import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Enters supinator muscle 10-20mm distal to radial head, anterior branch of radial nerve, lies anterior to radial neck in supination **Protection**: Maintain full forearm supination throughout approach, stay proximal to 2cm distal to radial head, avoid retractor placement into supinator muscle **Location**: Anterior to lateral epicondyle and radiocapitellar joint, 20-30mm anterior to skin incision, divides into PIN and superficial sensory branch at level of radiocapitellar joint **Protection**: Avoid anterior dissection beyond capsular incision, stay within Kocher interval (ECU-anconeus), no anterior retractors **Location**: From lateral epicondyle to supinator crest, forms posterolateral corner, primary restraint to posterolateral rotatory instability **Protection**: Identify and preserve during Kocher interval development, tag with suture if detached and repair at closure, avoid excessive posterior dissection **Location**: Encircles radial neck from anterior to posterior sigmoid notch, stabilizes proximal radioulnar joint, attaches to anterior and posterior margins of sigmoid notch **Protection**: Minimize dissection around radial neck, repair if incised for fracture exposure, avoid circumferential dissection that destabilizes PRUJ **Location**: Anterior bundle from medial epicondyle to sublime tubercle of coronoid, primary valgus restraint, at risk in associated elbow dislocation **Protection**: Assess stability under fluoroscopy with valgus stress, repair via separate medial approach if opens greater than 3mm, avoid excessive valgus force during reduction **Patient Position**: Supine with arm across chest or on hand table, or lateral decubitus **Surgical Approach**: Lateral Kocher approach (between ECU and anconeus) or direct lateral splitting EDC **Incision**: 6-10cm lateral incision centered over radial head from lateral epicondyle extending distally ### Absolute Indications - Displaced Mason type 2 fractures (marginal fragment greater than 2mm displaced, greater than 30% articular surface) - Mason type 3 fractures if reconstructable with stable fixation (alternative is arthroplasty) - Block to forearm rotation - mechanical impingement from displaced fragment - Associated elbow instability requiring radial head preservation (terrible triad, Essex-Lopresti) ### Relative Indications - Mason type 2 fractures with 2mm displacement but patient preference for surgery - Radial head fracture with concurrent MCL or LCL injury requiring stability - Marginal fractures involving greater than 25% of radial head circumference ### Contraindications - Mason type 1 fractures (less than 2mm displacement, no block to rotation) - Comminuted fractures not amenable to stable fixation (consider arthroplasty) - Active infection at surgical site - Medical comorbidities precluding surgery - Small fragment less than 25% of head circumference (consider excision if stable elbow) ### Mason Classification (1954) - Most Common **Type 1**: Undisplaced or minimally displaced (less than 2mm), no mechanical block to rotation - Treatment: Non-operative with early ROM **Type 2**: Displaced fracture (greater than 2mm) with potential mechanical block, usually involves greater than 30% of articular surface - Treatment: ORIF if reconstructable, excision if small fragment and stable elbow **Type 3**: Comminuted fracture with multiple fragments - Treatment: ORIF if reconstructable, arthroplasty if not reconstructable, excision only if stable elbow **Type 4**: Radial head fracture with associated elbow dislocation - Treatment: Address all components of instability (radial head, coronoid, ligaments) ### Hotchkiss Modification (1997) - Type 1: Non-displaced or minimally displaced - Type 2: Displaced greater than 2mm but reconstructable - Type 3A: Comminuted but reconstructable - Type 3B: Comminuted not reconstructable - Type 4: Associated with elbow dislocation ### Decision Making Based on Classification - **Type 1**: Non-operative, early ROM, NSAIDs for pain - **Type 2**: ORIF if fragment greater than 25% of head, good bone quality, no severe comminution - **Type 3A**: ORIF with plate if stable construct achievable - **Type 3B**: Arthroplasty if elbow unstable, excision if stable - **Type 4**: Comprehensive approach to terrible triad ### Terrible Triad of the Elbow **Definition**: Radial head fracture + coronoid fracture + elbow dislocation **Mechanism**: Posterolateral rotatory force with axial load **Pathoanatomy**: - Stage 1: LUCL disruption with posterolateral subluxation - Stage 2: Coronoid fracture (usually tip or anteromedial facet) - Stage 3: Radial head fracture - Stage 3B: MCL rupture with complete dislocation **Management Sequence**: 1. Coronoid fixation first (establishes foundation for valgus stability) 2. Radial head ORIF or arthroplasty (lateral column stability) 3. LUCL