The Role of Prosthetic Replacement in the Management of Comminuted Radial Head Fractures

The role of prosthetic replacement in the management of comminutedradial head fractures

A. Mohan Krishnaa, N. Somasekhar Reddyb,*

ABSTRACT

A displaced and badly comminuted fracture of the radial head is part of a complex instability injury of 3 joints namelyelbow, radio-ulnar and wrist joints. If it is associated with Mason type IV and Essex Lopresti injury to forearm, simpleexcision of the radial head may lead to instability of the elbow joint and painfully restricted movements of the wrist.Management should be aimed at achieving the normal anatomy so that the function of elbow, radio-ulnar and wristjoints will be restored to a satisfactory level. We report the medium term result of a patient who had prostheticreplacement of radial head. Our patient in this case report was informed, that the details of the management would besubmitted for publication.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Radial head fracture, Radial head prosthesis, Fracture dislocation of elbow, Radial head replacement,Radial head fracture with DRUJ instability

CASE REPORT

A 30-year-old gentleman was admitted following a roadtraffic accident with injury to his right upper limb. Hehad an elbow deformity with pain over forearm down tothe wrist. He has mild fullness over volar aspect of the fore-arm with tenderness over the dorsum of the distal radio-ulnar joint and wrist joints with limitation of movements.X-rays confirmed dislocation of the elbow joint witha comminuted, displaced fracture of the radial head andfracture of the tip of the coronoid process. There was nogross dislocation at the distal radio-ulnar joint on theX-ray (Fig. 1).

Surgery was done under brachial block. Dislocation wasfirst reduced. Radial head was exposed through a posterolateral approach. It was found to be too comminuted tofix and was excised. There was about 3e5 mm of lineartranslatory movement between the radius and ulna confirm-ing the axial forearm instability. Then the radial head was

recreated using the excised fragments. It is very importantfor two reasons. One is to make sure that all the brokenpieces were removed. The second reason is to size theappropriate prosthetic component. Radial neck wasprepared to get a uniform cut and the medullary canalwas prepared with a gouge and a narrow pointed rasp.Sometimes a high-speed burr is necessary to shape themedullary canal to accept the stem of the trial component.The preparation of the medullary canal can be tedious asone cannot hammer the prosthesis in to the canal due tothe high risk of fracture of radial neck and shaft. I usedchrome cobalt uncemented prosthesis (Corin) (Fig. 2).This implant comes in three diameters and each diametercomes with a thick and a thin head, making a total of 6sizes. When the natural radial head diameter falls inbetween the prosthetic sizes it is advisable to go for thesmaller prosthetic head. This is to prevent over stuffingthe proximal radio-ulnar joint. But the thickness of thehead should be maintained as close to the natural as

aConsultant Orthopaedic Surgeon, bSenior Consultant Orthopaedic Surgeon, Apollo Hospitals, Hyderabad, India.* Corresponding author. Room No. 957, Apollo Hospitals, Jubilee Hills, Hyderabad 500 033, India. Tel.: þ91 98480 25355, email: nreddy12@yahoo.comReceived: 4.7.2012; Accepted: 4.8.2012; Available online 21.8.2012Copyright � 2012, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2012.08.002

Apollo Medicine 2012 DecemberVolume 9, Number 4; pp. 336e338 Case Report

possible by inserting less or more of the prosthetic stem into the medullary canal to appropriately support the capitel-lum. There was no valgus instability after reducing theradial head suggesting the integrity of medial collateralligament. At 90� of flexion elbow joint was stable andhence no attempt was made to fix the small fragment ofcoronoid process. Elbow was immobilised at about 100�

of flexion and forearm in full supination to maintainmaximum interosseous space.

Active and active assisted movements were started after3 weeks. Four months following the procedure, patientregained 15� short of full extension with terminal restrictionof flexion. There was terminal restriction of both supinationand pronation. Elbow joint was stable and he has no pain at

DRUJ or wrist joint. At his next visit at 18 monthsfollowing surgery he has full pronation with marginalimprovement in flexion and extension. X-ray of the elbowdid not show any evidence of prosthesis loosening orerosion of the capitellum.

