Aims. The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Methods. Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Results. Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Conclusion. Irrespective of the patient’s age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved. Cite this article: Bone Joint J 2024;106-B(10):1158–1164

Radial head fractures are among the most common fractures around the elbow. Radial head arthroplasty is one of the surgical treatment options after complex radial head fractures. This surgery is usually done under general anaesthesia. However, there is a recent anaesthetic technique - wide awake local anaesthesia no tourniquet (WALANT) - that has proven useful in different surgical settings, such as in distal radius or olecranon fractures. It allows a good haemostatic control without the use of a tourniquet and allows the patient to actively collaborate during the surgical procedure. Furthermore, there are no side effects or complications caused by the general anaesthesia and there's an earlier patient discharge. The authors present the case of a seventy-six-year-old woman who presented to the emergency department after a fall from standing height with direct trauma to the left elbow. The radiological examination revealed a complete intra-articular comminuted fracture of the radial head (Mason III). Clinical management: The patient was submitted to surgery with radial head arthroplasty, using WALANT. The surgery was successfully completed without pain. There were no intra or immediate post-operative complications and the patient was discharged on the same day. Six weeks after surgery, the patient had almost full range of motion and was very pleased with the functional outcome, with no limitations on her activities of daily living. The use of WALANT has been expanded beyond the hand and wrist surgery. It is a safe and simple option for patients at high risk of general anaesthesia, allowing similar surgical outcomes without the intraoperative and postoperative complications of general anaesthesia and permitting an earlier hospital discharge. Furthermore, it allows the patient to actively collaborate during the surgery, providing the surgeons the opportunity to evaluate active mobility and stability, permitting final corrections before closing the incision

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR. From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD). The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05). This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures

Background. Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomical monopolar press-fit radial head system commonly used for the treatment of radial head fractures. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with RHA between November 2007 and April 2014. Patients with a minimum of 12-month follow-up were included. Most recent radiographs were evaluated for loosening, stress shielding, and instability. Post-operative motion and outcomes were reported at most-recent follow-up. Results. At an average follow-up of 30 months, 7 of the 17 patients (41%) demonstrated radiographic loosening. Six of the 10 patients (60%) without loosening demonstrated stress shielding (average 6mm). Functional outcome scores included a mean ASES of 74, MEPS of 87, VAS Pain of 1, VAS Function of 8 and SANE of 79. Average flexion-extension arc was 13°–138°, and average pronation-supination was 77°–76° (Figure 1). Of the patients with radiographic loosening, 86% had undergone RHA with an associated ligamentous injury of the elbow. Satisfaction among patients was high, as no patient reported an unsatisfactory outcome. Conclusions. The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation due to a high rate of implant loosening observed

There is an increasing trend towards radial head replacement (RHR) or fixation for complex radial head fractures. These injuries are identified by grossly displaced fragments or elbow instability. The aim of this study was to examine the outcome of a surgical protocol that emphasised delayed radial-head excision (RHE) as the procedure of choice. When the humero-ulnar joint was congruent, intervention was delayed 10 to 14 days to allow time for ligamentous healing. RHR was performed if instability was demonstrated on-table. A retrospective study was performed to identify the outcome of patients undergoing surgery for a radial head fracture between 2008 and 2014. There were 18 Mason Type III and 18 Mason Type IV injuries. There was an associated coronoid fracture in 17 patients. RHE was performed in 28 patients, of which the reoperation rate was 2 (7.1%). RHR was performed in 15 patients, of whom 4 (27%) had reintervention. RHR was most common in the Type III coronoid fractures. The cumulative reoperation rate was 9.3% at six months and 15.4% at two years. The median Oxford Elbow Score (OES) was 85.4 (IQR 73.4 to 99.5). Time from injury was the only predictor of the Oxford Elbow Score (p=0.04). This surgical protocol resulted in a reduced need for RHR, a low reintervention rate, and satisfactory function. RHR should be reserved for cases where stability cannot be achieved on-table. Stability can be maximised by delaying RHE until early ligamentous healing occurs

