Olecranon Fractures and
Radial Head Fractures
John T. Capo, MD
Original Authors: Andrew H. Schmidt, MD, Gregory J. Schmeling, MD
and David C. Templeman, MD; March 2004
Revised October 2006, John T. Capo, MD,
Current Author: John T. Capo, MD, Revised July 2010
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Elbow Anatomy
• Three distinct joints
– humeral(trochlea) – ulnar
– humeral(capitellar) – radial
– proximal radial-ulnar(PRUJ)
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Factors Responsible for
Elbow Stability: Bony Anatomy
• Normal muscle forces drive
elbow posteriorly
– Brachialis: base coronoid
– Biceps: radial tuberosity
• Resist AP forces:
– Coronoid process
– Radial Head
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Factors Responsible for
Elbow Stability: Bony Anatomy
• Varus/Valgus
– Radial Head
– Trochlea
– Medial coronoid
facet
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MCL
LCL
Ligamentous Stability
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Surgical Anatomy
• Articular cartilage
– Sigmoid notch of ulna: bare
spot centrally
• Coronoid process: preserve
height
– As high as radial head on
lateral view
– Tip subtends angle of 30º from
ulnar shaft
– Twice as high as olecranon tip
• Beware of narrowing
sigmoid fossa when treating
comminuted fractures of the
olecranon.
30°
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Olecranon Fractures
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Mechanism of Injury
• Acute Tension overload: Tension applied by
the triceps with flexion of the elbow.
• Direct Trauma
• Chronic overload: stress fracture,
osteopenia, pediatric injuries.
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Evaluation
• Check integrity of skin
• Check extension of elbow
• Evaluate neurovascular status, especially
ulnar nerve
• X-rays in three views (AP, Lateral, Oblique:
-shows radial head in profile)
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Imaging
AP View
Lateral View
Oblique View
(sometimes helpful,
good for Radial Head)
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Classification
• Numerous
classifications:
–
–
–
–
–
Colton
Morrey
Schatzker
AO/ASIF
OTA
• Criteria
– Displacement
– Direction of fracture
– Degree of
comminution
– Percent involvement
– Associated injuries
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Mayo Clinic Classification
•Type I: Nondisplaced 12%
•Type II: Displaced/ elbow stable 82%
•Type III: Elbow unstable 6%
•Both types II and III subdivided into:
–A: noncomminuted
–B: comminuted
Morrey BF, JBJS 77A: 718-21, 1995
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Treatment Objectives
• Restoration of the articular surface.
• Restoration and preservation of the elbow
extensor mechanism.
• Restoration of elbow motion and prevention
of stiffness
– Goal is to begin early ROM
• Prevention of complications.
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Treatment Methods
• Nonoperative
– Rarely used
– Non-displaced with intact elbow extension
• Operative
– Open reduction and internal fixation
• Tension band wire with pins or intramedullary screws
• Plate
– Excision of olecranon and triceps repair
• Comminuted, unreconstructable fractures
• Elderly patients
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Nonoperative Treatment
• Nondisplaced fractures
• Long arm cast - complicated by stiffness
• Long-arm splint for 7-10 days followed by
functional bracing for 4-6 weeks
– complicated by loss of reduction
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Indications for Surgery
• Disruption of extensor mechanism
– Unable to actively extend elbow
• Articular incongruity
– Any displaced fracture
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Olecranon Excision
•Elderly patients
–those with osteoporosis
–involving <50% of joint
•Re-attach triceps anteriorly
–At joint surface
•No difference in isometric
strength but fewer
complications in the excision
group
Gartsman et al, JBJS 63A:718,
1981-
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ORIF: Surgical Technique
• Evaluate comminution of
dorsal cortex
– If intact: tension band wire
appropriate
– If comminuted, plate
appropriate
• Evaluate orientation of
fracture line
– Transverse: tension band wire
– Oblique, complex  plate
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Positioning
• Arm position
– Supine with arm across chest.
– Lateral or prone also may be used.
– Supine with arm on hand table
• Tourniquet
• Regional or general anesthesia
• Posterior approach
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Tension Band Wire
• For most simple, transverse,
non-comminuted fractures
• Use 18- or 20-gauge steel
wire or small braided cable.
– Be sure wires cross over
dorsal cortex.
– 2 smaller (22 gauge) wires
may be less prominent
• May use with either parallel
K-wires or an
intramedullary screw.
