You are on page 1of 5

COPYRIGHT 2002

BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Open Reduction and Internal Fixation of Fractures of the Radial Head


BY DAVID RING, MD, JAIME QUINTERO, MD, AND JESSE B. JUPITER, MD
Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, and Hospital Universitario Clnica San Rafael, Bogota, Colombia

Background: The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. Methods: Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. Results: The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of 100. Conclusions: Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.

n appreciation of the role played by the radial head in the overall stability of the elbow and forearm1-9 has motivated many investigators to recommend preservation of the radial head, either by operative fixation10-22 or by prosthetic replacement3,5,23,24, following fracture. Improvements in the techniques and implants for operative fixation10 and prosthetic replacement24 of the radial head have increased the appeal of these treatments. The purposes of this retrospective review of patients with a fracture of the radial head treated with open reduction and internal fixation were to clarify which types of fractures may be more amenable to open reA video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

duction and internal fixation and to provide data for comparison with clinical series in which alternative techniques, such as prosthetic replacement, are used. Materials and Methods ixty-nine consecutive sexually mature patients who had had open reduction and internal fixation of a displaced fracture of the radial head at Massachusetts General Hospital, Boston, Massachusetts, or Hospital Universitario Clnica San Rafael, Bogota, Colombia, between January 1990 and January 1997 were identified. Patients with a nondisplaced fracture or an isolated fracture of the radial neck were excluded. During the study period, twelve patients with a radial head fracture had primary resection of the radial head and six of them had insertion of a silicone radial head prosthesis.


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 10 O C T O B E R 2002 O P E N RE D U C T I O N A N D IN T E R N A L F I X A T I O N FR A C T U RES OF T H E R A D I A L HE A D
OF

The primary indication for operative treatment was restriction of forearm rotation by displaced fracture fragments. Patients who were not able to fully rotate the forearm after injury because of discomfort had aspiration of the elbow hematoma and injection of 1% lidocaine without epinephrine. With the elbow anesthetized, it was possible to distinguish motion limited by fracture fragments from motion limited by pain alone. In twenty-six patients in whom the fracture of the radial head was part of a fracture-dislocation of the elbow or forearm or was associated with an injury of the medial collateral ligament, repair of the radial head was indicated to maintain length and stability of the forearm and elbow. The human research committee approved a research protocol involving retrospective review of medical records and radiographs and invitation of patients to return for a free physical and radiographic examination after they gave informed consent. Five patients could not be located, four had died, and four declined to participate. Thus, the study population consisted of fifty-six patients. Study Population All fifty-six patients were evaluated at a minimum of two years (average, forty-eight months) after the injury. There were thirty-five male patients and twenty-one female patients with an average age of thirty-six years (range, seventeen to sixty-two years). Nineteen injuries were the result of a fall from a standing height; twenty-seven, a fall from a greater height (including seven sustained in a fall down stairs); four, a fall during a sports activity; three, a motor-vehicle accident; and three, a bicycle accident. Twenty-seven (48%) of the fifty-six fractures were part of a more complex injury pattern; these patterns included a posterior Monteggia fracture (an apex posterior fracture of the ulna with posterior dislocation of the radial head)25 in twelve patients, posterior dislocation of the elbow joint in ten (with concomitant fracture of the coronoid process [the so-called terrible triad injury26] in five of them), an EssexLopresti lesion (rupture of the interosseous ligament of the forearm)27 in three, a fracture of the lateral epicondyle in one, and an injury of the medial collateral ligament in one. Four patients had another injury of the ipsilateral upper extremity: two had a scaphoid fracture, and two had a fracture of the distal part of the radius. Twelve patients had associated trauma to the head, chest, abdomen, or other extremities. Classification of Fractures According to the Mason classification system28, thirty patients had a Type-2 fracture (a partial articular fracture or marginal fracture with displacement) and twenty-six had a Type-3 fracture (a fracture involving the entire head of the radius, splitting it into two or more fragments). It is important to note that, in Masons original description, all partial articular fractures, both simple and comminuted, were classified as Type 228, whereas, later, some investigators using his classification characterized a fracture as Type 2 only if it consisted of a single simple fragment12,15,29. We used Masons original description,

