), elbow dislocation etc
  • Over half of radial head fractures are associated with other injuries about the elbow

Classification

Mason Classification

"Some observations on fractures of the head of the Radius With a Review of 100 cases" Br J Surg 42: 123-132, 1954

Mason (1954)Classification of Radial Head Fractures
Type Description
I Undisplaced (< 2mm)
II Marginal fracture with displacement (> 2mm)
III Comminuted fracture with whole head involvement
IV

Fracture of the radial head associated with dislocation of the elbow

NB: Type IV not described by Mason

Coronal CT Scan of Minimally displaced Fracture of the Radial Head <2mm
Coronal CT Scan of
Minimally Displaced Fracture
of the Radial Head <2mm
Transverse CT Scan of Minimally displaced Fracture of the Radial Head <2mm
Transverse CT Scan of
Minimally Displaced Fracture
of the Radial Head <2mm
3D Reconstruction CT Scan of Minimally displaced Fracture of the Radial Head <2mm
3D Reconstruction CT Scan of
Minimally Displaced Fracture
of the Radial Head <2mm

Essex- Lopresti Lesion

  • (ALRUD – acute longitudinal radioulnar dissociation) lesions
  • injury to interosseous membrane & TFCC
    • axial instability of forearm with subluxation of DRUJ

Aetiology

  • Usually due to a fall onto the outstretched hand & may be associated with dislocation of the elbow

Pathology

  • Radial head is important for acute + long term stability & to prevent pathologic proximal migration.

  • Valgus Stability
    • Radial head is secondary stabiliser resisting valgus load
    • Radial head excision ↓lever arm to medial ligament & therefore ↑MCL tension for same valgus force
  • Longitudinal Stability
    • Radius vs. ulna load sharing at the elbow varies according to pronation/supination (as central portion interosseous ligament changes alignment) & flexion/extension
    • But Halls + Travill quoted → ulna = 60% + radius = 40%
    • Radial head preservation paramount when interosseous ligament torn
    • In proximal radial migration, deformity is at wrist = distal ulna dorsal + distal to carpus = supination + extension block
    • Limited results from ulna shortening, Sauve-Kapandji, Darrach, in established proximal radial migration
    • Salvage = one bone forearm (radioulnar synostosis) to maintain elbow flexion/extension & wrist function albeit fixed in rotation
    • Radial head replacement

History

  • Mechanism of Injury
  • Pain around wrist

Examination

  • Need to palpate for tenderness around MCL, DRUJ. If there is an Essex-Lopresti lesion or valgus instability then primary radial head excision will lead to poor results.

Investigations

Xrays

  • AP/ lateral views of the elbow usually sufficient
    • Fat pad sign
    • If no fracture seen but fat pad sign present
      • Radiocapitellar views with the forearm in neutral rotation & the XRay tube angled 45 deg cephalad

Treatment

Decision making

  • High vs. low energy injury (status of interosseous ligament)
  • Age + demands of patient
  • Associated dislocation

Child

  • Acceptable angulation
    • 30° in young children due to potential remodelling
    • 15o in older children (older than 10)
  • Unacceptable angulation
    • 1. Manipulation under GA
    • 2. Open reduction if more than 45o & irreducible

Adults

  • Depends on Mason Type
    • I
      • nonoperative
        • early motion as soon as comfortable
        • ± aspiration of haemarthrosis for early R.O.M
    • II
      • ORIF
    • III
      • without Essex- Lopresti or dislocation
        • excise
      • with Essex- Lopresti
        • replacement
    • IV
      • as for III
        • if the anterior band of the MCL is disrupted need to repair primarily
        • aim to retain the radial head if at all possible
  • Summary
    • if head is salvageable do so
    • if Essex- Lopresti
      • save head
      • or if excise pin radius & ulna for 4-6/52
      • or radial head replacement
    • if elbow unstable
      • ie MCL torn
        • ORIF head / replace head
        • ± repair ligament if excise or not
    • In adults operation indicated if
      • Angulation more than 30°
      • Depression of articular surface > 2mm
      • Greater than 1/3 of head involved

Complications

  • Reduced motion
  • Radial head overgrowth
  • Premature physeal closure
  • Non union
  • Avascular necrosis of the radial head
  • Alteration in the carrying angle
  • Neuromuscular problems (ie ® valgus with ulna nerve problems)
  • Radio/ulna synostosis
  • Myositis ossificans

Prognosis

  • results of initial conservative Mx of Mason II & III fractures are no different to early excision
  • Also the results of delayed excision of the radial head are satisfactory giving some justification for the initial closed treatment of these fractures with delayed excision of the radial head to be considered at a later date if needed as symptoms develop