FRCS (Tr & Orth) Oral Examination: Abbreviated Fractures of the Radial Head Case Presentation
A 32-year-old man fell while rollerblading, injuring his left dominant elbow. He complained of pain and a reduced range of movement. These are the emergency department radiographs, which shows an isolated injury.
1. How would you manage this patient?
This shows a minimally displaced fracture of the radial head. I would complete a history and a full examination of the patient, confirm that this is a closed injury and that there is no neurovascular deficit. I would ensure that the patient has adequate analgesia and carefully assess the range of movement, accepting that this may be limited due to pain. While some surgeons might aspirate the joint for hematoma, I do not routinely do so. I would immobilize the limb with a collar and cuff and advise analgesia, early movement, and physiotherapy. I would also review the patient in the fracture clinic at the 2-week point to reassess them and ensure that their pain was settling, the range of movement was improving, there was no clear mechanical block to forearm rotation, and there had not been any radiographic fracture displacement.
For a minimally displaced fracture of the radial head, a complete history and full examination should be conducted to ensure that the injury is closed and that there is no neurovascular deficit. Adequate analgesia should be provided, and the range of movement should be carefully assessed, although limitations may be expected due to pain. Immobilization with a collar and cuff, along with advice for analgesia, early movement, and physiotherapy, is recommended. A 2-week follow-up in the fracture clinic should be scheduled to reassess the patient for pain relief, improved range of motion, and radiographic fracture displacement.
2. What would your indications for surgery be?
Surgery would be considered for a radial head fracture associated with more complex fracture dislocations of the elbow where joint stability is compromised. Surgery would also be indicated for isolated radial head fractures that are open injuries, where there is a mechanical block to movement, or for displaced fractures where healing of the displaced fracture fragments in situ will lead to impingement or subsequent loss of motion.
Surgery for radial head fractures would be indicated in cases where the fracture is associated with more complex fracture dislocations of the elbow and joint stability is compromised. Surgery would also be recommended for isolated fractures of the radial head that are open injuries, where there is a mechanical block to movement, or for displaced fractures where healing of the displaced fracture fragments in situ will lead to impingement or subsequent loss of motion.
3. How would you decide between fixation and replacement for comminuted fracture types?
For comminuted fracture types, open reduction and internal fixation would be reserved for non-comminuted fractures with three or fewer fragments. Attempted fixation of more comminuted fractures is often prone to failure of fixation and non-union. For more comminuted fracture patterns where the fracture is not fixable and elbow stability may be compromised, radial head replacement may be more reliable. Radial head resection may also be an option in non-repairable fractures where a careful assessment shows that the remaining stabilizers of the elbow joint are intact. It should also be noted that non-repairable fracture patterns are often associated with higher-energy injuries, which have a higher associated rate of ligamentous and other bony injuries that need to be carefully excluded.
For comminuted fractures of the radial head, open reduction and internal fixation are best reserved for non-comminuted fractures with three or fewer fragments. Fixation attempts for more comminuted fractures are often prone to failure of fixation and non-union. For more comminuted fracture patterns that are not fixable and compromising elbow stability, radial head replacement may be more reliable. Additionally, radial head resection may be an option in non-repairable fractures, where a careful assessment shows that the remaining stabilizers of the elbow joint are intact. However, it is important to note that non-repairable fracture patterns are often associated with higher-energy injuries, which have a higher associated rate of ligamentous and other bony injuries that should be carefully excluded.
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