classifying comminuted partial articular fractures as Type 2. According to the classification of proximal radial and ulnar fractures in the Association for the Study of Internal Fixation Comprehensive Classification of Fractures30, there were forty-six Type-B fractures (six B2.1, ten B2.2, twenty-three B2.3, three B3.2, and four B3.3) and ten Type-C fractures (three C1.2, two C2.1, two C2.3, and three C3.3). According to the descriptions of the Mason Type-2 fractures at the time of the operative exposure, fifteen consisted of a single fragment and fifteen were comminuted. Sixteen Mason Type-2 fractures were isolated injuries; eleven were part of a fracture-dislocation of the elbow (eight were part of a posterior Monteggia fracture, and three were associated with a posterior fracture of the coronoid process); and one fracture each was associated with an injury of the interosseous ligament (an Essex-Lopresti lesion), a fracture of the lateral epicondyle, and an injury of the medial collateral ligament. The Mason Type-3 fractures consisted of two or three large fragments in twelve patients and more than three fragments in fourteen. Thirteen fractures were isolated injuries, eleven were part of a fracture-dislocation of the elbow (four were part of a posterior Monteggia fracture, five were associated with a posterior dislocation of the elbow, and two were associated with a fracture of the coronoid process), and two were associated with an injury of the interosseous ligament (an Essex-Lopresti lesion). Operative Techniques The operations were performed by twenty-one different surgeons, and no standard protocols were used. The skin incision varied according to the associated injuries. A midline dorsal incision31 was used when access to the ulna or the medial side of the elbow was desired, and a lateral skin incision was used for access to the radial head alone. Operative exposure of the radial head was performed through the Kocher interval between the anconeus and extensor carpi ulnaris muscles in forty-eight patients32. A wider exposure through a damaged lateral collateral ligament and common extensor muscles with subsequent reattachment of these soft tissues to the lateral epicondyle was performed in seven patients with a fracture-dislocation of the elbow. A Boyd exposure33, which elevated the anconeus, extensor carpi ulnaris, and supinator and thereby exposed the ulna and radius together, was used in one patient. Of the thirty Mason Type-2 fractures, four were treated with a 2.0-mm T-shaped plate and screws (Synthes, Paoli, Pennsylvania) and the remaining twenty-six were treated with screws alone (2.0-mm screws [Synthes] were used in twentyfour patients, and Herbert screws [Zimmer, Warsaw, Indiana] were used in two). Two patients had ancillary fixation with small Kirschner wires. Autogenous cancellous bone graft obtained from the olecranon was applied in one patient. In three of the fifteen patients with a comminuted fracture, a portion of the radial head could not be repaired and was discarded. Of the twenty-six Mason Type-3 fractures, twenty-two were treated with a plate and screws (Synthes). A 2.0-mm


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 10 O C T O B E R 2002 O P E N RE D U C T I O N A N D IN T E R N A L F I X A T I O N FR A C T U RES OF T H E R A D I A L HE A D
OF

T-shaped plate was used for nineteen of those fractures; an L-shaped plate, for two; and a condylar blade-plate, for one. The remaining four fractures were treated with 2.0-mm obliquely oriented screws alone, to secure the radial head fragments to the radial neck. Three patients had ancillary fixation with small Kirschner wires. Autogenous cancellous bone graft from the lateral epicondyle was applied in two patients. In six of the fourteen patients who had a comminuted fracture with more than three fragments, a portion of the radial head could not be repaired and was discarded. The articular surface was identified by direct inspection. The plates were placed on the nonarticular portion of the radial head. When screws were placed on the articular surface they were either countersunk below the articular surface or headless screws (e.g., Herbert screws) were used. The incision made in the annular ligament was repaired at the time of closure. The lateral collateral ligament was repaired in three patients, and both the medial and the lateral collateral ligaments were repaired in one patient. All twelve of the ulnar fractures were fixed with a plate and screws. The fracture of the lateral epicondyle was fixed with screws. All three patients with an Essex-Lopresti lesion had pinning of the radius to the ulna in supination for four to eight weeks34. The average duration of postoperative immobilization of the elbow in a splint or cast was two weeks (range, one day to six weeks). When the immobilization was discontinued, active mobilization and functional use of the arm for light daily tasks was initiated. Evaluation The final clinical and radiographic evaluations were performed by one of us. Failure of fixation and nonunion requiring a second operation to excise the radial head were considered unsatisfactory results. Patients who retained the radial head were evaluated with the system of Broberg and Morrey35 at the final evaluation, and a fair or poor result was considered unsatisfactory. Recovery of <100 of forearm rotation with an otherwise satisfactory functional result was also considered a poor result. Radiographic signs of arthrosis were assessed according to the criteria of Broberg and Morrey35. Statistical comparison of dichotomous variables was performed with use of the Fisher exact test (SPSS, Chicago, Illinois), with p < 0.05 considered significant. Results Mason Type-2 Fractures he thirty patients with a Mason Type-2 fracture were followed for an average of fifty-eight months (range, twenty-four to 114 months). Complications included a nonunion of the ulna, which healed after a second operation, and a proximal radioulnar synostosis. The average arc of elbow motion was 119 (range, 75 to 140) with an average of 130 (range, 120 to 140) of flexion and an average flexion contracture of 11 (range, 0 to 45).

