Purpose. Evaluation of our experience on the treatment of comminuted, radial head fractures, and of the outcomes of pyrocarbon prosthetic replacement in such cases. Materials and Methods. We evaluated 47 cases of prosthetic replacement, performed from May 2003 to July 2008. There were 18 males and 29 females with an average follow-up of 48 months (12 to 60). The Hotchkiss classification was used to characterize the fractures. The indicators for the procedure were type III fractures in 27 cases, type IV fractures in 10 cases, comminuted radial head fractures (associated with disruption in medial collateral ligament) in 3 cases, Monteggia variant in 5 cases, and Essex Lopresti in 2 cases. Functional outcomes were assessed using the Mayo Elbow Performance Index and the Visual Analog Scales (VAS) of pain, joint motion, and stability. Results. The mean VAS score for elbow pain was 1 (0.5–2.1). Patients showed an average arch of motion from 6 degrees to 140, with 75 degrees of pronation, and 67 of supination. By the Mayo Elbow Performance Index, 42 patients had good to excellent results, 3 fair, and 2 poor. The complications that we have encountered were: implant dislocations (2 cases), elbow stiffness (1), implant dissociation (1), stem rupture (1), and transient PIN palsy (2 cases with complete recovery of nervous function at 5 and 8 weeks). There was no persistent instability, infection, synosthosis, severe degenerative changes, or impingement. Conclusion. The pyrocarbon implants are a good treatment option in complicated, radial head fractures, but the outcome depends on the severity of the initial fracture and the associated lesions. We have also encountered a tendency towards overestimating the prosthesis size, causing restriction of motion, impingement, overstuffing, or dislocation. For these results we are now using the non-modular prosthesis in our center, but further studies are required

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.

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity.