Back to Operative Surgery
Trauma

Open Reduction Internal Fixation of Radial Head Fracture

Surgical technique guide for Open Reduction Internal Fixation of Radial Head Fracture - FRCS exam preparation

Core Procedure
advanced
By OrthoVellum Medical Education Team

Reviewed by OrthoVellum Editorial Team

Editorial maintenance, source checking, and correction workflow • Published by OrthoVellum Medical Education Team

Editorial boardMethodologyReview policyReport a correction
High Yield Overview

OPEN REDUCTION INTERNAL FIXATION OF RADIAL HEAD FRACTURE

Lateral Kocher approach (between ECU and anconeus) or direct lateral splitting EDC | advanced

Critical Danger Structures - 5 SPECIFIC Anatomical Zones

Posterior Interosseous Nerve (PIN)

Location: Enters supinator muscle 10-20mm distal to radial head, anterior branch of radial nerve, lies anterior to radial neck in supination

Protection: Maintain full forearm supination throughout approach, stay proximal to 2cm distal to radial head, avoid retractor placement into supinator muscle

Radial Nerve Proper

Location: Anterior to lateral epicondyle and radiocapitellar joint, 20-30mm anterior to skin incision, divides into PIN and superficial sensory branch at level of radiocapitellar joint

Protection: Avoid anterior dissection beyond capsular incision, stay within Kocher interval (ECU-anconeus), no anterior retractors

Lateral Ulnar Collateral Ligament (LUCL)

Location: From lateral epicondyle to supinator crest, forms posterolateral corner, primary restraint to posterolateral rotatory instability

Protection: Identify and preserve during Kocher interval development, tag with suture if detached and repair at closure, avoid excessive posterior dissection

Annular Ligament

Location: Encircles radial neck from anterior to posterior sigmoid notch, stabilizes proximal radioulnar joint, attaches to anterior and posterior margins of sigmoid notch

Protection: Minimize dissection around radial neck, repair if incised for fracture exposure, avoid circumferential dissection that destabilizes PRUJ

Medial Collateral Ligament (MCL)

Location: Anterior bundle from medial epicondyle to sublime tubercle of coronoid, primary valgus restraint, at risk in associated elbow dislocation

Protection: Assess stability under fluoroscopy with valgus stress, repair via separate medial approach if opens greater than 3mm, avoid excessive valgus force during reduction

Mnemonic

My Surgeon Makes Arthroplasty DecisionsMASON Classification Memory Aid

Mnemonic

RaCe CoLTERRIBLE TRIAD Components

Positioning and Preparation

Patient Position: Supine with arm across chest or on hand table, or lateral decubitus

Surgical Approach: Lateral Kocher approach (between ECU and anconeus) or direct lateral splitting EDC

Incision: 6-10cm lateral incision centered over radial head from lateral epicondyle extending distally

Absolute Indications

  • Displaced Mason type 2 fractures (marginal fragment greater than 2mm displaced, greater than 30% articular surface)
  • Mason type 3 fractures if reconstructable with stable fixation (alternative is arthroplasty)
  • Block to forearm rotation - mechanical impingement from displaced fragment
  • Associated elbow instability requiring radial head preservation (terrible triad, Essex-Lopresti)

Relative Indications

  • Mason type 2 fractures with 2mm displacement but patient preference for surgery
  • Radial head fracture with concurrent MCL or LCL injury requiring stability
  • Marginal fractures involving greater than 25% of radial head circumference

Contraindications

  • Mason type 1 fractures (less than 2mm displacement, no block to rotation)
  • Comminuted fractures not amenable to stable fixation (consider arthroplasty)
  • Active infection at surgical site
  • Medical comorbidities precluding surgery
  • Small fragment less than 25% of head circumference (consider excision if stable elbow)

Operative Technique - Step by Step

Step 1: Assess under anesthesia

Assess under anesthesia: test elbow stability with valgus and posterolateral rotatory stress. Under fluoroscopy, apply valgus stress to assess MCL: if opens greater than 3mm has MCL injury needing repair. Posterolateral rotatory test for lateral ligament: if subluxates has LUCL injury. Block to forearm rotation indicates mechanical impingement from displaced fragment - absolute indication for surgery.

Exam Pearl

Technical Tip: EXAM KEY: Stability assessment under anesthesia critical before deciding ORIF vs excision - unstable elbow requires radial head preservation.

