- See:
Radial Head Excision
- Discussion:
- marginal radial head frx w/ displacement, depression, or angulation.
- by definition has less than 30 % of articular involvement and more than 2 mm of displacement;
- motion may be blocked by articular step off;
- Non Operative Treatment:
- decisions regarding treatment are made on basis of exam of elbow after administration of local anesthetic block;
- need to determine whether restriction of forearm rotation is from displaced fracture fragments vs pain;
- patients that cannot fully rotate the forearm after injury because of discomfort need to have hematoma aspiration and injection of lidocaine without epinephrine;
- w/ the elbow anesthetized, it is possible to distinguish motion limited by fracture fragments from motion limited by pain;
- note that often a reduction can be facilitated by application of firm pressure over anterolateral fracture segment, as the forearm is repeatedly supinated and pronated;
-
w/ no mechanical block, or w/ at least 20-140 deg of flexion and 70 deg of pronation and supination, then frx is be treated similar to
type I frx;
- immobilize elbow & wrist for 2-3 wks & then allow & encourage ROM;
- early mobilization, however, should be considered cautiosly when frx involves a large segment of the articular surface (1/3);
- in active individual, frx involving > 1/3 of articular surface should be rxed w/ sling or splint support for minimum of 2 wks;
- Operative Treatment:
-
indications for surgery:
- articular step off more than 2 mm that cannot be closed reduced;
- failure to achieve functional ROM after administration of local anesthetic block is indication for operative treatment, esp in younger pts;
- failure to achieve a satisfactory ROM after administration of local anesthetic block is indication for operative rx, esp in younger pt;
-
radial head excision:
- immediate, complete radial-head resection is to be avoid in Type-II fracture.
- results of acute resection of frx frag are unpredictable;
-
delayed radial-head excision:
- because late
excision of radial head is as good as early excision, non operative management is indicated initially.
- consider excision if any tilt or displacemnt > 1/4 of the head;
-
ORIF:
-
implants:
- consider use of Herbert screw because it can be counter sunk beneath articular surface or use one or two AO cortical mini-screws (
screws);
- screws: AO screws: 1.5, 2.0 or 2.7 mm cortex, depending on size of fragment;
- note that most radial head frx occur thru non articulating portion of radial head, which allows screws to be placed w/o having to counter-sink screw head;
- most often 2.7 mm miniscrews are chosen and are countersunk to avoid screw prominence;
- if a coutnersink is to be used, be sure that the screw is not too long, so as the screw tip does
not extend beyond the cortical surface;
- over drilling of the proximal fragment is not required (can result in fragment comminution), especially if the
fragment is held in compression during screw insertion;
- for
lag screw effect, 2.7 mm drill-gliding hole is made thru the near cortical fragment, which is followed by 2 mm drill hole;
- minicondylar plate;
- indicated if the head requires attachment to the neck;
- consider use of 2.0 or 2.7 mm L-shaped plate;
-
surgical approach:
-
Kocher Approach:
- it is essential that LCL is not damaged, and hence the dissection procedes anterior to lateral ligament and anterior to the head and neck;
- anterior surface of the lateral epicondyle is exposed, and subsequent dissection achieves full visualization of the articular surface;
- further visualization is achieved w/ forearm pronation;
- reduction and temporary fixation is obtained w/ K wires or tenaculum clamp;
- often these frx require insertion of 2 or more screws parallel to joint line, w/ one screw placed in anterior half and one placed in posterior half;
- application of a plate requires more distal exposure;
- exposure can be enlarged w/ osteotomy of lateral epicondyle & its reflection anteriorly with the extensor muscle origins;
- at the time of surgery, look for injury to the lateral ligamentous complex, and consider operative repair if instability is an issue;
- suture anchors can be attached to the lateral epicondyle;
- if stable anatomic reduction cannot be obtained, then frx fragment is
excised;
- Managment of Associated Injuries: (
complex fractures)
- following radial head fixation, determine whether lateral stability exists, and whether LCL repair is indicated;
- if
Essex-Lopresti injury is present, the distal ulna is splinted in supination (and in some cases is crossed pined);
Open Reduction and Internal Fixation of Fractures of the Radial Head.
Primary Nonoperative Treatment of Moderately Displaced Two-Part Fractures of the Radial Head.