repair (posterolateral rotatory stability) 4. MCL assessment and repair if valgus instability persists ### Essex-Lopresti Injury **Definition**: Longitudinal radioulnar dissociation - Radial head fracture - Interosseous membrane disruption - DRUJ disruption **Clinical Signs**: - Radial head fracture with wrist pain - DRUJ tenderness and instability - Positive DRUJ stress test (piano key sign) - Proximal radial migration on AP forearm radiograph **Management Principles**: - Radial head MUST be preserved (ORIF or arthroplasty) - Excision contraindicated - causes progressive radial migration - DRUJ assessment and repair if unstable - Consider interosseous membrane reconstruction if acute - Post-op splinting with forearm supinated and wrist neutral ### Associated MCL Injury **Assessment**: Valgus stress under fluoroscopy - Opening greater than 3mm = MCL disruption requiring repair **Management**: Separate medial approach for MCL repair if unstable ### Kocher Approach Anatomy **Internervous Plane**: Between ECU (PIN) and anconeus (PIN) - True internervous plane as both muscles supplied by PIN - Safe for PIN as nerve remains anterior in supination **Key Landmarks**: - Lateral epicondyle (origin of LUCL and common extensors) - Radial head (palpable with forearm rotation) - Supinator crest (insertion of LUCL) **Superficial Dissection**: - Incise fascia between ECU and anconeus - Identify LUCL running from lateral epicondyle to supinator crest - Preserve or tag LUCL if detached **Deep Dissection**: - Incise lateral capsule longitudinally - Maintain forearm supination to protect PIN - Expose radial head and neck ### Safe Zone Concept **Anatomic Basis**: - Radial head articulates with sigmoid notch through 250° arc during rotation - Safe zone is 110° arc on anterolateral radial head without PRUJ articulation **Identification**: 1. Arm at side, forearm supinated 2. Mark lateral aspect of radial head with K-wire under fluoroscopy 3. This is center of safe zone 4. Safe zone extends approximately 55° anterior and posterior **Clinical Significance**: - Hardware outside safe zone impinges on PRUJ during rotation - Causes pain, stiffness, loss of forearm rotation - Plate positioning critical - must be low-profile and in safe zone ### Fixation Options **Headless Compression Screws**: - 2.0-2.4mm buried beneath articular cartilage - Advantages: No prominence, minimal hardware - Disadvantages: Need adequate fragment size (greater than 25% of head) - Technique: Countersink screw head below cartilage surface **Mini-Fragment Plates**: - 2.0-2.4mm plate contoured to radial head - Advantages: Better for comminution, more stable construct - Disadvantages: Risk of prominence if not in safe zone - Technique: Low-profile, anatomic contouring, position in safe zone **Combination**: - Plate for main fracture line - Lag screws for additional fragments - Optimize stability while minimizing hardware ### PIN Injury Prevention **Risk Factors**: - Forearm pronation during approach - Dissection greater than 2cm distal to radial head - Retractor placement into supinator muscle **Prevention**: - Maintain full forearm supination throughout - Stay proximal to safe zone for dissection - Avoid retractors anterior to radial head **Recognition**: Post-op weakness of thumb/finger extension (EPL, EDC, EIP) **Management**: Observation for 3-6 months (usually neuropraxia), explore if no recovery ### Heterotopic Ossification Prevention **Risk Factors**: - Associated head injury - Burns - Delayed surgery - Extensive soft tissue dissection **Prevention**: - Gentle soft tissue handling - Early ROM within 48-72 hours - Indomethacin 25mg TDS for 6 weeks (if high risk) - Low-dose radiation (700cGy single dose within 72 hours post-op) **Management**: Observation if asymptomatic, excision after maturation if limiting function ### Stiffness Prevention **Risk Factors**: - Prolonged immobilization - Articular step-off - Hardware prominence - Heterotopic ossification **Prevention**: - Stable fixation allowing early motion - Anatomic reduction (less than 1mm step-off) - Brief splinting (48-72 hours only) - Aggressive active ROM from week 1-2 **Management**: Arthroscopic or open capsular release after 6 months if severe ### Post-Traumatic Arthritis Prevention **Risk Factors**: - Articular incongruity (greater than 1mm step-off) - Cartilage damage at initial injury - Hardware prominence causing mechanical wear **Prevention**: - Anatomic articular reduction - Bury screws beneath cartilage - Low-profile plate positioning **Management**: Non-operative initially, radial head excision or arthroplasty if severe symptoms ### Step 1: Assess under anesthesia Assess under anesthesia: test elbow stability with valgus and posterolateral rotatory stress. Under fluoroscopy, apply valgus stress to assess MCL: if opens greater than 3mm has MCL injury needing repair. Posterolateral