Radial head fractures; ORIF radial head; radial head arthroplasty; coronoid process fracture; ligament repair Elbow Anatomy Spectrum of injuries

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1 Radial head fractures; ORIF radial head; radial head arthroplasty; coronoid process fracture; ligament repair This information aims to help you understand your condition and gain maximum benefit from your treatment. It covers the most commonly asked questions. However, every individual is different, and you should ask as many questions as you like. Elbow Anatomy The elbow joint is a type of hinge joint. It bends (flexion) and straightens (extension), as well as rotating to position your palm up or down. The joint is formed by the end of the upper arm bone (distal humerus) together with the 2 forearm bones (the radius and the ulna). The point of your elbow is the end of the ulna (the olecranon). The coronoid process is a lip at the front of the ulna. The ulna articulates with the trochlea (part of the distal humerus) The end of the radius is the radial head. The radial head articulates with the capitellum (part of the distal humerus) Two important ligaments help to hold the bones together (the medial ulnar collateral ligament, MUCL; the lateral ulnar collateral ligament, LUCL). As well as the ligaments, the radial head and coronoid process are important in keeping the joint stable. Spectrum of injuries Injuries occur either from a simple fall or from a high energy injury such as a car crash in a younger person. Sometimes the bones break without the elbow dislocating but sometimes a dislocation also occurs. In terms of treatment planning the displacement (how far the pieces are away from each other) and the amount of comminution (how many pieces there are), the smoothness of the articular surface and whether the elbow dislocated are important. However sometimes a very minor looking fracture can represent a very severe elbow injury that will have a very poor outcome without surgery. The most common injuries that are encountered are: 1) Simple radial head fractures Radial head fractures are the most common injury. The term simple implies that no other important structures are injured These fractures can be treated without surgery that are expected to heal well with a very good outcome. Sometimes the radial head fragment are displaced enough that rotation of the forearm is blocked. If this is the case then ORIF (open reduction and internal fixation) of the radial head is recommended.

2 2) Complex radial head, coronoid process fractures and fracture dislocations In this situation there is a combination of bony and ligament injuries. These are generally severe injuries that are best treated with surgery If surgery is needed it is either done through cuts on one side or other (or both) of the arm or through an open cut on the back of the elbow. It is very important that elbow movement is started as early as possible and certainly within three weeks of the injury. Radial head ORIF The aim of this surgery is to bring the fracture fragments back together in their normal positions and to hold them there with metalwork. Radial head replacement Sometimes the radial head is broken into so many pieces that it is not possible to put it back together again. In this case it is replaced with a prosthesis Coronoid process ORIF Small pieces of the coronoid process do not need to be fixed. Larger pieces may need to be repaired. Various techniques may be used. LUCL and MUCL repairs The need for ligament repair is dictated by the type of injury and what bony repairs have been performed You will come to hospital on the day of surgery. You will have a general anaesthetic. A nerve block may also be used. The surgery usually takes 2hrs After surgery You will stay in hospital 1-2 nights after surgery You will see a physiotherapist before you leave hospital. If needed the dressings will be changed before you leave hospital. Use ice wrapped in a tea towel over the dressings for the first week. Use regular painkillers for the first 2-4 weeks. Keep the outer dressings intact until your first post-operative visit. The speed of recovery is variable. It can be rapid or seem slow. Most improvement occurs in the first 6 months. The end of recovery is around months after surgery. Appointments after surgery with Dr Smith 7-10 days; 6 weeks, 3 months, 6 months, 12 months. Rehabilitation exercises Specific rehabilitation exercise sheets will be given to you in hospital and during your follow-up visits. Only do the exercises shown to you in hospital and demonstrated to you in clinic. Your therapist will suggest whether you can do the exercises yourself at home or would be better with regular supervised physiotherapy sessions. You will need to get into the habit of doing the exercises several times a day for around 6 months. Milestones & Return to work/sports Dictated by procedure & whether ligament repair was required See specific rehabilitation sheets Driving You cannot drive while you are using a sling. Once you have been told that you can remove the sling you can drive when you feel that you have full control of the vehicle. It is your responsibility to make this decision. Lifting In the long-term this is dictated by whether an ORIF or a total elbow arthroplasty or a distal humerus hemiarthroplasty was required Likely outcomes The main aim of surgery is to improve pain and function. Range of motion and strength should be close to normal though this is more difficult to predict. Patient satisfaction rates after surgery are around 95%. No surgery will result in a joint that feels and functions completely normally after these fractures.

