What is the recommended treatment for chronic radial head dislocation?

Treatment of Chronic Radial Head Dislocation

Surgical intervention with ulnar osteotomy combined with open reduction and annular ligament reconstruction is the recommended treatment for chronic radial head dislocation in patients with incapacitating symptoms and a preserved concave radial head articular surface. 1, 2, 3

Patient Selection Criteria

The decision to operate depends on two critical anatomic features:

• Normal concave radial head articular surface - This is the most important criterion; surgery should not be attempted if the radial head has developed significant dome-shaped deformity 3, 4
• Assessment of duration - Dislocations less than 3 years old ("early") typically have preserved radial head morphology and normal radial notch anatomy, making them better surgical candidates 4
• Longstanding dislocations (>3 years) develop progressive deformity: the radial notch angle increases from 30° to 46°, notch depth decreases from 2.3mm to 0.2mm, and the radial head becomes dome-shaped 4

Surgical Technique

The optimal approach combines three components:

1. Oblique Ulnar Osteotomy with Angulation and Elongation

• This is the key to successful reduction - correction of ulnar malalignment allows the radial head to reduce without excessive tension 2, 5
• Perform an oblique osteotomy with both angulation and elongation of the ulna 2
• Use rigid plate fixation at the osteotomy site 2
• Add bone grafting if necessary to maintain correction 2

2. Open Reduction of the Radial Head

• Mobilize and dilate the annular ligament if it remains intact 5
• Place two drill holes in the proximal ulna at the original attachments of the annular ligament 3

3. Annular Ligament Management

• If the annular ligament is intact, preserve it and relocate the radial head into it after dilatation - this avoids reconstruction morbidity 5
• If the annular ligament is avulsed or damaged, reconstruct it using triceps tendon or other suitable tissue secured through the drill holes 3

Postoperative Management

• Apply a cast with the forearm in neutral rotation for 2-4 weeks 2
• Initiate active finger motion exercises immediately to prevent stiffness 6, 7
• Avoid prolonged immobilization beyond 3-4 weeks 6, 8

Expected Outcomes

Using the modified technique with oblique ulnar osteotomy:

• 78% achieve good reduction without serious contracture 2
• Patients with slight preoperative radial head deformity may develop postoperative subluxation 2
• Full recovery of range of motion is achievable, with return to work by 5 months 1
• All patients in one series were fully active without elbow pain or instability at 48-month follow-up 3

Critical Pitfalls to Avoid

• Do not attempt surgery if the radial head has developed dome-shaped deformity - longstanding dislocations with significant morphologic changes have poor outcomes 4
• Do not perform reduction without correcting ulnar malalignment - this is the primary cause of redislocation 2
• Age and duration of dislocation are less important than radial head morphology - even dislocations of 7 years duration can be successfully treated if the articular surface is preserved 3
• Reevaluate any patient with unremitting pain during follow-up - this may indicate complications requiring intervention 6

Non-Surgical Management

Therapeutic abstention or radial head resection may be considered for patients with minimal symptoms or those with severe radial head deformity that precludes successful reduction 1