Open Reduction and Internal Fixation of Complex Radial Head Fractures

Med. J. Cairo Univ., Vol. 81, No. 1, December: 815-821, 2013 www.medicaljournalofcairouniversity.net Open Reduction and Internal Fixation of Complex Radial Head Fractures SHERIF M. ABDELGAID, M.D.; MOHEMED ABOELNASS, M.D. and ESLAM ELSAYED ALY, M.Sc. The Department of Orthopedic Surgery, Al-Razi Orthopedic Hospital, Kuwait Abstract Fractures of the radial head have an incidence of about 1.7% to 5.4% of all adult fractures. These fractures are classified as simple or complex, depending upon whether there is an associated fracture or a ligamentous injury. Thorough clinical & radiological assessment should be done to differentiate simple fractures from complex fractures with concomitant elbow injury. The management of complex radial head fractures remains controversial including radial head excision, open reduction & internal fixation and radial head replacement. The aim of this study is to assess the possibility and review the results of open reduction and internal fixation of complex radial head fractures. Twelve patients with complex radial head fractures underwent open reduction and internal fixation during the period from 2006 to 2009. The overall outcome was rated using Mayo Elbow Performance Score. Excellent results were achieved in 5 cases 41.5%; good in 6 cases 50%; % fair in one case 8.5% and no poor results. No infection, skin complications or heterotropic ossification in all cases. We conclude that, in such complex injuries, preservation of radial head by open reduction and internal fixation is mandatory together with appropriate treatment of concomitant injuries to regain the elbow stability for better outcomes. Key Words: Radial head fractures Mason classification Essex-lopresti lesion. Introduction FRACTURES of the radial head have an incidence of about 1.7% to 5.4% of all adult fractures [1]. 85% of these fractures occur in young and active people [2]. According to the Mason classification, type I fracture is a fissure or marginal fracture without displacement; type II fracture is a marginal sector fracture with displacement; and type III fractures are comminuted fractures with the head is completely detached from the neck. Johnston added a fourth type in which radial head is fractured with dislocation of the elbow Joint [3,4] Fig. (1) Dis- Correspondence to: Dr. Eslam Elsayed Al y, The Department of Orthopedic Surgery, Al-Razi Orthopedic Hospital, Kuwait placement of 30% of the articular surface or step off >2mm should be considered as a Mason type II fracture, opposed to the nondisplaced type I fracture [5] Mason type-iii classified into three subtypes, A: Fracture of the entire radial neck, with the head completely displaced from the shaft. B: Fracture involving the entire head, which consists of more than two large fragments completely displaced from the shaft. C: Fracture with a tilted and impacted articular segment, and some articular fragments displaced from the shaft [6]. Fig. (2). Radial head fractures are further classified as simple or complex, depending upon whether there is an associated fracture or a ligamentous injury [7]. There is a strong correlation between the likelihood of associated injury and the severity of the radial head fracture: The incidence can increase from 20% in Mason type I fractures to 80% in type III fractures. LCL lesions are found in 11 % of cases, MCL lesions in 1.5% and a combination of both MCL and LCL lesions in 6% [8]. Another type of complex radial head fracture is that associated with acute longitudinal radioulnar dissociation (ALRUD) or Essex-Lopresti lesion withrupture of the interosseous membrane (IOM) and triangular fibrocartilage complex. Partial ruptures of the IOM diagnosed with MRI in nine of 14 patients with a Mason type I fracture, suggesting that injuries of the IOM are more frequent than generally expected. [9]. 5% to 10% of fractures of radial head are associated with elbow dislocation. The combination of an elbow dislocation, radial head fracture and coronoid fracture is called' the terrible triad of the elbow' as it can result in severe joint instability and many post-traumatic complications [10]. Fractures of the coronoid process classified into three types. Type I is a small fleck of bone, type II 815

