This is what happens even with simple fractures!
1. Immediately after injury, the displacement is 15 degrees.
2. Reduction, comparison and fixation with plaster, everything seemed fine.
3. A month later, the bones shifted again and fused with displacement.
It is not too late to perform the operation, but it will be more difficult than osteosynthesis performed in the first 2-3 weeks after the injury, and the result may not be as good.
It is necessary to perform an osteotomy, eliminate the deformity, replace the defect with artificial or your own bone, and fix it with a plate. For strong fixation, the screws must lock into the threads of the plate, creating a single structure with it. The radiograph on the left shows the Chronos block in the defect of the radius after correction of its shortening and deformation. The plate is precisely molded to the shape of the bone. Thanks to stable fixation, empty spaces are quickly filled with bone regenerate.
7 months after the operation, the bone looks monolithic, the regenerate has filled the empty spaces, the shape of the bone and the function of the hand have become normal. The plate does not need to be removed.
Anatomy of a radial head fracture
How does the elbow joint work? The radius articulates with the humerus and proximal ulna. This joint allows flexion and extension of the forearm, as well as pronation (turning the palm down) and supination (turning the palm up) of the forearm.
The head of the radius is covered with articular cartilage. This ensures sliding of the articular surface in two planes, which is extremely important for the elbow joint. Thus, articular fractures with post-traumatic arthrosis can lead to a mechanical obstacle to movement.
The head is also an important stabilizer of the elbow joint.
A fracture of the radial head, in addition to severe pain, is characterized by:
- significant decrease in elbow joint mobility, including passive and rotational movements,
- hemarthrosis,
- deformations of the outer surface of the elbow joint.
If a fracture of the head of the radial bone of the elbow joint is suspected, it is necessary to exclude the possibility of fracture-dislocation of the head of the radial bone, accompanied by a violation of the interosseous membrane. Therefore, if a fracture is suspected, adjacent joints should also be examined.
Most radial head fractures are isolated, but are sometimes accompanied by the following injuries:
- fracture of the coronoid process of the ulna
- rupture of the collateral ligament of the elbow joint
- interosseous membrane rupture
- Fracture-dislocation Goliazzi
Such an injury, which is also accompanied by a fracture of the head of the humerus, can occur with damage to the medial collateral ligaments and a fracture of the ulna bones with their shortening.
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There are two main types of osteosynthesis
1) Internal (immersion) osteosynthesis is a method of treating fractures using various implants that fix bone fragments inside the patient’s body. Implants are pins, plates, screws, knitting needles, and wire. Implants are made from metal that is resistant to oxidation in the internal environment of the body (stainless steel, titanium alloys, molybdenum-chromium-nickel alloys. The surface of bone implants can be smooth, polished or have special pores to allow ingrowth into body tissue. 2) External (transosseous) osteosynthesis, when bone fragments are connected using distraction-compression external fixation devices (the most common of which is the Ilizarov apparatus). Absolute indications for osteosynthesis are fractures that do not heal without surgical fastening of the fragments, for example, fractures of the olecranon and patella with divergence of fragments, some types of fractures of the femoral neck; fractures in which there is a risk of perforation by a bone fragment of the skin, i.e. transformation of a closed fracture into an open one; fractures accompanied by interposition of soft tissue between fragments or complicated by damage to a great vessel or nerve. Relative indications include the impossibility of closed reposition of fragments, secondary displacement of fragments during conservative treatment, slowly healing and non-union of fractures, and false joints. Contraindications to immersion osteosynthesis are open fractures of limb bones with a large area of damage or contamination of soft tissues, local or general infectious process, general serious condition, severe concomitant diseases of internal organs, severe osteoporosis, decompensated vascular insufficiency of the limbs. Depending on the strength of the connection of the fragments, a distinction is made between stable osteosynthesis, if there is no need for additional fixation, and unstable osteosynthesis, if, after connecting the fragments, mobility between them remains and additional external fixation is required, for example, with a plaster cast. Stable osteosynthesis contributes to a more complete preservation of the function of the joints of the injured limb and makes it possible to begin functional treatment early. The strength of the fastener itself is of great importance, because until the fragments consolidate, it takes the load upon itself. In cases where the retainer does not have sufficient strength, ductility and other mechanical properties, it becomes deformed or breaks under the influence of load. Stable internal osteosynthesis is most convenient for the patient, as it causes the least inconvenience and is the most functional.
