What is the treatment for a displaced radial head or neck fracture?

Treatment of Displaced Radial Head/Neck Fractures

Displaced radial head and neck fractures in adults should be treated with open reduction and internal fixation (ORIF) using headless cannulated screws for fractures with 3 or fewer fragments, while comminuted fractures (>3 fragments) require radial head replacement with a prosthesis. 1, 2

Initial Assessment and Classification

• Obtain standard radiographs and CT scan to evaluate fragment number, displacement, impaction, and associated injuries (ligamentous, cartilaginous, or other fractures), as these determine management strategy 1, 2
• Carefully assess for associated injuries including elbow ligament injuries, forearm fractures, and elbow instability, which are common and critically influence treatment decisions 1, 2
• Classify fractures by fragment number and displacement, as this directly determines surgical approach 2, 3

Treatment Algorithm Based on Fracture Pattern

Displaced Fractures with ≤3 Fragments (Fixable Pattern)

• Perform ORIF with headless cannulated screws as the preferred fixation method 1
• This approach provides satisfactory biomechanical stability, requires smaller incisions, has fewer complications, and less frequently requires hardware removal compared to plate fixation 1
• Reserve plate fixation only for the small subset of fractures with comminution of the neck that cannot be stabilized with screws alone 1

Displaced Fractures with >3 Fragments (Unfixable Pattern)

• In elderly patients without associated injuries: radial head excision is acceptable and associated with good long-term results 1, 2
• In younger patients OR any patient with elbow/forearm instability: prosthetic radial head replacement is mandatory to prevent subluxation or dislocation 1, 2
• Radial head arthroplasty is preferred over tenuous fracture fixation when associated ligament injuries exist, as maintenance of joint stability could be compromised by ineffective fixation 3

Alternative Technique: Percutaneous Fixation

• Closed reduction and internal fixation (CRIF) with retrograde intramedullary K-wires is an emerging technique showing good results in Mason type II and III fractures 4
• This yields good anatomical reduction, faster rehabilitation, and easier hardware removal, though the learning curve is long 4

Critical Management Principles

• Avoid open reduction if possible in pediatric cases due to higher complication rates, but adult displaced fractures typically require open treatment 5
• Fragmented unstable fractures are prone to early failure of fixation and nonunion when fixed, making prosthetic replacement the safer choice for comminuted patterns 2
• Restoration of radiocapitellar contact is essential in unstable fractures to prevent elbow and forearm subluxation or dislocation 2

Common Pitfalls to Avoid

• Do not attempt ORIF on highly comminuted fractures (>3 fragments), as fixation failure and nonunion are common; proceed directly to radial head replacement 2, 3
• Do not excise the radial head in patients with elbow or forearm instability without prosthetic replacement, as this leads to persistent instability 1, 2
• Do not miss associated ligament injuries, as these mandate more aggressive treatment (prosthetic replacement over excision) to maintain joint stability 1, 3