Dangers at this step

  • Excessive force causing additional injury to already compromised ligaments
  • Failure to identify associated instability patterns requiring comprehensive repair

Step 2: Position supine with arm across chest or on hand table, or lateral decubitus

Position supine with arm across chest or on hand table, or lateral decubitus. Must allow full elbow flexion-extension and forearm pronation-supination for intraoperative assessment. Lateral decubitus gives good access if other injuries. Supine with arm across chest standard. Ensure shoulder abducted less than 90° to avoid brachial plexus traction.

Exam Pearl

Technical Tip: EXAM KEY: Test positioning before draping - must achieve full supination (PIN protection) and rotation (assess PRUJ stability).

Dangers at this step

  • Brachial plexus traction from excessive shoulder abduction
  • Inadequate positioning preventing intraoperative stability assessment

Step 3: Mark incision 6-10cm lateral, centered over radial head

Mark incision 6-10cm lateral, centered over radial head. Palpate lateral epicondyle, radial head (rotates with forearm), ulna. Incision from lateral epicondyle extending 6-8cm distally. Can curve slightly posterior to follow Kocher internervous plane.

Exam Pearl

Technical Tip: EXAM KEY: Palpate radial head with forearm rotation to confirm level before incision - prevents too proximal or distal approach.

Dangers at this step

  • Skin necrosis from excessive tension or poor tissue handling
  • Incision too anterior risking radial nerve proper injury

Step 4: Full forearm supination and maintain throughout approach

Full forearm supination and maintain throughout approach. PIN enters supinator 1-2cm distal to radial head in pronation, but rotates anteriorly away from field in supination. Maintain full supination throughout approach and deep dissection for maximum safety. Have assistant hold forearm in supination.

Exam Pearl

Technical Tip: EXAM KEY: Supination is key to PIN protection - test and maintain throughout approach. Most PIN injuries from forearm pronation during dissection.

Dangers at this step

  • PIN injury if forearm pronates during dissection
  • Inadvertent relaxation of supination during critical dissection steps

Step 5: Incise skin and subcutaneous tissue, identify Kocher interval

Incise skin and subcutaneous tissue, identify Kocher interval. Develop internervous plane between anconeus (posterior interosseous nerve) posteriorly and ECU (posterior interosseous nerve) anteriorly. Palpate interval between muscle bellies. Both supplied by PIN so safe internervous plane.

Exam Pearl

Technical Tip: EXAM KEY: Kocher interval is true internervous plane - safe for PIN as both muscles supplied by it, nerve remains anterior in supination.

Dangers at this step

  • Nerve injury from dissection anterior to proper plane
  • Neuropraxia from excessive retractor pressure

Step 6: Develop Kocher interval, expose lateral capsule

Develop Kocher interval, expose lateral capsule. Bluntly separate anconeus from ECU with finger or instrument. Identify LUCL running from lateral epicondyle to supinator crest - preserve or tag for repair. Incise capsule longitudinally to expose radial head and neck. Minimal periosteal elevation to reduce heterotopic ossification risk.

Exam Pearl

Technical Tip: EXAM KEY: LUCL is critical for posterolateral stability - identify and preserve, or tag if detached and repair at closure.

Dangers at this step

  • LUCL disruption causing iatrogenic posterolateral instability
  • Excessive periosteal stripping increasing heterotopic ossification risk

Step 7: Assess fracture pattern and fragment size/number

Assess fracture pattern and fragment size/number. Inspect articular surface. Count fragments and assess size - need greater than 25% of head circumference for stable fixation. If less than 25% or greater than 3 fragments with poor bone quality, consider arthroplasty over ORIF. Clear hematoma and debris with irrigation and visualization.

Exam Pearl

Technical Tip: EXAM KEY: Intraoperative decision making - if too comminuted for stable ORIF, convert to arthroplasty rather than attempting doomed fixation.

Dangers at this step

  • Proceeding with ORIF when fracture not amenable to stable fixation
  • Losing small fragments during irrigation

Step 8: Anatomic reduction of articular surface, less than 1mm step-off

Anatomic reduction of articular surface, less than 1mm step-off. Reduce fragments to restore spherical radial head contour. Use dental pick or freer to lever fragments. Check reduction from anterior, lateral, posterior views. Accept less than 1mm step-off for best functional outcome. Greater than 1mm step-off leads to post-traumatic arthritis.

Exam Pearl

Technical Tip: EXAM KEY: Articular step-off greater than 1mm causes post-traumatic arthritis and poor outcome - take time to achieve anatomic reduction.

Dangers at this step

  • Inadequate reduction leaving articular incongruity
  • Iatrogenic fracture from aggressive manipulation

Step 9: Provisional fixation with 0.9-1.0mm K-wires

Provisional fixation with 0.9-1.0mm K-wires. Hold reduction with small K-wires outside safe zone (remove later) or small pointed reduction forceps. Confirm reduction with fluoroscopy AP and lateral, and direct visualization checking articular congruity. Multiple views essential to assess 3-dimensional reduction.

