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ORIF of Radial Head Fractures

- Discussion:
      -The surgical treatment of isolated mason type 2 fractures of the radial head in adults: comparison between radial head resection and open reduction and internal fixation.

    - posterolateral approach: (Kocher Approach)
          - approach the fascial plane between the ECU and anconeus muscle
          - direct lateral approach is preferred by some surgeons because it spares the lateral ulnohumeral ligament; 
          - it is essential that LCL is not damaged, and hence the dissection procedes anterior to lateral ligament and anterior to the head and neck; 
          - at the time of surgery, look for injury to the lateral ligamentous complex, and consider operative repair if instability is an issue; 
          - anterior surface of the lateral epicondyle is exposed, and subsequent dissection achieves full visualization of the articular surface;
          - further visualization is achieved w/ forearm pronation;
          - reduction and temporary fixation is obtained w/ K wires or tenaculum clamp;
          - often these frx require insertion of 2 or more screws parallel to joint line, w/ one screw placed in anterior half and one placed in posterior half;
          - application of a plate requires more distal exposure; 
          - if stable anatomic reduction cannot be obtained, then frx fragment is excised
    - enhanced exposure:
           - can be enlarged w/ osteotomy of lateral epicondyle & its reflection anteriorly with the extensor muscle origins;
           - radial nerve is identified in the substance of the supinator;
           - temporary fixation with K wires following reduction; 
           - suture anchors can be attached to the lateral epicondyle; 
- Implants: (safe zone for implant insertion)
        - proximal radial plate:
        - dorsal distal radius plate (may be contoured to fit the radial head and neck);
        - minicondylar plate;
                  - indicated if the head requires attachment to the neck;
                  - consider use of 2.0 or 2.7 mm L-shaped plate; 
        - screws:
                  - note that most radial head frx occur thru non articulating portion of radial head, which allows screws to be placed w/o having to counter-sink screw head; 
                  - AO screws: 1.5, 2.0 or 2.7 mm cortex, depending on size of fragment; 
                  - most often 2.7 mm miniscrews are chosen and are countersunk to avoid screw prominence;
                  - if a coutnersink is to be used, be sure that the screw is not too long, so as the screw tip does not extend beyond the cortical surface;
                  - over drilling of the proximal fragment is not required (can result in fragment comminution), especially if the fragment is held in compression during screw insertion;
                  - for lag screw effect, 2.7 mm drill-gliding hole is made thru the near cortical fragment, which is followed by 2 mm drill hole; 

- Complications
    - posterolateral instability
    - avascular necrosis:
           - may occur following ORIF of comminuted fractures when most of the soft tissue attachements have been stripped;
           - when this complication occurs and is symptomatic, a delayed excision may be performed once the capsulo-ligamentous structures have healed;
    - non union:
           - in the presentation by Ring D, et al (15th Annual Meeting of Orthopaedic Trauma Association, 1999), the authors noted 7 patients with radial head non union following ORIF on 70 patients;
                   - the authors point out that the limited blood supply may lead to the relatively high occurance of non union;

  Case Example:


Comminuted Fractures of the Radial Head. Comparison of Resection and Internal Fixation.

Repairing the annular ligament is not necessary in the operation of Mason type 2, 3 isolated radial head fractures if the lateral collateral ligament is intact: Minimum 5 years follow-up.