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Tension Band Wire
Reduce fracture
-hold with tenaculum
Place K-wires across
fracture -engage
anterior cortex
Pass Tension wire
deep to tendon with
angiocath – two knots
over dorsal cortex
From Hak and Golladay, JAAOS, 8:266-75, 2000
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Case Example Transverse Fracture
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Engage anterior cortex
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Intramedullary Screw ?
• Need to add tension
band wire
• Long/large screw
required
– 6.5mm cancellous
– 85-110 mm long
Mal-reduction
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Anatomy of the Proximal Ulna
• Beware of the bow of the
proximal ulna, which may
cause a medial shift of the
tip of the olecranon if a
long screw is used.
From Hak and Golladay, JAAOS, 8:266-75, 2000
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Plate Fixation
• Use for comminuted
fractures, fractures
with shaft extension,
or oblique fracture
line:
– DCP
– Plates designed for
proximal Ulna
• Screw placement
crucial for stability
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Complex Olecranon Fracture
As fracture becomes more distal and
oblique- more amenable to plate fixation
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Plate Fixation
Courtesy: Fred Behrens, MD
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Locking plate fixation may also be used
Image courtesy of Brian Solberg
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Coronoid Fractures
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CORONOID PROCESS
Anatomy
• Anterior aspect of the greater
sigmoid notch
– articulates with trochlear
– brachialis insertion
• Laterally,
– lesser semilunar notch articulates
with radial head
• Medially,
– attachment of anterior fibers of
MCL
• Resist posterior elbow subluxation
Courtesy: Virak Tan, MD
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CORONOID PROCESS
Fracture
• Isolated fracture is UNCOMMON
• Usually occurs in association with
other elbow injuries
– dislocation (~10% have coronoid fx)
– olecranon fx (~5% have coronoid fx)
• Mechanism
– similar to elbow dislocation
– axial load with elbow in slight flexion
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CORONOID FRACTURE
Classification: Morrey
• Type I – tip
• Type II – 50%
• Type III – > 50%
IIIB – also w/
olecranon
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B
A
A>B
Coronoid Height should be at
least 2X olecranon tip height
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CORONOID FRACTURE
Treatment
• Type I
– according to concurrent pathology
(usually early motion)
• Type II
– early motion, unless unstable
– internal fixation
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CORONOID FRACTURES
• Medial coronoid facet
– MCL attachment
– Posterior medial varus
rotatory instability:
– *can lead to arthrosis
Courtesy Virak Tan, MD
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CORONOID FRACTURE
Treatment- medial facet
• Anatomic reduction critical
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CORONOID FRACTURE
Treatment
• Type III
– internal fixation
• Screw from below
• Plate from above
– reconstruction with bone graft
( tip of olecranon)
– +/- hinged external fixation
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CORONOID FRACTURE
• Usually occurs in association with other
elbow injuries
• Approach:
– Lateral if radial head out
– Medial over the top
• Preserve UCL
– Indirect posterior
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Proximal Ulna with Distal Shaft
Extension
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Plate Location
• No mechanical difference between
posterior or lateral placement -King et
al, J Shoulder Elbow Surg 5:437, 1996
• Less problems with plate prominence
when placed laterally
– Also can get bicortical screw
purchase
• Posterior Plate allows more
advantageous screw placement
– Coronoid screw
– IM screw
– Olecranon tip screw
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Indirect Reduction
-sometimes useful
ex fix; distractor; push-pull;
fix plate proximally first
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Case Example - Comminuted Fracture
Involving the Coronoid Process
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Dorsal plate
Screw through plate to
fix the coronoid process
DC Plate needed for
bending forces
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Outcomes:
Olecranon Fractures
• Union 76-98 %
• 19 point scale = pain+function+ROM+x-ray
• IM screw & TBW
• IM screw
• TB-wire
17.7
17.2
16.7
Murphy DF et al., Clin Orthop 224:215, 1987
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Proximal Plating
• 73% Good
/Excellent
• 24 Monteggia
• 13 Complex
• LCDCP
• Simpson, Injury 27
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Combined Proximal Ulna Fractures
• Complex fractures
– Olecranon
– shaft
– coronoid
• Must combine
different fixation
techniques
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Displacement of Fragments
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How to hold and repair
coronoid fragment?
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Temporarily pin through
distal humerus.
