What is the treatment for an intraarticular fracture of the radial head?

Treatment of Intraarticular Fracture of Radial Head

The optimal treatment for intraarticular fractures of the radial head depends primarily on fracture displacement, comminution, and associated injuries, with surgical fixation indicated for displaced fractures (>2mm) that cause mechanical block to motion.

Classification and Assessment

• Radial head fractures are commonly classified using the modified Mason-Hotchkiss classification, which describes three types based on fragment number and displacement 1
• Type 1: Non-displaced fractures
• Type 2: Displaced fractures with 2 or fewer intra-articular fragments
• Type 3: Comminuted fractures with 3 or more intra-articular fragments 2
• Comminution of the radial head and complete loss of cortical contact of at least one fragment are associated with high occurrence of associated injuries 3

Treatment Algorithm

Non-operative Management

• Indicated for:
  • Non-displaced and minimally displaced fractures 1
  • Fractures without mechanical block to pronation/supination 3
• Treatment approach:
  • Removable splints are appropriate for minimally displaced fractures 4
  • Early mobilization is recommended to prevent stiffness 1
  • Radiographic follow-up at approximately 3 weeks and at immobilization removal to confirm healing 4

Surgical Management

• Indications for surgery:
  • Mechanical block to pronation/supination 3
  • Displacement >2mm causing functional limitation 3
  • Comminuted fractures 3
  • Associated ligamentous injuries or elbow instability 1

Open Reduction Internal Fixation (ORIF)

• Best for:
  • Mason Type 2 fractures (partial articular) that are non-comminuted 5
  • Mason Type 3 fractures with 2-3 simple fragments 5
  • Recent evidence suggests ORIF may be considered even for fractures with more than 3 intra-articular fragments, as similar clinical outcomes have been reported 2

Radial Head Arthroplasty

• Indicated for:
  • Severely comminuted fractures (traditionally >3 fragments) 5
  • Fractures with associated ligamentous injury or proximal ulna fractures 1
  • Cases where adequate reduction and fixation cannot be achieved 1

Radial Head Excision

• May be considered for:
  • Isolated radial head fractures without associated ligamentous injury 1
  • Failed ORIF or radial head replacement 1
  • Note: Long-term results have been favorable, but this approach is less commonly used as first-line treatment 1

Outcomes and Complications

• Factors affecting outcomes:

  • Fracture comminution: Comminuted Mason Type-2 fractures associated with fracture-dislocations have poorer outcomes 5
  • Articular incongruity: Total articular incongruity immediately post-operatively correlates with clinical outcomes 6
  • Associated injuries: Fracture-dislocations of elbow or forearm may compromise long-term results, especially regarding forearm rotation 5

• Potential complications:

  • Fixation failure requiring secondary procedures 5
  • Limited forearm rotation (<100 degrees) 5
  • Arthritis development 6
  • Hardware-related issues 6

Special Considerations

• Arthroscopic evaluation is an option during surgical treatment of intra-articular fractures to improve diagnostic accuracy 4
• Associated ligament injuries (SLIL, LT, or TFCC tears) may be treated at the time of fracture fixation 4
• For complex fractures with significant comminution, combined internal and external fixation may be necessary to maintain reduction throughout healing 6