rotatory test for lateral ligament: if subluxates has LUCL injury. Block to forearm rotation indicates mechanical impingement from displaced fragment - absolute indication for surgery. **Technical Tip**: EXAM KEY: Stability assessment under anesthesia critical before deciding ORIF vs excision - unstable elbow requires radial head preservation. - Excessive force causing additional injury to already compromised ligaments - Failure to identify associated instability patterns requiring comprehensive repair ### Step 2: Position supine with arm across chest or on hand table, or lateral decubitus Position supine with arm across chest or on hand table, or lateral decubitus. Must allow full elbow flexion-extension and forearm pronation-supination for intraoperative assessment. Lateral decubitus gives good access if other injuries. Supine with arm across chest standard. Ensure shoulder abducted less than 90° to avoid brachial plexus traction. **Technical Tip**: EXAM KEY: Test positioning before draping - must achieve full supination (PIN protection) and rotation (assess PRUJ stability). - Brachial plexus traction from excessive shoulder abduction - Inadequate positioning preventing intraoperative stability assessment ### Step 3: Mark incision 6-10cm lateral, centered over radial head Mark incision 6-10cm lateral, centered over radial head. Palpate lateral epicondyle, radial head (rotates with forearm), ulna. Incision from lateral epicondyle extending 6-8cm distally. Can curve slightly posterior to follow Kocher internervous plane. **Technical Tip**: EXAM KEY: Palpate radial head with forearm rotation to confirm level before incision - prevents too proximal or distal approach. - Skin necrosis from excessive tension or poor tissue handling - Incision too anterior risking radial nerve proper injury ### Step 4: Full forearm supination and maintain throughout approach Full forearm supination and maintain throughout approach. PIN enters supinator 1-2cm distal to radial head in pronation, but rotates anteriorly away from field in supination. Maintain full supination throughout approach and deep dissection for maximum safety. Have assistant hold forearm in supination. **Technical Tip**: EXAM KEY: Supination is key to PIN protection - test and maintain throughout approach. Most PIN injuries from forearm pronation during dissection. - PIN injury if forearm pronates during dissection - Inadvertent relaxation of supination during critical dissection steps ### Step 5: Incise skin and subcutaneous tissue, identify Kocher interval Incise skin and subcutaneous tissue, identify Kocher interval. Develop internervous plane between anconeus (posterior interosseous nerve) posteriorly and ECU (posterior interosseous nerve) anteriorly. Palpate interval between muscle bellies. Both supplied by PIN so safe internervous plane. **Technical Tip**: EXAM KEY: Kocher interval is true internervous plane - safe for PIN as both muscles supplied by it, nerve remains anterior in supination. - Nerve injury from dissection anterior to proper plane - Neuropraxia from excessive retractor pressure ### Step 6: Develop Kocher interval, expose lateral capsule Develop Kocher interval, expose lateral capsule. Bluntly separate anconeus from ECU with finger or instrument. Identify LUCL running from lateral epicondyle to supinator crest - preserve or tag for repair. Incise capsule longitudinally to expose radial head and neck. Minimal periosteal elevation to reduce heterotopic ossification risk. **Technical Tip**: EXAM KEY: LUCL is critical for posterolateral stability - identify and preserve, or tag if detached and repair at closure. - LUCL disruption causing iatrogenic posterolateral instability - Excessive periosteal stripping increasing heterotopic ossification risk ### Step 7: Assess fracture pattern and fragment size/number Assess fracture pattern and fragment size/number. Inspect articular surface. Count fragments and assess size - need greater than 25% of head circumference for stable fixation. If less than 25% or greater than 3 fragments with poor bone quality, consider arthroplasty over ORIF. Clear hematoma and debris with irrigation and visualization. **Technical Tip**: EXAM KEY: Intraoperative decision making - if too comminuted for stable ORIF, convert to arthroplasty rather than attempting doomed fixation. - Proceeding with ORIF when fracture not amenable to stable fixation - Losing small fragments during irrigation ### Step 8: Anatomic reduction of articular surface, less than 1mm step-off Anatomic reduction of articular surface, less than 1mm step-off. Reduce fragments to restore spherical radial head contour. Use dental pick or freer to lever fragments. Check reduction from anterior, lateral, posterior views. Accept less than 1mm step-off for best functional outcome. Greater than 1mm step-off leads to post-traumatic arthritis. **Technical