A displaced and badly comminuted fracture of the radial head is part of a complex instability injury of 3 joints namely elbow, radio-ulnar and wrist joints. If it is associated with Mason type IV and Essex Lopresti injury to forearm, simple excision of the radial head may lead to instability of the elbow joint and painfully restricted movements of the wrist. Management should be aimed at achieving the normal anatomy so that the function of elbow, radio-ulnar and wrist joints will be restored to a satisfactory level. We report the medium term result of a patient who had prosthetic replacement of radial head. Our patient in this case report was informed, that the details of the management would be submitted for publication.

1. The Role of Prosthetic Replacement in the Management of
Comminuted Radial Head Fractures

2. Apollo Medicine 2012 December
Volume 9, Number 4; pp. 336e338
Case Report
The role of prosthetic replacement in the management of comminuted
radial head fractures
A. Mohan Krishnaa, N. Somasekhar Reddyb,*
ABSTRACT
A displaced and badly comminuted fracture of the radial head is part of a complex instability injury of 3 joints namely
elbow, radio-ulnar and wrist joints. If it is associated with Mason type IV and Essex Lopresti injury to forearm, simple
excision of the radial head may lead to instability of the elbow joint and painfully restricted movements of the wrist.
Management should be aimed at achieving the normal anatomy so that the function of elbow, radio-ulnar and wrist
joints will be restored to a satisfactory level. We report the medium term result of a patient who had prosthetic
replacement of radial head. Our patient in this case report was informed, that the details of the management would be
submitted for publication.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Radial head fracture, Radial head prosthesis, Fracture dislocation of elbow, Radial head replacement,
Radial head fracture with DRUJ instability
CASE REPORT
A 30-year-old gentleman was admitted following a road
traffic accident with injury to his right upper limb. He
had an elbow deformity with pain over forearm down to
the wrist. He has mild fullness over volar aspect of the forearm with tenderness over the dorsum of the distal radioulnar joint and wrist joints with limitation of movements.
X-rays confirmed dislocation of the elbow joint with
a comminuted, displaced fracture of the radial head and
fracture of the tip of the coronoid process. There was no
gross dislocation at the distal radio-ulnar joint on the
X-ray (Fig. 1).
Surgery was done under brachial block. Dislocation was
first reduced. Radial head was exposed through a postero
lateral approach. It was found to be too comminuted to
fix and was excised. There was about 3e5 mm of linear
translatory movement between the radius and ulna confirming the axial forearm instability. Then the radial head was
a
recreated using the excised fragments. It is very important
for two reasons. One is to make sure that all the broken
pieces were removed. The second reason is to size the
appropriate prosthetic component. Radial neck was
prepared to get a uniform cut and the medullary canal
was prepared with a gouge and a narrow pointed rasp.
Sometimes a high-speed burr is necessary to shape the
medullary canal to accept the stem of the trial component.
The preparation of the medullary canal can be tedious as
one cannot hammer the prosthesis in to the canal due to
the high risk of fracture of radial neck and shaft. I used
chrome cobalt uncemented prosthesis (Corin) (Fig. 2).
This implant comes in three diameters and each diameter
comes with a thick and a thin head, making a total of 6
sizes. When the natural radial head diameter falls in
between the prosthetic sizes it is advisable to go for the
smaller prosthetic head. This is to prevent over stuffing
the proximal radio-ulnar joint. But the thickness of the
head should be maintained as close to the natural as
Consultant Orthopaedic Surgeon, bSenior Consultant Orthopaedic Surgeon, Apollo Hospitals, Hyderabad, India.
Corresponding author. Room No. 957, Apollo Hospitals, Jubilee Hills, Hyderabad 500 033, India. Tel.: þ91 98480 25355, email: nreddy12@
yahoo.com
Received: 4.7.2012; Accepted: 4.8.2012; Available online 21.8.2012
Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
*
http://dx.doi.org/10.1016/j.apme.2012.08.002

