Radial Head Fracture

Brian J. Hartigan

Indications

1. Displacement greater than 2 mm or angulation of the neck

2. Large fragment (more than marginal lip or greater than 25% articular surface)

3. Elbow motion or forearm rotation mechanically blocked

4. Associated injury to interosseous ligament/distal radioulnar joint, elbow collateral ligaments or coronoid process

1. Severe comminution precluding rigid internal fixation; consider excision or excision and prosthetic replacement when associated with injury to interosseous ligament/distal radioulnar joint, collateral ligament, or coronoid process

2. Low demand patient (relative); consider excision

3. Open fracture with contaminated wound

Preoperative Preparation

1. Evaluation

a. Document complete neurovascular examination, especially posterior interosseous nerve.

b. Assess medial collateral ligament—tenderness and valgus stress test at 30 degrees flexion.

c. Assess interosseous ligament/distal radioulnar joint—tenderness along forearm and wrist.

d. Assess for mechanical block; consider sterile intra-articular injection of local anesthetic to allow evaluation of range of motion.

2. Adequate radiographs

a. AP and lateral of the elbow

b. Neutral PA view of the wrist with contralateral comparison view to assess for longitudinal stability

c. Consider CT scan with axial, sagittal and coronal cuts to assess fragment size, comminution, and degree of displacement.

3. Prepare patient for possible need for excision if reduction and internal fixation technically impossible.

Special Instruments, Position, and Anesthesia

1. Patient supine on operating table with affected arm positioned over the chest

2. Tourniquet placed high up on arm

3. Can be done with general or regional anesthetic

4. Instrumentation

a. Kirschner wires

b. Mini-fragment internal fixation set with reconstruction plates

c. Herbert mini-screw set

Tips and Pearls

1. Place tourniquet as high on the arm as is possible to ensure adequate exposure available. If the arm is short or obese, consider using sterile tourniquet.

2. Administer IV antibiotics prior to tourniquet inflation.

3. Hold arm in position by clamping stockinette over hand to drapes using nonpenetrating clamp.

4. Place hardware on the radial head/neck within the “safe zone”: 110 degree arc on the lateral side of the radial head extending 65 degrees anteriorly and 45 degrees posteriorly from the midpoint of the radial head with the arm in neutral rotation (Fig. 8–1).

5. Check for impingement of hardware in the proximal radioulnar joint prior to closure by visualizing the radial head while pronating and supinating the forearm at various positions of elbow flexion/extension.

6. Repair lateral capsule complex carefully to avoid instability.