Abstract
Background: Radial head fractures often occur in association with
other elbow fractures and soft-tissue injuries. Radial head replacement is
indicated for irreparable radial head fractures associated with elbow
instability. The purpose of this study was to analyze the results after
treatment of such injuries with a titanium radial head prosthesis, repair of
torn collateral ligaments, and early mobilization of the elbow.
Methods: Sixteen patients with sixteen Mason type-III radial head
fractures and collateral ligament injury were treated with use of a titanium
radial head prosthesis over a five-year period at the Royal Adelaide Hospital
and Modbury Public Hospital in South Australia. The surgery was performed
acutely in ten patients and was delayed an average of thirty-seven days
(range, fifteen to seventy-nine days) in six. All patients were followed
clinically and radiographically for a mean of 2.8 years (range, 1.2 to 4.3
years).
Results: Eight patients had an excellent result; five, a good
result; and three, a fair result, according to the Mayo Elbow Performance
Score. The three fair results occurred in patients with delayed surgery. The
mean flexion contracture was 15° (range, 0° to 42°), with an
average loss of 10° (range, 0° to 25°) of full flexion compared
with that of the contralateral elbow. Both pronation and supination decreased
an average of 12° (range, 0° to 45°) compared with that of the
contralateral forearm.
Conclusions: The results of treatment of Mason type-III radial head
fractures with a monoblock titanium radial head prosthesis and soft-tissue
reconstruction are satisfactory. Early mobilization of the elbow is important
for the restoration of elbow range of motion and function.
Level of Evidence: Therapeutic study, Level IV (case
series [no, or historical, control group]). See Instructions to Authors for a
complete description of levels of evidence.
The management of comminuted Mason type-III radial head fractures with
associated fractures and ligament disruptions remains
controversial1. A
variety of surgical options have been advocated for these complex injuries.
Open reduction and internal fixation of the radial head is often impossible
technically. Simple excision of the radial head in patients with an associated
interosseous membrane disruption or a medial collateral ligament injury yields
poor results with frequent wrist or elbow
instability2-6.
A number of different materials have been used to replace the radial head,
including Silastic7,
acrylic8,
vitallium9,
titanium6, and
cobalt-chromium10.
Swanson Silastic prostheses were popular but have fallen out of favor because
fragmentation and the resulting synovitis over time can lead to joint
erosion7,11.
Furthermore, recent biomechanical studies have demonstrated that metallic
prostheses more closely reproduce the loads across the elbow
joint12,13.
Our algorithm14
for the management of these injuries includes an initial assessment of the
radial head fracture to determine if it is repairable. If adequate reduction
and stability of the fracture cannot be obtained, the radial head is excised
and replaced with a metallic radial head prosthesis. The stability of the
medial and lateral collateral ligaments is assessed intraoperatively, and they
are repaired if found to be disrupted. Early motion of the elbow is instituted
postoperatively.
The purpose of this study was to analyze the results after treatment of a
series of Mason type-III radial head fractures with use of radial head
prosthetic replacement, collateral ligament repair, and early elbow
mobilization.
Between 1996 and 2001, sixteen patients with a Mason type-III radial head
fracture were managed with replacement of the radial head with a titanium
prosthesis. Ten patients presented immediately and had the operation within
three days after the injury. Six patients were initially treated at other
institutions, were then referred because of elbow pain, stiffness, and
instability, and had the operation at an average of thirty-seven days (range,
fifteen to seventy-nine days) after the injury. The eight men and eight women
had an average age of forty-five years (range, twenty-one to seventy-two
years). All injuries affected the dominant, right arm. Nine patients,
including four who performed manual labor, were employed full time when the
injury occurred. Eleven patients sustained the injury in a fall and five, in a
motor vehicle accident.
Associated injuries included chondral injuries to the capitellum in two
patients, distal radial fractures in two, coronoid fractures in two, and elbow
dislocations in two.
Preoperative assessment included examination for bruising and localized
tenderness over the distal radioulnar joint, interosseous membrane, and medial
collateral ligament. Plain radiographs were made of the elbow and wrist
(Fig. 1).
Indications for the use of the prosthesis included: (1) an acute fracture
(often resulting from a high velocity injury with an associated dislocation)
in which satisfactory reduction and/or fixation could not be obtained, such
that early motion could be instituted, and (2) delayed presentation of a
fracture with persistent pain or instability.
