forhrptmtrhf - Kerala Journal of Orthopaedics

Kerala Journal of Orthopaedics • kjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015
original article
Functional Outcomes of Radial Head
Replacement as a Primary Treatment
Measure in Traumatic Radial Head
Fractures
Roncy Savio Kuruvilla, John T John and Joice Varghese MJ
Article Info
Abstract
Keywords
radial head fractures
collateral ligament
metallic implants
Introduction: Radial head is considered the second main stabiliser of the elbow
in valgus, after the medial collateral ligament. In the event of a coronoid fracture,
or a deficient medial collateral ligament, or a disrupted lateral collateral ligament,
radial head is the main stabilizer of the elbow. It is due to the key role that radial
head plays in the stability of the elbow that surgeons have increasingly tried to
conserve the radial head 1 .
Isolated radial head fractures constitute about 5.4% of all fractures and 33% of all
elbow fractures 2 .
The management of radial head fractures depends on the degree of comminution, displacement, free intra articular fragments, the percentage of articular
surface involved and the angulations between the radial neck and shaft of radius.
Radial head replacement with metallic implants can be used to treat irreparable
radial head fractures.
Correspondence
roncyk@gmail.com
Source of funding
Nil
Conflict of interest
Nil
Available online at
http://www.kjoonline.org/
Method: From a period of 2012–2014, 5 patients who underwent radial head
replacement for irreparable radial head fractures were taken up for the study and
evaluated. Of the 5 patients, 4 patients presented with comminuted radial head
fracture associated with elbow dislocation. Of which one patient had bilateral
radial head fractures on one side associated with an elbow dislocation which was
subjected to replacement and included in the study. All patients were followedup clinically and radiographically. Mean follow up of the group is 20.8 months
(shortest 12 months, longest 30 months). The outcome was based on Mayo Elbow
Performance Scoring.
Result: On the basis of Mayo Elbow Performance Scores, 2 patients had excellent
results; 3 patients had good results. None of the patients had elbow instability
following radial head replacement. The prostheses were found to be well fixed
and none had any signs of infection.
Conclusion: The treatment of irreparable radial head fractures with primary
radial head replacement using metal prosthesis and surrounding soft tissue
reconstruction provided satisfactory results. Proper technique, correct implant,
early mobilization are important for the final outcome and restoration of
function.
Cite this paper as: Roncy Savio Kuruvilla et al. Functional Outcomes of Radial Head Replacement
as a Primary Treatment Measure in Traumatic Radial Head Fractures. Kerala Journal of Orthopaedics
2016;28(1–2):53–57.
adial head is considered the sec-
ond main stabiliser of the elbow
R
in valgus, after the Medial collateral
c 2016 Kerala Journal of Orthopaedics
Copyright ligament. In the event of a coronoid
fracture, or a deficient medial collateral ligament, or a disrupted lateral
53
Roncy Savio Kuruvilla et al
collateral ligament, radial head is the main stabilizer
of the elbow. It is due to the key role that radial head
plays in the stability of the elbow that surgeons have
increasingly tried to conserve the radial head 1 .
Isolated radial head fractures constitute about 5.4%
of all fractures and 33% of all elbow fractures, while
bilateral fracture of radial head is an unusual injury. It
usually occurs by fall on outstretched hand 2 .
The management of radial head fractures depends
on the degree of comminution, displacement, free intra
articular fragments, the percentage of articular surface
involved and the angulations between the radial neck
and shaft of radius 3 .
The Mason–Hotchkiss classification is used to
classify radial head fractures and is useful when
assessing further treatment options 4 .
1. non-displaced radial head fractures (or small
marginal fractures)
2. partial articular fractures with displacement
(>2 mm)
3. comminuted fractures involving the entire radial
head
(a) fracture of the entire radial neck, with the
head completely displaced from the shaft
(b) articular fracture involving the entire head,
consisting of more than two large fragments
(c) fracture with a tilted and impacted articular
segment
4. fracture of the radial head with dislocation of the
elbow joint
According to Mason, Type 1 fractures were immobilized in a splint for an average of 16 days
followed by active ROM and Type 3 fractures were
treated with excision of the radial head. Type 2
fractures were treated either non-operatively or with
excision of the radial head. Type 2 injuries treated
non-operatively included depressed, but not tilted,
fractures less than 1/4 of the radial head or fractures
greater than 1/4 of the articular surface that were
determined not to interfere with movement of the joint.
Treatment of radial head fractures remains similar
today and continues to be based primarily on the
Mason classification.
