Open Treatment of Radial Head Fractures and Olecranon Fractures
Radial Head Fractures
Patient Selection
Figure 1Illustration depicts the Mason classification of radial head fractures.
Mason classification (Figure 1)
Type I—Nondisplaced; no mechanical block to motion.
Treat with sling and early range of motion (ROM)
Can be assessed after injection of lidocaine through the soft spot
Type II—More than 2 mm of displacement and more than one-third of radial head involved.
Type III—Comminuted, multifragmented fractures.
Options for management—Fragment excision, open reduction and internal fixation(ORIF), radial head excision, or arthroplasty.
Consider fragment excision if elbow stability is not compromised and fragments are less than 25% of the head.
May perform ORIF by fixation within the safe zone or lateral area, with arm in neutral position.
Consider arthroplasty or radial head excision in cases with severe comminution.
Preoperative Imaging
Include three views of elbow—Lateral, AP, and oblique.
Obtain prereduction and postreduction images if a reduction is performed.
CT is helpful in complex injury patterns.
Procedure
Room Setup/Patient Positioning
Supine position with arm table or with arm over chest
A tourniquet helps with visualization
Mini C-arm for intraoperative imaging
Use regional or general anesthesia
In the presence of other bony injuries, can use universal posterior incision
For isolated injuries, lateral incision is preferred
Special Instruments/Equipment/Implants
For ORIF, have a radial head replacement on standby
Kirschner wires (K-wires) and suture anchors
Surgical Technique
Figure 2Illustration shows the muscle-splitting approach. The radial head may be approached easily through a split in the tendon origin of the extensor digitorum communis (blue line).
Make lateral incision overlying epicondyle and extending down over radial head.
Create full-thickness skin flaps.
For associated lateral ulnar collateral ligament (LUCL) injury, use Kocher interval, between anconeus and extensor carpi ulnaris tendon.
If LUCL is intact, perform exposure through the tendinous origin of extensor digitorum communis (Figure 2).
Keep forearm in pronation to protect posterior interosseous nerve.
Once radial head is exposed, determine whether to fix via ORIF, perform arthroplasty, or excise.
Can obtain provisional fixation with small K-wires.
Preferable to use headless screws rather than plates if the decision is made to proceed with ORIF.
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