Radial Head Fracture: Open Reduction and Internal Fixation with Medartis 30mm CCS Screws and LUCL repair using Arthrex Biocorkscrew anchor
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Radial head fractures are common (approximately 20% of acute elbow injuries) and occur as a result of a fall onto an outstretched hand with the elbow in extension and wrist in pronation. The force is transmitted as an axial load through the wrist and through the radial head. They are more common in females and peak in the 4th decade.
The classification of radial head fractures is based a description of radial head fractures by Mason, but later modified by Broberg & Morrey and Hotchkiss . The classification can be used in the decision making about which fractures may benefit from replacement of the radial head.
With respect to the above classification, radial head fixation is reserved for Mason Type II fractures and is the lead author’s default method of management for fractures that are significantly displaced, and/or cause a mechanical block to motion and are potentially reconstructible. In younger patients and those with better bone quality, it is possible to anatomically reduce and fix comminuted fractures. If the fracture is reducible and a stable fixation is possible, an attempt at fixation is a reasonable option even if there is little residual soft tissue attachment to the fracture fragments.
The aim of fixation is to restore the radial height and joint congruity and confer stability to the elbow joint. This includes range of motion in the flexion-extension arc as well as prono-supination.
It must be appreciated by those treating these fractures that radial head trauma can range from a simple, isolated fracture to complex fracture patterns with significant associated soft tissue components such as :
Lateral collateral ligament (LCL) injury. The most common association from axial loading in supination
Medial collateral ligament (MCL) injury .Occurring due to axial & valgus force
Combination LCL & MCL injuries. These are a higher energy and sit at the severe end of spectrum
Coronoid fractures. Occurring due to axial load in extension +/- dislocation
Fracture dislocation. These may result in “terrible triad” injuries of elbow dislocation, radial head fracture and coronoid fracture.
Essex-Lopresti injury. An associated distal radioulnar joint injury with rupture of the interosseous membrane
Khalfayan et al. retrospectively compared Mason Type-2 fractures treated non-operatively or by open reduction and internal fixation and reviewed outcomes at a mean of 1.5 years. Clinical outcomes were significantly better in the open reduction and internal fixation group, with almost a 90% rate of good to excellent results against approximately 40% in the nonoperative group.
Wu et al. also demonstrated good outcomes with this method of fixation and showed no significant difference in Mayo Elbow Performance scores (MEPs) nor range of movement between the tripod technique, radial head arthroplasty and plate fixation techniques.
Complications rates reported were highest after plate fixation, followed by screw fixation and arthroplasty. Of note, the authors reported over a 30% revision rate for patients undergoing radial head plating against just over 6% after “tripod” screw fixation.
However, risks of major complications are higher in terrible triad and complex fractures with associated instability. Watters et al reported a revision rate of almost 30% in patients undergoing either plate fixation or radial head arthroplasty in the treatment of these terrible triad injuries.
The Medartis Cannulated Compression Screw (CCS) has several design features of note that aid radial head fracture fixation.
The screws are made of titanium and come in a range of diameters and lengths to allow great flexibility in addressing complex fracture patterns. With respect to radial head fractures, the relevant screw diameters are the 3.0 and 2.2mm headless CCS screws, although the range includes diameters from 2.7mm up to 7.0mm. These come in either a short or long distal thread option and range from 10-30mm in 1mm increments for the 2.2 and 3.0mm screws. The 3.0mm screws also have lengths from 30-40mm in 2mm increments. The screws also have self cutting threads so the screws can be applied once the Kirschner wires have been sited appropriately. The benefit of not having to over drill minimises the risk of loss of reduction involved in this step. There is no plate option with this set.
Readers will find the following OrthOracle operative technique also of interest:
Khalfayan EE, Culp RW, Alexander AH. Mason type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma. 1992;6(3):
Wu H, Shen L, Chee YH. Screw fixation versus arthroplasty versus plate fixation for 3-part radial head fractures, Journal of Orthopaedic Surgery 2016;24(1):57-61
Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res 2014 Jul;472(7):2128-35.
Author:Samuel Chan FRCS (Tr & Orth)
Institution: Queen Elizabeth Hospital, Birmingham, UK.