CASE SUMMARY 1

“RADIAL HEAD FRACTURE”

INTRODUCTION

Radial head fracture may represent an isolated intra-articular fracture or combined

complex injury involving the ulnar collateral, interosseous or the distal radioulnar

ligament. Careful and thorough assessment is needed to differentiate these two forms of

injuries. The main goal of its treatment is to maintain a good elbow function and thus to

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retain an adequate elbow motion and joint stability. With a proper choice of treatment and

rehabilitation program, this type of fractures can be managed adequately with good

functional outcome.

CASE REPORT (RN 833864)

L.K.W., a 21-year-old male was admitted on the 23rd January 2002 with a history

of fall from a flight of stairs approximately 10 feet high. His left elbow directly hit the

ground at the end of the fall. The patient has no significant past medical or surgical

histories. He works as an air-conditioner mechanic and is a right-handed person.

Examination revealed a swollen left elbow with tenderness over the lateral side of the

joint. No wounds were noted on the left elbow region. There was reduced range of motion

in all directions. The pulses were palpable distally and there was no neurological deficits

noted. The left elbow AP and lateral radiographs revealed fracture of the left radial head

with displacement. The wrist radiographs showed that the distal radioulnar joint was

intact. A diagnosis of fracture of the left radial head (Mason type II) was made and the

patient was admitted for open reduction and screw fixation. On admission the elbow was

put on a backslab in the functional position and analgesics were given.

He underwent an open reduction and screw fixation of the fracture on the 30th of

January 2002. After given a supraclavicular block, the upper limb was cleaned and

draped. Exsanguination was followed by torniquet inflation up to 250 mmHg. The

Kocher’s approach was used and the interval between the anconeus and the extensor carpi

ulnaris entered. The annular ligament was noted to be intact and partial resection was

done for better exposure of the radial head. The radial head was noted to be fractured into

three pieces and there was also a chondral fracture fragment involving the capitellar

cartilage (~ 1 cm diameter) which was impacted into the radial head fracture site. The

impacted cartilage was removed and the joint was washed and cleared from any debris.

The radial head was then fixed with two 2.0 mm cortical screws inserted under lag screw

principles. The screws were inserted in the non-articulating area of the radial head (see

DISCUSSION on ‘The safe zone”). Post-screw fixation assessment for stability of the

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fixation as well as the elbow joint was performed and all the ligaments were noted to be

intact. The area was again washed with saline. The annular ligament and fascia was

repaired with Dexon 3/0. Skin was closed with Dafilon 4/0 sutures. Post-operatively the

left upper limb was elevated on a drip stand to avoid excessive swelling and edema.

Post-operatively, the check radiograph was acceptable with stable reduction of the

fracture fragments and the patient was discharged well. At 2 weeks post-op, the wound

was healing, sutures were removed and passive elbow range of motion exercise was

started. At 6 weeks the patient had full extension, supination and pronation of the left

elbow with a slightly limited flexion. Physiotherapy was continued further. At 11 weeks

post-op, the elbow range of motion was full in all directions and radiographs showed that

the screw fixation is stable and the fracture line disappearing. The patient was allowed to

go back to work and was discharged from follow-up.

DISCUSSION

Radial head and neck fractures represent approximately 1.7 to 5.4 % of all

fractures. Radial head fractures alone account for about 1/3 of all elbow fractures and are

involved in approximately 20 % of elbow trauma cases (Caputo et al. 1998). Combined

with olecranon fractures, they account for more than one-half of the fractures at this site

(Morrey et al. 1995). 10% of cases of elbow dislocations had been found to be associated

with radial head fractures (Kupersmith et al. 2001).

The head of radius is cylindrical in shape and is covered by hyaline cartilage. This

cartilage layer is somewhat wider, whitish glistening in the area which articulates with the

radial notch of the ulna (Caputo et al. 1998), making it easier to identify intra-operatively

in the process of recognizing ‘the safe zone’ – which is the non-articulating area of the

head (a safe place to insert/place implants) that is more yellowish and has a thinner

cartilaginous layer. The head is palpable in the depression behind the lateral side of the

extended elbow, where it can be felt rotating in pronation-supination movements. The

upper surface of the radial head is spherically concave to fit the capitulum.

