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Trauma
Current Concepts and Controversies in the Management of Radial Head Fractures

By Nikolaos T. Roidis, MD, PhD, DSc; Stamatios A. Papadakis, MD; Nikolaos Rigopoulos, MD; George Basdekis, MD; Lazaros Poultsides, MD; Theofilos Karachalios, MD; Konstantinos Mal
ORTHOPEDICS 2006; 29:904
CME Information

October 2006

Although radial head fractures comprise a very common injury in everyday clinical practice, their proper management remains difficult and controversial. Radial head fractures often are misd
symptoms are similar to elbow sprains; they usually result from a fall onto the outstretched hand. This type of fracture may be isolated or associated with more complex injuries such as fract
around the elbow, soft-tissue injuries, and rupture of the distal radioulnar joint.

Incidence and Mechanism of Injury
Radial head fractures may be the result of indirect trauma and constitute approximately one third of all fractures and elbow dislocations. Radial head fractures are involved
in approximately 20% of elbow trauma cases 1,2 and 5%-10% of elbow dislocations are associated with a radial head fracture. 3,4 Eighty-five percent of fractures occur in
adults aged between 20 and 60 years (mean age: 30-40 years) and the ratio between males and females is approximately 1:2. 1
Undisplaced or minimally displaced fractures represent 40%-60% of all the fracture types seen. 5 The usual scenario for a radial head fracture is a fall with the arm abducted
and the elbow between 0° and 80° of flexion as shown by Amis and Miller.6 The force of the fall at the time of injury is of varying value and is resulting in a valgus pronation
force that is transmitted across the proximal radius to the elbow. The radial head is pushed against the capitellum and may be split or broken. The articular cartilage of the
capitellum may be bruised or chipped, resulting in an injury not only to the radial head, but also to the capitellum.
Occasionally, a fracture of the radial head may be a result of a valgus force to the elbow, and the injury also may become complicated by a fracture of the olecranon. 7 A
direct blow also could cause a radial head fracture, but this is considered uncommon.6 Although radial head fracture may be an isolated lesion, the displaced and often
comminuted radial head fracture can frequently be associated with a fracture of the coronoid process, a torn medial collateral ligament (MCL) that renders the elbow joint
completely unstable to valgus stress, and/or an injury to the interosseous membrane and the triangular fibrocartilage complex, causing axial instability of the forearm with
subluxation of the distal radioulnar joint (Essex-Lopresti dislocation). 1,8

Validity of classification schemes
The optimal classification for a given injury should fulfill the following requirements:
to
to
to
to
to
to

be simple and concise,
be practical,
provide accurate consecutive levels of severity,
be easily memorized,
provide treatment guidelines, and
provide prognostic characteristics.

Mason 2 and/or Mason-Johnston9 classifications are purely radiographic and have been proven insufficient to guide clinical treatment. Morgan et al 10 demonstrated a poor reliability of class
by Mason’s system. Additionally, Morrey 4 reported that this classification is particularly useful for simple (uncomplicated) radial head fractures. If the fracture is complex, the treatment plan is
injury. 1,4,5 However, it has been traditionally used to characterize radial head fractures.

Mason Type I is an undisplaced fracture; Type II, displaced, with involvement of >30% of the head and usually lower than its half; and Type III, a comminuted fracture involving the entire he
the Type IV category, which characterizes a concurrent radial head fracture and an ulnohumeral dislocation. Although the radial head fracture classification is a simple radiographic evaluatio
that would relate to various treatment protocols and prognosis has yet to be established.

Mason in his classification did not include associated injuries, presenting as an acute mechanical block, or tears of the interosseous membrane of the forearm that may influence the treatme
after a radial head fracture. For that reason, many authors have attempted to propose modifications based on the physical signs and the associated injuries, beyond the pure radiographic fr
The Hotchkiss 11 modification includes clinical examination and provides guidelines for the treatment of such injuries.
The Schatzker and Tile 7 classification divides radial head fractures into three types:
Type I: split-wedge fracture,
Type II: impaction fracture, and
Type III: severely comminuted fracture.

The AO classifies12 the different fracture patterns into simple (21-B2.1), multifragmentary without depression (21-B2.2), and multifragmentary with depression (21-B2.3). Although this classif
purposes, it is not very helpful for daily practice and does not indicate the severity of the articular head fracture. 7

Morrey reported one additional level of classification (Mayo classification) that can be expressed in several ways: uncomplicated and complicated; simple and complex; or with or without ass
additional injury in complicated fractures may either be another fracture or ligament injury or both. Complicated injury patterns about the elbow joint are considered as complex elbow instabili

Associated Injuries and Complicated Radial Head Fractures

The degree of ligamentous injury that occurs with a radial head fracture is not always fully appreciated. Previous investigators have reported various results with regard to the incidence of as
ligamentous injuries. 1,8 The combination of a radial head fracture with attenuation or MCL tear has been reported to occur in 1%-2% of patients. 1