Stable restoration of radial length is usually important for elbow or forearm stability. If this cannot be
achieved with ORIF, a proximal radius prosthesis will
be necessary 5,6 .
Prosthetic replacement for unreconstructable radial
head fractures is indicated
• when the elbow joint is unstable
54
• with an unstable coronoid fracture
• with medial collateral ligament insufficiency or
ulnohumeral instability
• after radial head excision with evidence of medial
collateral ligament insufficiency or ulnohumeral
instability
• with associated interosseous membrane injury
(Essex–Lopresti injury).
Materials and Methods
Between 2012 and 2014, 5 patients who underwent
radial head replacement for irreparable radial head
fractures were taken and evaluated. Of the 5 patients,
4 patients presented with comminuted radial head
fracture associated with elbow dislocation. One patient
had bilateral radial head fractures associated with an
elbow dislocation on one side which was subjected to
replacement and was included in the study. All patients were followed-up clinically and radiographically.
Mean follow up of the group is 20.8 months (shortest 12
months, longest 30 months) the outcome was based on
Mayo Elbow Performance Scoring.
Surgical Procedure
Arthroplasty was completed through a lateral Kocher’s
incision 7–9 . The incision began superior to the lateral
epicondyle and extended distally to the proximal ulna
to about 6 cms distal to the tip of olecranon. The
internervous plane between the anconeus and Extensor
Carpi Ulnaris (ECU) is developed. The Posterior
interosseous nerve (PIN), supplying the ECU can be
safely moved away from the field by pronating the
forearm. The joint capsule is opened longitudinally at
the annular ligament to enter the joint. The capsule
should not be dissected too far anteriorly as the PIN
runs over the front of the capsule. After visualising
the fracture, the fragments are removed. Using a
saw, the radial head is resected at the level of the
neck. The size of the radial head is determined
using sizing dishes provided. The radial canal is
prepared. It is important to identify the proper axial
orientation. The forearm should be in midrotation with
the radial tuberosity directed medially. This position
is favourable for broaching and implantation. Starting
with the smallest broach, the canal was prepared
for the stem. Sequentially larger broaches were used
until a tight fit was achieved. The appropriate trial
stem corresponding to the last broach used was
placed in the canal. Then the appropriate trial head
was used to assemble the entire construct. A trial
reduction is carried out and the elbow is manipulated
through the full range of elbow flexion-extension
and forearm pronation-supination positions. The head
should articulate with the capitellum and the sigmoid
Kerala Journal of Orthopaedicskjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015
Roncy Savio Kuruvilla et al
55
Figure 1
Figure 2
notch smoothly during the range of motion. After
finding the suitable trial, the implant stem and head
corresponding to the trial is implanted using the same
technique. The movements were checked once again.
The annular ligament and capsule closed. The lateral
collateral ligament was repaired if found torn. The
wound is closed in layers over a mini drain. The elbow
immobilised in a slab in 90 degrees of flexion.
Post Operative Protocol
On the immediate postoperative day, the slab is
removed, the wound dressed and continuous passive
motion of the elbow done. The slab was replaced
after the manipulation. In the postoperative period
patient received 2 doses of intravenous antibiotics.
Patient was put on oral indomethacin 25 mg daily
for a period of 3 weeks to reduce the incidence of
heterotrophic ossification. The first week rehabilitation
included 15 minutes of active movements three times a
day. The elbow was immobilised in the long arm slab
for the rest of the day.
In the event of ligament repair, as was the case
in 2 of our cases, the postoperative mobilization was
more guarded. The above elbow slab was continued in
such cases for a period of 6 weeks with intermittent
mobilization.
Figure 3. Mayo’s Elbow Performance Scoring.
Outcome Measures
The outcomes of the patients were scaled using
a Mayo’s Elbow performance scoring 10 on their
Kerala Journal of Orthopaedicskjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015
Roncy Savio Kuruvilla et al
56
Figure 4. The range of motion of a patient ‘A’ who underwent radial head replacement.
Table 1. Mayo Elbow Performance Scoring of on Final Follow-up
A30 months
B26 months
C24 months
D12 months
E12 months
29/M
48/F
34/M
39/M
42/M
Pain
45
30
45
30
30
Motion
20
20
15
15
15
subsequent follow ups. The criteria in the Mayo’s
scoring system are given below.
Results
The 5 patients were included in the study. Mode of
injury in 4 of them was a fall on an outstretched hand.