Rehabilitation
Experts recommend gradually starting rehabilitation after the anesthesia wears off and a normal state of consciousness is restored. Initially, you need to rotate your feet and hands, move your fingers, strain your muscles, and press on the bed. All this can be done on the first day after surgery to speed up recovery. Experts recommend following 7 rules:
- Breathing exercises are performed in a lying, sitting and standing position.
- Vibration massage is carried out using camphor oil (rubbing and light tapping are acceptable).
- Physical exercises can be performed with the help of a partner to prevent depression and decreased mobility of the limbs (the procedures can be entrusted to relatives and close friends).
- Elastic bandages are used to tighten the leg muscles to prevent veins from dilating and blood clots.
- The diet is followed for at least 7 days after surgery. It is allowed to eat only porridge-like foods (this reduces the load on the gastrointestinal tract).
- Electromyostimulation should be performed 48 hours after installation of the implant to prepare the muscles for increased loads.
- Special procedures are carried out in the treatment center by a specialist and include balneotherapy, laser therapy, application, oxygen baths, hydromassage.
Before starting the recovery period, you should consult with your doctor in the presence of relatives and close friends. This is a mandatory condition, since the patient will not be able to perform all the procedures independently and will need help. Periodically during rehabilitation you need to visit your doctor to prevent the development of complications.
Treatment of radial head fractures
The main goals of therapy for this injury include:
- restoration of the possibility of rotational movement,
- restoration of the entire range of motion of the forearms and elbows,
- carrying out prevention of the possibility of early occurrence of arthrosis of the elbow joints.
Treatment tactics are based on the degree of displacement, the size of the fragments and the presence of an intra-articular component in fractures of the radial head. And it depends on the type of classification above.
Fractures of the head of the elbow without displacement are treated conservatively. For this type of treatment, immobilization is used with plaster, a plastic polymer bandage and a rigid orthosis.
Immobilization is carried out for a period of no more than 3 weeks in the position of bending the arm at the elbow joint at an angle of 100-110 degrees and supination (turning the palm upward) of the forearm at an angle of 45 degrees!!! The elbow joint is very “capricious” in relation to the duration of immobilization. So, according to research and personal experience, I assure you that it is catastrophically difficult to develop the elbow joint to full range of motion after being in a cast for more than 3 weeks.
After three weeks, the plaster or polymer bandage is cut off or replaced with a hinged piece to begin developing movements in the elbow joint.
Surgical treatment of radial head fractures is used when:
- an open fracture is observed,
- conservative treatment does not produce results,
- a segmental fracture is observed,
- there is a compound fracture,
- there is a fracture with the inability to move the elbow joint as a result of displacement,
- when Goleazzi is damaged.
Fixation of fragments or endoprosthetics of the radial head is usually carried out through the posterolateral approach (Kocher), between the extensor carpi ulnaris muscle and the anconeus muscle. In the position of pronation of the forearm with abduction and protection of the radial nerve during surgery.
This type of treatment uses:
- endoprosthetics,
- bone osteosynthesis,
- resection of the head of the radial bones,
- installation of Kirschner spokes.
Removal of the head of the radial bone occurs in severe fractures with the presence of many splinters and fragments. In this case, patients experience valgus instability and pain. However, this method is widely used in Russia due to the lack of experience in endoprosthesis replacement of the radial head by surgeons or, more often, due to the lack of endoprosthesis in a medical institution. Not many patients have the financial ability to purchase a prosthesis at their own expense.
Complications
If the operation is performed incorrectly or if the specialist’s recommendations are not followed, the following complications are possible:
- Decreased joint mobility.
- Infection and accumulation of pus.
- Pain syndrome at rest and during movement.
- Implant dislocation (extremely rare).
- Formation of blood clots and varicose veins.
- Allergic reaction to the implant.
- Loosening of the apparatus.
To avoid serious consequences, follow all instructions from a specialist during rehabilitation. Find out all the contraindications in advance and undergo a comprehensive diagnosis. If, after surgery, acute pain in the joint appears and the body temperature rises, contact your doctor immediately.