Radial Head Fracture

Radial head fractures are intra articular elbow injuries and range from a nondisplaced marginal fracture to complete radial head comminution associated with elbow dislocation and longitudinal forearm instability.

The radial head contributes to:

Valgus stability
Axial load transmission from wrist to elbow
Stability after medial collateral ligament injury
Longitudinal forearm stability through interaction with the interosseous membrane and distal radioulnar joint

The radial head should therefore not be excised casually in an unstable elbow or forearm.

Modified Mason classification

Mason I

Nondisplaced or minimally displaced
Less than approximately 2 mm displacement
No mechanical block to rotation

Mason II

Displaced by more than approximately 2 mm or angulated
Partial radial head fracture
May cause mechanical block to pronation or supination

Mason III

Severely comminuted fracture involving most or all of the radial head
Frequently mechanically unreconstructible

Mason IV

Radial head fracture associated with elbow dislocation.

Associated injury patterns

Terrible triad

Elbow dislocation
Radial head fracture
Coronoid fracture

This represents a highly unstable elbow.

Essex Lopresti injury

Radial head fracture
Interosseous membrane disruption
Distal radioulnar joint instability

Failure to recognise this injury before radial head excision can produce proximal radial migration, chronic wrist pain and severe longitudinal instability.

Patients have lateral elbow pain and tenderness over the radial head.

Pain is reproduced by:

Forearm pronation
Supination
Elbow movement

A true mechanical block to rotation is more important than radiographic displacement alone.

Examine the entire forearm.

Specifically assess:

Distal radioulnar joint tenderness
Wrist pain
Interosseous membrane tenderness
Valgus stability
Posterolateral elbow instability

Document posterior interosseous nerve function.

Mason I

Treat nonoperatively.

Use a sling briefly for comfort, often only several days.

Begin early elbow and forearm motion.

Avoid immobilisation beyond approximately one week unless another injury requires it because elbow stiffness develops rapidly.

Mason II

A displaced fracture without mechanical block or instability may still be managed nonoperatively.

Operate when there is:

Mechanical block to rotation
Significant displacement affecting joint congruity
Associated elbow instability
Associated forearm instability
Failed nonoperative care

Perform ORIF when the fracture is reconstructable.

Mason III

If the radial head can be reconstructed reliably, ORIF can be attempted.

Severe comminution involving more than approximately three major fragments is less predictably reconstructable.

In an unstable elbow or Essex Lopresti type injury, replace an unreconstructible radial head with a radial head prosthesis rather than excising it.

The implant must restore native radial length.

Overstuffing the radiocapitellar joint produces:

Lateral elbow pain
Loss of motion
Capitellar wear
Altered elbow mechanics

An implant that is too short fails to restore stability.

Radial head excision

Radial head excision has a limited role.

It may be considered in an older low demand patient with an unreconstructible isolated fracture and:

Intact interosseous membrane
Stable distal radioulnar joint
Stable collateral ligaments

Do not excise the radial head when there is:

Essex Lopresti injury
Medial collateral ligament disruption
Elbow instability
Coronoid fracture with instability
Young high demand patient where replacement is feasible

Terrible triad

Treatment generally requires:

Radial head fixation or replacement
Coronoid fixation when clinically significant
Lateral collateral ligament complex repair

Assess residual medial instability after reconstruction.

Rehabilitation

Stable fractures and reconstructions require early motion.

Use a hinged brace where ligament injury requires controlled movement.

Avoid prolonged immobilisation.

Major complications include:

Elbow stiffness
Loss of forearm rotation
Heterotopic ossification
Persistent instability
Radial head nonunion
Post traumatic arthritis
Proximal radial migration after inappropriate excision

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Pelvic Fracture

Pelvic fractures range from stable pubic ramus injuries to complete disruption of the pelvic ring with massive retroperitoneal haemorrhage.

A pelvic ring injury should be approached first as a potential haemorrhagic emergency, not merely an orthopaedic fracture.

Major bleeding sources include:

Presacral and pelvic venous plexus
Exposed cancellous bone
Internal iliac arterial branches

The retroperitoneum can contain several litres of blood.

Associated injuries frequently involve:

Bladder
Urethra
Rectum
Vagina
Abdominal viscera
Spine
Major nerves

Tile classification

Based on mechanical stability.

Type A: Stable

Posterior arch remains stable.

Avulsion or fracture not significantly involving pelvic ring stability.

Stable or minimally displaced pelvic ring fracture.

Transverse sacral fracture.

Type B: Rotationally unstable, vertically stable

Open book injury.

Lateral compression injury.

B2.1 typically involves ipsilateral anterior ring injury.

B2.2 may produce a contralateral bucket handle pattern.

Bilateral rotational instability.

Type C: Rotationally and vertically unstable

Unilateral complete instability.

Subclassified according to posterior lesion through:

Ilium
SI joint
Sacrum

Bilateral injury with one side type C and the opposite side type B.

Bilateral complete instability.

Young Burgess classification

Based on force direction.

