fracture radial head

deals with fractures of isolated radial head with evaluation , management and postoperative protocol

1. Isolated radial head fractures

2. ISOLATED RADIAL HEAD FRACTURES Kc gopalakrishnan

3. 1.5 to 4 % of all fractures in adult 33 % of all elbow injuries

4. Isolated Radial head fractures Davidson et al- all 111 patients with entire radial head fractures had associated wrist or elbow ligamentous injury( clin orthop 1993) 30 – 70% associated injuries in various studies

5. Isolated Radial head fractures Rockwood and Green- assume associated injuries unless proved otherwise

6. Isolated Radial head fractures Possible to get isolated radial head fractures in elderly but rare -Rockwood and Green

7. Isolated Radial head fractures “Entire radial head fracture or displaced partial radial head fracture always associated with ligamentous injury-” Rockwood and Green

8. ISOLATED RADIAL HEAD FRACTURE

9. APPLIED ANATOMY

10. APPLIED ANATOMY Radial head act as secondary stabilizer to valgus stress, primary being MCL Radial head resection in presence of intact MCL does not alter valgus instability much

11. APPLIED ANATOMY PROXIMAL RADIO ULNAR JOINT 260* arc covered with articular cartilage 100* arc safe zone Pronation-supination

12. APPLIED ANATOMY RADIO CAPITELLAR JOINT Radial head transmits 60% of axial load of forearm to capitellum ( Morrey JBJS 1988)

13. APPLIED ANATOMY RADIO CAPITELLARJOINT This load is g reatest with forearm in pronation and b/w 0-30* elbow flexion

14. MECHANISM OF INJURY Indierect injury Axial load thru pronated forearm Valgus injury Posterolateral rotatory load

15. MECHANISM OF INJURY

16. MECHANISM OF INJURY Disruption of interroseous membrane due to acute shortening of radius producing longitudinal traction

17. ASSOCIATED INJURIES ELBOW DISLOCATION ESSEX LOPRESTI CAPITELLUM FRACTURE CORONOID FRACTURE

18. ASSOCIATED INJURIES MCL injury Olecranon fraccture dislocation

19. Detecting associated associated injuries Clinical examination X-ray evaluation CT Intraoperative evaluation

20. Detecting associated associated injuries

21. CLINICAL EVALUATION Even minor fractures are painful due to haemarthrosis Document forearm rotation after LA injection to joint to rule out mechanical block

22. DOCUMENT MCL injury PIN injury DRUJ injury Interroseous membrane injury

23. DOCUMENT

24. BROBERG MORREY MODIFICATION OF MASON CLASSIFICATION 1 Marginal/ segmental fracture < 2mm displacement No block to forearm rotation

25. BROBERG MORREY MODIFICATION OF MASON CLASSIFICATION 2 Displaced segmental fracture > 2mm/ >30* angulation Mechanical block to forearm rotation

26. BROBERG MORREY MODIFICATION OF MASON CLASSIFICATION 3 Communited entire radial head fracture

27. BROBERG MORREY MODIFICATION OF MASON CLASSIFICATION 4 Radial head fracture associated with elbow dislocation

28. HOTCHKISS MODIFICATION OF MASON CLASSIFICATION TYPE 1- minimally displaced radial head fracture , no block to forearm rotation, can be treated non operatively

29. HOTCHKISS MODIFICATION OF MASON CLASSIFICATION TYPE 2- displaced partial radial head fracture that blocks forearm rotation/ entire radial head fracture amenable to fixation, treatment is ORIF

30. HOTCHKISS MODIFICATION OF MASON CLASSIFICATION TYPE 3- communited entire radial head fracture not amenable to fixation, radial head excision or replacement .

31. Goals of treatment Correcton of block to free forearm rotation Stable elbow Prevent late arthrosis Early mobilisation

32. Non operative treatment Modified mason 1 fractures No associated lig injuries No bony block to ROM

33. Non operative treatment Early(3-4d) ROM Large undisplaced fragments need to be monitored with x-ray Loss of elbow extension Redisplacement Non union Various studies have reported 90% favourable results in mason 1 injury

34. Non operative treatment 80% favourable result with MASON 2&3 fractures treated nonoperatively and added with delayed radial head excision when required for pain(JBJS (Am) :86-A; 3, 570.)

35. Non Operative Rx

36. More than 2 wks POP

37. Retain/Regain

38. Safe Zone Smith and hotchkiss 65* ant and 45* pos to line bisecting anterior and pos head with arm in neutral rotation

39. Safe Zone

40. ORIF. implant in SAFE ZONE

41. CONSIDER ORIF Displaced MASON 2(>2mm) partial radial head fractures which block forearm rotations Entire radial head fractures with unstable elbow if Less than three articular fragments Sufficient size and bone quality ti accept screws No metaphyseal bone loss

42. Partial radial head fracture

43. Entire radial head fracture

44. Better understanding of anatomy and safezones for implant and current implants have improved clinical results of internal fixation King et al have repoted 100% excellent results with internal fixation for Mason 2 fractures They have reported only 33%good results with Mason 3 fractures treated by internal fixation

45. Due to inadequate fixation or selection of fracture pattern- include Nonunion Restriction of forearm motion Implant failure Infection PIN injury

46. Inadequate fixation

47. Extending the indication

48. Primary Radial head excision

49. Primary Radial head excision Modified mason 3 fractures with Intact MCL No injury to DRUJ Coronoid and olecranon intact Partial radial head fractures hindering forearm rotation not amenable to reconstruction

50. 15 yr follow up studies Antuna et al- 81 % painfree , radigraphic OA did not produce clinical symptoms Hebertson et al- 90% excellent results, OA changes in 50%

51. COMPLICATIONS LOSS OF ELBOW MOTION LOSS OF STRENGTH ELBOW OA CHANGES PROXIMAL MIGRATION OF RADIUS( up to 2 mm assymptomatic ) WRIST PAIN VALGUS INSTABILITY OF ELBOW

52. EVOLVING ?

53. Radal head arthroplasty Silicone prosthesis Insabilty Destructive synovitis Discarded Metal prosthesis Press fit / cemented Smooth stem Unipolar or modular bipolar head

54. Smooth stem Act like spacer Produce radiolucencies but asymptomatic No overstuffing of radiocapitellar joint

55. Fixed stem Overstuffing if radiocapitellar joint if prosthesis more than 1 mm proximal to coronoid process Open up elbow on lateral side Capitellar wear and synovitis So exact sizing must No significant diff b/w monopolar or bipolar heads

56. Over stuffing with opening up

57. TAKE HOME MESSAGE Isolated radial head fracture do occur but is rare Always look for wrist or elbow ligamentous injury Document forearm rotation Nonoperative treatment involves supervised mobilization NOT immobilization

58. TAKE HOME MESSAGE Selection of type of fracture amenable to fixation crucial Follow safe zones for implants Radial head arthroplasty is still evolving

59. DIDN’T MEAN TO CONFUSE!!!!!!!!!!