Roidis et al 13-16 reported on the results of an MRI evaluation of 24 consecutive patients with an acute radial head fracture (Mason type II & III) wi
dislocation or tenderness at the distal radioulnar joint. The evaluation was done with elbow anteroposterior (AP) and lateral radiographs and magn
(MRI) performed with the patient in a splint in sagittal, coronal, axial, axial oblique, and coronal oblique planes.17 The authors investigated the inte
lateral collateral ligament, the presence of capitellar osteochondral defects or bone bruises and loose bodies. The MRI evaluation of the participan
high percentage of ligamentous injuries. The incidence of associated injuries was: MCL not intact, 13/24 (54%); lateral collateral ligament not intac
collateral ligaments not intact, 12/24 (50%); capitellar osteochondral defects, 7/24 (29%); capitellar bone bruises, 23/24 (96%); and loose bodies,

The results of this study clearly showed a high incidence of osteochondral and ligamentous injuries in radial head fractures initially presented as u
the validity of the radiographic classification systems (Figure 1). Radial head fractures that initially present as uncomplicated-displaced or commin
may have associated ligamentous injuries that dramatically alter the classification, prognosis, and appropriate treatment protocols.

The cost per MRI examination is very high and is not recommended as part of routine preoperative work-up. It is necessary to perform a detailed c
examination in every comminuted radial head fracture. Careful intraoperative examination under fluoroscopy may be helpful in determining the pre
ligamentous injuries.

Due to the high incidence of intra-articular loose bodies, careful intraoperative evaluation and irrigation of the joint should be performed. A high lev
used when treating this type of fracture because concomittant osseous, osteochondral, and ligamentous injuries might be present. In that way an
may be a complicated fracture leading to elbow instability that can be very easily misdiagnosed.

Figure 1: MRI demonstrating a
radial head fracture with a
concomitant bone bruise at the

Radial Head Fractures

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concomitant bone bruise at the
capitulum humeri.

Herbertsson et al 18 reported on a long-term follow-up study aiming at the evaluation of the incidence and the long-term results of closed uncompli
fractures in a defined population of adults. Seventy women and 30 men who were a mean age of 47 years when they sustained a fracture of the r
Mason type II fracture in 76 patients and a Mason type III fracture in 24) were re-examined after a mean of 19 years. They reported predominantly
patients had no symptoms in the injured elbow at follow-up, 21 had occasional pain, and 2 had daily pain. The injured elbows had a slight flexion deficit compared with the uninjured elbows
deviation, 138°±8° compared with 140°±7°) as well as a small extension deficit (mean and standard deviation, –4°±8° compared with –1°±6°) (P<.001 for both).

Good long-term results for “uncomplicated” radial head fractures are reported in the previously reported study while the authors reported that there were no associated soft-tissue injuries. Mo
(77 of 100) were the result of low-energy trauma. Additionally, no information provided focused on possible instability issues on initial clinical examination. 16 Furthermore, two letters to the e
concerning the results of the previously cited study. 19,20 The first by Ring19 who among others reported that: “Displaced fractures are often associated with other fractures or ligament injurie
This makes sense, given that substantial displacement of the radial head would by necessity be associated with substantial displacement of either the forearm or elbow articulation and this w
of injury to the structures that stabilize these joints. Some authors have cautioned that all, or nearly all, complex fractures of the entire radial head (Mason type 3) will be part of a more comp
difficult to detect associated injury to the elbow or forearm when treating fractures of the radial head.” The second was by Hausman and Mullett 20 who, among others, reported that, “There is
displaced radial head fractures are frequently associated with associated ligamentous injury. Indeed there is growing skepticism that a displaced radial head fracture can occur in the absenc
lateral collateral ligament injury.

Biomechanical studies have clarified the key role of the medial collateral ligament particularly in radial head fracture or excision. Poor outcomes from treatment of radial head fractures witho
injuries have been reported. The superior results reported by Herbertsson et al 18 are at odds with these reports and our personal experience. To combine type II and III fracture groups in a
misleading impression of a benign injury with almost universal good outcome.”

Most radial head fractures can be diagnosed with standard radiographic evaluation with anteroposterior and lateral projections of the elbow. The direction of the x-ray beam in AP projection
the radial head because the elbow joint can rarely be extended.21 The radiographic evaluation may reveal a vertical split or a single fragment of the lateral portion of the head usually displac
fragments of the radial head. The radial head-capitellum view can be useful in identifying fractures of the posterior half of the radial head22 or in a fat pad sign that refers to intra-articular he
is the only visible radiographic sign in an undisplaced radial head fracture. An additional radiographic evaluation of the wrist should be made if pain is present to exclude injury of the distal ra
concomitant injury to the capitellum (bruised or chipped) is an important complication, it cannot be established radiographically. Tomograms or computed tomography (CT) scans about the e
defining the comminution and the degree of displacement especially when open reduction and internal fixation is considered.

