
Lateral curved incision, 4 cm, centered on radial head and lateral epicondyle, following the lateral humeral ridge.
Palpate the LCL. Even when it is avulsed from the lateral epicondyle, it is usually still palpable.
Extensor tendon split on the anterior edge of the LCL. Alternatively, a Kocher approach can be used but this is not my preference.
Evaluate the integrity of the LCL and Incise the anular ligament anterior to the lateral ulnar collateral ligament
Evacuate the fracture haematoma and washout the joint
Reduce the fracture and fix with headless screws
If the neck is involved we prefer to do a low profile fixation with headless screws from the head into to neck. In some cases, a radial neck plate may be needed to achieve adequate fixation.
In cases with severe comminution, fragments are removed and stability is evaluated by applying a valgus stress to the elbow
The radial pull test is used to evaluate longitudinal instability of the forearm
We prefer to replace the radial head by a metallic prosthesis but a radial head resection may be an option if the elbow and forearm are stable
Placement of the radial head prosthesis depends on the system used
The height of the prosthesis is crucial and should be level with the proximal edge of the lesser sigmoid notch, when the forearm is in neutral position (
). Figure 4
If the LCL was avulsed it should be reinserted (
). This can be done using bone tunnels and transosseus fixation or by using a bone anchor to fix the ligament. Figure 5
The extensor tendon split is closed to the LCL to provide extra strength to the lateral structures
A dynamic external fixator can be used if the elbow is unstable following bony reconstruction of all fractures and repair of the ligaments. This is almost never indicated for isolated radial head fractures.
Figure 4.
3D CT scan of the elbow with correct position of a radial head prosthesis, flush with the lesser sigmoid notch of the proximal ulna.
Figure 5.
Intra-operative photograph of a left elbow. A radial head fracture is visible and the LCL complex and common extensors are avulsed from the humerus.
Pearls and Pitfalls of Technique
Avoid immobilization of non-displaced fractures. Early mobilization does not increase the risk of displacement of the fragments and decreases the risk of stiffness.
Always evaluate the posterior aspect of the capitellum with the arthroscopic technique. Osteochondral lesions are common and fragments may cause symptoms.
Use an extensor tendon split approach to the radial head instead of Kocher’s interval. This allows for improved visualization of the radial head and avoids damaging the LCL. The anterior capsule can be released from the extensor tendon split. This greatly increases the view and workspace.
Fluoroscopic evaluation of the length of the screws can be deceiving. Always rotate the forearm after placement of the screws and be aware of crepitus or scraping.
Over- or under-lengthening of the radius with a prosthesis will decrease the chances of a good result. Use the lesser sigmoid notch on the proximal ulna as a landmark, as the radiohumeral relationship may be disturbed.
Potential Complications
Potential complications specific to the arthroscopic technique include injury to neurovascular structures. Marking the ulnar nerve on the skin, insufflating the joint, and experience with elbow arthroscopy all decrease the risk of nerve damage.
Increased swelling of the forearm and elbow can lead to decreased range of motion and theoretically there is a risk of compartment syndrome of the forearm. Low pressure of the pump or saline bags, as well as minimizing the operating time will decrease the occurrence of swelling.
With regards to the open technique, iatrogenic injury to the LCL can be avoided by using an extensor split approach.
Impingement of hardware and malorientation or placement of a prosthesis should be avoided. Standard antibiotic prophylaxis will decrease the risk of an infection.
Stiffness is common and strong fixation of fragments is necessary as this should allow for early mobilization.
Post–operative Rehabilitation
Associated lesions will often dictate the post-operative rehabilitation, but if at all possible, the elbow should be mobilized immediately. Short immobilization may be indicated for comfort but should not exceed 1 week.
In cases of ligamentous repair we prefer to use a dynamic elbow brace. Full flexion is permitted but extension is blocked from 60 degrees for the first 2 weeks. Between 2 and 4 weeks extension is permitted to 30 degrees and between 4 and 6 weeks both flexion and extension are free. The brace is discontinued after 6 weeks.
