radial head fracture
Post on 01-Jun-2015
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RADIAL HEAD FRACTURE
Dr krunal h patel
EPIDEMIOLOGY
OF 4%OF ALL FRACTURE AND 30%OF ALL ELBOW FRACTURE.
1/3 PT ASSOCIATED INJURY TO SHOULDER,HUMERUS,FOREARM,WRIST OR HAND.
RARE IN CHILDREN DUE TO CARTILAGENOUS NATURE OF RADIAL HEAD.
RADIAL NECK FRACTURE MORE COMMON IN CHILDREN.
ANATOMY OF PROXIMAL RADIUS
RADIOCAPITELLAR JOINT TRANSMIT 50-60% LOAD ACROSS ELBOW
RADIUS HEAD SURGICAL ANATOMY
IMPORTANT FOR
VALGUS STABILITY
POSTEROLATERAL ROTATORY STABILITY
LONGITUDINAL FOREARM STABILITY
(ALONG WITH INTEROSSI MEMBRANE & DRUJ)
ELBOW STABILITY
MCL & U-H JOINT:PRIARY STABILIZER
RADIAL HEAD(R-C JOINT) & CAPSULE:SECONDARY STABILIZER
CONT..
MUSCLE ATTACHMENT AROUND PROXIMAL RADIUS SUPINATOR ATTACHMENT AT PROXIMAL RADIUS.
BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.
POST.INTEROSSI NERVE AT RISK
PIN TRAVERSES FROM ANTERIOR TO POSTERIOR THROUGH SUPINATOR MUSCLE.
ALWAYS CHECK PRE OPERATIVE ACTIVE FINGER EXTENSION
MECHANISM OF INJURY
(1) FALL ON OUTSTRECHED HAND(MOST COMMON)
DISTAL RADIUS
INTEROSSI MEMBRANE(FOREARM)
RADIAL HEAD IMPACTION AGAINST CAPITELLUM
(2)VALGUS INJURY TO ELBOW/DIRECT INJURY
MCL RUPTURE/OLECRANON FRACTURE UNSTABLE ELBOW
DIAGNOSIS
HISTORY:FALL ON OUTSTRETCHED HAND/DIRECT INJURY
EXAMINATION:
ELBOW
SWELLING
ECCHMOSIS
ANCONEUS TRIANGLE FULLNESS
RANGE OF MOTION RESTRICTION
STABILITY
ACTIVE FINGER EXTENSION
FOREARM/INTEROSSI MEMBRANE TENDERNESS
WRIST TENDERNESS
ESSEX LAPROSTI INJURY
X RAY FINDINGS STANDARD AP AND LATERAL X RAY of elbow
OBLIQUE(GREEN SPAN)VIEW
FOREARM AND WRIST X RAY IF REQUIRED
X RAY FINDINGS
CLASSIFICATION OF RADIAL HEAD FRACTUREMason classification
Type IMinimally displaced fx, no mechanical
blockto rotation, intra-articular displacement <2mm
Type IIDisplaced fx >2mm or angulated, possible
mechanical block to forearm rotation
Type IIIComminuted and displaced fx, mechanical
block to motion
Type IV (Hotchkiss/JOHNSTO
N modification OF TYPE 3)
Radial head fracture with elbow dislocation
MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% ANDDISPLACEMENT OF >2 MM
TREATMENT GOAL
CORRECTION OF ANY BLOCK TO FOREARM ROTATION
EARLY ROM OF ELBOW AND FOREARM
STABILITY OF ELBOW AND FOREARM
PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW
NON OPERATIVE TREATMENT
INDICATION:
ISOLATED RADIAL HEAD FRACTURE WITH MASON TYPE 1 (UNDISPLACED <2MM)
PLASTER SLAB FOR 3 WEEKS
EARLY ACTIVE MOBILIZATION OF ELBOW
PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR FRACTURE
OPERATIVE MANAGEMENT OPEN REDUCTION & INTERNAL FIXATION
INDICATION FOR ORIF:
Mason type II with mechanical block(displaced)
Large fragment >2 mm
Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME)
Mechanical block to motion (lignocaine inj in elbow joint)