The average arc of forearm rotation was 144 (range, 0 to 160), with an average of 72 (range, 0 to 80) of supination and an average of 72 (range, 0 to 80) of pronation. Four patients recovered <100 of forearm rotation. All four patients had a comminuted fracture associated with a more complex injury pattern (a posterior Monteggia fracture in two patients, a fracture-dislocation of the elbow in one, and an Essex-Lopresti injury in one). Fifteen patients had no pain; fourteen, mild pain; and one, moderate pain. None of the patients had elbow weakness, and one had mild elbow instability. According to the system of Broberg and Morrey, the average score was 92 points (range, 54 to 100 points), with the result rated as excellent in eleven patients, good in seventeen, fair in one, and poor in one. The result was unsatisfactory for four patients overall: two had an unsatisfactory Broberg and Morrey rating and diminished forearm rotation, and two had diminished forearm rotation alone. There was a trend toward unsatisfactory results in patients with comminution of the fracture (p = 0.10), and there was a significant association between an unsatisfactory result and a complex injury pattern (p = 0.037). Four of the five patients with a comminuted fracture associated with a complex injury and none of the ten with an isolated comminuted fracture had an unsatisfactory result (p = 0.0036). Mason Type-3 Fractures A second operation to resect the repaired radial head was required in ten patients with a Mason Type-3 fracture. In three patients, the fixation devices loosened within one month after the open reduction and internal fixation. In the remaining seven patients, the fracture failed to heal and the fixation devices loosened or broke. All seven patients had painful crepitation and requested removal of the radial head, which was performed at an average of eight months (range, six to eleven months) after the initial operation. One other patient had evidence of a delayed union on radiographs made sixteen months after the operation but had no symptoms. At the most recent evaluation (forty-eight months after the injury), the fracture was healed. The sixteen patients who retained the radial head were evaluated at an average of forty-four months (range, twentyfive to 102 months) after operative fixation of the fracture. The average arc of elbow motion was 111 (range, 40 to 130), with an average of 129 (range, 110 to 140) of flexion and an average flexion contracture of 18 (range, 5 to 70). The average arc of forearm rotation was 127 (range, 20 to 175), with an average of 59 (range, 10 to 90) of supination and an average of 67 (range, 10 to 85) of pronation. The arc of forearm rotation was <100 in four of the five patients who had more than three fracture fragments and had retained the radial head. The average Broberg and Morrey score was 86 points (range, 51 to 99 points), and the result was rated as excellent in five patients, good in seven, fair in three, and poor in one. Five of the sixteen patients had an unsatisfactory result: four had an unsatisfactory Broberg and Morrey rating, and one had diminished forearm rotation alone.


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 10 O C T O B E R 2002 O P E N RE D U C T I O N A N D IN T E R N A L F I X A T I O N FR A C T U RES OF T H E R A D I A L HE A D
OF