Treatment Guidelines

Although radial head fractures are considered a relatively benign injury, their treatment is of great importance and has developed over the years by using various techniques and methods. 1,1
treatment is to maintain good elbow function and thus to retain adequate motion and joint stability. In general, the treatment of radial head fractures is based on the fracture type and the pre
injury (complicated/uncomplicated fractures). 1,11,21,23

Type I Fractures

There is no doubt that radial head fractures with no or minimal displacement should be treated conservatively. The only concern in patients’ treatment must be early motion, as early as toler
helpful to maintain the shape and molds slight incongruities without risk of further displacement. 11,21,23 Aspiration followed with or without instillation of local anesthetic into the elbow joint h
joint from hematoma. Additionally, it reduces the pain and allows the joint’s range of motion (ROM) evaluation identifying the presence of bony blocks. Holdsworth et al 24 found that aspiratio
procedure in improving the initial ROM and pain relief, did not alter the final outcome.

Several positions of immobilization have been advocated for the treatment of these fractures. Thompson25 and Unsworth-White et al 26 in their study compared flexion versus extension splin
Mason type I fractures. Both authors showed that splinting in full extension is better than 90° of flexion. The loss of extension in their group of patients was <10° in comparison with the othe

Patients with type I fractures generally obtain good to excellent restoration of elbow function after 2 to 3 months of active motion exercises. Early motion compared with prolonged immobiliza
advantages in elbow function. 1,11,21,23 Early motion should be restricted for fractures that involve less than one third of the articular surface in the elderly or low-demand individuals. Active p
fractures involving more than one third of the articular surface should be splinted for a minimum of 2 weeks, followed by protected motion for an additional 7 to 10 days.23 Good results in typ
expected in 86%-100% of patients. 5,27 Minimal loss of elbow extension and forearm rotation is not uncommon, but the loss rarely affects arm function. Contracture, occasional pain, and infl
Displacement–following or not early motion–and nonunion are rare and are treated by osteosynthesis or delayed excision of the radial head. Sometimes, osteochondral fracture of the capite
for a poor result in type I fractures. 11

Figure 2: AP (A) and lateral (B) radiographs demonstrating a type-I radial
head fracture associated with a fracture of the capitellum. Postoperative
AP (C) and lateral radiographs (D) of the same patient treated with open
reduction and internal fixation.

Type II Fractures

Early studies advocated either conservative management or excision of the radial head as the standard treatment for type II fractures. 1,11,23 As knowledge increased, the understanding of t
the radial head as a secondary stabilizer to valgus stress and as an axial weight bearing structure led to the better understanding of its biomechanics, and dictated treatment options. Curren
have been developed based on the specific type (degree of displacement) of fracture being treated, but the final choice of treatment is still controversial (Figure 2).

The evaluation of the mechanical block is highly important for the final treatment decision, as not all of the marginal displaced fractures require internal fixation. 4,28 Minimally displaced or un

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fractures can be managed conservatively in a manner similar to that of type I fractures. Surgery is not advisable in the presence of 70° of active pronation and supination regardless of the ra
displacement occurs despite immobilization, a delayed radial head excision can be performed from 1 month to 20 years with 77% good or excellent results.30 Acute mechanical block in disp
best treated by open reduction and internal fixation especially in young and active individuals. Preservation of the radial head should always be considered when associated injuries about th
are present. Treatment options include open reduction and internal fixation, excision of the fragments, excision of the radial head and prosthetic radial head replacement.

Open Reduction and Internal Fixation

Currently internal fixation has become popular (Figures 2 and 3), since contemporary techniques have improved surgical outcomes. 21,31,32 AO mini-screws and mini-plates, (Synthes, Paoli
(Zimmer, Warsaw, Ind), and absorbable polyglycolide pins are used for the restoration of the fractured radial head and neck.21,31-33 The indications and contraindications for open reduction
shown in Table 1. An insertion of one or two 2.0- or 2.7-mm AO cortical mini-screws parallel to the radiohumeral joint can easily fixate isolated large fragments, by using a posterolateral obliq
Screw heads are countersunk and care should be taken that the screw tips do not protrude out the articulating portion of the radial head. Impacted fractures of the head often require elevatio
surface. The defect beneath the elevated fragment is best filled with cancellous bone graft from the lateral epicondyle of the humerus. 23

Hardware placement for the fixation of radial head fractures should not affect the proximal radioulnar joint. The non-articulated portion of the radial head is referred to as the “safe zone.” The
corresponds to approximately 110° of radial head surface. According to Hotchkiss, 11 it is estimated intraoperatively by reference marks onto the radial head during forearm rotation. Caputo e
a portion of the radial head that lies between perpendicular axes through the radial styloid and Lister’s tuberosity.