3. The role of prosthetic replacement in the management of comminuted radial head fractures
Case Report
337
DRUJ or wrist joint. At his next visit at 18 months
following surgery he has full pronation with marginal
improvement in flexion and extension. X-ray of the elbow
did not show any evidence of prosthesis loosening or
erosion of the capitellum.
DISCUSSION
Fig. 1 Pre-operative X-ray showing fracture dislocation of
elbow joint.
possible by inserting less or more of the prosthetic stem in
to the medullary canal to appropriately support the capitellum. There was no valgus instability after reducing the
radial head suggesting the integrity of medial collateral
ligament. At 90 of flexion elbow joint was stable and
hence no attempt was made to fix the small fragment of
coronoid process. Elbow was immobilised at about 100
of flexion and forearm in full supination to maintain
maximum interosseous space.
Active and active assisted movements were started after
3 weeks. Four months following the procedure, patient
regained 15 short of full extension with terminal restriction
of flexion. There was terminal restriction of both supination
and pronation. Elbow joint was stable and he has no pain at
Resection of the radial head for simple fractures has been
shown to give satisfactory long term results.1,2 However
unrecognised complex injuries with elbow or axial forearm
instability may be responsible for unstable elbow, proximal
migration of radius, with or without chronic wrist pain.3
This instability is a major concern in young and active
people whereas in a relatively sedentary and elderly people
it may not cause any significant problem for the day to day
activities. Silicon radial head prosthesis did not offer rigid
stability. Proximal migration of the radius progressed with
break-up of the implant and subsequent synovitis.4,5
Metallic radial head offered better stability against valgus
forces at elbow and axial forearm instability.6e8 However
over stuffing of the radio capitellar joint must be avoided,
as it may produce capitellar erosion especially when done
as a late reconstructive procedure for chronic wrist pain.9
We recommend this procedure strongly in young people
to avoid long term consequences of elbow, radio-ulnar
and wrist joint instabilities. Loosening of the stem as
a major complication was not reported in the literature
when the procedure was done in young people. We believe
that for any reason if the prosthesis has to be explanted after
a period of 6e12 months it may not lead to any instabilities
mentioned above as the interosseous membrane and other
soft tissues would have got stabilised by then to a large
extent preventing proximal migration of radial shaft. Even
though the role of radial head prosthesis in stabilising the
elbow and axial forearm instability seems well proven, it
is being used less often mainly because of lack of awareness of secondary instability and non-availability of radial
head prosthesis.
CONFLICTS OF INTEREST
All authors have none to declare.
REFERENCES
Fig. 2 Post-operative X-ray showing radial head replacement.
1. Goldberg I, Peylan J, Yosipovitch Z. Late results of excision of
the radial head for an isolated closed fracture. J Bone Joint Surg
Am. 1986;68:675e679.

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Apollo Medicine 2012 December; Vol. 9, No. 4
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3. Sowa DT, Hotchkiss RN, Welland AJ. Symptomatic proximal
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5. Valderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflammatory arthritis after failure of silicon rubber replacement of the
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6. Moro JK, Werler J, MacDermid JC, Patterson SD, King GJ.
Arthroplasty with a metal radial head for unreconstructable
Mohan Krishna and Somasekhar Reddy
fractures of the radial head. J Bone Joint Surg Am. 2001;83:
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7. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason
type III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg Am.
2005;87:65e76.
8. Grewal Ruby, Dermid Joy C, Faber Kenneth J,
Drosdowech Darren S, King Graham JW. Comminuted radial
head fractures treated with a modular metallic radial head
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Erratum to “Colour Doppler ultrasound in controlled ovarian
stimulation with intrauterine insemination”
[Apollo Med 9 (3) (2012) 252e263]
Kavita Bhadauriaa,*, Reeti Sahnib, Sohani Vermab, Payal Q. Khatric
The above mentioned article published in the September issue is an Original Article, but was published as a Case Report by
mistake. The journal regrets for this error.
DOI of original article: 10.1016/j.apme.2012.07.014.
a
Resident, bSenior Consultant, cAssociate Consultant, Department
of Radiodiagnosis and AARU, Indraprashta Apollo Hospitals, New
Delhi 110076, India.
*
Corresponding author.
Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights
reserved.
http://dx.doi.org/10.1016/j.apme.2012.11.001

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