What is the treatment for a comminuted displaced fracture of the head of the radius?

Treatment of Comminuted Displaced Radial Head Fracture

For comminuted displaced radial head fractures, radial head excision or prosthetic replacement is the definitive treatment, with prosthetic replacement strongly preferred when there is associated elbow or forearm instability to prevent proximal migration of the radius and subsequent wrist complications. 1, 2

Initial Assessment and Classification

The critical first step is determining whether associated injuries exist, as this fundamentally changes management:

• Examine the distal radioulnar joint meticulously in all patients with displaced radial head fractures, as concurrent longitudinal forearm instability (Essex-Lopresti injury) occurs and dramatically alters treatment 2
• Assess for elbow instability by evaluating for associated fractures (coronoid, olecranon) or ligament injuries (lateral collateral ligament complex) 1
• Test forearm rotation and elbow extension - limitations suggest significant fracture displacement requiring intervention 3

Treatment Algorithm Based on Fracture Pattern

For Isolated Comminuted Displaced Fractures:

Radial head excision is the standard treatment when the fracture has extensive comminution that precludes stable fixation 1, 4

• Excision should be performed within the first 5 weeks post-injury - early resection (within 5 weeks) produces markedly better results than late resection 4
• Long-term results of radial head excision are good when the elbow and forearm are stable 1
• Internal fixation of comminuted radial head fractures cannot be recommended due to high rates of early failure and nonunion 1, 4

For Comminuted Fractures WITH Instability:

Prosthetic radial head replacement is mandatory rather than simple excision 1, 2

• Instability indicators requiring prosthetic replacement include:

  • Concurrent distal radioulnar joint dislocation (Essex-Lopresti injury) 2
  • Elbow dislocation or subluxation 1
  • Associated coronoid or olecranon fractures 1
  • Medial or lateral collateral ligament disruption 1

• Timing is critical: Restoration of radial length must be achieved within one week of injury for excellent results 2

• Delayed surgery (4-10 weeks) produces suboptimal outcomes 2

• Radial head excision alone in unstable injuries leads to proximal migration of the radius (5-10mm), chronic wrist pain, and stiffness 2

Critical Technical Considerations

Proper implant sizing is essential - underlengthening the radius by using an undersized radial head prosthesis allows proximal migration and ulnocarpal abutment at the wrist 5

• The prosthetic dimensions must match native anatomy to restore elbow stability and kinematics 5
• In cases where radial head excision was performed without recognizing instability, salvage requires ulnar shortening osteotomy combined with delayed radial head prosthetic replacement 2

Common Pitfalls to Avoid

• Never perform isolated radial head excision without thoroughly evaluating the distal radioulnar joint - missing an Essex-Lopresti injury leads to devastating wrist complications 2
• Do not attempt internal fixation of severely comminuted radial head fractures - reconstruction attempts have poor results with high failure rates 1, 4
• Do not delay definitive treatment beyond one week when instability is present - delayed surgery (>4 weeks) significantly worsens outcomes 2
• Avoid conservative management if active elbow movement is not expected within 3 weeks - this indicates the need for surgical intervention 4

Postoperative Management

• Active finger motion exercises should begin immediately following surgery to prevent stiffness, which is one of the most functionally disabling complications 6
• Early wrist motion is not routinely necessary following stable fracture fixation 6
• Radiographic follow-up at approximately 3 weeks to assess healing 6