DISCUSSION

Resection of the radial head for simple fractures has beenshown to give satisfactory long term results.1,2 Howeverunrecognised complex injuries with elbow or axial forearminstability may be responsible for unstable elbow, proximalmigration of radius, with or without chronic wrist pain.3

This instability is a major concern in young and activepeople whereas in a relatively sedentary and elderly peopleit may not cause any significant problem for the day to dayactivities. Silicon radial head prosthesis did not offer rigidstability. Proximal migration of the radius progressed withbreak-up of the implant and subsequent synovitis.4,5

Metallic radial head offered better stability against valgusforces at elbow and axial forearm instability.6e8 Howeverover stuffing of the radio capitellar joint must be avoided,as it may produce capitellar erosion especially when doneas a late reconstructive procedure for chronic wrist pain.9

We recommend this procedure strongly in young peopleto avoid long term consequences of elbow, radio-ulnarand wrist joint instabilities. Loosening of the stem asa major complication was not reported in the literaturewhen the procedure was done in young people. We believethat for any reason if the prosthesis has to be explanted aftera period of 6e12 months it may not lead to any instabilitiesmentioned above as the interosseous membrane and othersoft tissues would have got stabilised by then to a largeextent preventing proximal migration of radial shaft. Eventhough the role of radial head prosthesis in stabilising theelbow and axial forearm instability seems well proven, itis being used less often mainly because of lack of aware-ness of secondary instability and non-availability of radialhead prosthesis.

CONFLICTS OF INTEREST

All authors have none to declare.

REFERENCES

1. Goldberg I, Peylan J, Yosipovitch Z. Late results of excision ofthe radial head for an isolated closed fracture. J Bone Joint SurgAm. 1986;68:675e679.

Fig. 1 Pre-operative X-ray showing fracture dislocation ofelbow joint.

Fig. 2 Post-operative X-ray showing radial head replacement.

The role of prosthetic replacement in the management of comminuted radial head fractures Case Report 337

2. Morrey BF, Chao EY, Hui FC. Biomechanical study of theelbow following excision of the radial head. J Bone JointSurg Am. 1979;61:63e68.

3. Sowa DT, Hotchkiss RN, Welland AJ. Symptomatic proximaltranslation of the radius following radial head resection. ClinOrthop. 1995;317:106e113.

4. Morrey BF, Askew L, Chao EY. Silastic prosthesis replacementfor the radial head. J Bone Joint Surg Am. 1981;63:454e458.

5. Valderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflam-matory arthritis after failure of silicon rubber replacement of theradial head. J Bone Joint Surg Br. 1994;76:78e81.

6. Moro JK, Werler J, MacDermid JC, Patterson SD, King GJ.Arthroplasty with a metal radial head for unreconstructable

fractures of the radial head. J Bone Joint Surg Am. 2001;83:1201e1211.

7. Bain GI, Ashwood N, Baird R, Unni R. Management of Masontype III radial head fractures with a titanium prosthesis, liga-ment repair, and early mobilization. J Bone Joint Surg Am.2005;87:65e76.

8. Grewal Ruby, Dermid Joy C, Faber Kenneth J,Drosdowech Darren S, King Graham JW. Comminuted radialhead fractures treated with a modular metallic radial headarthroplasty. J Bone Joint Surg Am. 2006;88:2192e2200.

9. Van Riet Roger P, Van Glabbeek Francis, Verborgt Olivier,Gielen Jan. Capitellar erosion caused by metal radial head pros-thesis. J Bone Joint Surg Am. 2004;86:1061e1064.

Erratum to “Colour Doppler ultrasound in controlled ovarianstimulation with intrauterine insemination”[Apollo Med 9 (3) (2012) 252e263]

Kavita Bhadauriaa,*, Reeti Sahnib, Sohani Vermab, Payal Q. Khatric

The above mentioned article published in the September issue is an Original Article, but was published as a Case Report bymistake. The journal regrets for this error.

DOI of original article: 10.1016/j.apme.2012.07.014.aResident, bSenior Consultant, cAssociate Consultant, Departmentof Radiodiagnosis and AARU, Indraprashta Apollo Hospitals, NewDelhi 110076, India.*Corresponding author.Copyright � 2012, Indraprastha Medical Corporation Ltd. All rightsreserved.http://dx.doi.org/10.1016/j.apme.2012.11.001

338 Apollo Medicine 2012 December; Vol. 9, No. 4 Mohan Krishna and Somasekhar Reddy

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