Exam Pearl

Technical Tip: EXAM KEY: Provisional fixation allows assessment before committing to screw placement - easier to adjust reduction now than after screws placed.

Dangers at this step

  • K-wire placement in safe zone interfering with definitive fixation
  • Inadequate provisional fixation allowing reduction loss

Step 10: Identify safe zone for hardware placement (110° anterolateral arc)

Identify safe zone for hardware placement (110° anterolateral arc). With forearm supinated and shoulder at side, mark lateral aspect of radial head under fluoroscopy - this is center of safe zone. Safe zone extends approximately 55° anterior and posterior. Place all hardware within this arc to avoid PRUJ impingement. Mark boundaries with K-wires or methylene blue.

Exam Pearl

Technical Tip: EXAM KEY: Safe zone concept critical - hardware outside this zone impinges on PRUJ with rotation causing pain, stiffness, and forearm rotation loss.

Dangers at this step

  • Incorrect safe zone identification leading to hardware prominence
  • Rotation of forearm during marking changing safe zone position

Step 11: Definitive fixation: buried headless screws or mini-fragment plate

Definitive fixation: buried headless screws or mini-fragment plate. Headless screws 2.0-2.4mm buried beneath articular cartilage in safe zone, or mini-fragment (2.0-2.4mm) plate contoured to radial head in safe zone. Plate gives more stability for comminution. At least 2 screws for fragment greater than 25%. Countersink screw heads below cartilage surface. Contour plate anatomically to radial head curvature.

Exam Pearl

Technical Tip: EXAM KEY: Buried headless screws avoid prominence but need adequate fragment size. Plate better for comminution but must be in safe zone and low-profile.

Dangers at this step

  • Malposition of hardware outside safe zone
  • Screw prominence above cartilage causing articular damage

Step 12: Remove provisional K-wires, test reduction and PRUJ stability

Remove provisional K-wires, test reduction and PRUJ stability. Rotate forearm through full pronation-supination while palpating radial head - should be smooth without crepitus or catching. No hardware prominence with rotation. Assess PRUJ stability - radial head should not sublux anteriorly or posteriorly. Fluoroscopy in pronation and supination to confirm no hardware impingement.

Exam Pearl

Technical Tip: EXAM KEY: Intraoperative rotation testing identifies hardware prominence or PRUJ instability before closure - revise if problems identified.

Dangers at this step

  • Missing hardware prominence that will cause post-op pain and stiffness
  • Inadequate stability assessment leading to post-op instability

Step 13: Repair annular ligament if incised for exposure

Repair annular ligament if incised for exposure. If annular ligament incised to expose fracture, repair with absorbable 2-0 suture to restore PRUJ stability. Side-to-side repair without overtightening. Test forearm rotation after repair - should be smooth through full arc.

Exam Pearl

Technical Tip: EXAM KEY: Annular ligament stabilizes proximal radioulnar joint - failure to repair causes PRUJ instability and forearm rotation loss.

Dangers at this step

  • Over-tightening annular ligament causing restricted rotation
  • Inadequate repair leading to chronic PRUJ instability

Step 14: Assess elbow stability under fluoroscopy, repair ligaments if unstable

Assess elbow stability under fluoroscopy, repair ligaments if unstable. Valgus stress test: if opens greater than 3mm medially, has MCL injury requiring repair. Posterolateral rotatory test: if subluxates, LUCL requires repair. If terrible triad, address coronoid fracture if not already done. Document stability with fluoroscopic images.

Exam Pearl

Technical Tip: EXAM KEY: Stability assessment after radial head fixation determines need for ligament repair - unstable elbow doomed to poor outcome without ligament repair.

Dangers at this step

  • Missing associated instability requiring ligament repair
  • Excessive force during testing causing additional injury

Step 15: If LUCL injured: repair to lateral epicondyle with suture anchors

If LUCL injured: repair to lateral epicondyle with suture anchors. Debride footprint on lateral epicondyle to bleeding bone. 2-3 suture anchors in epicondyle, pass through LUCL and common extensor origin, tie with elbow reduced. Test stability after repair - should resist posterolateral rotatory stress.

Exam Pearl

Technical Tip: EXAM KEY: LUCL is primary restraint to posterolateral rotatory instability - anatomic repair to epicondyle essential for stability.