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Lag through ulnar shaft,
then close book
Plate designed for proximal Ulna
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Complications
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Potential Complications
•
•
•
•
•
•
•
Hardware symptoms in 22 - 80%
34-66% require hardware removal
Hardware failure 1-5%
Infection 0-6%
Pin migration 15%
Ulnar neuritis 2-12%
Heterotopic ossification 2-13%
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Complications
• Macko & Szabo JBJS1985
– 16/20 Prominent K- Wires
– 4 skin breakdown; 1 infection
– 2 loss off reduction
• Danzinger OTA
– 62% of 34 with complications
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Radial Head Fractures
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Radial Head Importance
Radiocapitellar joint
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Radial Head Importance
Buttress to axial
migration of the
radius
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Radial Head Importance
Resists posterior
dislocation of the
elbow
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Valgus stability
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Valgus Elbow Stability
• The radial head is a secondary restraint to
valgus forces
– function by shifting the center of varus-valgus
rotation laterally, so that the moment arm and
forces on the medial ligaments are smaller.
• Radial head is more critical when there is
injury to both the ligamentous and muscletendon units about the elbow.
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Radial Head Importance
Resists postlateral rotatory
instability (PLRI)
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Mechanism of Injury
• Usually occurs in a fall.
• Axial load to the elbow with combined
valgus force.
• Can be combined with high energy injuries
– Elbow dislocation
– Coronoid fracture
– Collateral ligament injuries
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Physical Exam
• Neurovascular
• Evaluate elbow stability
–
–
–
–
valgus stress: 30 degrees flexion, forearm pronated
PLRI: valgus, supination, axial load
AP stability with progressive extension
Axial stability:
• elbow flexed, push on fisted hand, check proximal
migration of radial shaft
• Tenaculum on shaft pull proximally
• Evaluate distal radio-ulnar joint stability
• Measure forearm rotation
– Mechanical block?
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Imaging
• Plain X-ray
– AP
– Lateral
– Oblique: Coyle view
• MRI
– Ligamentous injury
– skeletally immature patient.
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Classification
Mason
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Modified Mason Classification
• Type I: nondisplaced
– No block to forearm rotation, displacement < 2mm
• Type II: displaced
– Internal fixation possible
• Type III: displaced, severely comminuted
– Judged to be irreparable
– Usually requires excision to allow elbow movement
Hotchkiss R, JAAOS 5:1, 1997
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Simplified Classification
Fixation unnecessary
Fixation required and possible
-ORIF
Unreconstructable
-Arthroplasty
-Excision (rare)
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RH Fractures:
Treatment Algorithm
(20%)
excision
Arthroplasty
/ Excise
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Difficulties with ORIF
of Radial Head
• Angulation and offset of radial head
• Cancellous bone in head-poor screw purchase
• Comminuting worse than expected
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Is ORIF worth the effort?
• Boulas & Morrey, 1998: ORIF best
functional results
• Pomianowski, Morrey et al 2001:
– Biomechanically native radial head functions best
– Arthroplasty restores stability but not identical to
RH
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Does ORIF produce good Results?
• Ring & Jupiter: JBJS 2003:
– Poor functional results with >3 fragments
– Older Plates
• King, Evans, Kellam, 1991:
– Mason II: 100% good/excellent results
– Mason III: 33% G/E results
– Excellent results: “anatomic reduction, stable fixation,
early ROM”
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Surgical
Technique
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Identify capitellum
first
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Keep LUCL ligament
origin intact
Stay above
equator of
Radial Head
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3.5 – 4.0
cm
Post Interosseus Nerve
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Radial Head Fractures-Simple
Partial Articular
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IF screws
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Good ROM
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Head & Neck:
complete articular
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Comminution
often worse than
anticipated
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Fixation into the head difficult
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Radial Head Fixation - Safe Zone
From Hotchkiss R, JAAOS 5:1, 1997
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Radial Head Fixation
• Small Kirschner wires used provisionally
• Use small screws to fix head fragments
– 1.3 to 2.4 mm headed screws
• Bury head with countersink
– Headless compression screws
• May have to remove head fragments and fix on
back table
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Radial Head Fixation
• Secure radial head to neck with small plates
– Locking preferred
– Radial head specific plates
– Blade or small Hand set plates
• Keep hardware in “Safe Zone”
– 100° arc centered on the dorsal aspect of the neutrally
rotated forearm.
– Check forearm rotation intraoperatively.