816 Open Reduction & Internal Fixation of Complex involves 50% of the height of the coronoid process or less, and type III involves >50% of the height of the coronoid process [11]. Clinically: Tenderness or ecchymosis at the medial joint line may represent a medial collateral ligament injury, whereas tenderness at the DRUJ could reflect longitudinal instability of the elbow. All 3 major nerves in the arm are examined, with particular attention to the posterior interosseous nerve (PIN). Forearm rotation is assessed to see if a mechanical block to motion exists. Indications for operative treatment of radial head fractures are fracture with >15 of angulation or >25% displacement, intra-articular step-off >2mm of articular or that create a mechanical block to motion [12]. The management of complex radial head fractures with associated ligament disruption remains controversial. Several surgical options have been advocated for these complex injuries, including ORIF, excision of the radial head, and arthroplasty. Biomechanically, the radial head is the secondary constraint of the ulnohumeral joint in resisting valgus stress [13]. The radial head becomes the main stabilizer if the coronoid process is fractured, the medial collateral ligament is incompetent, or the lateral ulnar collateral ligament is disrupted [14]. Accordingly, simple radial head excision is contraindicated in these injuries as it yields poor results with a lot of complications including, valgus elbow instability, elbow stiffness and proximal migration of the radius [15]. Radial head arthroplasty is indicated for complex radial head fractures that cannot be managed reliably with ORIF [16]. Aim of the study: To assess the possibility and review the results of open reduction and internal fixation of complex radial head fractures. Material and Methods Twelve patients (seven males & five females) with complex radial head fractures underwent open reduction and internal fixation during the period from 2006 to 2009. All patients are young active with the average age was 28 years (range eighteen to thirty seven years). There were two cases with Mason type-ii fractures, seven cases Masson type III and three Mason type-iv variations (posterior elbow dislocation). Associated medial collateral ligament disruption was detected in two patients (one with Mason type- II & one Mason type III). Lateral collateral ligament disruption was found in three cases with Mason type-iii. Interosseous membrane disruption was detected in three patients (one with Mason type- II & two with Mason type-iii). Patients with Mason type-iv (posterior dislocation) had concomitant fracture tip of the coronoid process in two cases and fracture olecranon in one case. One case with Mason type III fracture head had concomitant fracture olecranon without dislocation (Table 1). Surgical technique: Our technique is quite similar to those reported by Capo et al., [12], Nirmal et al., [17] and Kaas et al., [18]. Under general or infraclavicular block anesthesia the elbow is first examined for 1) Axial migration: The elbow is stabilized on the hand table with the forearm in neutral rotation, and a load placed by the surgeon on the fisted hand. Proximal migration of the radius into the capitellum is observed. Alternatively, the radial shaft can be grasped with a tenaculum and pulled proximally and radial shortening can be observed at the DRUJ on fluoroscopy. 2) Medial collateral ligament: With the forearm pronated and the elbow flexed to 30, valgus stress is applied, the degree of opening, the feel of the end point, and radiographic appearance are observed. 3) Anteroposterior stability: Evaluated in progressive extension. If posterior subluxation of the elbow is seen at more than 30 of flexion, then the radial head should be repaired or replaced. Then the patient is turned to lateral position with the arm rested over arm support, the forearm hanged off the support and the elbow flexed 90. The surgical exposure depends on the associated lesions. Mason type II fractures need exposure of radial head only and approached through Kocher posterolateral approach. Skin incision extends from the posterior surface of the lateral epicondyle and continuing downward and medially 6cm distal to the tip of the olecranon over the posterior border of the ulna. The interval between the anconeus and extensor carpi ulnaris (Kocher interval) is identified and opened to expose the joint capsule which is incised longitudinally exposing the radial head and capitellum. Pronation of the forearm will keep the PIN away from the field. Longitudinal traction of forearm will distract the joint. This distraction together with increasing the forearm flexion will bring the head more superficial in the wound and facilitate fracture inspection and reduction. The articular fragment is reduced to the remaining part of the head using spatula or K wire. The reduction is hold by pointing reduction clamp and temporary

