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Open reduction internal fixation (ORIF) is recommended for Mason Type II fractures with a mechanical block and Mason Type III fractures where stable fracture fixation is feasible. Radial head fractures with concomitant injuries (e.g., coronoid, olecranon, and/or capitellum fractures) or substantial elbow instability that requires a soft tissue repair provide an opportunity for an ORIF to be performed.
There is no clear consensus on the optimal treatment of radial head fractures with >2 mm displacement and no mechanical block to rotation. Good results have been shown with nonoperative treatment of these injuries. 1,2 Ultimately, this decision should be made after a thorough discussion with the patient regarding the risks and benefits.
For more comminuted radial head fractures, it is still a matter of debate regarding which ones can be fixed versus replaced. Often, this decision is made intraoperatively after inspecting the fracture fragments. High complication rates and poor clinical results after ORIF of radial head fractures with more than three fragments have been noted prompting recommendation that the radial head be replaced in these cases. 3 However, new techniques and implants, such as radial head–specific plates, have been developed, which have expanded the surgeon’s ability to fix more comminuted radial head fractures.
The preoperative examination of the patient with a radial head fracture begins with a neurovascular examination and inspection of the soft tissue to rule out open injuries. Palpation along the interosseous membrane and distal radioulnar joint (DRUJ) as well as stability assessment will identify associated injuries of the forearm and wrist. Active and passive elbow motion and any block must be determined and documented. Attention must be given to joint crepitus when moving the extremity and, particularly, when rotating the forearm. Varus and valgus stability should be investigated in full extension and 30 degrees of flexion, and, if possible, documented under fluoroscopy.
Elbow radiographs, including anteroposterior (AP) and lateral projections as well as an oblique lateral view of the elbow, can be helpful. If an Essex-Lopresti injury is suspected, then radiographs of the forearm and wrist should also be taken. Ultimately, the intraoperative determination of DRUJ stability after radial head fixation is most important to identify an Essex-Lopresti injury. A computed tomography (CT) scan can be used for more comminuted radial head fractures.
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