We consider the following to be indications for surgery:
- Major loose intra-articular fragments Displaced fractures which under anesthesia can be demonstrated to constitute a block to motion
- Displaced fractures of the radial head associated with fractures of the olecranon or with rupture of the ulnar collateral ligament, or with both
- Fractures of the radial head associated with an injury to the distal radio-ulnar joint and inter-osseous membrane rendering the radius axially unstable
Although excision of the radial head might be contemplated as definitive treatment for a comminuted fracture if such a fracture is in isolation, it cannot be considered an option if the fracture of the radial head is associated with rupture of the ulnar collateral ligament and instability of the elbow joint. Although the ulnar collateral ligament is the primary stabilizer and the radial head the secondary stabilizer of the elbow, a repair of the ulnar collateral ligament will not render the elbow stable if the radial head is missing. Therefore, under these circumstances, either an open reduction and internal fixation of the radial head fracture can be performed, or the radial head can be excised and replaced with a prosthesis, which will act as a spacer and will stabilize the joint. We feel that preservation of the radial head is preferable to excision. The decision regarding whether an open reduction and fixation is feasible must be based, as in all other fractures, on the personality of the fracture. A biological spacer is always better than a prosthesis. It is better to reduce and fix a radial head, even if not perfectly, and have it act as a spacer. If pain is the sequela of the less than perfect reduction, a late excision can be carried out. The ligaments will have healed and instability will have been prevented.
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