Tip**: EXAM KEY: Articular step-off greater than 1mm causes post-traumatic arthritis and poor outcome - take time to achieve anatomic reduction. - Inadequate reduction leaving articular incongruity - Iatrogenic fracture from aggressive manipulation ### Step 9: Provisional fixation with 0.9-1.0mm K-wires Provisional fixation with 0.9-1.0mm K-wires. Hold reduction with small K-wires outside safe zone (remove later) or small pointed reduction forceps. Confirm reduction with fluoroscopy AP and lateral, and direct visualization checking articular congruity. Multiple views essential to assess 3-dimensional reduction. **Technical Tip**: EXAM KEY: Provisional fixation allows assessment before committing to screw placement - easier to adjust reduction now than after screws placed. - K-wire placement in safe zone interfering with definitive fixation - Inadequate provisional fixation allowing reduction loss ### Step 10: Identify safe zone for hardware placement (110° anterolateral arc) Identify safe zone for hardware placement (110° anterolateral arc). With forearm supinated and shoulder at side, mark lateral aspect of radial head under fluoroscopy - this is center of safe zone. Safe zone extends approximately 55° anterior and posterior. Place all hardware within this arc to avoid PRUJ impingement. Mark boundaries with K-wires or methylene blue. **Technical Tip**: EXAM KEY: Safe zone concept critical - hardware outside this zone impinges on PRUJ with rotation causing pain, stiffness, and forearm rotation loss. - Incorrect safe zone identification leading to hardware prominence - Rotation of forearm during marking changing safe zone position ### Step 11: Definitive fixation: buried headless screws or mini-fragment plate Definitive fixation: buried headless screws or mini-fragment plate. Headless screws 2.0-2.4mm buried beneath articular cartilage in safe zone, or mini-fragment (2.0-2.4mm) plate contoured to radial head in safe zone. Plate gives more stability for comminution. At least 2 screws for fragment greater than 25%. Countersink screw heads below cartilage surface. Contour plate anatomically to radial head curvature. **Technical Tip**: EXAM KEY: Buried headless screws avoid prominence but need adequate fragment size. Plate better for comminution but must be in safe zone and low-profile. - Malposition of hardware outside safe zone - Screw prominence above cartilage causing articular damage ### Step 12: Remove provisional K-wires, test reduction and PRUJ stability Remove provisional K-wires, test reduction and PRUJ stability. Rotate forearm through full pronation-supination while palpating radial head - should be smooth without crepitus or catching. No hardware prominence with rotation. Assess PRUJ stability - radial head should not sublux anteriorly or posteriorly. Fluoroscopy in pronation and supination to confirm no hardware impingement. **Technical Tip**: EXAM KEY: Intraoperative rotation testing identifies hardware prominence or PRUJ instability before closure - revise if problems identified. - Missing hardware prominence that will cause post-op pain and stiffness - Inadequate stability assessment leading to post-op instability ### Step 13: Repair annular ligament if incised for exposure Repair annular ligament if incised for exposure. If annular ligament incised to expose fracture, repair with absorbable 2-0 suture to restore PRUJ stability. Side-to-side repair without overtightening. Test forearm rotation after repair - should be smooth through full arc. **Technical Tip**: EXAM KEY: Annular ligament stabilizes proximal radioulnar joint - failure to repair causes PRUJ instability and forearm rotation loss. - Over-tightening annular ligament causing restricted rotation - Inadequate repair leading to chronic PRUJ instability ### Step 14: Assess elbow stability under fluoroscopy, repair ligaments if unstable Assess elbow stability under fluoroscopy, repair ligaments if unstable. Valgus stress test: if opens greater than 3mm medially, has MCL injury requiring repair. Posterolateral rotatory test: if subluxates, LUCL requires repair. If terrible triad, address coronoid fracture if not already done. Document stability with fluoroscopic images. **Technical Tip**: EXAM KEY: Stability assessment after radial head fixation determines need for ligament repair - unstable elbow doomed to poor outcome without ligament repair. - Missing associated instability requiring ligament repair - Excessive force during testing causing additional injury ### Step 15: If LUCL injured: repair to lateral epicondyle with suture anchors If LUCL injured: repair to lateral epicondyle with suture anchors. Debride footprint on lateral epicondyle to bleeding bone. 2-3 suture anchors in epicondyle, pass through LUCL and common extensor origin, tie with elbow reduced. Test stability after repair - should resist posterolateral rotatory