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ORIF: Goals
-multiple screws into
head
-low profile to avoid
impingement
-IF screw
-begin early ROM
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Case Example
•
•
•
•
•
32 y.o. male, Fell from roof
Left elbow injury
NV intact
Closed injury
Moderate swelling
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CT Scan
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Problems
1.
2.
3.
4.
5.
Radial head fracture
Coronoid fracture
Fragments in joint
Collateral ligaments
Humeral ulnar joint not reduced
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-Approach
-Fix the coronoid? What technique?
-Radial head fix/replace?
-How do you repair collateral
ligaments:
Drill holes or suture anchors
*Sequence of events
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Sequence
1. Lateral approach
2. Piece together RH on
back table
3. Fix head to plate
4. Weave sutures thru
LCL
5. Suture anchor in
coronoid base, run
sutures in capsule
over coronoid
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Sequence
6. Reduce elbow in
flexion
7. Tie coronoid sutures
8. Fix rad head to shaft
9. Tie LCL sutures to
lat epicondyle
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6 month F/U
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6 month F/U
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Complications
• Improperly placed hardware
– Late removal and capsular release
• Loss of fixation
– Late radial head excision if soft-tissues healed
• Posterior interosseous nerve injury
• Elbow stiffness
– Capsular release
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Radial Head Arthroplasty
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Unreconstructable Fractures
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Arthroplasty
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New Modular Components
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Metallic
MODULAR
RADIAL
HEAD
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Radial Head Arthroplasty
•
•
•
•
•
•
Metallic not silicone
Non-cemented- head self centers on capitellum
Modular: avoid head/shaft mismatch
Must preserve or repair LCL
Use especially if other areas of instability
DON’T OVERSTUFF THE JOINT
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Excision of Head
• If entire head is comminuted and all
ligamentous are intact
–
–
–
–
1. no axial instability
2. no post instability
3. no valgus instability
4. no PLRI
Very rare!
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Acute Instability with Posterior
Elbow Dislocation
• Restoration of radial head function required.
• Internal fixation should be performed when
possible, along with repair of the lateral
ligaments.
• If repair is not possible, prosthetic
replacement with a metallic spacer should
be considered.
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Essex - Lopresti Lesion
• Defined as longitudinal disruption of forearm
interosseous ligament, usually combined with
radial head fx and/or dislocation plus distal
radioulnar joint injury
• Difficult to diagnose
• Treatment requires restoring stability of both
elbow and DRUJ components of injury.
• Radial head excision in this injury will result in
disabling proximal migration of the radius.
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Outcomes
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Outcomes after Excision are
Controversial
• There are recent papers reporting long-term
outcomes after radial head excision that
give conflicting results:
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Resection of the Radial Head after
Mason Type-III Fractures …
• 21 patients reviewed after 16-30 years
• 17 of 21 (81%) excellent results.
• Only 1 fair result.
Ikeda and Oka, Acta Orthop Scand 71:191, 2000
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Primary nonoperative treatment of moderately displaced
two-part fractures of the radial head.
Akesson, Herbetsson et al JBJS, 2006 Sep;88(9):1909-14.
• 49 pts, mean age of 49 years at the time of the injury
• 2 part fracture of the radial head , displaced 2 to 5 mm and that
included >/=30% of head
• All treated closed: cast or early ROM
• Average f/u of 19 yrs
• 6 patients required delayed Radial head excison
• 40 patients had no subjective complaints
– eight were slightly impaired as the result of occasional elbow pain, and
one had daily pain.
• ROM: 137° Flexion to -3 ° Extension , Supination 86 degrees
• Degenerative changes on radiographs was higher for the injured
elbows than for the uninjured elbows (82% vs 21%) p < 0.01.
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Results of Acute Excision of the Radial
Head in…Fracture Dislocations
• 10 cases
• Follow-up 4.6 years
• Results:
– 4 excellent, 5 good, 1 fair
– Degenerative changes present in 8 of 10
• Although early results satisfactory, the
incidence of degenerative changes
worrisome.
Sanchez-Sotelo J et al., J Orthop Trauma 14:354, 2000
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The Functional Outcome with Metallic Radial Head
Implants in the Treatment
of Unstable Elbow Fractures
• 20 patients evaluated after mean 12 years (6-29
years)
• All had radial head fx’s with elbow dislocation
and associated injuries to MCL, coronoid, or
proximal ulna.