Herbert screws can be used for radial head fractures alone, without extension of the fracture line to the radial neck as they provide a reliable and effective fixation. 33 Another treatment optio
polyglycolide pins. 3,35 The partial excision of a displaced fragment, although advocated in the past, 1,21,23 is currently not being used because it can lead to subluxation of the remaining radi

When fractures are extended to the radial neck, a mini AO plate (2.0-2.7 mm) can be used to secure the head to the shaft of the radius (Figure 3). In a comminuted radial neck fracture alon
grafting should be considered to support the radial neck.36 When there is no concomitant fracture of the radial head, the use of an intramedullary pin is advisable. 37 Patterson et al 38 reporte
comparative study between different plates for the fixation of radial neck fractures. They concluded that the two important variables affecting construct stiffness are plate thickness and incor
plate. The optimal position for the placement of the plate in complex fractures of the proximal radius associated with neck dissociation is the direct lateral position in neutral rotation. 39

The postoperative care in type II fractures must be individualized. Normally, a posterior splint in neutral rotation is used either in full extension 5 or in 90° of flexion. 1 The immobilization period
Painless active ROM is permitted as soon as tolerated. The allowance of mobilization and the ROM must be made with respect to concomitant injuries. Patients must be directed to alternate
within the splint and active motion exercises. Continued passive motion is not useful. 7 Results after open reduction and internal fixation in type II fractures are satisfactory in 90% of the case
usually is seen despite treatment. 1,21,23,40

Figure 3: AP (A) and lateral (B) radiographs of a radial head fracture extended
to the radial neck. Postoperative radiographs of the same patient after the
fixation of the fracture using mini-screws and plate (C, D).

Type III Comminuted Fractures

Comminuted fractures are high-energy injuries and are currently treated by early complete excision of the radial head or radial head replacement. 1,11,21,23 Partial excision is not recommend
performed within 48 hours after the injury4 when osteosynthesis is not possible, although these fractures are not considered ideal for internal fixation. Internal fixation techniques are demand
the presence of multiple fragments. These fractures are very difficult to fix due to poor bone quality or inadequate fixation of very small fragments. An intraoperative decision should always b

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anatomic reduction and stable internal fixation (Figure 4). 31,32 If this is not possible the surgeon should be prepared to excise the entire radial head rather than leaving behind inadequate st
consequently may lead to prolonged immobilization or late displacement.

Figure 4: Various types of the most commonly used radial head implants.

Authors following radial head excision have reported good objective and subjective results.41,42 Delayed excision can be performed, 30 but this usually is indicated in patients with no mecha
when other conditions (eg, polytrauma patients) do not allow immediate excision.11 After a short course of immobilization, early active and passive motion of the elbow joint is allowed. This
optimal result depending on the severity of the initial injury and the presence of associated injuries. Although radial head excision is an easily performed technique, it is often associated with
(Table 2).

Type IV Fracture-Dislocation

According to Morrey 1 radial head fractures with a posterior dislocation of the elbow are classified as complicated injuries. These injuries should be treated by immediate reduction of the dislo
fractured radial head according to the previous mentioned guidelines. Every effort should be made for the preservation of the radial head.

An elbow dislocation is often associated with medial ligaments injuries, which are the primary stabilizers to valgus stress at the elbow. For such cases the preservation of the radial head is o
maintaining elbow stability. 5 If the radial head cannot be preserved, torn ligaments must be repaired and radial head prosthesis is considered. However, Harrington and Tountas 43 have repo
replacement without ligamentous reconstruction with satisfactory results. Unfortunately, poor results are associated with this type of fracture. Loss of elbow flexion and forearm rotation of an
seen. A higher incidence of heterotopic ossification is also seen. 8 Early motion in <1 week with a hinged splint is favored, with 75% satisfactory results.44 Other complications include injurie
median and ulnar nerves, and rarely to the radial nerve.

Radial Head Replacement

Currently, radial head arthroplasty is used in comminuted radial head fractures in an attempt to minimize the complications of radial head excision (Table 2). Its use may be indicated in com
radial head occurring in combination with tears of the interosseous ligament of the forearm or complex instability after elbow joint dislocation. 1,5,11,23

The radial head prosthesis is intended to prevent proximal migration of the radius in response to axial loading of the forearm.45 It resists valgus and posterior elbow instability by providing ef
contact that approaches that of the native radial head. It facilitates the uneventful healing of the medial collateral and interosseous ligaments, as well as the distal radioulnar joint.

The use of the first prosthetic radial head replacement is attributed to Speed, 46 who in 1941 implanted ferrule caps over the neck of the radius. Several authors have since developed prosth
variety of materials such as acrylic, 47 vitallium,48,49 and silicone rubber. 50 Silicone implants have an overall increase in failure rate compared with metallic implants, including reactive synov
fractures of silastic implants, and a questionable amount of supporting axial stability. 31,48,51,52

Knight et al,48 in 1993, showed both clinically and biomechanically that vitallium prostheses could provide excellent resistance to axial load as well as lateral stability in Mason type III and IV
the radial head. Judet et al 53 reviewed the results in five patients who had had an acute radial head fracture–Mason type III–with ligamentous instability. They initially used bipolar titanium p
cobalt-chromium prosthesis with a cemented stem and a polyethylene articulation with the head component. Three results were excellent and two were rated as good. There were no compl

Moro et al 54 reported their results in 24 patients with unreconstructable fractures of the radial head. Patients were treated with a metallic radial head implant. They concluded that arthroplas
head implant is a viable treatment option that appears to be safe and effective. Alternatively, implantation of a frozen allograft radial head prosthesis has been used by Szabo et al 55 in proxi
following radial head excision. They concluded that patients had relief of wrist and elbow pain and reported satisfactory results. The indications and contraindications for a radial head replace
3. Complications are shown in Table 4.