Anterior posterior compression

APC I

Symphyseal widening below approximately 2.5 cm
Posterior SI ligaments intact
Usually mechanically stable or minimally unstable

APC II

Symphyseal widening greater than approximately 2.5 cm
Anterior SI joint opening
Sacrospinous and sacrotuberous ligament disruption
Posterior SI ligaments intact

Rotationally unstable but vertically stable.

APC III

Complete anterior and posterior SI ligament disruption
Complete hemipelvic instability
High haemorrhage risk

Lateral compression

LC I

Pubic ramus fracture
Ipsilateral sacral compression fracture

Most common pelvic ring pattern.

LC II

Rami injury plus posterior iliac crescent fracture through the SI complex

LC III

Ipsilateral lateral compression with contralateral external rotation injury

Called a windswept pelvis.

Vertical shear

Vertical displacement of one hemipelvis with complete posterior ligament disruption.

Severely unstable and associated with major bleeding and neurological injury.

Denis sacral zones

Useful when the posterior injury passes through the sacrum.

Zone I

Lateral to neural foramina.

Lowest neurological risk.

Zone II

Through neural foramina.

Risk of radicular injury.

Zone III

Central sacral canal.

Highest risk of cauda equina, bowel and bladder dysfunction.

Follow major trauma resuscitation principles.

Inspect for:

Pelvic deformity
Perineal bruising
Scrotal or labial haematoma
Rectal bleeding
Vaginal bleeding
Open wounds
Leg length discrepancy
Neurological deficit

Do not repeatedly spring or compress the pelvis after an unstable injury has been identified because repeated manipulation can disrupt clot.

Look for urethral injury:

Blood at urethral meatus
Inability to void
Perineal haematoma
High risk pelvic ring pattern

Perform retrograde urethrography before blind catheterisation when urethral disruption is suspected.

Open pelvic fractures involving rectum or perineum have extremely high septic and haemorrhagic morbidity.

Haemorrhage control

In an unstable pelvic ring injury, apply a pelvic binder over the greater trochanters, not around the iliac crests.

The binder:

Reduces pelvic volume in APC injury
Improves tamponade
Stabilises fracture surfaces

Initiate balanced haemostatic resuscitation when major bleeding is present.

A practical massive transfusion strategy uses approximately:

Packed red cells : plasma : platelets in a 1 : 1 : 1 ratio during active uncontrolled haemorrhage.

Correct:

Hypothermia
Acidosis
Hypocalcaemia
Coagulopathy

Persistent haemodynamic instability requires rapid haemorrhage control.

Options include:

Preperitoneal pelvic packing
External pelvic fixation or pelvic C clamp where appropriate
Angiography with arterial embolisation

These are complementary rather than competing techniques.

Angioembolisation is particularly effective when CT or ongoing physiology suggests arterial bleeding.

Preperitoneal packing rapidly controls predominantly venous and cancellous bleeding and is valuable in an unstable patient requiring immediate operative control.

Temporary mechanical stabilisation

APC injuries can be stabilised using:

Binder
Anterior external fixator
Pelvic C clamp in selected posterior instability

Vertical shear may require:

Skeletal traction
Temporary external fixation
Definitive posterior fixation

Stable pelvic fracture

Tile A and many LC I injuries can be managed nonoperatively.

Provide analgesia and mobilise early with protected weight bearing according to pain and stability.

Prolonged bed rest should be avoided.

Operative indications

Fixation is appropriate for:

APC II and III instability
Vertical shear
Tile C fracture
Displaced crescent fracture
Symptomatic unstable posterior ring injury
Progressive displacement
Open unstable pelvic fracture
Selected LC injuries demonstrating instability under stress

Posterior ring

Posterior stability is critical.

Options include:

Percutaneous iliosacral screws
Transsacral screws
Posterior plating
Lumbopelvic fixation for severe spinopelvic dissociation

Careful preoperative CT assessment is mandatory because sacral dysmorphism alters safe screw corridors.

Anterior ring

Options include:

Symphyseal plate
Ramus screw
External fixation

In vertically unstable injuries, anterior fixation alone is inadequate. The posterior ring must also be stabilised.

Open pelvic fracture

Urgently address:

Haemorrhage
Faecal contamination
Urinary injury
Devitalised perineal tissue
Unstable bone

Broad antimicrobial coverage is required when rectal or gross perineal contamination exists, for example:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, renal adjusted.

Perform repeated debridement as necessary.

Faecal diversion is considered with:

Rectal injury
Massive perineal contamination
Destructive anorectal injury

It is not mandatory for every open pelvic wound.

VTE prophylaxis

Pelvic fracture carries high venous thromboembolism risk.

Begin pharmacological prophylaxis once haemostasis is secure and bleeding risk is acceptable.

A commonly used regimen is:

Enoxaparin 40 mg subcutaneously once daily, with adjustment for renal function, body weight and local trauma protocol.

Major complications include:

Fatal haemorrhage
DVT or pulmonary embolism
Pelvic sepsis
Neurological injury
Chronic pelvic pain
Sexual dysfunction
Urological dysfunction
Malunion
Leg length discrepancy

Radial Head Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management