Radial Head Fracture: Open Reduction and Internal Fixation

Introduction

Surgical treatment of displaced radial head fractures has evolved from excision of fracture fragments or the entire head of the radius, to several techniques of open reduction and internal fixation (ORIF), and modern types of radial head replacement. The first documented case of an ORIF of a radial head fracture was performed in 1909. Initially, ORIF was used sporadically, largely because of the perception that it had “not proved successful in anyone's hands.” The poor earlier results were probably due to an inadequate understanding of anatomy and less refined techniques for effective internal fixation. By the late 1970s reports of successful efforts of ORIF began to emerge.

Loss of contact of the radial head fracture fragments is associated with an increase in associated injuries, but frequently the fracture fragment has a periosteal hinge, indicating that its viability is possible. The ideal fracture for fixation is a simple, large (constituting 30% of the head) fragment that involves the anterolateral margin of the head ( Fig. 38.1 ). However, despite the bigger technical challenge of fixing smaller fragments, biomechanical studies have also shown a benefit of fixation of fragments smaller than one-third of the radial head. The anterolateral margin of the head does not articulate with the lesser sigmoid notch: instrumented fixation of this fragment does not result in impingement ( Fig. 38.2 ). Although it is well recognized that nonoperative management may be effective in selected type II fractures, recent review articles on the subject have confirmed the positive experience with ORIF in approximately 90% of cases. ^a Effectiveness is clearly correlated with the degree of comminution and injury severity ( Table 38.1 ).

a See references .

Geel et al. reported less than a 10-degree loss of extension and a 10-degree loss of pronation and supination in 19 patients who underwent ORIF. A similar outcome was observed by Sanders and French in eight patients treated for difficult type III fractures. Ikeda et al. reported excellent and good results in nine out of ten patients, using low-profile mini plates for severely comminuted radial head fractures. Nine patients required hardware removal. In a study of 56 patients, Ring et al. reported excellent results in patients with minimally comminuted fractures with three or fewer articular fragments, whereas results were unfavorable in patients with more comminuted fractures or if the fracture was associated with an elbow dislocation. However, this experience was not confirmed in a 2014 study by Pike et al. who noted a trend toward less favorable outcomes and increased complications and found no significant differences when comparing the outcomes of ORIF of simple and complex radial head fractures. If there are multiple but large fragments, open reduction may therefore be favorable, but results can be disappointing. Radial head resection in this situation has been shown to have poorer results than ORIF. Several studies comparing the results of ORIF and prosthetic replacement of the radial head in comminuted fractures suggest that primary radial head replacement may yield better results in these difficult fractures. ^b

b See references .

Cannulated headless screws have been reported to provide virtually normal function. The traditional Association for the Study of Internal Fixation (AO) technique using the 2.0 or 2.7 screws has been reported as satisfactory in 100% of patients with Mason type II fractures but in only 33% of those with Mason type III fractures. Esser et al. reported on 26 cases of osteosynthesis, 11 with type II and 9 with type III. All cases were graded as satisfactory after osteosynthesis ( Fig. 38.3 ). A small buttress plate can be used for radial neck fractures, but this often needs to be removed, as it commonly interferes with rotation of the forearm, even if the plate is placed in the best position (see Fig. 38.2 ). A statistically significant better forearm arc of motion and elbow flexion arc was documented with the “low-profile axial fixation” technique ( Fig. 38.4 ). In this instance, the fracture is fixed by inserting a threaded K-wire or cannulated screw through the margin of the radial head across the fracture and engaging the opposite radial cortex ( Fig. 38.5 ). Bioabsorbable polylactic pins have also been used since the early 1990s, for fixation of radial head fractures. In a prospective randomized study of 135 patients, results of fixation using polylactic pins have been shown to yield at least comparable results compared to other types of fixation. However, despite favorable results, biocompatibility may be an issue unique to this type of fixation. Some other technique modifications have also been proposed. Fibrin adhesive seal was used as early as 1995, but despite excellent short-term results, this has never become a mainstream technique.

In comparison to resection or prosthetic replacement of the radial head, ORIF has been shown to be preferable if a stable fixation can be achieved. In a cadaveric study, ORIF has biomechanically been shown to be superior to resection or prosthetic radial head replacement.

A retrospective study by Parasa and Maffulli of 29 patients with radial head fractures, managed with different surgical methods, showed the best results in Mason type II fractures, followed by type III. Comparing different techniques, the best outcome was observed with screw fixation, followed by excision of the radial head, Kirschner wire fixation, partial excision, silastic implant, and plating. One prospective study by Khalfayan et al. compared the results of 16 patients treated by closed reduction and 20 by ORIF; the former had only 44% satisfactory results, compared with 90% in the group treated by ORIF. Boulas et al. compared results of ORIF with resection, Silastic radial head replacement, and conservative treatment in 36 patients; the best clinical scores were found in patients treated with ORIF, and the authors recommended this type of treatment for displaced radial head fractures.

Arthroscopic techniques to reduce and fix radial head fractures are being used with good results. The largest series published to date shows good midterm results in 16 patients with arthroscopic reduction and fixation in displaced radial head fractures ( Fig. 38.6 ).