Sherif M. Abdelgaid, et al. 817 fixed with K.wire. In situ definitive fixation is performed using mini screws (2.4mm). In cases with Mason type III direct lateral surgical approach is used because it allows enough proximal radial shaft exposure needed for plate fixation. The skin incision is centered over the lateral epicondyle and extends distally over the radial head and neck, anterior to the posterolateral collateral ligament complex. The muscle interval between the extensor carpi ulnaris and extensor digitorum communis is identified and opened. Then the fibers of the supinator will be seen run obliquely at approximately a 45 ' angle from the muscle fibers of the extensor mass. The supinator is divided for a distance of approximately 3cm from the articular surface of the radial head with the forearm in pronation to protect PIN. However, further distal dissection requires identification of the PIN. Two small blunt bone spikes are inserted subperiosteally around the neck to facilitate proximal radius exposure. The head fragments are assembled to each other with small K wires. If In situ reduction of is difficult, the entire head is removed and reassembled on the side table. The head is fixed with screws to the transverse limb of mini fragment T plate. Then the head-plate construct returned back inside the wound and fixed to the shaft with screws through the longitudinal limb of the T plate. The head is compressed to the shaft using spatula during plate fixation. Plates and screws are fixed within the nonarticular "safe zone" of the radius to prevent impingement of the hardware with the proximal radioulnar joint which limits the forearm rotation. This zone comprises approximately 100 ' and is on the dorsal aspect of the radius, in line with the Lister tubercle of the wrist. With the forearm in neutral rotation, the direct lateral surface of radial neck is the center of the safe zone [19]. In cases with torn lateral collateral ligament, the ligament is repaired using non absorbable sutures through drill-holes into lateral epicondyle. Cases with torn medial collateral ligament, repair is not required since there was no elbow instability persists after radial head fixation. In cases with torn interosseous membrane, the distal radioulnar joint is fixed with K wire which removed after 4 weeks. In cases with fractures coronoid or olecranon process, a posterior midline skin incision is used. 15-cm skin incision is centered on the olecranon just lateral to its tip. Full thickness fasciocutaneous flaps are elevated to expose the lateral and medial side of the elbow. Radial head fracture exposed through Kocher interval between anconeus and extensor carpi radialis muscles. Coronoid fracture is approached by muscle elevation from the lateral side of proximal ulna. When it is part of a terrible triad of the elbow, the coronoid process exposure is done through the olecranon fracture. Two pull out non absorbable sutures are passed over the top of the small coronoid fragment & through the capsular attachments. The sutures are pulled out through drill-holes in the ulna, and tied over the bone. Check X-ray then taken to assess the reduction & fixation. The wound is closed on layers over redivac which is removed after 48hrs. Examples of cases: Figures (3,4,5). Follow-up: Postoperatively, Indomethacin has been for 6 weeks as analgesia and to reduce the prevalence of heterotopic ossification unless there were contraindications for its use. Above elbow posterior slab is applied with elbow flexed 90' and forearm in neutral rotation for two weeks. At the end of 2 nd week the stitches were removed and a removable posterior above elbow splint is worn for eight weeks with early gradual range of motion within a safe arc program is started in the 3 r d week. Patient was discharged from the hospital in 3 rd postoperative day and followed-up in outpatient clinic with two weeks interval for 2 months, then monthly for six months and lastly every three months. The overall outcome was rated with the Mayo Elbow Performance Score (MEPS), (Table 2) [20]. Elbow arthritis was rated according to the system of Broberg and Morrey as grade 0 (normal joint), grade 1 (slight joint space narrowing with minimum osteophyte formation), grade 2 (moderate joint-space narrowing with moderate osteophyte formation), or grade 3 (severe degenerative changes with gross destruction of the joint) [21]. Results The follow-up duration ranged from 32 to 44 months (mean, 38 months). According to Mayo Elbow Performance Score, excellent results were obtained in 5 cases 41.5%; results were good in 6 cases 50%; % fair results obtained in one case 8.5% and no poor results (Table 3). Fell down on outstretched hand were the most common mechanism of injury (8 patients) followed by fall from height in three patients and R.TA in one patient (Table 3). Eleven of twelve patients included in this study regained functional arc of elbow motion allowing comfortable daily living activities (Table 4).

