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

ESSEX LAPROSTI INJURY
 WRIST TENDERNESS
 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 FRACTURE
Mason classification

Minimally displaced fx, no mechanical

Type I blockto rotation, intra-articular displacement
<2mm

Displaced fx >2mm or angulated, possible

Type II
mechanical block to forearm rotation

Comminuted and displaced fx, mechanical

Type III
block to motion
Type IV
(Hotchkiss/JOHNSTO
Radial head fracture with elbow dislocation
N modification OF
TYPE 3)

MORREY MODIFIED MASON CLASSIFICATION BY

QUANTIFYING DISPLACEMENT AREA >30% AND
DISPLACEMENT 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