Dangers at this step

  • Non-anatomic repair leading to persistent instability
  • Over-tensioning causing elbow stiffness

Step 16: Irrigate thoroughly, achieve hemostasis

Irrigate thoroughly, achieve hemostasis. Pulse lavage with 3L saline to remove debris and reduce infection risk. Bipolar cautery for bleeding. Check hemostasis with tourniquet down before closure. Minimize hematoma formation to reduce heterotopic ossification risk.

Exam Pearl

Technical Tip: EXAM KEY: Hematoma increases heterotopic ossification risk - meticulous hemostasis and consider drain if extensive dissection.

Dangers at this step

  • Thermal injury to PIN from cautery near supinator
  • Inadequate hemostasis leading to hematoma and heterotopic ossification

Step 17: Repair capsule with absorbable suture

Repair capsule with absorbable suture. Close lateral capsule with 2-0 absorbable suture. Creates soft tissue envelope protecting radial head. Don't overtighten - should allow rotation. Test ROM before completing capsular closure.

Exam Pearl

Technical Tip: EXAM KEY: Capsular repair provides soft tissue stability but must allow rotation - test ROM before tying sutures.

Dangers at this step

  • Over-tightening capsule causing post-op stiffness
  • Inadequate repair allowing capsular insufficiency

Step 18: Close Kocher interval, subcutaneous layer, skin

Close Kocher interval, subcutaneous layer, skin. Approximate anconeus-ECU interval with absorbable suture. Subcutaneous with 3-0 absorbable. Skin with monofilament or staples. Avoid tension on wound edges. Gentle tissue handling throughout to minimize scarring.

Exam Pearl

Technical Tip: EXAM KEY: Gentle tissue handling and tension-free closure reduces complications - heterotopic ossification and wound problems common after elbow trauma.

Dangers at this step

  • Wound tension causing dehiscence or skin necrosis
  • Excessive tissue trauma increasing heterotopic ossification risk

Step 19: Apply soft dressing and posterior elbow splint at 90° flexion

Apply soft dressing and posterior elbow splint at 90° flexion. Soft padding then splint at 90° flexion, forearm neutral. Splint for comfort and soft tissue rest 48-72 hours only, not for fracture stability. Remove for early ROM exercises. Educate patient on importance of early motion.

Exam Pearl

Technical Tip: EXAM KEY: Elbow stiffness is major complication - brief splinting for comfort only, emphasize early ROM to prevent stiffness.

Dangers at this step

  • Prolonged immobilization causing severe stiffness
  • Splint too tight causing compartment syndrome or nerve compression

Step 20: Post-operative protocol: early ROM to prevent stiffness

Post-operative protocol: early ROM to prevent stiffness. Day 1-2: remove splint for gentle active ROM exercises 3-4 times per day within comfort. Week 2: aggressive active ROM, begin forearm rotation. Week 4-6: progressive strengthening. Consider indomethacin 25mg TDS for 6 weeks if high risk for HO. Avoid passive stretching for first 6 weeks.

Exam Pearl

Technical Tip: EXAM KEY: Stiffness is enemy after radial head fracture - early aggressive ROM essential. Indomethacin reduces heterotopic ossification if high-risk patient.

Dangers at this step

  • Patient non-compliance with ROM leading to stiffness
  • Overly aggressive passive stretching causing inflammation and increased HO risk

Complications - Comprehensive Analysis

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 32-year-old presents with a terrible triad injury. Walk me through your management approach. What is the terrible triad and how do you manage it?"

EXCEPTIONAL ANSWER
Terrible triad is the combination of radial head fracture plus coronoid fracture plus elbow dislocation, resulting in global elbow instability. Named for historically poor outcomes when components not recognized or inadequately treated. Mechanism is posterolateral rotatory force with axial load causing sequential failure: LUCL disruption, coronoid fracture, radial head fracture, and potentially MCL rupture. Management requires addressing all three components in proper sequence for optimal stability. First, I assess coronoid fracture size and location - fix if greater than 50% height (valgus instability) or tip fragment with capsule attachment (even if small, as capsule insertion critical). Second, address radial head fracture - ORIF if reconstructable with stable fixation, or arthroplasty if comminuted. Critical that radial head is preserved, not excised, as it provides lateral column support. Third, repair lateral collateral ligament complex - LUCL primarily, with common extensor origin. Fourth, assess MCL stability under fluoroscopy with valgus stress - if opens greater than 3mm requires separate medial approach for repair. Finally, confirm concentric stable reduction through full ROM with fluoroscopy. Post-op protocol focuses on early protected ROM to prevent stiffness while maintaining stability - typically hinged external fixator if grossly unstable, otherwise early active motion within safe arc.
VIVA SCENARIOStandard

EXAMINER

"You've fixed a Mason type 2 radial head fracture with a plate. Post-operatively, the patient complains of pain with forearm rotation and mechanical catching. What's your differential and management?"