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The head is held on to the radial notch of the ulna by the annular ligament, which

tapers at its lower end to hold the neck of radius. The superior radioulnar joint is a

uniaxial synovial pivot joint between the radial head and the annular ligament. The elbow

joint capsule and the triangular lateral collateral ligament are attached to the annular

ligament and both the elbow and the superior radioulnar joint share the same synovial

membrane. The non-articulating portion of the radial head is the most common area to be

fractured as it lacks strong subchondral osseous support (Morrey et al. 1995). This is

beneficial in the sense that it allows easier fracture fixation within the safe zone of the

radial head.

Elbow joint stability is maintained by the ligaments (mainly the medial and lateral

collateral ligaments), the bones and the muscles which traverse the joint. The medial

collateral ligament consists of the anterior band (the anterior medial collateral ligament,

AMCL), the posterior band (PMCL) and the transverse band. Out of these three, the

AMCL is the main ligament contributing to the strength of the medial collateral ligament.

The lateral collateral ligament is also triangular in shape with its apex attached to the

lateral humeral epicondyle and the base fused to the annular ligament. Morrey et al.

(1991) found out that the MCL acts as the primary constraint of the elbow joint with the

radial head as the secondary constraint of the elbow joint. They found out that absence of

the radial head does not significantly alter the three dimensional characteristics of motion

in the elbow joint, provided that the MCL is intact.

The most common mechanism of injury is fall onto an outstretched hand with the

elbow extended and the forearm pronated. This causes transmission of axial load across

the radiocapitellar joint and fracture of the radial head. Clinically the patient will have

local swelling and tenderness over the head of radius. There is reduced movement of the

elbow. Presence of echymosis along the medial elbow in a patient with radial head

fracture (without ulnar bone injury) is pathognomonic for a medial collateral injury

(Kupersmith et al. 2001) as the radial head is anatomically isolated from the medial side

by muscle planes and fascia.

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It is necessary to assess the elbow function when examining the patient. Morrey et

al. 1995 advocate the use of local anaesthetics that is injected into the elbow joint before

examination is performed. This is preceded by joint aspiration, allowing 2 benefits:

(i) Aspiration of the joint relieves the pressure-increase due to haemarthrosis.

(ii) Infiltration of local anaesthetics provides temporary pain relief to allow proper

examination of the elbow joint.

Examination is performed to assess the ligaments (in particular the medial

collateral and the distal radioulnar joint); and the range of motion of the elbow to exclude

bony block to full movement.

Standard AP and lateral radiographs of the elbow should be obtained upon

suspicion of a radial head fracture. A valgus-stress view usually helps in the diagnosis of

medial collateral ligament involvement (medial joint space widening). The radial head-

capitellum view may also be helpful (Kupersmith et al. 2001)

Treatment of radial head fractures was first described by Thomas in 1905.

Operative management at the time was limited to simple excision. Carstam first

mentioned regarding open reduction and internal fixation in 1950 and since his published

result, ORIF has become more popular for certain type of fractures of the radial head

(quoted from Furry et al. 1998). Currently, treatment of radial head fractures remains

controversial and frequently guided by the severity of the fracture as classified by Mason.

Mason’s Classification of radial head fracture is the most widely used and

accepted classification system.

Table 1 : Modified Mason’s Classification for Radial Head Fractures

( Chapman’s Textbook of Orthopedic Surgery)

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TYPE CHARACTERISTICS

I Undisplaced fracture

II Marginal fracture with displacement; involvement of more than 30%

of the headIII Comminuted fracture involving the entire radial head

IV Fracture of radial head with associated elbow dislocation

(Modified by Johnston 1962)

Morrey et al. (1995) practically classified this fracture into simple and complex

fractures. Simple fractures are those without an associated injury. These fractures include

those of type I, II and III of the Mason’s classification. Mason’s type IV injury is included

into the complex group.

Conservative treatment remains the choice of treatment for most type I and

some type II fractures of the radial head. Treatment consists of early motion, usually

within several days or as early as pain allows. This has been shown to prevent stiffness

and loss of terminal extension (Kuppersmith et al. 2001). Early motion in type I fractures

was associated with 90 percent chance of a good outcome, even though complications can

still occur, the most common being non-union (Morrey et al. 1995). Morrey et al. (1995)

also suggested that type II fractures that show at least 20 to 140 degrees of flexion and 70

degrees of forearm rotation in both directions (supination and pronation) are amenable for

non-operative treatment. However, in these cases immobilization should be carried out

longer (for 2 to 3 weeks) before active range of motion can be started.

