Overview
Radial head fractures can be isolated, or part of a complex elbow dislocation ("terrible triad") or an Essex-Lopresti injury. When the fracture is confirmed to be isolated, the goal is a pain-free, stable arc of flexion-extension and pronation-supination. The Mason classification (types I–IV) is widely used.
Indications
Nonoperative Treatment
Most radial head fractures (Mason types I and II) are treated nonoperatively.
Before choosing nonoperative treatment, confirm two things:
The injury is isolated, not part of a complex dislocation.
There is no mechanical block to flexion-extension or pronation-supination.
If there is no block, a sling with immediate use as pain allows gives predictably good results.
Mason I and II fractures have shown no difference between operative and nonoperative treatment, with similar function and low complication rates. Undisplaced or minimally displaced fractures do well with a home exercise program.
Operative Treatment
Displaced Mason type II and III fractures that are part of an elbow dislocation (Mason type IV), or that have a motion limitation not explained by pain.
Type II Fractures
When surgery is indicated, ORIF is usual.
Good results have been reported with minifragment screws, with or without a buttress plate in the safe zone (the part of the radial head that does not articulate with the ulna).
Headless compression screws, including cross-screw fixation and the "tripod" technique, have also given good results.
Partial excision of the radial head gives satisfactory results.
If the remaining articular surface is small, excision with radial head replacement is needed, because the radial head is a primary stabilizer in complex fracture-dislocations.
Excision alone, without replacement, can work well in a stable elbow without longitudinal forearm injury (such as Essex-Lopresti), although this situation is less common.
Type III Fractures
These are often part of a more severe injury and are less often suitable for ORIF than type II fractures.
Radial head excision may be an option for isolated fractures in elderly patients, but results are inferior in younger patients. Rule out elbow and forearm instability before excision. Because of long-term arthrosis, valgus instability and longitudinal forearm instability, many surgeons avoid excision in younger patients.
Ideal fracture for ORIF: Three or fewer fragments, each large enough for a minifragment screw, with minimal metaphyseal bone loss.
Replacement is more reliable with complete articular involvement or metaphyseal impaction.
Metallic prostheses have given good short- and long-term results, with better elbow scores, higher satisfaction, shorter operative time, and a lower nonunion rate than ORIF.
Acute arthroplasty is better than delayed arthroplasty (after failed ORIF, nonunion or malunion) for function and revision.
Main complication: Overstuffing of the radiocapitellar joint, which causes erosion, pain and loss of motion.
Main advantage: It maintains the radiocapitellar relationship for elbow and longitudinal radioulnar stability, while allowing immediate motion without risking loss of fixation.
Surgical Approach: Kocher vs Kaplan
Kaplan | Kocher | |
|---|---|---|
Interval | Extensor digitorum communis – extensor carpi radialis longus (more anterior) | Extensor carpi ulnaris – anconeus (more posterior) |
Advantage | Significantly better view of the proximal radius and coronoid (anatomic studies); the ECRB can be elevated further along the supracondylar ridge to reach the coronoid | Lower risk to the posterior interosseous nerve |
Disadvantage | Distal dissection puts the posterior interosseous nerve at greater risk | Risk of iatrogenic injury to the nearby LCL fibers |
In trauma, there is often a rent in the fascia that can be used for the approach.
Surgical Technique (Technique 62.10)
Exposure
Expose the radial head and neck through a Kocher or Kaplan approach.
Preserve the lateral collateral ligament. In terrible triad injuries, it is often avulsed from the epicondyle and is repaired at the end of the procedure.
Mason Type II (Partial Articular) Fracture
Reduce the fragment without stripping its periosteum, using tamps, dental picks or Freer elevators as needed.
Fix it with one or two small screws.
A buttress plate adds stability if the apex of the fracture is comminuted, or if elevating an impacted segment has left a large defect beneath it.
If reliable fixation cannot be achieved, as in fracture-dislocations, consider radial head replacement.
Mason Type III (Comminuted) Fracture
Reduce the articular surface and hold it with K-wires. Occasionally, it is easier to remove the fragments and reassemble them on the back table.
Apply a small plate to the lateral surface of the proximal radius, in the safe zone with the wrist in neutral, and fix it with screws as needed.
Variable-angle locking screws help secure each fragment.
Threaded K-wires cut flush with the articular surface, or headless compression screws, are useful adjuncts for multiplanar fixation.
Fill any defect with bone graft if needed.
Check pronation and supination to confirm full motion with no mechanical block.
Postoperative Care
Apply a molded posterior plaster splint at 90°.
Day 1: Remove the splint, support the arm in a sling, and start active and active-assisted exercises.
3 weeks: Discontinue the sling and increase exercises as tolerated.
8 weeks: Weight bearing as tolerated usually begins.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.10.