Presence of other complex ipsilateral elbow injuries(without metaphyseal bone loss)
FRAGMENT EXCISION LEADS TO INSTABILITY
TRY TO PRESERVE SMALLEST FRAGMENT
Surgical approach for ORIF:
Kaplan direct lateral approach
Interval between EDC and ECRB
Keep forearm pronated to protect PIN
PIN present approx. 2 cm below radial head
Do not extend exposure below annular ligament
Gentle retraction
ADVANTAGE:
No disruption LATERAL LIGAMENT COMPLEX(LUCL)
DISADVANTAGE:
PIN at risk
KOCHER POSTEROLATERAL APPROACH
Interval between ECU and anconeus
Keep forearm pronated to protect PIN
Advantage:
Less of a risk of PIN injury than the kaplan
Disadvantage:
LATERAL LIGAMENT COMPLEX may injured
Leads to instability
HOTCHKISS APPROACH DIRECTLY THROUGH EDC
PROTECT LATERAL LIGAMENT COMPLEX
PRONATE FOREARM WHILE FIXATION
SAFE ZONE OF RADIUS HEAD FIXATION
LONGITUDINAL LINE B/W LISTER TUBERCLE AND RADIUS STYLOID PROCESS
NO ARTICULATION WITH ULNA
SAFE FOR IMPLANT INSERTION:NO IMPINGMENT IN ROTATION
POSTERO-LATERAL ZONE IN FULL SUPINATION(CAPUTO A)
IN NEUTRAL(MID PRONE)POSITION : ANTEROLATERAL ZONE
Which implant to use?
Mini fragment screw(2.4 or 2.7 mm)(counter sink must)
Headless compression compression screw/Herbert screw
Low profile plate/mini t plate(in safe zone/postero lateral)
K WIRE
COMPLICATION OF ORIF
PIN INJURY
HARDWARE FAILURE
HARDWARE IMPINGEMENT
STIFFNESS OF ELBOW
RESTRICTION OF SUPINATIONPRONATION
RADIAL HEAD REPLACEMENT
To prevent proximal migration of the radius
Silicon implant poor outcome : SILICON SYNOVITIS
Titanium/vitallium metallic implant of choice
Indication: Extensive communition of radial head/excess bone loss
Elbow instability:
essex lapresti lesion,
coronoid fracture,
elbow dislocation,
collateral ligament injury,
olecranon fracture
RADIAL HEAD REPLACEMENT PROSTHESIS
LOOSE STEMMED PROSTHESIS
THAT ACTS AS A STIFF SPACER
BIPOLAR PROSTHESIS
That is cemented into the neck of the radius
COMPLICATIONS: Overstuffing of joint
capitellar wear problems
Malalignment instability
COMPLICATION OF REPLACEMENT
Post operative infection of implant
Ulnar nerve/pin injury
Immediate post operative dislocation
Recurrent instability
Heterotrophic ossification
Contracture /stiffness
Crps type 1
RADIAL HEAD EXCISION
INDICATION:
Low demand, sedentary patients
In a delayed setting for continued pain of an isolated radial head fracture
CONTRAINDICATION:
In children
Presence of destabilizing injuries (Essex-lopresti lesion,fracture dislocation elbow(mason type 4),monteggia)
Terrible triad of elbow(coronoid fracture,MCL deficiency)
COMPLICATION OF EXCISION
PROXIMAL MIGRATION OF RADIUS
INFERIOR RADIO ULNAR JOINT DISTURBANCE
PAIN & WEAKNESS OF WRIST
Joint instability
Decreased strength
Cubitus valgus
EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR SYNOSTOSIS.
THANK YOU
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