Of the fourteen patients with a Mason Type-3 fracture and more than three articular fragments, three had failure of fixation requiring radial head excision, six had a painful nonunion treated with excision, and four recovered <100 of forearm rotation; thus, only one patient had a satisfactory result. In contrast, of the twelve patients in whom the radial head was split into two or three simple fragments, none had early failure and only one had nonunion; the smallest arc of forearm rotation was 100. The difference in the prevalence of unsatisfactory results between the group with more than three articular fragments and that with two or three simple fragments was significant (p = 0.001). Unsatisfactory results were as common after isolated Mason Type-3 fractures (seven of thirteen patients) as they were after treatment of complex injury patterns (eight of thirteen patients) (p = 1.0). Overall, fourteen (54%) of the twenty-six patients with a Mason Type-3 fracture had an unsatisfactory result. Discussion he radial head was once considered a surplus, or expendable, part of the skeleton36, but it is now recognized as an important stabilizer of the elbow and forearm articulations1-9. It is important to restore radiocapitellar contact through repair or replacement of the radial head when treating unstable fracture-dislocations of the forearm or elbow, such as those associated with injury of the interosseous ligament of the forearm (an Essex-Lopresti lesion27) or posterior dislocation of the elbow with fractures of the radial head and coronoid process (the so-called terrible triad of the elbow26). Some have suggested that repair or replacement of the radial head should be considered in healthy, active patients even when the elbow or forearm articulation is stable37. The relative merits of open reduction and internal fixation of the radial head, as compared with excision of the radial head and prosthetic replacement, for maintenance of radiocapitellar contact are controversial. Prosthetic replacement provides immediate stability without the risk of early collapse. However, there have been difficulties with prosthetic size and design, and the long-term effects of contact between a metal prosthesis and the capitellar articular cartilage are not known24. As our data and those of others have demonstrated, open reduction and internal fixation can be technically challenging and there is a risk of both early collapse and later nonunion10. In addition, if the radial head heals with enlargement or deformity, forearm rotation can be restricted. The data in our study should be interpreted in light of several limitations, including inconsistent surgical indications, the lack of a prospective protocol, the involvement of multiple surgeons with varied experience, and the lack of a control group such as one treated with radial head excision alone or excision with prosthetic replacement. On the other hand, because open reduction was so strongly favored at our institutions during the study period, these data provide a good opportunity for reviewing the results in a relatively large number of patients who received this treatment.

We noted several trends in this study. First, when a fracture involves the entire head of the radius (Mason Type 3), open reduction and internal fixation is much less likely to be successful when there are more than three articular fragments. Complex fractures may include impacted articular fragments or small fragments with meager subchondral bone not amenable to any form of internal fixation. Not only do these factors increase the difficulty of operative fixation, they also increase the risk of both early and late failure of the fixation. In our opinion, Mason Type-3 fractures with more than three articular fragments are probably better treated with excision of the radial head fragments with or without prosthetic replacement. We favor prosthetic replacement unless the patient is infirm or has limited functional demands and instability of the elbow and forearm have been carefully ruled out. Another trend was that the results of open reduction and internal fixation of partial articular (Mason Type-2) fractures seemed to be less predictable when there was more than a single simple fragment, particularly when such a comminuted fracture was part of a complex injury pattern. Mason noted that Type-2 partial articular fractures with more than one fragment were particularly likely to lead to restriction of forearm rotation, and he recommended resection28. In our study, treatment of a comminuted partial articular fracture of the radial head with internal fixation was followed by severe limitation of forearm rotation in four of fifteen patients, suggesting that this may not always be the best form of treatment. The restriction of the forearm rotation could not be attributed to prominence of an implant in any of the patients. All four of the comminuted Mason Type-2 fractures resulting in restricted forearm rotation were part of a more complex injury pattern, and there were no unsatisfactory results following treatment of the isolated comminuted fractures. This finding suggests that it is the combination of a comminuted partial articular fracture with a complex injury that is associated with loss of forearm rotation. Partial articular fractures of the radial head are often part of a more complex injury pattern and usually involve the anterolateral portion of the radial head, which may be especially important to elbow stability38. When internal fixation proves tenuous or impossible and stability is in question, resection of the radial head and prosthetic replacement should be considered. Our data suggest that open reduction and internal fixation of the radial head is effective for partial articular fractures with a single fragment and for complete articular fractures with three or fewer fragments. Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our study suggests that this form of treatment should be reserved for relatively simple fracture patterns. Comminuted fractures and those associated with complex elbow or forearm dislocation may be better treated by radial head excision with or without prosthetic replacement.


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 10 O C T O B E R 2002 O P E N RE D U C T I O N A N D IN T E R N A L F I X A T I O N FR A C T U RES OF T H E R A D I A L HE A D
OF

David Ring, MD Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 525, Boston, MA 02114. E-mail address: dring@partners.org Jaime Quintero, MD Departamento de Ortopedia y Traumatologia, Hospital Universitario Clnica San Rafael, Carrera 8 No. 17-45 Sur, Bogot DC, Colombia Jesse B. Jupiter, MD

Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 527, Boston, MA 02114 In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References
1. Carn RM, Medige J, Curtain D, Koenig A. Silicone rubber replacement of the severely fractured radial head. Clin Orthop. 1986;209:259-69. 2. Gupta GG, Lucas G, Hahn DL. Biomechanical and computer analysis of radial head prostheses. J Shoulder Elbow Surg. 1997;6:37-48. 3. Harrington IJ, Tountas AA. Replacement of the radial head in the treatment of unstable elbow fractures. Injury. 1981;12:405-12. 4. Hotchkiss RN, Welland AJ. Valgus stability of the elbow. J Orthop Res. 1987;5:72-7. 5. Knight DJ, Rynaszewski LA, Amis AA, Miller JH. Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br. 1993; 75:572-6. 6. Mackay I, Fitzgerald B, Miller JH. Silastic replacement of the head of the radius in trauma. J Bone Joint Surg Br. 1979;61:494-7. 7. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11:315-9. 8. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop. 1991;265:187-95. 9. Pribyl CR, Kester MA, Cook SD, Edmunds JO, Brunet ME. The effect of radial head and prosthetic radial head replacement on resisting valgus stress at the elbow. Orthopedics. 1986;9:723-6. 10. Heim U. [Surgical treatment of radial head fracture]. Z Unfallchir Versicherungsmed. 1992;85:3-11. German. 11. Heim U, Pfeiffer KM. Internal fixation of small fractures: technique recommended by the AO-ASIF group. 3rd ed. New York: Springer; 1988. 12. Geel CW, Palmer AK, Redi T, Leutenegger AF. Internal fixation of proximal radial head fractures. J Orthop Trauma. 1990;4:270-4. 13. Khalfayan EE, Culp RW, Alexander AH. Mason Type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma. 1992;6:283-9. 14. Esser RD, Davis S, Taavao T. Fractures of the radial head treated by internal fixation: late results in 26 cases. J Orthop Trauma. 1995;9:318-23. 15. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma. 1991;5:21-8. 16. Pearce MS, Gallannaugh SC. Mason type II radial head fractures fixed with Herbert bone screws. J R Soc Med. 1996;89:340P-4P . 17. Ramon Soler R, Paz Tarela J, Soler Minores JM. Internal fixation of fractures of the proximal end of the radius in adults. Injury. 1979;10:268-72. 18. Fama G, Maran R, Ferrari GP. Osteosynthesis of fractures of the upper end of the radius. Ital J Orthop Trauma. 1988;14:465-74. 19. Vierhout RJ, Oostvogel HJ, van Vroonhoven TJ. Internal fixation of fractures of the head of the radius. Neth J Surg. 1983;35:13-6. 20. Shmueli G, Herold HZ. Compression screwing of displaced fractures of the head of the radius. J Bone Joint Surg Br. 1981;63:535-8. 21. Sanders RA, French HG. Open reduction and internal fixation of comminuted radial head fractures. Am J Sports Med. 1986;14:130-5. 22. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5:1-10. 23. Judet T, Garreau de Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg Br. 1996;78:244-9. 24. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructable fractures of the radial head. J Bone Joint Surg Am. 2001;83:1201-11. 25. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J Orthop Trauma. 1991;5:395-402. 26. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP Bucholz RW, Heckman JD, editors. Rockwood and Green's fractures , in adults. 4th ed, volume 1. Philadelphia: Lippincott-Raven; 1996. p 929-1024. 27. Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation. Report of two cases. J Bone Joint Surg Br. 1951;33:244-7. 28. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42:123-32. 29. Radin EL, Riseborough EJ. Fractures of the radial head. A review of eightyeight cases and analysis of the indications for excision of the radial head and non-operative treatment. J Bone Joint Surg Am. 1966;48:1055-65. 30. Muller ME, Nazanan S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York: Springer; 1990. 31. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision. An anatomical appraisal. J Bone Joint Surg Br. 1995;77:696-9. 32. Kocher T. Textbook of operative surgery. Stiles HJ, Paul CB, translators. 3rd ed. London: Adam and Charles Black; 1911. 33. Boyd HB. Surgical exposure of the ulna and proximal third of the radius through one incision. Surg Gynecol Obstet. 1940;71:86-8. 34. Jupiter JB, Kour AK, Richards RR, Nathan J, Meinhard B. The floating radius in bipolar fracture-dislocation of the forearm. J Orthop Trauma. 1994; 8:99-106. 35. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68:669-74. 36. Gurd FB. Surplus parts of the skeleton: a recommendation for the excision of certain portions as a means of shortening the period of disability following trauma. Am J Surg. 1947;74:705-20. 37. Sanchez-Sotelo J, Romanillos O, Garay EG. Results of acute excision of the radial head in elbow radial head fracture-dislocations. J Orthop Trauma. 2000;14:354-8. 38. Morrey BF. Anatomy of the elbow joint. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1995. p 16-52.