Purpose. Assess and report the functional and post-operative outcomes of complex acute radial head fractures with elbow instability treated by arthroplasty using an uncemented modular anatomic prosthesis. Methods. Over a 3-year period (2007–2010), 21 patients (mean age 51.9 years) were treated primarily with modular radial head arthroplasty (mean follow up of 27.1 months). Data was collected retrospectively using clinical notes, operation documentation and prospectively using validated scoring systems namely the Oxford Elbow Index, Quick DASH and the Mayo Elbow Performance Score. Associated elbow fractures, ligamentous injury and short to mid term post-operative outcomes including radiographic assessment were recorded. Results. The mean Oxford Elbow Score was 34.80 (range 20–48). The mean Quick Dash score was 26.01 (range 0–68.2). The Mayo Performance score showed 6 scored excellent, 5 scored good, 3 scored fair and 2 scored poor. Regarding post-operative outcomes, 1 patient had a radial head dislocation, 1 patient had prosthesis removal for ongoing pain and 1 patient had a total elbow replacement due to associated proximal ulna fracture non-union. 11 patients had an associated ligamentous injury of which 6 had an associated coronoid fracture. Of note, 7 patient's radiographs showed early signs of implant loosening; this was mainly asymptomatic. Conclusions. With regard to complex radial head fractures with elbow instability, patient outcome measures showed good functionality and overall patient satisfaction despite radiographic evidence of loosening. Post-operative complication rates were low. These findings support the use of this radial head prosthesis in arthoplasty surgery for the treatment of complex acute radial head fractures with elbow instability

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

Introduction. This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation. Patients and Methods. From a prospective database we identified and analysed all patients who had sustained a fracture of the radial head or neck over a one year period. The degree of social deprivation was assessed using the Carstairs and Morris index. The relationship between demographic data, fracture characteristics and deprivation categories was determined using statistical analysis. Results. Two hundred and ninety radial head (n=203) and neck (n=87) fractures were diagnosed with a mean age of 44.3years (13–94). There was no significant difference with regards age or gender predominance when comparing radial head and neck fractures directly. The mean age of males was significantly younger when compared to females for radial head (p<0.001) and neck (p<0.001) fractures, but with no gender predominance seen. Associated injuries (n=25) were related to increasing age (p=0.006), radial head fractures (p=0.003) and increasing fracture complexity according to the Mason classification (p<0.001). Social deprivation was related to the mean age at the time of fracture and the mechanism of injury (p<0.05 for both). Conclusions. Proximal radial fractures are frequently fragility fractures affecting older females and assessment for osteoporosis is recommended. Complex radial head fractures require thorough investigation for the presence of associated injuries

We have achieved a retrospective study in 37 cases of complex radial heads fractures (By Morrey classification). We used the Judet bipolar prosthesis (1996) because it has an integrated articulation that allows an arc of motion of 35°. We revised clinical indication and surgical technique. We analyse clinical and radiographics findings with Bro-berg-Morrey scoring system (1986) for clinical outcome and radiographic Morrey evaluation (1981). Material: We report our experience over 5 years (since April of 2000 till June 2005) with floating radial head prosthesis over 36 patients. A bilateral case; and a 38 months of medial follow-up (range, 12 to 74 months). We made a clinical and radiographic control at 1, 3, 6 and every 12 months. We used the Broberg and Morrey scale to value the clinical results; and the radiographic value scale of the same author. The diagnosis distribution was the following:. 16 luxation fracture (Masson type-IV fracture). Monteggia variety. posttraumatic stiffness after primary treatment. Hotchkiss “terrible triad”. associated MCL tears. Results: There were two complications: 2 infections, only in one of them we needed to take away the implant. Its represented a 5,3%. We took away one prosthesis for a infection and another for a insufficient osteothomia (“overstuffing”). We had 2 cases of neuropatya (posterior interosseous and cubital) but it resolved without surgery. Six stiffness, four of them were posttraumatic stiffness, then there were stiffness before surgery. 1 case of osteolysis and prosthesis instability after 5 years. The clinical results were:. Excellent 21, 6% (8 cases). Good 56, 7% (22 cases). Fair 13, 5% (5 cases). Bad 8% (3 cases). Conclusion: The excellent-good result were 78,3% but there were much better in acute surgery (86,1%) than in secondary or delayed surgery (50%) Bypolar design allows a continuous contact against the convex humeral condyle during elbow movement. This clinical results confirm that floating prostheses is well tolerated and it can prevent proximal migration and provide stability while bone and soft tissue heal. From biomechanical point of view, this anatomic design may lead to longer functional lifetime compared with the standard metal prosthesis. In summary the floating head prostheses is a useful option in Masson III fracture associated with elbow dislocation with or without associated destabilizing fractures but is not free of complications