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Radial Head Prosthesis Design

Since Speed’s first report on vitallium radial head prosthesis a number of prostheses have been developed with a variety of results reported. 46-50 Design configurations based on cadaveric
measurements were tested with structural finite element method computer analyses. Materials examined included titanium alloy, cobalt-chrome alloy, alumina ceramic, and ultrahigh molecu
(UHMWPE). Metals and ceramic transmitted force at the distal bone and implant interface and strain shielded the proximal radial cortex while UHMWPE distributed load uniformly through th
entire bone and implant interface. 56-59

Prosthesis design has lagged in adequately matching morphologic characteristics of the proximal radius. 60 Most radial head designs are round at their articulation with the capitellum. Howev
cadaveric specimens demonstrated that the proximal radial head is ovoid in shape. Using CT scans of 8 cadaveric specimens, Cone et al 61 demonstrated that maximal diameter exceeds the
average of 2.5 mm. An additional mismatch of prosthetic radial head components and proximal radius morphology has been demonstrated. Using MRI scans of 46 normal elbows, Beredjiklia
that commercially available metallic radial head design may overestimate the dimensions of the radial neck. As a result, ineffective restoration of proximal radial length results (average: 4 mm
potentially adverse effects on elbow, forearm, and wrist mechanics. They propose that newer designs taking anatomic dimensions into account may lead to improved function after reconstru
to detect better implant designs, various authors have reported good results with a floating radial-head prosthesis for acute fractures of the radial head. 53,62

Various implants for radial head replacement have been developed using either a cemented or a cementless stem. A floating radial head prosthesis (Tornier SA, Saint-Ismier, France) has be
both with the humeral condyle and with the radial notch of the ulna. 53,62 The radial head of high-density polyethylene enclosed in a cobalt-chrome cup articulates in a semi-constrained man
of a cemented intramedullary stem with a neck-shaft angle of 15°. This semi-constrained implant allows free rotation and a uniplanar arc of motion of 35° from any given point (Figure 4). 53,6

Based on the shape-dimensional identification of the radius, a new radial head prosthesis (KPS) was designed. It is a modular prosthesis consisting of two parts: a vitallium stem and a head
and-socket joint between the stem and head allows the head to rotate and tilt. The upper surface of the head is concave to articulate with the spherical capitellum. The lateral surface of the h
the concave radial notch of the ulna, is approximated as a barrel-shaped surface. The mobile head of the implant allows for proper positioning and matching of the articulating surfaces durin
or load bearing. The shape of the prosthetic stem is close to being conoidal. Because the stem is cemented in place, there is no need to match the shape of the marrow cavity accurately. 57,

Implants with different design philosophy are currently available. These radial head implants use different stem designs (Avanta Orthopaedics, San Diego, Calif and Pyrocarbon radial head;
Austin, Tex with modular tapered stem; Swanson titanium radial head, Wright Medical Technology, Arlington, Tenn with non-modular tapered stem; Evolve modular radial head, Wright Medi
modular non-tapered stem) and are placed without the use of bone cement in the intramedullary canal (Figure 4). The Liverpool radial head replacement (Biomet, Warsaw, Ind) provides an a
articulating surface of the prosthesis angled at 10° to approximate the position of the natural radial head articulating surface and the stem offset from the body of the prosthesis to approxima
radius (Figure 4).

The evolution of radial head replacement is ongoing. The ideal radial head prosthetic implant has yet to be designed. These data suggest that further study and refinement of prosthesis des

Options and Current Thinking

Posterolateral oblique or Kocher approach to the elbow has been standardized as the most suitable for almost all indications concerning operative treatment of radial head pathology. It is a s
with respect to the deep radial nerve and can easily be expanded distally or proximally. In complex elbow instability where a radial head fracture is associated with a torn MCL, a posterior mi
just distal to the tip of the olecranon (global approach). A full thickness lateral flap (fasciocutaneous) is elevated on the deep fascia to protect the cutaneous nerves. This incision permits acc
the elbow when the MCL must be repaired to restore elbow stability. 15

Traditionally, the operative treatment of radial head fractures is performed through a posterolateral approach with the elbow joint flexed in a pronated position.1,4,5 This recommendation is pr
study by Strachan and Ellis 63 that described the position of the posterior interosseous nerve in the cadaver forearm. They showed that pronation moved the posterior interosseous nerve mo
the elbow joint to the radial tubercle. They therefore recommended placing the forearm in pronation during exposure of the radial head to help minimize the chance of posterior interosseous