818 Open Reduction & Internal Fixation of Complex Patient who had fair result reduced his activity level, due to continued pain and swelling and radiologic signs of secondary osteoarthritis (Brob- erg and Morrey grade 3) with pre-existing primary synovial chondromatosis. No infection, skin complications or heterotropic ossification in all cases. Table (1): Data of the patients. No Sex Age Side Mechanism Associated injuries Masson type MEPS Score 1 26 F R Fell down MCL III Excellent 2 21 M R R.T.A Coronoid fracture IV Good 3 26 M R Fell down LCL III Good 4 25 F L Fell down Interosseous lig II Excellent 5 36 F L Fell down Interosseous lig III Good 6 24 M R F.F.H Olecranon fracture IV Fair 7 18 M R F.F.H LCL III Excellent 8 37 F L Fell down Interosseous lig III Good 9 30 M L Fell down Olecranon fracture IV Good 10 22 M R F.F.H MCL II Good 11 31 F L Fell down Coronoid fracture III Excellent 12 29 M R Fell down LCL III Excellent Table (2): Mayo Elbow Performance Score (MEPS). (Morrey BF, An). Function Definition Points Score classification Pain None 45 Excellent >90 Mild 30 Moderate 15 Severe 0 Motion Arc >100 20 Good 75-80 Arc 50-100 15 Arc < 50 5 Stability Stable 10 Fair 60-74 Moderate instability 5 Chronic instability 0 Function Comb hair 5 Poor <60 Feed 5 Hygiene 5 Shirt 5 Shoe 5 Total 100 Table (3): Results according to MEPS score [18]. No. of patients % Excellent 5 41.5 Good Fair 6 1 50 8.5 Poor Table (4): Elbow & forearm R.OM in last follow-up. Biomechanical studies showed that activities of daily living can be accomplished without discomfort within a functional arc of motion of elbow flexion extension of 100, and forearm rotation of about 100 (pronation 50 to supination 50 ) [13]. No Flexion Extension Arc Pronation Supination Arc 1 110 110 2 130 140 3 110 130 4 5 110 115 145 120 6 7 80 110 70 130 8 120 110 9 130 150 10 125 140 11 110 130 12 120 120 I II III IV Fig. (1): Mason Johnston's Classification (Types I-IV). A B C Fig. (2): Mason type-iii radial head fracture patterns. A: A fracture of the entire radial neck, with the head completely displaced from the shaft. B: An articular fracture involving the entire head, which consists of more than two large fragments. Each fragment is completely displaced from the shaft. C: A fracture with a tilted and impacted articular segment, which must be reduced, and some articular fragments displaced from the shaft [6].

Sherif M. Abdelgaid, et al. 819 Fig. (3): Case No. 11; A & B: A.P & lateral views showed fracture head radius type III a & coronoid process. C & D: A.P & lateral views fixation of fractures. E,F,G & H: Nearly full R.O.M of injured elbow comparing with contra-lateral elbow. Fig. (4): Case No. 7; A: Lateral view showed posterior dislocation & fracture head radius type IV. B & C: A.P & lateral views after reduction of the dislocation. D & E: A.P & lateral view after fixation of head radius fracture.