EXCEPTIONAL ANSWER
This clinical picture suggests hardware prominence causing mechanical impingement at the proximal radioulnar joint (PRUJ). The radial head articulates with the sigmoid notch of the ulna through a 250° arc during forearm rotation. The safe zone for hardware is only 110° on the anterolateral surface - hardware outside this zone impinges on the ulna during pronation-supination. Differential diagnosis includes: hardware prominence outside safe zone (most likely given mechanical symptoms), articular incongruity from loss of reduction, PRUJ instability from annular ligament injury or malreduction, post-traumatic arthritis from cartilage damage, or heterotopic ossification. Initial assessment includes careful examination to localize tenderness, ROM assessment documenting degree of pronation-supination loss, and fluoroscopy during active rotation to visualize impingement. Treatment depends on timing and cause. If early (less than 6 months) and hardware prominence confirmed, may need revision surgery with plate removal and replacement with buried headless screws positioned in safe zone. If late (greater than 6 months) with confirmed union, remove hardware. If articular incongruity or PRUJ instability identified, may need radial head excision (if stable elbow) or arthroplasty (if unstable). Prevention requires careful intra-operative identification of safe zone with forearm supinated and arm at side, low-profile plate contouring, and rotation testing with fluoroscopy before closure.
VIVA SCENARIOStandard

EXAMINER

"A patient presents with a radial head fracture and wrist pain. On examination, the DRUJ is unstable. What injury pattern are you concerned about and how does this change your management?"

EXCEPTIONAL ANSWER
This presentation is concerning for Essex-Lopresti injury - a longitudinal radioulnar dissociation injury consisting of radial head fracture, interosseous membrane disruption, and DRUJ disruption. Mechanism is high-energy axial load driving radius proximally, disrupting interosseous membrane and DRUJ. Clinical signs include radial head fracture with wrist pain, DRUJ tenderness, positive DRUJ stress test (piano key sign with ulnar head subluxation), and potentially proximal radial migration on AP forearm radiograph compared to contralateral side. This diagnosis fundamentally changes management because the radial head is now a critical load-bearing structure preventing proximal migration of radius. Radial head excision is absolutely contraindicated - will result in progressive proximal radial migration, DRUJ arthrosis, ulnar-sided wrist pain, and poor functional outcome. Management requires: first, preserve radial head via ORIF if reconstructable or radial head arthroplasty if too comminuted (modern metal or pyrocarbon implants). Second, address DRUJ - assess stability and repair if unstable, may need K-wire fixation of DRUJ in reduced position for 6 weeks if grossly unstable. Third, consider interosseous membrane reconstruction if acute injury (controversial - some advocate immediate central band reconstruction, others accept lengthening of IOM). Post-operatively, splint forearm supinated and wrist neutral for 6 weeks to allow soft tissue healing. Long-term monitoring for progressive radial migration with serial radiographs. Prognosis guarded even with optimal treatment - may develop chronic DRUJ pain and ulnar impaction.

ORIF Radial Head Fracture - Exam Day Essentials

High-Yield Exam Summary

References

  1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42(172):123-132. doi:10.1002/bjs.18004217203

  2. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5(1):1-10. doi:10.5435/00124635-199701000-00001

  3. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547-551. doi:10.2106/00004623-200204000-00006

  4. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17(3):137-151. doi:10.5435/00124635-200903000-00002

  5. Guitton TG, Ring D. Science of Variation Group. Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. J Bone Joint Surg Am. 2011;93(21):2015-2021. doi:10.2106/JBJS.J.00711

  6. Doornberg JN, Parisien R, van Duijnhoven N, Kloen P. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007;89(5):1075-1080. doi:10.2106/JBJS.F.00608

  7. Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: surgical technique and clinical experience. J Orthop Trauma. 2007;21(10):718-724. doi:10.1097/BOT.0b013e318158ab44

  8. Grewal R, MacDermid JC, King GJ. Open reduction internal fixation versus excision of radial head fractures: a systematic review. J Hand Surg Am. 2009;34(10):1861-1869. doi:10.1016/j.jhsa.2009.09.007

  9. Struijs PA, Smit G, Steller EP. Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review. Arch Orthop Trauma Surg. 2007;127(2):125-130. doi:10.1007/s00402-006-0240-9

  10. Kaas L, van Riet RP, Vroemen JP, Eygendaal D. The epidemiology of radial head fractures. J Shoulder Elbow Surg. 2010;19(4):520-523. doi:10.1016/j.jse.2009.10.015