Indications for open reduction and internal fixation include mechanical block of

motion, fracture where greater than 1/3 of the articular surface is involved, displacement

of more than 2 to 3 mm of the fracture fragment and more than 2 to 3 mm of articular

depression. Other indications are lesions involving the capitellar cartilage, an associated

proximal ulnar fracture, injury to the medial collateral ligament or to the distal radio-ulnar

joint (Essex-Lopresti injury). In this particular patient, the indications to perform ORIF

are involvement of more than 1/3 of the articular surface and also capitellar cartilage

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lesion. Contraindications to ORIF include older age patient, an underlying osteoarthritis

and injury to the bony capitellum.

Studies have shown that ORIF is the treatment of choice for Mason type II

fractures. King et al. (1991) treated 14 elbows with type II injury and revealed that all

patients showed good or excellent results after an average of 32 months of follow-up.

Khalfayan et al. (1992) reviewed 29 cases of Mason type II fractures (10 were treated by

ORIF, 19 conservatively) and found out that patients treated conservatively have higher

incidence of pain, functional limitations, loss of strength and radiographic evidence of

arthritis. The same group also showed higher incidence of articular depression,

displacement and joint narrowing radiographically. The use of fibrin adhesive seal was

advocated by Arce et al. (1995) when they fixed 15 type II fractures with the Fibrin

Adhesive System (FAS). After operation, the elbows were immobilized for a mean of 2.3

weeks. On follow-up (ranged from 20 to 48 months), no patient had any pain, 4 patients

showed limitation of full extension while one patient showed limitation of supination. The

reconstruction was, in all cases, practically anatomical by radiographic evaluation.

However, they advised against the use of FAS for comminuted radial head fractures of

more than two fragments.

Boulas and Morrey (1998) studied 36 fractures (type not mentioned) treated in 4

different ways - ORIF, excision, silastic head replacement and conservative. They found

out that the grip strength of patients treated with ORIF was significantly better compared

to other groups even though all groups showed comparative results in Clinical

Performance Index and elbow motions. Furry et al. (1998) concluded that fractures of the

radial head which were treated by ORIF had a low reported incidence of avascular

necrosis and non-union. He suggested that the radial head should be preserved when

technically feasible and replaced if otherwise. O’Driscoll et al. (2000) suggested that

small fragments not suitable for screw fixation can be fixed with threaded Kirschner

wires as an alternative. Smooth K-wires should be avoided as they have a tendency to

migrate post-operatively.

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In this patient, the fracture was a three part fracture and was noted to be displaced

with involvement of more than 30% of the circumference of the head which puts it into

the Mason type II fracture. The fragments were noted to be reducible and stable to be

fixed with 2 screws inserted under lag screw principles. As suggested by Furry et al.

(1998), fractures noted intra-operatively to be feasible for ORIF should be treated as such.

It was also noted during operation that the ligaments were not involved in the injury. This

carries a good prognosis in the context of union of the fracture as studied by Ring and

Jupiter (2000).

The main danger in exposure and fixation of radial head fractures is possibility of

the posterior interosseus nerve (PIN) injury. The close proximity of this nerve to the

operative field makes it vulnerable to iatrogenic injury and the resultant paralysis of the

muscles of the extensor compartment is one of the dreaded complications in this type of

surgery. In the classical Kocher’s approach, the plane between the anconeus and the

extensor carpi ulnaris, ECU is utilized. Incision is made starting from the posterior

surface of the lateral humeral epicondyle and this is continued longitudinally about 5 cm

down to the level of the lower aspect of the radial head. The interval between the

anconeus (supplied by the radial nerve) and the extensor carpi ulnaris, ECU (supplied by

the PIN) is identified and separated using a retractor. The forearm is fully pronated to

move the PIN away from the operative field. Morrey et al. (1993) suggested that the

capsule should be divided anterior to the lateral ligamentous complex that attaches to the

ulna. Witt and Kamineni (1998) studied 21 cadaver-elbows and observed that the first

branches of the PIN at risk (in the posterolateral approach) were situated about 6 cm from

the articular surface of the radial head. This corresponds to the distal aspect of the

bicipital tuberosity on the radius. Diliberti et al. (2000) found out that for the

posterolateral approach of the lateral aspect of the radial head, the PIN is safest with the

forearm in pronation.