stress. **Technical Tip**: EXAM KEY: LUCL is primary restraint to posterolateral rotatory instability - anatomic repair to epicondyle essential for stability. - Non-anatomic repair leading to persistent instability - Over-tensioning causing elbow stiffness ### Step 16: Irrigate thoroughly, achieve hemostasis Irrigate thoroughly, achieve hemostasis. Pulse lavage with 3L saline to remove debris and reduce infection risk. Bipolar cautery for bleeding. Check hemostasis with tourniquet down before closure. Minimize hematoma formation to reduce heterotopic ossification risk. **Technical Tip**: EXAM KEY: Hematoma increases heterotopic ossification risk - meticulous hemostasis and consider drain if extensive dissection. - Thermal injury to PIN from cautery near supinator - Inadequate hemostasis leading to hematoma and heterotopic ossification ### Step 17: Repair capsule with absorbable suture Repair capsule with absorbable suture. Close lateral capsule with 2-0 absorbable suture. Creates soft tissue envelope protecting radial head. Don't overtighten - should allow rotation. Test ROM before completing capsular closure. **Technical Tip**: EXAM KEY: Capsular repair provides soft tissue stability but must allow rotation - test ROM before tying sutures. - Over-tightening capsule causing post-op stiffness - Inadequate repair allowing capsular insufficiency ### Step 18: Close Kocher interval, subcutaneous layer, skin Close Kocher interval, subcutaneous layer, skin. Approximate anconeus-ECU interval with absorbable suture. Subcutaneous with 3-0 absorbable. Skin with monofilament or staples. Avoid tension on wound edges. Gentle tissue handling throughout to minimize scarring. **Technical Tip**: EXAM KEY: Gentle tissue handling and tension-free closure reduces complications - heterotopic ossification and wound problems common after elbow trauma. - Wound tension causing dehiscence or skin necrosis - Excessive tissue trauma increasing heterotopic ossification risk ### Step 19: Apply soft dressing and posterior elbow splint at 90° flexion Apply soft dressing and posterior elbow splint at 90° flexion. Soft padding then splint at 90° flexion, forearm neutral. Splint for comfort and soft tissue rest 48-72 hours only, not for fracture stability. Remove for early ROM exercises. Educate patient on importance of early motion. **Technical Tip**: EXAM KEY: Elbow stiffness is major complication - brief splinting for comfort only, emphasize early ROM to prevent stiffness. - Prolonged immobilization causing severe stiffness - Splint too tight causing compartment syndrome or nerve compression ### Step 20: Post-operative protocol: early ROM to prevent stiffness Post-operative protocol: early ROM to prevent stiffness. Day 1-2: remove splint for gentle active ROM exercises 3-4 times per day within comfort. Week 2: aggressive active ROM, begin forearm rotation. Week 4-6: progressive strengthening. Consider indomethacin 25mg TDS for 6 weeks if high risk for HO. Avoid passive stretching for first 6 weeks. **Technical Tip**: EXAM KEY: Stiffness is enemy after radial head fracture - early aggressive ROM essential. Indomethacin reduces heterotopic ossification if high-risk patient. - Patient non-compliance with ROM leading to stiffness - Overly aggressive passive stretching causing inflammation and increased HO risk 1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42(172):123-132. doi:10.1002/bjs.18004217203 2. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5(1):1-10. doi:10.5435/00124635-199701000-00001 3. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547-551. doi:10.2106/00004623-200204000-00006 4. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17(3):137-151. doi:10.5435/00124635-200903000-00002 5. Guitton TG, Ring D. Science of Variation Group. Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. J Bone Joint Surg Am. 2011;93(21):2015-2021. doi:10.2106/JBJS.J.00711 6. Doornberg JN, Parisien R, van Duijnhoven N, Kloen P. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007;89(5):1075-1080. doi:10.2106/JBJS.F.00608 7. Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: surgical technique and clinical experience. J Orthop Trauma. 2007;21(10):718-724. doi:10.1097/BOT.0b013e318158ab44 8. Grewal R, MacDermid JC, King GJ. Open reduction internal fixation versus excision of radial head fractures: a systematic review. J Hand Surg Am. 2009;34(10):1861-1869. doi:10.1016/j.jhsa.2009.09.007 9. Struijs PA, Smit G, Steller EP. Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review. Arch Orthop Trauma Surg. 2007;127(2):125-130. doi:10.1007/s00402-006-0240-9 10. Kaas L, van Riet RP, Vroemen JP, Eygendaal D. The epidemiology of radial head fractures. J Shoulder Elbow Surg. 2010;19(4):520-523. doi:10.1016/j.jse.2009.10.015

Open Reduction Internal Fixation of Radial Head Fracture

Open Reduction Internal Fixation of Radial Head Fracture