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Diliberti et al 64 and Witt et al 65 have defined a “safe zone” that helps the surgeon avoid injuring the posterior interosseous nerve during posterolateral approaches to the proximal part of the
found to decrease this zone while flexion and extension of the elbow joint had no effect on the reported distances of the so-called “safe zone.” This “safe zone” in supination was reported to
mm of the lateral aspect of the radius. 65 In a radial head replacement, a typical Kocher exposure allows suboptimal exposure for radial neck cut and offers difficult access for broaching and
extensile approach like that of Cohen and Hastings, 66 which offers improved access, ligament sparing, and perhaps less chance of posterior interosseous nerve injury should be considered

More recently, we have used the Boyd approach 15 to gain access to the radial head (Figure 5). This is the only approach that allows visualization of the radioulnar, radiohumeral, and ulnoh
posterior incision is made and the anconeus muscle is peeled off the ulna and elevated anteriorly. The ulnar part of the lateral collateral ligament and the annular ligament are then elevated
supinatoris) using either a sharp blade or a needle tip electrocautery. The ligament complex is then tagged with a suture for later repair. This exposure allows for excellent visualization of the
helpful in the management of radial neck fractures and for radial head implantation. After the radial head and neck fracture has been addressed, the ligament complex is repaired back to the

Figure 5: Boyd approach for radial head replacement (see text for details).

The Role of Radial Neck Osteotomy

Some of the currently available radial head implants may significantly alter elbow joint kinematics because of a mismatch between their design characteristics and the morphologic character
In the dynamic setting of elbow function, an ovoid shaped radial head prosthesis will improve function in the proximal radioulnar joint as well as the radiocapitellar joint. The stem of the vario
not fit in the proximal radius and that leads to significant alteration of the length of the radius. If an implant has these design characteristics (round radial head shape, radial neck mismatch) t
during supination-pronation movements is severely altered and normal joint kinematics are not replicated. 67

Moreover, a review of the literature shows a paucity of information on the proper position of the forearm for the radial neck osteotomy in prosthetic replacement. The axis of forearm rotation
important variable in normal forearm biomechanics and kinematics. The restoration of this axis is of paramount importance when a radial head implant is used. It is well known that if the pros
properly to the axis of forearm rotation, a cam effect will occur at the radiocapitellar articulation with forearm rotation. This cam effect can lead to postoperative pain and decreased ROM, as
dislocation of the prosthetic radial head implant.

A study was undertaken 68 to determine the radiographic anatomy of the proximal radius in three different views (full supination, full pronation, and neutral rotation) and to identify that positio
value for the angle between the axis of forearm rotation and the radial neck axis. It was our hypothesis that such a position should offer the optimal situation for the radial neck cut in radial h
approximate the normal biomechanical axis of forearm rotation. Anteroposterior and lateral radiographs of 20 healthy volunteers’ forearms were taken in three views (full supination, neutral r
Radial head maximum diameter and angular measurements between the axis of forearm rotation and the radial neck axis were made with digital calipers. Repeated-measures analysis of va
statistically significant difference between the three AP groups, with supination having the smallest values (P<.0001), but not for the lateral groups (P<.128). Comparison of the axis of forear
angle between the AP supinated position and the three lateral views revealed a statistically significant difference among all of the pairs, with the AP supinated position having the smallest va
most closely approximated the axis of forearm rotation with the forearm in the supinated position. For best approximating the native axis of forearm rotation during radial head replacement, t
perpendicular to the neck axis with the elbow extended and the forearm in the supinated position.

Conclusion

Currently, Mason type I and undisplaced Mason type II fractures can be managed conservatively. Displaced type II fractures can be treated by open reduction and internal fixation to achieve
mobilization of the neighboring joints. Management of unreconstructible Mason type III and Mason-Johnston type IV comminuted fractures of the radial head is difficult and controversial. Sur
internal fixation, excision, or excision and replacement of the radial head. Usually, comminuted fractures of the radial head are treated by excision. When the fracture is associated with ligam
excision may result in gross elbow instability and a poor outcome. Complications, such as valgus elbow deformity, elbow stiffness, proximal radial migration, synostosis, chronic ulnar wrist pa
changes, can develop months or years after initially successful treatment. These results have led to a search for a satisfactory prosthesis for a radial head. The ideal prosthetic radial head r
designed.