One of them sustained bilateral radial head fractures
following a Road Traffic Accident; however one side
was associated with elbow dislocation and included in
the study. The opposite radial head was fixed using a
Herbert’s screw. Radial head replacement was done in
all 5 patients as a primary procedure.
The average age of the patients included in the
study was 38.4 years. Four males and one female in the
study. The Mayo’s scoring was recorded on each follow
up visit. The following table shows the Mayo’s score on
their final follow up.
Stability
10
10
10
10
10
Function
25
25
25
25
25
Total
100
85
95
80
80
Functional Outcome as Measured by
MEPS
This shows excellent result in 2 of the patients and good
results for the other 3. None of the patients had a fair or
poor result as per MEPS scoring. None of the patients
had any signs of infection or implant loosening. There
were also no signs of elbow instability. The range
of movements were favourable and the patients were
themselves satisfied with the outcome.
Discussion
Radial head fractures constitute about 33% of fractures
around the elbow, while bilateral radial head fractures
are rare injuries. Usually the fracture of radial head
occurs by fall on outstretched hand, with the force
transmitted along the axis of forearm causing compression of the radial head against the capitellum causing
fracture of radial head and may cause macroscopic
Kerala Journal of Orthopaedicskjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015
Roncy Savio Kuruvilla et al
damage to capitellum. Anatomically the radial head is
susceptible to fractures because of a 15◦ angle between
the radial neck and shaft. The greater carrying angle
in females may explain the higher incidence of this
fracture in women.
The routine AP and Lateral radiographs are
adequate to diagnose a radial head fracture; internal
and external oblique radiographs are required rarely.
The excision of radial head is recommended by
many authors but recently there has been growing
interest in fixation of radial head fractures as operative
skills and technology improves. The surgical approach
for radial head excision which is mostly used is
Kocher’s exposure, as it provides greater protection for
posterior interosseous nerve but attention must be paid
for protection of LCL complex. Another interval is the
Kaplan interval between extensor carpi radialis brevis
and the extensor digitorum communis muscle 11,12 .
The importance of this timely report is that all
radial head fractures should be diagnosed promptly
and should be treated in a proper manner with early
rehabilitation to avoid complications.
Conclusion
Radial head replacement for irreparable radial head
fractures shows Excellent to good outcome in our
study.
A good operative technique, choice of implant and
early post operative mobilisation is imperative for the
final functional outcome of the patient.
57
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Morrey RC. Fractures of the head and neck of the radius. Br J
Surg 1940;28:106–118.
Hodge JC. Bilateral radial head and neck fractures. J Emerg
Med. 1999;17:877–881.
Manns RA and Lee JR. Critical evaluation of the radial
head-capitellum view in acute elbow with effusion. Clin Radiol.
1990;42:433–436
Mason ML. Some observations on fractures of the radial head
with a review of one hundred cases. Br J Surg. 1954;42:123.
Beingessner DM, Dunning CE, Gordon KD, Johnson JA and
King GJ. The effect of radial head excision and arthroplasty on
elbow kinematics and stability. J Bone Joint Surg Am
2004;86:1730.
King GJ. Management of comminuted radial head fractures
with replacement arthroplasty. Hand Clin 2004;20:429–441.
Radin EL and Riseborough EJ. Fractures of the radial head: A
review of eighty-eight cases and analysis of the indications for
excision of the radial head and non operative treatment. J Bone
Joint Surg 1966;48:1055–1064.
Kocher T. Textbook of operative surgery. 3rd ed. London: Adam
and Charles Black. 1911.
Morrey BF. Surgical exposures of the elbow In: Morrey BF, ed.
The Elbow and Its Disorders.2nd ed. Philadelphia:WB
Saunders. 1993:139–166.
Morrey BF, An KN and Chao EYS. Functional evaluation of the
elbow. In: Morrey BF, ed. The Elbow and its disorders, 2nd ed.
Philadelphia: WB Saunders, 1993.
Ring D. Open reduction and internal fixation of fractures of the
radial head. Hand Clin 2004;20:415.
Ring D, Quintero J and Jupiter JB. Open reduction and internal
fixation of fractures of the radial head. J Bone Joint Surg Am
2002;84:1811–1815.
Mikic ZD and Vukadinovic SM. Late results in fractures of the
radial head treated by excision. Clin Orthop 1983;181:220–228.
Ring D and King G. Radial head arthroplasty with a modular
metal spacer to treat acute traumatic elbow instability. Surgical
technique. J Bone Joint Surg Am 2008;90:63–73.
Kerala Journal of Orthopaedicskjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015