Placement of implant on the non-articulating portion of the radial head (the safe

zone) is crucial as it prevents hardware impingement during pronation and supination.

This zone can be recognized by the:-

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(1) Color and thickness of the cartilage

(2) Smith-Hotchkiss technique

(3) Caputo technique

Smith and Hotchkiss (1996) described a method for localizing this safe zone by

marking the side of the radial head in various positions of rotation of the forearm. The

limitation of this method is that it is only applicable for lateral approach and requires full

forearm rotation (Andrew et al. 1998). Caputo et al. (1998) studied 24 elbows in 12

cadavers and described that the arc of the safe zone encompassed the 90o angle between

the radial styloid and Lister’s tubercle, and this findings are constant in all three surgical

approaches (anterior, lateral and posterolateral).

Treatment of type III fractures remain a challenge to surgeons. Decision has to be

made whether to perform an open reduction and internal fixation or to remove the head

completely with or without radial head prosthetic replacement.

King et. al. (1991) internally fixed six type III radial head fractures in a study

comparing type II and III fractures. Type II showed 100% good to excellent results while

type III only showed 33% good to excellent results. They suggested that the degree of

comminution should be evaluated radiographically and intra-operatively, and the decision

whether to reconstruct or excise the radial head depends on whether anatomic reduction is

achievable or not. Morrey et al. (1995) did not recommend ORIF for type III fractures, as

it is a difficult procedure to perform. Furthermore, approximately 10% of type III

fractures are associated with an elbow dislocation, a combination that constitutes one of

the most difficult management problems. Ring and Jupiter (2000), in a retrospective

review of 73 patients, found out that ORIF of complex, comminuted fractures of the

radial head may lead to nonunion in upwards of 13% of patients. On the contrary, Esser et

al. (1995) had seven excellent and two good results out of nine type III fractures fixed

with using AO screws, Herbert screws and / or mini AO T-plates. However the number of

patients in this study is quite small.

The controversial issue on the best treatment option for non-reconstructable radial

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head fractures remains. First comes the question of stability following radial head

excision. It has been shown that, with excision alone (with the ligaments intact), the

radius migrates proximally 2.6 times farther than an intact radius under a given

mechanical load (Furry et al. 1998). Studies demonstrated that with removal of the radial

head alone, proximal radial migration is 0.4 mm. Combined with interosseous membrane

injury, the migration increased to 4.4 mm. Radial head resection with TFCC division

causes 2.2 mm of proximal radial migration. Combining all three, the migration increased

to 16.8 mm (quoted from Bernstein et al. 2000).

Morrey et al. (1991) found out that the radial head plays an important stabilizing

role in resisting valgus stress only when the medial collateral ligament is disrupted.

Therefore radial head excision alone in these circumstances will not suffice with regards

to the stability of the elbow to valgus force and replacement of the head should be done.

Shepard et al. (2001) in a cadaveric study of the effects of radial head excision on the

load-sharing capacity of the radius and ulna found out that radial shortening causes

slackening of the interosseous membrane, thereby negating its ability to transmit load

across the forearm. The resultant ulnar-positive wrist created a shift of applied load from

the distal radius to the distal ulna and thus increased distal ulnar loading (load is increased

approximately 10% with every millimeter of radial shortening). His study also concluded

that damage of the interosseous membrane will shift nearly the entire applied wrist force

to the ulna.

Next comes the issue of whether to remove the head completely or to replace it

with prosthesis. Furry et al. (1998) concluded that excision with radial head replacement

is useful for those fractures with associated ligamentous injury as it provides temporary or

permanent lateral stability (for associated MCL injury) and axial stability (for

interosseous or distal radioulnar joint injury). He also suggested that multi-fragmentary

fractures not amenable for ORIF should be replaced with prosthesis, especially in young

patients. Furthermore, elderly patients and those patients who are very ill or poly-

traumatized that could not tolerate prolonged anaesthesia should benefit from radial head

replacement which can often be performed with less operative time compared to ORIF.

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Radial head excision alone can be performed to treat non-reconstructable radial

head fractures, provided that the ligaments responsible for elbow stability are intact.

Wallenbock and Potsch (1997) retrospectively studied 23 patients with radial head

resection without implant insertion (average 17 years follow-up) and found out that all

patients had very good to satisfactory outcome without a single case of poor outcome.

