Radial Head Fractures Save or Replace?

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1 Radial Head Fractures Save or Replace? Current Solutions in Orthopedic Trauma Sepember 19, 2015 Jorge L. Orbay MD. Disclosure Skeletal Dynamics Elbow Joint Ulno-Humeral and Radio-Capitellar The key joint in the upper extremity Shoulder r 1

2 Elbow Ulno-Humeral and Radio-Capitellar The key joint in the upper extremity R Elbow Ulno-Humeral and Radio-Capitellar The key joint in the upper extremity Elbow Ulno-Humeral and Radio-Capitellar 2

3 Elbow Ulno-Humeral and Radio-Capitellar The key joint in the upper extremity 140 Flexion - Extension 180 Pronation - Supination Elbow Ulno-Humeral and Radio-Capitellar The key joint in the upper extremity 140 Flexion - Extension 180 Pronation - Supination Flexion - Extension Pronation - Supination Dysfunctional Elbow Stiffness / Instability 3

4 Dysfunctional Elbow Stiffness / Instability Elbow stiffness is a common complication even after low energy injuries. Elbow Trauma Proximal to the joint line - Humeral fracture Elbow Trauma Distal to the joint line 4

5 Elbow Trauma Distal to the joint line - Fracture radius / ulna - Ligament injuries Radial Head Fractures Mason Classification: Radial Head Fractures Type 1 (Non-Displaced) 5

6 Radial Head Fractures Type 2 (Shear) Radial Head Fractures Type 2 (Shear) 6

7 Radial Head Fractures Type 2 (Shear) Radial Head Fractures Type 2 (Shear) Radial Head Fractures Type 3 (Complete articular) 7

8 Radial Head Fractures Type 3 (Complete articular) Resection Radial Head Fractures Simple Inexpensive Resection Radial Head Fractures Abnormal biomechanics: Loss of motion - supination & extension 20% weakness of prono-supination 10% loss of elbow flexion torque 8

9 Radial Head Fractures Type 3 (Complete articular) + Variance Radial Head Fractures Type 3 (Complete articular) Osteoarthritis Radial Head Fractures Type 3 (Complete articular) RU Impingement 9

10 Radial Head Fractures Type 3 ORIF Radial Head Fractures Type 3 ORIF Radial Head Fractures Type 3 ORIF 10

11 ORIF ORIF ORIF 11

12 ORIF ORIF ORIF 12

13 ORIF Type III Radial Head Fracture 50% Failure Rate: 1- Avascular Necrosis 2- Non Union Surgical Approach Kocher 13

14 Kaplan Safety Zone 14

15 Radial Head Fractures Type 3 Replacement Radial Head Fractures Reproducible Cost Replacement 15

16 Measuring Head Diameter 16

17 Measuring Neck Cut Reaming 17

18 Approach medullar canal in pronation Trialing 18

19 Trialing Prevent Overstuffing 19

20 Radial Head Fractures Variable long term results: Loosening / migration Capitelar erosion Need for removal Radial Head Replacement: Spacer 20

21 Radial Head Replacement: Spacer Hemiarthroplasty - Radio-Capitelar Joint - PRUJ Radio-Capitelar force Radio-Ulnar force 21

22 Loosening Capitelar Erosion 22

23 Radial Head Kinematics 6 deg. off Radial Head Kinematics Radial Head Kinematics 23

24 Radial Head Kinematics Radial Head Kinematics 24

25 Long Stem = 3 Point Fixation 25

26 26

27 27

28 Radial Head Fractures Type 4: Dislocation Terrible Triad Ulna Fracture Essex Lopresti Radial Head Fractures Type 4: Dislocation 28

29 Radial Head Primary restrain to axial load on the radius Primary restrain to valgus strain on the elbow joint. A functional radial head will restore stability to the elbow with a type I or II coronoid fracture Posterior dislocation Radial head fracture Coronoid fracture Lateral ligament repair Radial head repair or replacement Coronoid repair for type II and III 29

30 Lateral ligament repair Radial head repair or replacement Coronoid repair for type II and III Elbow stabilization Coronoid Fracture Classification 30

31 Severe Instability 31

32 32

33 33

34 34

35 Radial Head and Proximal Ulna Fx 35

36 36

37 Essex-Lopresti Lesion Radial Head Fracture Essex-Lopresti Lesion Proximal Migration Radius Essex-Lopresti Lesion PIOL and DIOL prevent over-lengthening 37

38 Essex-Lopresti Lesion PIOL and Radial DIOL head prevent supports over-lengthening graft Essex-Lopresti 38

39 39

40 40

41 41

42 6 months F/U 6 months F/U 42

43 Conclusions Treatment of type 1 radial head fractures is usually early motion Conclusions Treatment of type 2 radial head fractures must be individualized: 1- Early motion 2- ORIF / HCS Conclusions Treatment of type 3 radial head fractures must be individualized: 1- Resection 2- ORIF 3- Replacement 43

44 Conclusions Radial head replacement is more reliable for fractures with 3 or more fragments. Conclusions Radial head replacement is succeptible to mechanical problems. Conclusions ORIF of displaced type III radial head fractures is technically demanding and succeptible to non union and AVN. 44

45 Conclusions Treatment of type 4 radial head fractures requires addressing concomitant instability 1- Elbow stabilization 2- IOL reconstruction Thank You! 45

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