• Results: 12 excellent, 4 good, 2 fair, 2 poor.
Harrington IJ et al., J Trauma 50:46, 2001
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Radial head arthroplasty with a modular metal
spacer to treat acute traumatic elbow instability.
Doornberg, Parisien, van Duijn, 2007 May;89(5):1075-80.
• 27 patients, modular metal spacer prosthesis, to treat traumatic elbow
instability
• Average of 40 months postoperatively
• ROM:
– 131 degrees of flexion with a 20 degrees flexion contracture
– 73 degrees of pronation, and 57 degrees of supination.
• Stability was restored to all twenty-seven elbows, and twenty-two patients had
a good or excellent result
• A modular metal radial head prosthesis can help to restore stability in
conjunction with repair of other fractures and reattachment of the lateral
collateral ligament to the epicondyle in the setting of traumatic elbow
instability with a comminuted fracture of the radial head.
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Conclusions
• Difficult fractures to treat
• Fractures and ligamentous injuries usually
occur in combination
• Crucial to evaluate other bony and
ligamentous structures
• Elbow stability and reduction is critical
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
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Return to
Upper Extremity
Index
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References
1: Guitton TG, Doornberg JN, Raaymakers EL, Ring D, Kloen P. Fractures of the capitellum and
trochlea. J Bone Joint Surg Am. 2009 Feb;91(2):390-7.
2: Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of
operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007
Oct;32(8):1200-9.
3: Villanueva P, Osorio F, Commessatti M, Sanchez-Sotelo J. Tension-band wiring for olecranon
fractures: analysis of risk factors for failure. J Shoulder Elbow Surg. 2006 MayJun;15(3):351-6.
4: Tashjian RZ, Katarincic JA. Complex elbow instability. J Am Acad Orthop Surg. 2006
May;14(5):278-86.
5: Doornberg J, Ring D, Jupiter JB. Effective treatment of fracture-dislocations of the olecranon
requires a stable trochlear notch. Clin Orthop Relat Res. 2004 Dec;(429):292-300.
6: Ates Y, Atlihan D, Yildirim H. Current concepts in the treatment of fractures of the radial
head, the olecranon and the coronoid. J Bone Joint Surg Am. 1996 Jun;78(6):969.
7: Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon,
and the coronoid. Instr Course Lect. 1995;44:175-85.
8: Perry CR, Tessier JE. Open reduction and internal fixation of radial head fractures associated
with olecranon fracture or dislocation. J Orthop Trauma. 1987;1(1):36-42.
9: van Riet RP, Sanchez-Sotelo J, Morrey BF. Failure of metal radial head replacement. J Bone
Joint Surg Br. 2010 May;92(5):661-7.
10: Antuña SA, Sánchez-Márquez JM, Barco R. Long-term results of radial head resection
following isolated radial head fractures in patients younger than forty years old. J Bone Joint
Surg Am. 2010 Mar;92(3):558-66.
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References
11: Frank SG, Grewal R, Johnson J, Faber KJ, King GJ, Athwal GS. Determination of correct
implant size in radial head arthroplasty to avoid overlengthening. J BoneJoint Surg Am. 2009
Jul;91(7):1738-46.
12: Adams JE, Hoskin TL, Morrey BF, Steinmann SP. Management and outcome of 103acute
fractures of the coronoid process of the ulna. J Bone Joint Surg Br. 2009 May;91(5):632-5.
13: Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement--what is the
evidence? Injury. 2008 Dec;39(12):1329-37.
14: Clembosky G, Boretto JG. Open reduction and internal fixation versus prosthetic replacement
for complex fractures of the radial head. J Hand Surg Am. 2009 Jul-Aug;34(6):1120-3.
15: Lim YJ, Chan BK. Short-term to medium-term outcomes of cemented Vitallium radial head
prostheses after early excision for radial head fractures. J ShoulderElbow Surg. 2008 MarApr;17(2):307-12.
16: Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in
management. J Am Acad Orthop Surg. 2007 Jul;15(7):380-7.
17: Rowland AS, Athwal GS, MacDermid JC, King GJ. Lateral ulnohumeral joint space
widening is not diagnostic of radial head arthroplasty overstuffing. J Hand Surg Am. 2007
May-Jun;32(5):637-41.
18: Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular
metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007
May;89(5):1075-80.
19: Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted radialhead
fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone
Joint Surg Am. 2006 Oct;88(10):2192-200.
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