Purpose: Metal radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. Little previous research is available on the utility and longevity of metal radial head arthroplasty for elbow reconstruction. The purpose of this study was to evaluate the functional outcome of patients with metal radial head arthroplasty (RHA) for elbow reconstruction. Methods: This was a retrospective review from one institution with three senior orthopaedic surgeons. 23 consecutive patients with 23 RHA were included in the study, 4 patients were lost to follow up. RHA was performed for conditions of rheumatoid arthritis, post traumatic radial head nonunion, post traumatic radial head malunion, elbow instability following previous radial head excision and failed silicone radial head implants. Patients were excluded from the study if they were treated for an acute injury with RHA (under 2 months from injury). There were 8 males and 15 females with a minimum of 2 year follow up. Analysis included chart review, personal interview, physical examination, radiographs and strength testing. Region specific questionnaires were used including: DASH, ASES, MEPI, PRWE, WOS and SF-36. Mean follow up was 9 yrs. Results: Mayo elbow performance scores were excellent in 11 patients, good in 4 patients, fair in 4 patients and poor in 4 patients. Subjective patient satisfaction was averaged at 8.4 out of 10. Patients demonstrated significantly less isometric strength and grip strength in the affected versed unaffected elbow. There was no statistically significant difference seen in ulnar variance or ulnohumeral joint space between the affected and unaffected limbs. Conclusions: In conclusion, RHA for elbow reconstruction is a safe procedure that provides patients with long term functional ROM and pain relief

Aim: Complex radial head fractures are often underestimated in their complexity with consequent poor outcomes. Method: We retrospectively reviewed thirty-two Mason 2 and 3 radial head fractures treated surgically with open reduction and internal fixation by generalist orthopaedic surgeons and trainees over a four-year period. They were clinically, radiologically and functionally assessed for this study. Functional assessment was done using the Mayo elbow performance score (MEPS). Results: There were fourteen Mason 2 and eighteen Mason 3 radial head fractures. The Mason 2 were fixed by K-wires (n=2), Herbert TM screws (n=5), Acutrack TM screws (n=3), and T-plates (n = 4). The Mason 3 were fixed by Herbert TM screws (n=6), Acutrack TM screws (n=4) and T plates. Average follow up was 47 months (range 22–65 months). The arc of elbow motion was 1040 (range 680_1400), with an average extension deficit of 230 (range 00–500) and an average flexion deficit of 200 (range 100–400). The average arc of forearm rotation was 1300 (range 00–1400), with an average supination of 660 (range 00–750), and an average pronation of 680 (range 00–800 ). The complications (N=17/32) included superficial skin infection (n=2), transient posterior interosseous nerve palsy (n=4), broken T -plate (n=1), intra-articular placement of a screw (n=1), loose and backed out screw (n=1), non-, union of radial head (n=2). Fixed flexion deformity if elbow (n=4) and mild elbow in stability (n=2). Second surgery was preformed in 18.7 % (n=6/32)(radial head replacement n=1, anterior capsulectomy n=4 and removal of screw n=1). Conclusion: Radial head trauma surgery is an underestimated source of poor clinical outcomes. Complex radial head fractures should be clinically and radiologically evaluated with the knowledge that they are difficult to accurately and comprehensively assess. The treatment of such fractures may warrant management by a sub-specialist, although this latter conclusion has not been corroborated to date

Purpose: To review the clinical outcome of patients who have had complex radial head fractures managed with titanium radial head replacement. Methods: There were 17 patients who had insertion of the radial head replacement. The indications for the prosthesis included acute Mason type III fracture which could not be stabilised satisfactorily with internal fixation. Other indications included delayed presentation including previously failed treatment. Patients were managed with radial head excision and insertion of the Wright Medical titanium radial head replacement. The lateral ligamentous complex was stabilised. A back slab was applied for a period of one week and then the elbow mobilised. The patients were followed up for a minimum of one year. The Mayo elbow performance index was used. Results: There were 7 patients with acute injuries of which 6 had associated injuries such as dislocation or coronoid process fracture. 6 of these patients had an excellent result and 1 had a good result. There were 9 patients with a delayed insertion of the radial head replacement. There were 3 patients who had an isolated radial head fracture and 6 patients with associated injuries, there were 2 excellent, 3 fair and 4 poor. Three of the 4 poor results had associated capitellar chondral injury. Two patients with fair results had other significant pathology in the upper limb. In the delayed presentation group the average flexion arc improved from 78 degrees to 102 degrees and the pro-supination improved from 117 degrees to 142 degrees. The average level of satisfaction on a visual analog score was 92 per cent. Conclusion: Patients who present with acute complex radial head fractures (including associated injuries), the results of radial head replacement are generally excellent. If there are significant associated injuries and a delay in presentation, then the outcome is often only fair. However, this group of patients have improvement in their pain, level of satisfaction and range of motion. Associated capitellar damage is a poor prognostic indicator