Radial - Head Fractures Christophe Spormann Endoclinic Zürich
Elbow Func6on > 90% Ac6vi6es of daily living : 100 Flexion Extension : 130-30 Pro Supina9on : 50-0 - 50 Extension deficit beeer tolerated than flexion deficit (Copeland,Gschwend, Landi, Shaffer: Dunitz, 1997, 81-89 Morrey,B.F; 1990, JBJS 72A: 601-18)
Epidemiology Incidence: 2,5 2,8 / 10 000 30% of elbow fractures Peak incidence men: 30 40 years Peak incidence women: 50 60 years
Radial Head Func6on
Radial Head Func6on
Mechanism of Injury
Classifica6on - Radial Head Fractures Either coronoid or radial head fractured with axial load in extension Amis AA, Miller JH: Injury 26(3):163-168,1998
Classifica6on - Radial Head Fractures Simple (uncomplicated) Primary Classification Secondary Classification Complex (complicated) Fracture Type Mason Type I Type II Type III Mayo Classification, Saunders, 2000 Associated Injury Ligament Dislocation Mason IV MCL LCL Distal R-U Essex Lopresti Fracture Coronoid Olecranon
Classifica6on - Radial Head Fractures Morrey modified Mason Classification by quantifying displacement area > 30% and displacement > 2mm
Radial head fracture: MRI evaluation of associated injuries LUCL 13/24 54 % MCL 18/24 80% LUCL MCL 12/24 50% Osteochondral Lesion Capitellum Bone Bruise Loose bodies 7/24 29% 23/24 95% 22/24 91% Journal of shoulder and elbow surgery: John Itamura 2005
In the presence of an intact medial collateral ligament the radial head contributes 30 % of valgus stability, whereas in medial ligament disruption the radial head becomes the main constraint, contributing 60% of valgus stability
Type I - Radial Head Fractures 73% of all radial head fractures Mason ML. Br J Surg. 1954 Most common radial head fractures De Muinck-Keizer et al., Orthopedics,2015 (38)
Type I - Radial Head Fractures Non-surgical : Splint 48h Early functional mobilization Ø 20% extension deficit Smits et al. Injury. 2014 Aspiration and bupivacaine injection without benefit for undisplaced radial head fractures Chalidis, Papadopoulos et al. J Shoulder Elbow Surg. 2009 Sep-Oct;18(5):676-9.
Type II - Radial Head Fractures 19% of all radial head fractures Mason ML. Br J Surg. 1954
Type II - Radial Head Fractures? Controversy: What fracture Type II needs surgery???
Type II - Radial Head Fractures No consensus: For isolated stable partial intraarticular fractures Kaas et al. J Hand Surg Am. 2012 ORIF not superior to conservative treatment in the long terme Akesson et al. J Bone Joint Surg Am., 2006 Yoon, King et al. Clin Orthop relat Res. 2014
Type II - Radial Head Fractures If conservative treatment: Immobilization as for type I fractures Complications: Residual pain Loss of motion >40 % of complications Delayed excision of radial head Lindenhovius, Felsh, Ring, Kloen: J Trauma. 2009
Type II - Radial Head Fractures ORIF: Restore the anatomical shape Articular stability Kelbérine et al. Rev Chir Orthop, 1991 King et al. J Orthop Trauma, 1991 Heim, Trèb. Helvetica Chir Acta, 1978
Type II - Radial Head Fractures
Type II - Radial Head Fractures L.F., m, 29.09.1961, left radial head fracture type II
Type II - Radial Head Fractures L.F., m, 29.09.1961, left radial head fracture type II
Type III - Radial Head Fractures Comminutive fractures: Resection radial head only if stable medial elbow ORIF difficult to restore Ring et al. J Bone Joint Surg Am., 2002 Chen et al. Int Orthop, 2011
Type III - Radial Head Fractures ORIF: Resection: Replacement: Together with stabilization of the elbow Difficult to achieve If stable medial elbow Metallic stable Metallic bipolar Silicon
Type III - Fracture
Radial Head Resec6on
Radial Head Resec6on - Outcome
Radial Head Resec6on
Radial Head Replacement
Radial Head Replacement Goal: Restore joint line
Radial Head Replacement 35 Radial neck anatomic curve : 15 35 ROM for full contact with capitellum
praeoperativ postoperativ 16 Mt 57 Mt
Failure - Radial Head Replacement Clinical reasons for failure of radial head prosthesis Pain 40 Stiffness 18 Instability 9 Infection 2 Radiographic Findings Implant related Loosening 31 Over-lengthening (over-stuffing) 11 Radial head subluxation 5 Component dissociation 3 JBJS br VOL. 92-B, No. 5, MAY 2010
Radial Head Replacement M.D.D., male, 17.01.1976, Polytrauma 2014 Elbow: Flexion Extension: 130-30 - 0 Pronation Supination: 45-0 - 10
Radial Head Replacement M.D.D., male, 17.01.1976, Polytrauma 2014
Radial Head Replacement 6 months postop.: M.D.D., male, 17.01.1976, Polytrauma 2014 Elbow: Flexion Extension: 135-15 - 0 Pronation Supination: 75-0 - 45
Type III - Radial Head Fractures Displaced comminuted fractures Are the fragments large enough to allow internal fixation? If a plate is needed, can it be placed in a safe zone? Is the fixation stable to allow early mobilization? YES Internal Fixation of Fragments NO Radial Head Replacement
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