Operative Procedure
Under general anesthesia, the patient is placed into a lateral position
with the arm on a bolster. A sterile tourniquet is applied to the upper arm.
With the pneumatic tourniquet control to 250 mm Hg, a global approach, which
is 20 to 25-cm posterior midline incision, is centered on the olecranon and a
full-thickness fasciocutaneous flap is
created15. The
Kocher interval between the anconeus and the extensor carpi ulnaris is
identified by a thin strip of fat, which can be seen deep to the deep
fascia16
(Fig. 2). The interval is
incised and the muscles are retracted to expose the lateral ligament complex.
An incision is made in the capsule anterior to the lateral ulnar collateral
ligament with a z-shaped incision through the annular
ligament14,17
(Fig. 3). The anterior capsular
flap can be released from the epicondyle and from the anterior aspect of the
humerus, thus exposing the lateral side of the joint without violating the
lateral ulnar collateral ligament. The radial head fracture can be visualized
well, and a decision can then be made as to whether open reduction and
internal fixation is feasible. Usually open reduction and internal fixation
can be performed through this approach if required. Simple soft-tissue closure
is all that will be necessary if satisfactory reduction and fixation can be
obtained. Releasing the posterior capsular flap will disable the lateral ulnar
collateral ligament and therefore make the elbow unstable. This step is
indicated only if extra exposure is required for open reduction and internal
fixation or if a metallic prosthesis needs to be inserted.
If the surgeon is not able to obtain a stable fixation, then the radial
head is excised. Once the free fragments have been removed, the neck length is
determined. The native neck-head rim is instinctively the ideal position;
however, this nonanatomic prosthesis has a long head so slightly more
resection of the neck is required. The medial collateral ligament and
interosseous radioulnar membrane are then assessed for stability. A Kocher
clamp is placed on the radial neck, and the radius is axially loaded to assess
the interosseous membrane competence. A change in the distance between the
radial neck and the capitellum of >2 mm should be considered abnormal.
Medial collateral ligament stability is assessed by placing a valgus force
on the elbow and assessing the distance between the radial neck and the
capitellum. The forearm is placed in pronation with the elbow at 30° of
flexion. A narrowing of the distance between the capitellum and the radial
neck of >2 mm indicates a disruption of the anterior band of the medial
collateral ligament. Instability of the elbow in the extended position
indicates that the anterior and posterior parts of the capsule are also
torn14.
Twelve patients had instability of the medial collateral ligament with
disruption of the lateral collateral ligament in six of the twelve patients.
The lateral ligament complex was often completely disrupted as a sheet from
the distal part of the humerus. In the patients who had delayed treatment, we
noted that the lateral capsular complex often had not healed, as it lay
translocated distally, overlying the capitellum to which it cannot heal. The
authors believe that this anatomical finding is the likely cause of chronic
posterolateral rotatory instability.
The medial side of the elbow is exposed next if there is a type-II or III
fracture of the coronoid
process14 or
evidence of instability of the medial collateral ligament
(Fig. 4). A full-thickness
fasciocutaneous medial flap is elevated, and the ulnar nerve is identified.
The cubital retinaculum is released to allow mobilization of the ulnar nerve.
A tape is placed around the nerve, but it is not clipped so that the assistant
cannot inadvertently pull on the nerve. The flexor carpi ulnaris is released
from the subcutaneous border of the ulna by dividing the deep fascia
approximately 2 mm from its insertion onto the
ulna16. Elevation
of the flexor carpi ulnaris muscle provides exposure to the coronoid process
and the medial collateral ligament. The medial collateral ligament is usually
disrupted as a sheet from its insertion into the medial epicondyle and is
simply repaired with Mitek suture anchors (Mitek Surgical Products, Westwood,
Massachusetts)14.
Fixation of the coronoid process is obtained by passing a number-5 Ethibond
suture (Ethicon, Somerville, New Jersey) through the anterior capsule as it
inserts into the coronoid process a few millimeters from its tip. The suture
is then passed through the proximal aspect of the ulna so that it can be tied
on its subcutaneous border. The medial collateral ligament and coronoid
process sutures are not tied until after the metallic radial head prosthesis
is inserted.