Outcomes/Evidence in the Literature
van Riet, RP, Morrey, BF, O'Driscoll, SW, Van Glabbeek, F. "Associated injuries complicating radial head fractures: a demographic study". Clin Orthop Relat Res. vol. 441. 2005. pp. 351-5.(Adult radial head fractures were evaluated for associated lesions. Mean age was 45 years. Gender ratio was approximately 1:1. Men were on average 7 years younger at the time of injury and sustained more severe injuries. About 67% of patients had a type 1 radial head fracture, 14% had a type 2, and 19% had a comminuted, type 3 fracture. Eight percent of type 1, 50% of type 2, and 75% of type 3 fractures had associated injuries. Associated fractures were common, with coronoid fractures as the most common associated fracture at the elbow. Clinically significant lateral and/or medial collateral ligament ruptures were found in 11% of patients but these injuries were shown to remain subclinical in many other patients. The radial head fractured as part of an elbow dislocation in 14% of patients. Not surprisingly, associated injuries were found to be more common in more severe injuries to the radial head.)
Holdsworth, BJ, Clement, DA, Rothwell, PN. "Fractures of the radial head--the benefit of aspiration: a prospective controlled trial". Injury. vol. 18. 1987. pp. 44-7.((This classic paper first showed the benefit of aspiration and early motion versus immobilization.)
Chalidis, BE, Papadopoulos, PP, Sachinis, NC, Dimitiou, CG. "Aspiration alone versus aspiration and bupivacaine injection in the treatment of undisplaced radial head fractures: A prospective randomized study". vol. 18. 2009. pp. 676-9.(Aspiration alone offers significant decrease in pain and facilitates early motion of the elbow in type 1 fractures. The use of a local anesthetic did not further improve the results. Local anesthetic may also have a detrimental effect on articular cartilage. With this in mind and the lack of data showing a significant improvement over aspiration alone, in my opinion the use of local anesthetic is not indicated, unless the anesthetic is administered in order to evaluate a mechanical block to motion.)
Ring, D, Quintero, J, Jupiter, JB. "Open reduction and internal fixation of fractures of the radial head". J Bone Joint Surg Am. vol. 84-A. 2002. pp. 1811-5.(The authors present the results of 56 surgically treated patients with type 2 and 3 radial head fractures. Failure of fixation or nonunion was shown to result in poorer results. The authors concluded that removal of the radial head, with or without radial head replacement, instead of open reduction internal fixation, is probably indicated in fractures with more than three fragments and when the radial head is fractured as part of a more complex injury pattern, potentially compromising fracture healing.)
Michels, F, Pouliart, N, Handelberg, F. "Arthroscopic management of Mason type 2 radial head fractures". Knee Surg Sports Traumatol Arthrosc. vol. 15. 2007. pp. 1244-50.(The authors present the results of 14 patients treated with arthroscopically-assisted reduction and internal fixation of type 2 radial head fractures. Results were good to excellent in all 14 patients. The authors identify the evaluation and potential treatment of associated intra-articular lesions as one of the advantages of this technique.)
Caputo, AE, Mazzocca, AD, Santoro, VM. "The nonarticulating portion of the radial head: anatomic and clinical indications for internal rotation". J Hand Surg Am. vol. 23. 1998. pp. 1082-90.(This paper is a must read for any surgeon who surgically treats radial head fractures. The authors showed a non-articulating portion of 113 degrees and found a correlation of this non-articulating portion with the location of Lister’s tubercle. As a guideline, palpate Lister’s tubercle and transfer this to the radial head. Hardware can be placed at an arc of 90 degrees with this mark at the center, without causing impingement.)
Smith, AM, Urbanosky, LR, Castle, JA, Rushing, JT, Ruch, DS. "Radius pull test: predictor of longitudinal forearm stability". JBJS-A.. vol. 84-A. 2002. pp. 1970-6.(Symptomatic longitudinal radioulnar disscociation following radial head resection is extremely difficult to treat and results are disappointing. The authors describe a test to avoid this problem. If the test is positive, radial head reconstruction with osteosynthesis or prosthetic replacement is absolutely indicated. Radial head fragments are resected and a Kocher clamp is attached to the proximal radial stump. The radius is then simply pulled proximally and the amount of translation is measured. An interosseus membrane rupture can be suspected with a translation of as little as 3 mm. A rupture of all longitudinal stabilizers will lead to a translation of more than 6 mm.)
van Riet,