820 Open Reduction & Internal Fixation of Complex Fig. (5): Case No. 4; A & B: A.P & lateral views showed fracture head radius type II. C & D: A.P & lateral views showed subluxed IRUJ. E &F: A.P & lateral views showed reduced IRUJ fixed with K wire, G & H: A.P & lateral views showed fixed fracture head radius. I,J,K & L: Nearly full R.O.M of injured elbow comparing with contra-lateral elbow. Discussion Treatment of complex radial head fractures with associated elbow instability due to concomitant ligamentous or bony injures, remains controversial. 50% to 75% of patients with type-ii and III fractures have concomitant pathology and it is quite possible to be missed. In such injuries, internal fixation or arthroplasty, rather than excision, should be considered for the healthy, active patient to avoid delayed complications of radial head excision such as pain, instability, proximal radial translation, decreased strength, osteoarthritis, or cubitus valgus. [22] When there is acute instability or concern about proximal migration of the radius and injury to the interosseous ligament of the forearm, preservation of the radial head offers the best solution. So, open reduction and internal fixation should be pursued in the treatment of comminuted fractures of the radial head unless extenuating factors, such as poor general health or advanced age, prevent the patient from participating in the postoperative rehabilitation protocol. Internal fixation of displaced fractures of the radial head requires careful preoperative planning and a clear understanding of elbow anatomy. Implants should be appropriate for the size of the fragments and must be placed in a manner that does not restrict forearm rotation which is imperative for an acceptable result [23]. The overall results of this study according to Mayo Elbow Performance Score showed satisfac- tory results (excellent & good) in 91.5% of cases with no poor results. Only one case achieved fair result (case No 6). This patient was suffering primary synovial chondromatosis affecting both elbows and knees. He sustained comminuted fractures radial head and olecranon of right elbow. Radial head fracture was fixed with plate & screws and olecranon fracture was fixed by tension band. The preoperative right elbow restricted R.O.M became much worse postoperatively with flexionextension arc 60 and supination & pronation, 30 and 40 respectively. The current literature on complex radial head and neck fractures is sparse and provides limited guidance for choosing the optimal treatment method [6]. Our results are similar to those obtained by Ikeda et al., 2003, they operated 10 patients with Mason type III and IV fractures using low-profile plates. The average follow-up was 28 months. 90% good to excellent results were achieved [24]. Our results are nearly the same to those obtained by Ring et al., 2002. They operated 12 patients with type III fracture radial head, none had early failure, 1 had nonunion, and all had an arc of forearm rotation 100. They recommended that fixation be reserved for fractures with three or fewer articular fragments [25]. However King et al., 1991, reported 100% excellent results after fixation of Mason type II fractures but only 33% excellent results for Mason type III injuries, suggesting that

Sherif M. Abdelgaid, et al. 821 comminuted fractures should be managed with arthroplasty for better outcomes [26]. Conclusion: Radial head fracture could be a serious, complex injury rather than a simple fracture. This necessitates thorough clinical & radiological patient assessment to detect concomitant bony or ligamentous injury. In such complex injuries, preservation of radial head by ORIF is mandatory together with appropriate treatment of concomitant injuries to regain the elbow stability for better outcomes. Radial head arthroplasty should be only done in cases with comminuted irreparable radial head fracture. References 1- TAYLOR T.K.F. and O'CONNOR B.T.: The effect upon the inferior radio-ulnar joint of excision of the head of the radius in adults. J. Bone. Joint. Surg. Br., 46: 83-8, 1964. 