Radial head fracture

radial head fracture

1. RADIAL HEAD FRACTURE Dr krunal h patel

2. EPIDEMIOLOGY OF 4%OF ALL FRACTURE AND 30%OF ALL ELBOW FRACTURE. 1/3 PT ASSOCIATED INJURY TO SHOULDER,HUMERUS,FOREARM,WRIST OR HAND. RARE IN CHILDREN DUE TO CARTILAGENOUS NATURE OF RADIAL HEAD. RADIAL NECK FRACTURE MORE COMMON IN CHILDREN.

3. ANATOMY OF PROXIMAL RADIUS RADIOCAPITELLAR JOINT TRANSMIT 50-60% LOAD ACROSS ELBOW

4. RADIUS HEAD SURGICAL ANATOMY IMPORTANT FOR VALGUS STABILITY POSTEROLATERAL ROTATORY STABILITY LONGITUDINAL FOREARM STABILITY (ALONG WITH INTEROSSI MEMBRANE & DRUJ)

5. ELBOW STABILITY MCL & U-H JOINT:PRIARY STABILIZER RADIAL HEAD(R-C JOINT) & CAPSULE:SECONDARY STABILIZER

6. CONT..

7. MUSCLE ATTACHMENT AROUND PROXIMAL RADIUS SUPINATOR ATTACHMENT AT PROXIMAL RADIUS. BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

8. POST.INTEROSSI NERVE AT RISK PIN TRAVERSES FROM ANTERIOR TO POSTERIOR THROUGH SUPINATOR MUSCLE. ALWAYS CHECK PRE OPERATIVE ACTIVE FINGER EXTENSION

9. MECHANISM OF INJURY (1) FALL ON OUTSTRECHED HAND(MOST COMMON) DISTAL RADIUS INTEROSSI MEMBRANE(FOREARM) RADIAL HEAD IMPACTION AGAINST CAPITELLUM (2)VALGUS INJURY TO ELBOW/DIRECT INJURY MCL RUPTURE/OLECRANON FRACTURE UNSTABLE ELBOW

10. DIAGNOSIS HISTORY:FALL ON OUTSTRETCHED HAND/DIRECT INJURY EXAMINATION: ELBOW SWELLING ECCHMOSIS ANCONEUS TRIANGLE FULLNESS RANGE OF MOTION RESTRICTION STABILITY ACTIVE FINGER EXTENSION FOREARM/INTEROSSI MEMBRANE TENDERNESS WRIST TENDERNESS ESSEX LAPROSTI INJURY

11. X RAY FINDINGS STANDARD AP AND LATERAL X RAY of elbow OBLIQUE(GREEN SPAN)VIEW FOREARM AND WRIST X RAY IF REQUIRED

12. X RAY FINDINGS

13. CLASSIFICATION OF RADIAL HEAD FRACTURE Mason classification Type I Minimally displaced fx , no mechanical blockto rotation, intra-articular displacement <2mm Type II Displaced fx >2mm or angulated, possible mechanical block to forearm rotation Type III Comminuted and displaced fx, mechanical block to motion Type IV (Hotchkiss/JOHNSTON modification OF TYPE 3) Radial head fracture with elbow dislocation MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% AND DISPLACEMENT OF >2 MM

14. TREATMENT GOAL CORRECTION OF ANY BLOCK TO FOREARM ROTATION EARLY ROM OF ELBOW AND FOREARM STABILITY OF ELBOW AND FOREARM PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW

15. NON OPERATIVE TREATMENT INDICATION: ISOLATED RADIAL HEAD FRACTURE WITH MASON TYPE 1 (UNDISPLACED <2MM ) PLASTER SLAB FOR 3 WEEKS EARLY ACTIVE MOBILIZATION OF ELBOW PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR FRACTURE

16. OPERATIVE MANAGEMENT OPEN REDUCTION & INTERNAL FIXATION INDICATION FOR ORIF: Mason type II with mechanical block(displaced) Large fragment >2 mm Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME) Mechanical block to motion (lignocaine inj in elbow joint) Presence of other complex ipsilateral elbow injuries(without metaphyseal bone loss) FRAGMENT EXCISION LEADS TO INSTABILITY TRY TO PRESERVE SMALLEST FRAGMENT

17. Surgical approach for ORIF: Kaplan direct lateral approach Interval between EDC and ECRB Keep forearm pronated to protect PIN PIN present approx. 2 cm below radial head Do not extend exposure below annular ligament Gentle retraction ADVANTAGE: No disruption LATERAL LIGAMENT COMPLEX(LUCL) DISADVANTAGE: PIN at risk

18. KOCHER POSTEROLATERAL APPROACH Interval between ECU and anconeus Keep forearm pronated to protect PIN Advantage: Less of a risk of PIN injury than the kaplan Disadvantage: LATERAL LIGAMENT COMPLEX may injured Leads to instability HOTCHKISS APPROACH DIRECTLY THROUGH EDC PROTECT LATERAL LIGAMENT COMPLEX

19. PRONATE FOREARM WHILE FIXATION

20. SAFE ZONE OF RADIUS HEAD FIXATION LONGITUDINAL LINE B/W LISTER TUBERCLE AND RADIUS STYLOID PROCESS NO ARTICULATION WITH ULNA SAFE FOR IMPLANT INSERTION:NO IMPINGMENT IN ROTATION POSTERO-LATERAL ZONE IN FULL SUPINATION(CAPUTO A) IN NEUTRAL(MID PRONE)POSITION : ANTEROLATERAL ZONE

21. Which implant to use? Mini fragment screw(2.4 or 2.7 mm)(counter sink must) Headless compression compression screw/Herbert screw Low profile plate/mini t plate(in safe zone/ postero lateral) K WIRE

22. COMPLICATION OF ORIF PIN INJURY HARDWARE FAILURE HARDWARE IMPINGEMENT STIFFNESS OF ELBOW RESTRICTION OF SUPINATIONPRONATION

23. RADIAL HEAD REPLACEMENT To prevent proximal migration of the radius Silicon implant poor outcome : SILICON SYNOVITIS Titanium/ vitallium metallic implant of choice Indication: Extensive communition of radial head/excess bone loss Elbow instability: essex lapresti lesion, coronoid fracture, elbow dislocation, collateral ligament injury, olecranon fracture

24. RADIAL HEAD REPLACEMENT PROSTHESIS LOOSE STEMMED PROSTHESIS THAT ACTS AS A STIFF SPACER

25. BIPOLAR PROSTHESIS That is cemented into the neck of the radius COMPLICATIONS: Overstuffing of joint c apitellar wear problems Malalignment instability

26. COMPLICATION OF REPLACEMENT Post operative infection of implant Ulnar nerve/pin injury Immediate post operative dislocation Recurrent instability Heterotrophic ossification Contracture /stiffness Crps type 1

27. RADIAL HEAD EXCISION INDICATION: Low demand, sedentary patients In a delayed setting for continued pain of an isolated radial head fracture CONTRAINDICATION: In children Presence of destabilizing injuries ( Essex- lopresti lesion,fracture dislocation elbow(mason type 4), monteggia ) Terrible triad of elbow( coronoid fracture,MCL deficiency)

28. COMPLICATION OF EXCISION PROXIMAL MIGRATION OF RADIUS INFERIOR RADIO ULNAR JOINT DISTURBANCE PAIN & WEAKNESS OF WRIST Joint instability Decreased strength Cubitus valgus EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR SYNOSTOSIS .