PROCEDURE 10 Radial Head Arthroplasty

Steven Papp, Michael D. McKee

Introduction

Isolated radial head fractures can occur but are usually minimally displaced.

Most comminuted radial head fractures have been shown to occur in conjunction with other associated injuries around the elbow or wrist (Davidson et al., 1993; Itamura et al., 2005).

This combination of injuries often makes the elbow more unstable; the radial head becomes an important elbow stabilizer in this scenario. Therefore, nonoperative treatment or a simple radial head resection for a comminuted radial head fracture is an uncommon treatment choice in this scenario.

Open reduction and internal fixation or radial head arthroplasty remain the treatment choices for displaced and comminuted fractures.

Displaced, comminuted (Mason type 3) radial head fractures are better treated by arthroplasty than marginal fixation, even in the hands of experienced surgeons (Ring et al., 2002).

The decision regarding fixation versus arthroplasty can be made intraoperatively.

Any surgeon trying to perform fixation of a displaced radial head fracture should be prepared and understand the technical merits of performing a radial head arthroplasty in case it is necessary.

Indications

PITFALLS

• The decision to fix or replace the radial head is made intraoperatively, and therefore the surgeon should be prepared to perform either as necessary.

The indications for radial head arthroplasty include a comminuted, unreconstructible radial head fracture with:

• Associated elbow dislocation with medial collateral injury (Doornberg et al., 2007) (Fig. 1)

• Associated fracture of the of the coronoid (terrible triad injury) (Pugh et al., 2004) (Fig. 2A and 2B)

• Interosseous membrane injury (Essex-Lopresti lesion) (Sowa et al., 1995) (Fig. 3)

FIGURE 1

FIGURE 2

FIGURE 3

Examination/Imaging

Controversies

• Isolated comminuted radial head fracture with minimal elbow instability

• Young age

• Open fracture with contamination

• Fixation versus arthroplasty in “technically” reconstructible fracture

Locations where the patient is tender—medial epicondyle, lateral epicondyle, radial head, interosseous membrane, distal radioulnar joint—are noted.

Bruising and swelling can often point to associated injuries.

Stable range of motion (ROM) is documented in supination, neutral, and pronation. ROM/stability testing may be most accurate after administration of a general anesthetic.

Preoperative neurovascular status is documented thoroughly, with special attention to the posterior interosseous nerve.

Radiographic imaging includes high-quality anteroposterior (AP)/lateral radiographs of the elbow (Fig. 4A and 4B).

Postreduction radiographs are usually best for understanding the fracture.

Preoperative fluoroscopy (after general anesthetic), including AP/lateral and moving fluoroscopic examination, can be helpful.

Computed tomography can be helpful (but is not mandatory) preoperatively to understand and plan the surgery; usually two- or three-dimensional reconstuctions are the most informative (Fig. 5A and 5B).

FIGURE 4

FIGURE 5

Treatment Options

• Nonoperative treatment may be indicated for some patients.

• Radial head fixation is preferred in simple fracture patterns.

• Radial head resection is an option if the elbow remains stable after resection (uncommon in our experience).

Surgical Anatomy

Bony structures: radial head and neck, capitellum, trochlea, coronoid (Fig. 6)

• The normal angle of the radial neck to the shaft is approximately 15° lateral flare (Fig. 7).

• The average radial head is elliptical at 22 × 24 mm, and the average height is 12 mm.

Ligamentous structures: lateral ulnar collateral, radial collateral, annular ligaments (Fig. 8)

• The lateral ulnar collateral ligament is most important for posterolateral instability.

Neurovascular structures

• The posterior interosseous nerve is in close proximity to the radial neck (Diliberti et al., 2000) (Fig. 9A and 9B).

• Pronation and supination have an effect on nerve position. Pronation increases the “safe” working distance.

FIGURE 6

FIGURE 7

FIGURE 8

FIGURE 9

Positioning

PEARLS

• Using a popliteal post allows the arm to hang freely, but taping of pillows and then sterile rolls allows the same arm position and easier intraoperative fluoroscopic examination.

• Since most dislocations are posterior, in the lateral decubitus position, gravity helps to reduce the elbow (Fig. 11).

FIGURE 11

PITFALLS

• Pad the axillary area carefully.

The lateral decubitus position allows free hanging of the arm (Fig. 10).

Bony prominences must be appropriately padded.

The endotracheal tube must be protected.

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