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4 Is surgery right for me? Surgery is generally successful. However, your surgeon cannot guarantee that the surgery will meet all of your expectations. No surgery is without risk. While every attempt is made to minimise these risks complications can occur. The surgeon will offer guidance and information but the final decision is yours and should not be made in a rush. You should consent to undergo surgery only when you are satisfied that the potential risks of surgery are outweighed by the potential benefits bearing in mind your own symptoms and functional limitations. Potential risks of surgery The risk of complications is higher in those who smoke or use tobacco products and consideration should be given to stopping use before surgery. Anaesthetic Risks: Problems following or during anaesthetics are very rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerebro-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE). Although uncommon these can be very serious or even lifethreatening Unsightly scarring Scars usually heal without any problems. In the short term they may be itchy and mildly tender, but this settles as the scar matures. By 12 months after the operation scars are usually fine and pale in colour. Occasionally the scar may become hypertrophic or keloid (raised and red). Some people are prone to this. There is sometimes an area of numbness around the scar. This is more troublesome in some locations than others. The numbness often improves with time, but some may be permanent. Infection (<1%). An infection at a surgical site is uncommon and typically is mild and superficial and would be expected to settle with oral (tablet) antibiotics. If there is any concern the surgeon or hospital should be contacted. Rarely there is a deep infection which may require re-admission to hospital for intravenous (through a drip) antibiotics. Neuro-Vascular damage (Damage to nerve or blood vessels). Orthopaedic surgery is often undertaken very close to important blood vessels and nerves. Damage to these vessels is very rare but can be very serious. Stiffness. With any injury or operation around a joint there is a small risk of developing a stiff joint afterwards. This should get better, often with a period of physiotherapy. Bleeding Blood loss is typically not significant in upper limb surgery. Open shoulder operations where a tourniquet cannot be used are most at risk. Occasionally enough bleeding occurs to make a patient anaemic (low blood count). Blood transfusion is rarely required. Failure of healing In any surgery where implants are inserted or soft tissues are repaired there is a small chance that healing may not occur. This can cause a poor result after surgery. Problems relating to implants Implants such as plates and screws, sutures, bone anchors and joint replacements are commonly used in orthopaedic surgery. Implants may work loose and move around if healing does not occur. They may also cause some pain at the insertion site. Joint replacements The materials used all wear out over time although most modern devices will last for at least 10 years. Fracture near the replacement, loosening and dislocation of the replacement may also occur. Change in symptoms. While the chance of symptom improvement is high it is possible that symptoms may remain unchanged or get worse. Re-operation (further surgery) Any of the problems listed above may result in the need for further surgery

5 Alternative treatment options Most orthopaedic conditions are best treated by an initial course of nonoperative treatment. Orthopaedic operations are generally not essential or life-saving but do have a very good chance of relieving symptoms. Surgery is only indicated when symptoms are quite severe and non-operative treatments have failed or are highly likely to fail. Many non-operative treatments are available: this list is by no means exhaustive and many patients find other options work well for them. Education Being well informed about your condition and its likely outcome and treatment options is extremely important. Please ask any questions that are important to you. Activity modification Sometimes a simple change of work practice or a modified technique in sports will alleviate symptoms. Occasionally a change of job or sports would be better. Not everyone is willing or able to change their work and lifestyle to this degree however. Medications Painkillers and Anti-inflammatories Paracetamol is safe even with long term regular use. Anti-inflammatories in general are preferred for short term use only and sometimes are best avoided entirely. Stronger painkillers such as codeine, tramadol and endone are required for more severe pain. There are concerns over dependency and build-up of tolerance in the longer term and therefore this is best avoided. Glucosamine and Chondroitin sulphate These are dietary supplements that may protect articular cartilage from wear. Clinical studies to date have shown that it can result in as good pain relief as anti-inflammatories. Evidence demonstrating prevention of or prevention of progression of arthritis in the long-term are still awaited. Steroid Injections Function like a powerful local anti-inflammatory. The purpose of the injection is to provide relief of symptoms such as pain and swelling as well as to confirm the source of the symptoms. The beneficial effects of the steroid injection may last for weeks or months or even be permanent. Alternatively, there may be no appreciable benefit following the injection. Physiotherapy and Hand Therapy Physiotherapists and Hand therapists are an integral part of the Orthopaedic team helping us to achieve the best possible outcomes. They have expert knowledge on a wide range of treatment options. Prostheses, splints and orthoses Can relieve pain by supporting painful joints and improve function by correcting deformity and improving the mechanics of joints muscles and tendons Other therapies No strong evidence suggests that treatments such as acupuncture and chiro are beneficial, but many patients fell they are helped by these therapies. Specific questions