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  • ORIF is carried out in 70% of patients for whom it is intended due to the fact that there is often more comminution found intraoperatively than was apparent on preoperative radiographs. One must be prepared for a "plan B" replacement.
  • Radial head replacement is recommended for:
    • Tenuous fixation
    • Mason type 3 fractures with more than three articular fragments
  • .
  • Advanced age, sedentary, smokers, patients on medications that impair healing (eg prednisone), significant medical comorbidities
  • Irreparable cartilage injury
  • patients with osteoporotic bone
  • ...

    • Closed reduction and possible pinning of the DRUJ
    • ORIF vs. replacement of the radial head


    • Arthroplasty:
      • Over- or understuffing the radiohumeral joint by 2.5 mm or more significantly alters elbow kinematics and radiocaptiallar pressure
    . Overstuffing may lead to pain and early EJD, while undersuffing increases the risk of valgus instability.
  • The plane of the articular surface of the radial head is located 0.9mm proximal to the plane of the lateral articular surface of the coronoid
  • A visual lateral ulnohumeral joint gap seen intraoperatively is a reliable indicator of over-lengthening greater than 2mm. Radiographic asymmetry of the medial ulnohumeral joint is insensitive for detecting over-lengthening, as incongruity of ulnohumeral joint only occurs after over-lengthening of the radius by 6mm or more.

    Image Added

    Figure: Overstuffed radial head replacement.


    • voids caused by impacted fragments should be filled with cancellous autograft from the lateral epicondyle


    • Heterotopic ossification
      • risk factors:
        • extensive muscle damage
        • neurotrauma
        • revisions
      • Prophylaxis modalities
        • indomethacin
        • radiation
    • radioulnar synostosis
    • nonunion
    • collapse
    • DJD
    • decreased range of motion
      • loss of full extension most common
    • Radial head overgrowth
    • Premature physeal closure
    • Avascular necrosis of the radial head
    • Alteration in the carrying angle
    • Neuromuscular problems (ulnar nerve problems with valgus)




    Radial Head Fractures

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    Mason Classification





    • Surgical Indications:
      • Radial head excision can be considered if it is an isolated injury(i.e. there is not an Essex-Lopresti fracture).
        • In the setting of an Essex-Lopresti fracture (radial head fracture, DRUJ disruption, and intraosseous membrane injury) proximal migration of the radius and a reduction in grip strength, valgus instability, posterolateral rotatory instability, heterotopic ossification, and post-traumatic arthritis of the ulnohumeral articulation may occur. Therefore it is recommended to either repair or replace the radial head.
        • optimal scenarios include elderly, low energy injuries, no concomitant ligamentous injuries
        • isolated, displaced two-part fractures are preferrably treated with ORIF
      • Simple excision of fragments less than 1/3 of radial head may be considered if unrepairable.
      • The radial head should be repaired or replaced when:
        • There are associated soft tissue injuries at the elbow, including:
          • Disruption of the anterior band of the MCL (secondary valgus instability)
          • Essex-Lopresti Fracture (secondary longitudinal instability)
          • Lateral collateral ligament (posterolateral rotatory instability; presence of radial head allows for proper tensioning of the LCL)
          • Elbow dislocation (posterolateral rotatory instability, recurrent posterior dislocation)
        • If there is a block to flexion/extension, or rotation
        • Angulation more than 30o
        • Depression of articular surface of more than 3 mm
        • Greater than 1/3 of radial head involved
      • Open reduction internal fixation is indicated for:
        • Partial articular fractures with a single fragment
        • Mason type 3 (complete articular) fractures with three or fewer fragments