The size of the radial head prosthesis is selected by comparing the excised
radial head fragments and the trial prosthesis. Care is required to ensure
that the appropriate length of neck has been excised. A Mersilene tape is
placed around the proximal part of the radius, providing a handle to control
its position. The medullary canal of the proximal part of the radius is
prepared with the provided broaches. The appropriate-sized monoblock titanium
radial head prosthesis (Wright Medical Technology, Arlington, Tennessee) is
then inserted (Fig. 5). The
stability of the joint and the prosthesis is assessed by taking the elbow
through a range of motion. If there is any doubt about the stability of the
elbow, it should be assessed with fluoroscopy. The sutures used to stabilize
the medial collateral ligament complex and the coronoid process are tied with
the elbow held in 90° of flexion and supination. The lateral collateral
ligament complex is then stabilized with transosseous interrupted sutures as
described by Osborne and
Cotterill18.
Postoperatively, the patient is placed into a dynamic elbow suspension
splint for seven days following surgery. The patient is discharged on the
second postoperative day, and the splint is set up at
home19. Active and
passive motion are begun two days after surgery. The exercise reduces edema,
keeps the elbow in full extension to minimize the development of a fixed
flexion deformity, and optimizes posterior wound-healing. Patients are
prescribed indomethacin for a period of six weeks to minimize the risk of
heterotopic bone formation.
The mean duration of follow-up was 2.8 years (range, 1.2 to 4.3 years). All
patients were independently assessed by a research nurse using a standardized
questionnaire and objective assessment. Visual analog scales were used to
record pain and satisfaction levels. Any limitation of the patient's
activities of daily living was noted, and the range of motion of both elbows
was determined with use of a goniometer. The stability of the elbow was
assessed by clinical examination by the senior author (G.I.B.). These
measurements enabled calculation of the Mayo Elbow Performance
Score20. A score of
=90 points indicated an excellent result; 75 to 89 points, a good result;
60 to 74 points, a fair result; and <60 points, a poor result. Grip
strength was measured with use of a Jamar dynamometer in the second position,
with the elbow at 90° of flexion and the wrist in neutral position.
Four patients had no other substantial injury identified except a
comminuted radial head fracture. Six patients had a medial collateral ligament
injury, and three of the six had an associated medial epicondylar fracture, a
capitellar chondral injury, or a dislocation in one patient each. Six patients
had disruption of both the medial and lateral ligament complexes. These
injuries were more severe and were associated with dislocations (two
patients), a fracture of the coronoid process (two), a capitellar chondral
injury (one), and an interosseous membrane injury and a distal radial fracture
(one).
Atable presenting specific data on the patients can be found in the
Appendix. At the time of the final follow-up, the average Mayo Elbow
Performance Score was 87 points (range, 65 to 100 points). Eight patients had
an excellent result; five, a good result; and three, a fair result. The three
fair results occurred in patients who had delayed surgery. Nine patients
reported little or no pain at rest or during activity, and five described an
ache over the lateral aspect of the elbow during activity. Two patients
described pain at rest that required the occasional use of analgesics. No
forearm or wrist pain was described at the time of the last review in any
patient, except one with a preexisting wrist problem.
Seven of the nine employed patients returned to full work duties. Two of
the patients who performed manual labor were unable to continue their
physically demanding jobs and were seeking alternative employment at the time
of the last assessment. No patients altered hand dominance as a consequence of
the injury.
The range of motion measurements demonstrated a significant loss of elbow
flexion, elbow extension, and forearm rotation in the affected extremity
compared with that in the unaffected limb (p < 0.02). The mean flexion
contracture was 15° (range, 0° to 42°) with a loss of 10°
(range, 0° to 25°) of full flexion. The loss of both pronation and
supination was, on the average, 12° (range, 0° to 45°) compared
with the contralateral limb.
The group that had delayed surgery had an average flexion deformity of
21° (range, 8° to 42°) compared with 10° (range, 0° to
30°) for the group treated acutely. The amount of loss of flexion and
forearm rotation was similar in both groups. Grip strength was found to be
reduced by an average of 12% on the side of the injury. No persistent
ligamentous laxity was evident.