References
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Morrey BF. Radial head fracture. In: Morrey BF, ed. The Elbow and its Disorders. 3rd ed. Philadelphia, Pa: WB Saunders; 2000:341-364.
Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954; 42:123-132.
Pan WT, Born CT, DeLong WG Jr. Fractures and dislocations involving the elbow joint. In: Dee R, ed. Principles of Orthopaedic Practice. 2nd ed. New York, NY: McGraw-Hill; 1997:4
Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect. 1995; 77:316-327.
Sharpe F, Kuschner SH. Radial head fractures. In: Baker CL Jr, Plancher KD, eds. Operative Treatment of Elbow Injuries. New York, NY: Springer-Verlag Inc; 2001:207-223.
Amis AA, Miller JH. The mechanisms of elbow fractures: an investigation using impact tests in vitro. Injury. 1995; 26:163-168.
Schatzker J. Fractures of the radial head. In: Schatzker J, Tile M, eds. The Rationale of Operative Fracture Care. 2nd ed. Germany: Springer-Verlag; 1996:131-135.
Davidson PA, Moseley JB Jr, Tullos HS. Radial head fracture. A potentially complex injury. Clin Orthop Relat Res. 1993; 297:224-230.
Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J. 1962; 31:51-56.
Morgan SJ, Groshen SL, Itamura JM, Shankwiler J, Brien WW, Kuschner SH. Reliability evaluation of classifying radial head fractures by the system of Mason. Bull Hosp Jt Dis. 199
Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP, eds. Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996:929-1024.
Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York, NY: Springer-Verlag; 1990.
Roidis N, Itamura J, Vaishnav S, Mirzayan R, Learch T, Shean C. MRI evaluation of comminuted radial head fractures. A rather complex injury. Presented at: the 69th Annual Meeting
of Orthopaedic Surgeons; February 13-17, 2002; Dallas, Tex.
Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch T, Shean C. Radial head fractures. MRI evaluation of associated injuries. J Shoulder Elbow Surg. 2005; 14:421-424.
Roidis NT, Papadakis SA, Karachalios TS, Mirzayan R, Itamura JM. Radial head fractures. In: Mirzayan R, Itamura JM, eds. Shoulder and Elbow Trauma. New York, NY: Thieme Me
2004:22-35.
Roidis NT, Karachalios TS, Rigopoulos N, Poultsides L, Malizos KN, Itamura JM. Letter to the Editor. e-JBJS. June 10, 2004.
Choi J, Learch T, Itamura J, Vaishnav S, Colletti P, Moon C, Terk MR. MR imaging of collateral ligaments in the flexed elbow. AJR Am J Roentgenol. 2001; 176(suppl):140.
Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karlsson M. Long-Term Follow-Up Study. Uncomplicated Mason type-II and III fractures of the radial head and n
follow-up study. J Bone Joint Surg Am. 2004; 86:569-574.
Ring D. More information on radial head fractures. Letter to the Editor. e-JBJS. May 4, 2004.
Hausman MR, Mullett H. Outcome of Mason type II & III radial head fractures. Letter to the Editor. e-JBJS. April 14, 2004.
Quintero J. Olecranon/radial head/complex elbow injuries. In: Ruedi M, Murphy WM, eds. AO Principles of Fracture Management. New York, NY: Thieme Medical Publishers Inc; 20
Greenspan A, Norman A. Radial head-capitellum view: an expanded imaging approach to elbow injury. Radiology. 1987; 164:272-274.
McKee MD, Jupiter JB. Trauma to the adult elbow and fractures of the distal humerus. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma. 2nd ed. Philadelph
1998:1455-1522.
Holdsworth BJ, Clement DA, Rothwell PN. Fractures of the radial head—the benefit of aspiration: a prospective controlled trial. Injury. 1987; 18:44-47.
Thompson JD. Comparison of flexion versus extension splinting in the treatment of Mason type I radial head and neck fractures. J Orthop Trauma. 1988; 2:117-119.