However it was not mentioned whether these patients had associated ligamentous injury

or not. Furry et al. (1998) and Moro et al. (2001) mentioned that radial head excision may

lead to complications such as pain, instability, new-bone formation around the resection

site, proximal radial migration and cubitus valgus. Prevention of these complications can

be achieved by replacing the head with prosthesis.

Different prosthetic materials have been used and studied. Acrylic, silicone-

rubber, Vitallium, cobalt-chromium and titanium had been used and described in

literatures. Vitallium prosthesis was studied by Knight et al. (1993) and they found out

that the metal’s rigidity improves elbow stability when there has been gross soft tissue

tearing. This implant also has a low incidence of symptomatic loosening and erosion. The

use of this metal avoids some disadvantages experienced with silicone-rubber heads

(sensitivity reactions, implant fractures and capitellar osteopenia from reduced load

transfer). It also helps to share and balance the forces acting across the elbow and allows

earlier mobilization. Morrey (1995) seemed to agree with Knight et al. (1993) when he

mentioned that a metal implant is a viable solution when radial head resection is indicated

and the elbow is unstable.

Silicone-rubber implants had been all but abandoned in the United States (Morrey

1995). This is due to complications associated with this implant. Other than those already

mentioned above, mechanical studies had shown that silicone-rubber allows proximal

radial migration 2.3 times farther than an intact radial head. Morrey (1995) found out that

silicone-rubber implants had no functional advantage over other types of prostheses in the

context of inhibiting proximal radial migration after radial head excision.

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Judet et al. (1996) reported a series of patients who received articulating cobalt-

chromium prosthesis with cemented stem and polyethylene articulation with the head

component (the so-called ‘floating prosthesis’) and found out that all patients rated their

outcome as fair (2), good (7) or excellent (3) using the Broberg and Morrey (1986) elbow

functional scoring system (Table 2). They concluded that this implant can overcome the

complications of silicone-rubber implants. Furthermore, they found out that there was no

radiographic evidence of lucency surrounding the cemented stems. Their report also

suggested indications for immediate insertion of this implant were Mason type III

fractures with ligamentous instability or associated destabilizing fractures such as

coronoid process fractures.

Kupersmith et al. (2001) suggested that the choice of implant to be used may

depend on the mechanism of injury of the radial head. He mentioned that for Essex-

Lopresti injury, where the instability is mainly in the longitudinal and axial direction, a

metallic implant should be used to counteract the resultant supra-physiologic loads on the

proximal radius. If the injury has been caused by a valgus stress, silastic implant insertion

(which is easier) can be carried out along with the more important reconstruction of the

MCL. If the MCL reconstruction cannot be done, then a metallic implant is a better

choice as it resists excessive valgus force on the elbow better while allowing the MCL to

heal.

Table 2 : Modified Functional Scoring System by Broberg and Morrey (1986)

(JBJS-78B 1996 : p 248)

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Grade Pain Strength (%)

Range of movements

( ) :

Flexion contracture

Flexion

Supination

Pronation Stability

Excellent

Good

Fair

Poor

-

Mild

Moderate

Disabling

Normal

80 - 100

80

<80

Full

<20

>90

>45

>50

20

90

45

50

>20

<90

<45

<50

Normal

Normal

Normal or

slight

instability

Unstable

Surgical timing for radial head excision is another debated issue. Knight et al.

(1993) suggested that early radial head excision for unstable fractures should be protected

by means of spacer insertion, the most suitable being the metal radial head. This allows

soft tissue healing and earlier mobilization. Morrey (1995) stated that type III fractures

are best treated with complete excision within 48 hours after injury; the reason being late

excision in type III injuries has been less successful in outcome as compared to that for

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the persistently symptomatic elbow after a type II injury. He recommended that delayed

excision can be carried out for persistent residual symptomatic elbow after ORIF. Delayed

excision can also follow failed conservative management of radial head fractures with

76% reduction of pain and 81% of improvement in strength.

CONCLUSION

Radial head fractures should be treated accordingly to ensure a good functional

outcome. Reconstruction (if possible) should be performed in order to restore the articular

surface and to enable satisfactory range of motion of the elbow post-operatively. The

important supporting ligaments (especially the MCL) should be managed as well in order

to maintain a stable elbow joint. Excision of the radial head with or without arthroplasty

is indicated for non-reconstructable fractures of the radial head.

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