RADIAL HEAD FRACTURE

Dr krunal h patel

EPIDEMIOLOGY

OF 4%OF ALL FRACTURE AND 30%OF ALL ELBOW FRACTURE.

1/3 PT ASSOCIATED INJURY TO SHOULDER,HUMERUS,FOREARM,WRIST OR HAND.

RARE IN CHILDREN DUE TO CARTILAGENOUS NATURE OF RADIAL HEAD.

RADIAL NECK FRACTURE MORE COMMON IN CHILDREN.

ANATOMY OF PROXIMAL RADIUS

RADIOCAPITELLAR JOINT TRANSMIT 50-60% LOAD ACROSS ELBOW

RADIUS HEAD SURGICAL ANATOMY

IMPORTANT FOR

VALGUS STABILITY

POSTEROLATERAL ROTATORY STABILITY

LONGITUDINAL FOREARM STABILITY

(ALONG WITH INTEROSSI MEMBRANE & DRUJ)

ELBOW STABILITY

MCL & U-H JOINT:PRIARY STABILIZER

RADIAL HEAD(R-C JOINT) & CAPSULE:SECONDARY STABILIZER

CONT..

MUSCLE ATTACHMENT AROUND PROXIMAL RADIUS SUPINATOR ATTACHMENT AT PROXIMAL RADIUS.

BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

POST.INTEROSSI NERVE AT RISK

PIN TRAVERSES FROM ANTERIOR TO POSTERIOR THROUGH SUPINATOR MUSCLE.

ALWAYS CHECK PRE OPERATIVE ACTIVE FINGER EXTENSION

MECHANISM OF INJURY

(1) FALL ON OUTSTRECHED HAND(MOST COMMON)

DISTAL RADIUS

INTEROSSI MEMBRANE(FOREARM)

RADIAL HEAD IMPACTION AGAINST CAPITELLUM

(2)VALGUS INJURY TO ELBOW/DIRECT INJURY

MCL RUPTURE/OLECRANON FRACTURE UNSTABLE ELBOW

DIAGNOSIS

HISTORY:FALL ON OUTSTRETCHED HAND/DIRECT INJURY

EXAMINATION:

ELBOW

SWELLING

ECCHMOSIS

ANCONEUS TRIANGLE FULLNESS

RANGE OF MOTION RESTRICTION

STABILITY

ACTIVE FINGER EXTENSION

FOREARM/INTEROSSI MEMBRANE TENDERNESS

WRIST TENDERNESS

ESSEX LAPROSTI INJURY

X RAY FINDINGS STANDARD AP AND LATERAL X RAY of elbow

OBLIQUE(GREEN SPAN)VIEW

FOREARM AND WRIST X RAY IF REQUIRED

X RAY FINDINGS

CLASSIFICATION OF RADIAL HEAD FRACTUREMason classification

Type IMinimally displaced fx, no mechanical

blockto rotation, intra-articular displacement <2mm

Type IIDisplaced fx >2mm or angulated, possible

mechanical block to forearm rotation

Type IIIComminuted and displaced fx, mechanical

block to motion

Type IV (Hotchkiss/JOHNSTO

N modification OF TYPE 3)

Radial head fracture with elbow dislocation

MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% ANDDISPLACEMENT OF >2 MM

TREATMENT GOAL

CORRECTION OF ANY BLOCK TO FOREARM ROTATION

EARLY ROM OF ELBOW AND FOREARM

STABILITY OF ELBOW AND FOREARM

PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW

NON OPERATIVE TREATMENT

INDICATION:

ISOLATED RADIAL HEAD FRACTURE WITH MASON TYPE 1 (UNDISPLACED <2MM)

PLASTER SLAB FOR 3 WEEKS

EARLY ACTIVE MOBILIZATION OF ELBOW

PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR FRACTURE

OPERATIVE MANAGEMENT OPEN REDUCTION & INTERNAL FIXATION

INDICATION FOR ORIF:

Mason type II with mechanical block(displaced)

Large fragment >2 mm

Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME)

Mechanical block to motion (lignocaine inj in elbow joint)

Presence of other complex ipsilateral elbow injuries(without metaphyseal bone loss)

FRAGMENT EXCISION LEADS TO INSTABILITY

TRY TO PRESERVE SMALLEST FRAGMENT

Surgical approach for ORIF:

Kaplan direct lateral approach

Interval between EDC and ECRB

Keep forearm pronated to protect PIN

PIN present approx. 2 cm below radial head

Do not extend exposure below annular ligament

Gentle retraction

ADVANTAGE:

No disruption LATERAL LIGAMENT COMPLEX(LUCL)

DISADVANTAGE:

PIN at risk

KOCHER POSTEROLATERAL APPROACH

Interval between ECU and anconeus

Keep forearm pronated to protect PIN

Advantage:

Less of a risk of PIN injury than the kaplan

Disadvantage:

LATERAL LIGAMENT COMPLEX may injured

Leads to instability

HOTCHKISS APPROACH DIRECTLY THROUGH EDC

PROTECT LATERAL LIGAMENT COMPLEX

PRONATE FOREARM WHILE FIXATION

SAFE ZONE OF RADIUS HEAD FIXATION

LONGITUDINAL LINE B/W LISTER TUBERCLE AND RADIUS STYLOID PROCESS

NO ARTICULATION WITH ULNA

SAFE FOR IMPLANT INSERTION:NO IMPINGMENT IN ROTATION

POSTERO-LATERAL ZONE IN FULL SUPINATION(CAPUTO A)

IN NEUTRAL(MID PRONE)POSITION : ANTEROLATERAL ZONE

Which implant to use?

Mini fragment screw(2.4 or 2.7 mm)(counter sink must)

Headless compression compression screw/Herbert screw

Low profile plate/mini t plate(in safe zone/postero lateral)

K WIRE

COMPLICATION OF ORIF

PIN INJURY

HARDWARE FAILURE

HARDWARE IMPINGEMENT

STIFFNESS OF ELBOW

RESTRICTION OF SUPINATIONPRONATION

RADIAL HEAD REPLACEMENT

To prevent proximal migration of the radius

Silicon implant poor outcome : SILICON SYNOVITIS

Titanium/vitallium metallic implant of choice

Indication: Extensive communition of radial head/excess bone loss

Elbow instability:

essex lapresti lesion,

coronoid fracture,

elbow dislocation,

collateral ligament injury,

olecranon fracture

RADIAL HEAD REPLACEMENT PROSTHESIS

LOOSE STEMMED PROSTHESIS

THAT ACTS AS A STIFF SPACER

BIPOLAR PROSTHESIS

That is cemented into the neck of the radius

COMPLICATIONS: Overstuffing of joint

capitellar wear problems

Malalignment instability

COMPLICATION OF REPLACEMENT

Post operative infection of implant

Ulnar nerve/pin injury

Immediate post operative dislocation

Recurrent instability

Heterotrophic ossification

Contracture /stiffness

Crps type 1

RADIAL HEAD EXCISION

INDICATION:

Low demand, sedentary patients

In a delayed setting for continued pain of an isolated radial head fracture

CONTRAINDICATION:

In children

Presence of destabilizing injuries (Essex-lopresti lesion,fracture dislocation elbow(mason type 4),monteggia)

Terrible triad of elbow(coronoid fracture,MCL deficiency)

COMPLICATION OF EXCISION

PROXIMAL MIGRATION OF RADIUS

INFERIOR RADIO ULNAR JOINT DISTURBANCE

PAIN & WEAKNESS OF WRIST

Joint instability

Decreased strength

Cubitus valgus

EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR SYNOSTOSIS.

THANK YOU