2- JACKSON J.D. and STEINMANN S.P.: Radial head fractures. Hand Clin., 23: 185-93, 2007. 3- MATSUNAGA F.T., TAMAOKI M.J., CORDEIRO E.F., et al.: Are classifications of proximal radius fractures reproducible? BMC Musculoskelet Disord, 10: 120, 2009. 4- PIRES R.E.S., REZENDE F.L., MENDES E.C., CAR- VALHO A.E.R., ALMEIDA FILHO I.A., REIS F.B. and ANDRADE M.A.P.: Radial Head Fractures: Mason Johnston's Classification Reproducibility, Malaysian Orthopaedic Journal, 5: (2): 6-10, 2011. 5- BROBERG M.A. and MORREY B.F.: Resultsof treatment of fracture-dislocations of the elbow. Clin. Orthop. Relat. Res., 216: 109-19, 1987. 6- IKEDA M., SUGIYAMA K., KANG C., TAKAGAKI T. and OKAAND Y.: Internal Fixation Comminuted Fractures of the Radial Head. Comparison of Resection J. Bone. Joint. Surg. Am., 87: 76-84, 2005. 7- MORREY B.F., TANAKA S. and AN K.N.: Valgus stability of the elbow. A definition of primary and secondary constraints. Clin. Orthop., 265: 187-95, 1991. 8- VANRIET R.P., MORREY B.F., O'DRISCOLL S.W. and VAN GLABBEEK F.: Associated injuries complicating radial head fractures: A demographic study. Clin. Orthop. Relat. Res., 441: 351-5, 2005. 9- HAUSMANN J.T., VEKSZLER G., BREITENSEHER M., et al.: Mason type- I radial head fractures and interosseous membrane lesions, a prospective study. J. Trauma., 66: 457-61, 2009. 10- RING D., JUPITER J.B. and ZILBERFARB J.: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J. Bone. Joint. Surg. Am., 84-A: 547-51, 2002. 11-REGAN W. and MORREY B.F.: Fractures of the coronoid process of the ulna. J. Bone. and Joint. Surg., 71-A: 1348-1354, Oct., 1989. 12- CAPO J.T.M.D. and DZIADOSZ D.: Operative Fixation of Radial Head Fractures, Techniques in Shoulder and Elbow Surgery, 8 (2): 89-97, 2007. 13- MORREY B.F.: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. J. Bone. Joint. Surg. [Am.], 77-A: 316-27, 1995. 14- MCKEE M.D., PUGH D.M., WILD L.M., SCHEMITSCH E.H. and KING G.J.: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J. Bone. Joint. Surg. Am., 87: 22-32, 2005. 15- MIKIC Z.D. and VUKADINOVIC S.M.: Late results in fractures of the radial head treated by excision. Clin. Orthop., 181: 220-8, 1983. 16- SHORE B.J., MOZZON J.B., MACDERMID J.C., FABER K.J. and KING G.J.: Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty. J. Bone. Joint. Surg. Am., 90: 271-80, 2008. 17- CAPUTO A.E., MAZZOCCA A. and SANTORO V.: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J. Hand Surg., 23: 1082-1090, 1998. 18- MORREY B.F., AN K.N. and CHAO E.Y.S.: Functional evaluation of the elbow. The Elbow and Its Disorders, 2nd ed. Philadelphia: WB Saunders, 869, 1993. 19- NIRMAL C. TEJWANI M.D. and HEMANG MEHTA: Fractures of the Radial Head and Neck: Current Concepts in Management J. Am. Acad. Orthop. Surg., 15: 380-387, 2007. 20- KAAS L., JUPITER J., VAN DIJK N. and EYGENDAAL D.: Management of radial head fractures: Current concepts Shoulder and Elbow, 3, pp. 34-40, 2011. 21- BROBERG M.A. and MORREY B.F.: Results of treatment of fracture-dislocations of the elbow. Clin. Orthop. Relat. Res., 216: 109-19, 1987. 22- ANTUNA S.A., SANCHEZ-MARQUEZ J.M. and BAR- CO R.: Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J. Bone. Joint. Surg. Am., 92: 558-66, 2010. 23- HOTCHKISS R.N.: Displaced Fractures of the Radial Head: Internal Fixation or Excision? J. Am. Acad. Orthop. Surg., 5: 1-10, 1997. 24- IKEDA M., YAMASHINA Y., KAMIMOTO M. and OKA Y.: Open reduction and internal fixation of comminuted fractures of the radial head using low-profile mini-plates. J. Bone. Joint. Surg. Br., 85: 1040-1044, 2003. 25- RING D., QUINTERO J. and JUPITER J.: Open reduction & internal fixation of fractures of the radial head. J. Bone. Joint. Surg. Am., 84: 1811-15, 2002. 26- KING G.J., EVANS D.C. and KELLAM J.F.: Open reduction and internal fixation of radial head fractures. J. Orthop. Trauma., 5: 21-28, 1991.