At the final follow-up examination, the average pain score, measured on the
100-point visual analog scale (with 100 indicating the most severe pain), was
17 points (range, 0 to 45 points). In the acutely treated group, the average
final pain score was 15 points (range, 0 to 25 points). In the delayed surgery
group, the average pain score improved from 81 points (range, 60 to 90 points)
preoperatively to 22 points (range, 10 to 45 points) at the time of the last
follow-up.
Injury to the collateral ligaments seemed to be associated with a poorer
outcome at the time of the final follow-up. The average Mayo Elbow Performance
Score20 decreased
from 98 points for patients with no collateral ligament injury to 88 points
for those with a medial collateral ligament injury and to 78 points when
collateral ligaments were incompetent at the time of surgery. The restriction
of motion associated with increasing collateral ligament injury accounted for
the main decrease in these scores. The average flexion deformity increased
from 5° for patients with no ligament injury to 11° for those with a
medial ligament injury and to 26° for those with injury to both collateral
ligaments. No patient demonstrated collateral ligament instability following
repair.
Radiographically congruent articulation of the radial head prosthesis with
the capitellum and the proximal part of the ulna could be demonstrated at the
time of the final follow-up in all patients. There was no evidence of erosion
or sclerosis of the proximal radioulnar joint or periprosthetic lucency within
the radial medullary canal. Heterotopic ossification did not develop following
surgery in any patient.
Complications
There were six complications relating to the injury or the operation. A
regional sympathetic mediated pain syndrome developed ipsilaterally in the
upper limb of one patient, and an ulnar nerve neuropathy developed in three
individuals. These all resolved by nine months postoperatively. There were
also two superficial wound infections that responded to oral antibiotics.
Two patients had an associated distal radial fracture and two previous
injuries of the same limb (a rotator cuff tear and degenerating wrist
arthritis from a previous scapholunate dissociation), which limited their
ability to rehabilitate the limb easily.
In this series, we used a titanium monoblock radial head prosthesis, which
has a number of design problems including lack of modularity, difficulties
with sizing, and a nonanatomical design. In addition, titanium does not have
ideal wear characteristics. A modular prosthesis in which the ideal size of
the stem and head components can be independently selected would make
insertion easier and may improve motion and stability following surgery.
Using a staged approach to the management of these injuries, our principal
aim was to provide stability of the fracture and of the elbow and then allow
early active mobilization. No patient had evidence of recurrent instability
despite the fact that a restricted mobilization program was not used. We
believed that use of the dynamic elbow suspension
splint19 was
important to minimize edema in the early postoperative period, allowing a more
aggressive mobilization program.
Acute repair of collateral ligaments performed because of gross instability
and subluxation after reduction of simple elbow dislocations has had mixed
results21,22.
Complex elbow injuries require a different approach from that used for a
simple
dislocation23. By
performing an acute repair of the medial collateral ligament complex, the
surgeon can be confident that earlier mobilization can be instituted. Radial
head replacement adds to the stability of the elbow following these
complicated injuries.
The results in this series compare favorably with those in other studies of
radial head replacement for the treatment of radial head fractures with gross
instability of the
elbow6,9,10,24.
In particular, Harrington and Tountas, in a study of seventeen patients who
had replacement of the radial head with a titanium prosthesis, reported that
fourteen patients had a good or excellent functional
result6. Knight et
al. reported on thirty-one radial head fractures in complex elbow injuries
that were treated with radial head replacement with use of a monoblock
vitallium prosthesis inserted without
cement9. At 4.5
years, pain relief was achieved in 71% of the patients and, clinically, there
was an average restriction in flexion and forearm rotation of 10° and an
average flexion deformity of 20°. In a study of twenty-five patients who
were managed with a titanium monoblock prosthesis inserted without cement,
Moro et al. reported that seventeen had a good or excellent result; five, a
fair result; and three, a poor
result25.
Radial head fractures associated with concomitant injuries about the elbow
are complex injuries. Treatment should be aimed at restoring the normal
anatomy and, when possible, allowing early motion and restoration of function.
Replacement of the unsalvageable radial head with a metallic prosthesis and
acute repair of the torn collateral ligaments optimizes joint stability and
allows early safe active motion in these patients.
A table showing specific data on all treated elbows is available with the
electronic versions of this article, on our web site at
(go to the article citation and click on "Supplementary Material")
and on our quarterly CD-ROM (call our subscription department, at
781-449-9780, to order the CD-ROM).
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