What is the management and treatment for a suspected radial head dislocation of the elbow?

Management of Radial Head Dislocation

Immediate closed reduction under anesthesia should be attempted first, but if unsuccessful, proceed directly to open reduction with repair of the lateral collateral ligament complex and consider radial head preservation or replacement if fractured—do not simply resect the radial head, as this leads to poor outcomes and recurrent instability. 1

Initial Diagnostic Confirmation

• Obtain CT without contrast if radiographs show abnormal radiocapitellar alignment to fully characterize the injury pattern, identify associated fractures (particularly coronoid process), and assess for the "terrible triad" constellation (posterior elbow dislocation + radial head fracture + coronoid fracture). 2

• Look specifically for coronoid process fractures on CT imaging, as these injuries indicate severe instability and are commonly missed on plain radiographs—their presence fundamentally changes management. 2, 1

• Assess for joint effusion on lateral radiographs (anterior and posterior fat pad signs), which may indicate occult fractures even when the dislocation appears isolated. 2, 3

Acute Management Algorithm

For Isolated Radial Head Dislocation (No Fractures):

• Attempt closed reduction under general anesthesia in the operating room with fluoroscopic guidance to confirm concentric reduction and assess stability through range of motion. 4

• If closed reduction fails, proceed immediately to open reduction rather than repeated manipulation attempts, as soft tissue interposition (typically the annular ligament) is the usual block to reduction. 4, 5

• During open reduction, repair or reconstruct the annular ligament using drill holes in the proximal ulna at the original attachment sites to secure the radial head anatomically. 5

For Radial Head Dislocation with Associated Fractures ("Terrible Triad"):

• Preserve or replace the radial head—never perform simple excision, as all patients treated with radial head resection in the highest quality study experienced redislocation and poor functional outcomes. 1

• Repair the radial head fracture with internal fixation if the articular surface is salvageable (normal concave surface without severe comminution). 5, 1

• Replace the radial head with a prosthesis if the fracture is not reconstructible, as radiocapitellar contact is essential for elbow stability. 1

• Always repair the lateral collateral ligament complex, as failure to do so is associated with recurrent instability and poor outcomes. 1

• Consider internal fixation of coronoid fractures, particularly if the fragment is large, as coronoid integrity is critical for preventing posterior subluxation. 1

Surgical Technique Considerations

• Perform ulnar osteotomy (oblique angulation with elongation) if treating chronic dislocations (>3 months old), as correction of ulnar malalignment is key to maintaining reduction and preventing redislocation. 6

• Use rigid plate fixation for ulnar osteotomy with bone grafting if necessary to achieve stable correction. 6

• The only absolute criterion for attempting radial head preservation is a normal concave articular surface—age and duration of dislocation are less important factors. 5

Postoperative Management

• Apply a cast or splint with the forearm in neutral rotation for 2-4 weeks, then begin protected range of motion. 6

• Initiate active finger motion exercises immediately to prevent hand stiffness, which is a functionally disabling complication. 2

• Monitor closely for redislocation, which occurs in approximately 64% of cases when the radial head is resected versus significantly lower rates when preserved or replaced. 1

Critical Pitfalls to Avoid

• Do not miss coronoid fractures—they indicate severe instability and require CT imaging for identification, as they are frequently not visible on plain radiographs. 2, 1

• Do not resect the radial head as definitive treatment—this leads to recurrent instability, arthrosis, and poor functional outcomes in the majority of patients. 1

• Do not fail to repair the lateral collateral ligament—all patients with satisfactory outcomes in the highest quality study had undergone ligament repair. 1

• Do not accept persistent instability or subluxation—these lead to progressive arthrosis and may require total elbow arthroplasty. 1

• Do not underestimate chronic dislocations—these require ulnar osteotomy in addition to radial head reduction to correct the underlying deformity. 6

Expected Outcomes

• Patients treated with radial head preservation and ligament repair achieve an average of 92° ulnohumeral motion and 126° forearm rotation at long-term follow-up. 1

• Redislocation rates approach 100% when the radial head is resected versus significantly lower rates with preservation or replacement. 1

• Advanced ulnohumeral arthrosis develops in approximately 70% of patients even with optimal treatment, emphasizing the severity of this injury pattern. 1