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Unsworth-White J, Koka R, Churchill M, et al. The nonoperative management of radial head fractures: a randomized trial of three treatments. Injury. 1994; 25:165-167.
Kuntz DG, Jr, Baratz ME. Fractures of the elbow. Orthop Clin North Am. 1999; 30:37-61.
Hotchkiss R. Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg. 1997; 5:1-10.
MacAusland WR Jr, Wyman ET Jr. Fractures of the adult elbow. Instr Course Lect. 1975; 24:169.
Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone joint Surg Am. 1986; 68:669-674.
Furry KL, Clinkscales CM. Comminuted fractures of the radial head. Arthroplasty versus internal fixation. Clin Orthop Relat Res. 1998; 353:40-52.
Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002; 84:1811-1815.
McArthur RA. Herbert screw fixation of fracture of the head of the radius. Clin Orthop Relat Res. 1987; 224:79-87.
Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation. J Hand Surg Am. 1998; 23:1082-1090.
Pelto K, Hirvensalo E, Bostman O, Rokkanen P. Treatment of radial head fractures with absorbable polyglycolide pins: a study on the security of the fixation in 38 cases. J Orthop Tra
Hotchkiss RN. Fractures of the radial head and related instability and contracture of the forearm. Instr Course Lect. 1998; 47:173-177.
Keller HW, Rehm KE, Helling J. Intramedullary reduction and stabilisation of adult radial neck fractures. J Bone Joint Surg Br. 1994; 76:406-408.
Patterson JD, Jones CK, Glisson RR, Caputo AE, Goetz TJ, Goldner RD. Stiffness of simulated radial neck fractures fixed with 4 different devices. J Shoulder Elbow Surg. 2001; 10:5
Soyer AD, Nowotarski PJ, Kelso TB, Mighell MA. Optimal position for plate fixation of complex fractures of the proximal radius: a cadaver study. J Orthop Trauma. 1998; 12:291-293
Esser RD, Davis S, Taavao T. Fractures of the radial head treated by internal fixation: late results in 26 cases. J Orthop Trauma. 1995; 9:318-323.
Coleman DA, Blaire WF, Shurr D. Resection of the radial head for fracture of the radial head. J Bone Joint Surg Am. 1987; 69:385-392.
Morrey BF, Chao EY, Hui FC. Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am. 1979; 61:63-68.
Harrington IJ, Tountas AA. Replacement of the radial head in the treatment of unstable elbow fractures. Injury. 1981; 12:405-412.
Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987; 216:109-119.
Hotchkiss RN, An KA, Sowa DT, Basta S, Weiland AJ. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the
1989; 14(2 Pt 1):256-261.
Speed K. Fracture of the head of the radius. Surg Gynecol Obset. 1941; 73:845-850.
Cherry JC. Use of acrylic prosthesis in the treatment of fracture of the head of the radius. J Bone Joint Surg Br. 1953; 35:70-71.
Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br. 1993; 75:572-576.
Carr CR. Metallic cap replacement of the radial head. J Bone Joint Surg Am. 1971; 53:1661.
Swanson AB, Jaeger SH, La Rochelle D. Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty. J Bone Joint Surg Am. 1981; 63:1039-1049
Morrey BF, Askew L, Chao EY. Silastic prosthetic replacement for the radial head. J Bone Joint Surg Am. 1981; 63:454-458.
Carn RM, Medige J, Curtain D, Koenig A. Silicone rubber replacement of the severely fractured radial head. Clin Orthop Relat Res. 1986; 209:259-269.
Judet T, Garreau De Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg Br. 1996; 78:244-249.
Moro JK, Werier J, MacDermid JC, Patterson SD, King GJW. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001; 83:
Szabo RM, Hotchkiss RN, Slater RR Jr. The use of frozen-allograft radial head replacement for treatment of established symptomatic proximal translation of the radius: preliminary ex
Hand Surg Am. 1997; 22:269-278.
Gupta GG, Lucas G, Hahn DL. Biomechanical and computer analysis of radial head prostheses. J Shoulder Elbow Surg. 1997; 6:37-48.
Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN. Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Su
1834.
van Riet RP, Van Glabbeek F, Baumfeld JA, et al. The effect of the orientation of the noncircular radial head on elbow kinematics. Clin Biomech (Bristol, Avon). 2004; 19:595-599.
Skalski K, Swieszkowski W, Pomianowski S, Kedzior K, Kowalik S. Radial head prosthesis with a mobile head. J Shoulder Elbow Surg. 2004; 13:78-85.
Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg. 1999; 8:471-475.
Cone RO, Szabo R, Resnick D, Gelberman R, Taleisnik J, Gilula LA. Computed tomography of the normal radioulnar joints. Invest Radiol. 1983; 18:541-545.
Popovic N, Gillet P, Rodriguez A, Lemaire R. Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis. J Orthop Traum
Strachan JCH, Ellis BW. Vulnerability of the posterior interosseous nerve during radial head resection. J Bone Joint Surg Br. 1971; 53:320-323.
Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Jo
813.
Witt J. Toward safe exposure of the proximal part of the radius: landmarks and measurements. J Bone Joint Surg Am. 2001; 83:1589-1590.
Cohen MS, Hastings H II. Post-traumatic contracture of the elbow. Operative release using a lateral collateral ligament sparing approach. J Bone Joint Surg Br. 1998; 80:805-812.
Birkedal JP, Deal DN, Ruch DS. Loss of flexion after radial head replacement. J Shoulder Elbow Surg. 2004; 13:208-213
Roidis N, Stevanovic M, Martirosian A, Abbott DD, McPherson EJ, Itamura JM. A radiographic study of proximal radius anatomy with implications in radial head replacement. J Should
12:380-384.

Authors

Drs Roidis, Rigopoulos, Basdekis, Poultsides, Karachalios, and Malizos are from the Department of Orthopedics, University of Thessaly, Larissa, and Dr Papadakis is from the Department o
Center of Mykonos, Mykonos, Greece, and Dr Itamura is from the Department of Orthopedics, Keck School of Medicine, Los Angeles, Calif.
Drs Roidis, Papadakis, Rigopoulos, Basdekis, Poultsides, Karachalios, Malizos, and Itamura have no industry relationship to declare.
Reprint requests: Nikolaos T. Roidis, MD, PhD, DSc, Dept of Orthopedics, University of Thessaly, 34 Akronos St, Larissa 41447, Hellenic Republic, Greece.

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· U.K. emergency helicopter ambulance services may be over-used for minor injuries

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