Surgical technique guide for Open Reduction Internal Fixation of Radial Head Fracture - FRCS exam preparation
Reviewed by OrthoVellum Editorial Team
Orthopaedic clinicians and medical editors • Published by OrthoVellum Medical Education Team
Lateral Kocher approach (between ECU and anconeus) or direct lateral splitting EDC | advanced
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
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
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
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
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
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
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
| Complication | Recognition | Prevention | Management |
|---|---|---|---|
| Posterior interosseous nerve (PIN) injury (1-5% incidence) | Post-op weakness of thumb/finger extension (EPL, EDC, EIP, EPB, APL), preserved wrist extension (ECRL/ECRB innervated before PIN branch), no sensory loss. EMG/NCS at 3-4 weeks confirms neuropraxia vs axonotmesis | Forearm fully supinated during approach, stay proximal to 2cm distal to radial head, avoid retraction into supinator, no anterior retractors, maintain supination throughout case | Usually neuropraxia recovering 3-6 months with observation and occupational therapy for compensatory strategies. If no recovery at 3 months repeat EMG. If transection identified intra-op perform primary repair. Consider exploration at 4-6 months if no clinical or electrical recovery |
| Radioulnar synostosis (2-5% incidence) | Progressive loss of forearm rotation beginning weeks post-op, firm endpoint to rotation, radiographs show bone bridging proximal radius to ulna, CT confirms location and extent | Minimize periosteal stripping of radius and ulna, gentle handling of interosseous membrane, avoid hematoma, early ROM, maintain plane between ECU-anconeus, indomethacin prophylaxis if high risk | If symptomatic and established: synostosis takedown after maturation (6-12 months) with post-op indomethacin 25mg TDS for 6 weeks and radiation (700cGy) within 72 hours. Functional results better if some rotation preserved |
| Heterotopic ossification (5-15% after trauma, higher with head injury) | Progressive stiffness weeks to months post-op, pain with ROM, palpable hard masses, radiographs show periarticular calcification/ossification, alkaline phosphatase elevated during active formation | Gentle soft tissue handling, minimize periosteal stripping, early ROM within 48 hours, meticulous hemostasis, indomethacin 25mg TDS for 6 weeks if high risk (head injury, burns, prior HO), single-dose radiation (700cGy) within 72 hours post-op | Observation if asymptomatic or mild stiffness. Excision after maturation (12-18 months) if limiting function - confirm maturity with serial radiographs (no progression for 3-6 months) and normal alkaline phosphatase. Post-excision: indomethacin for 6 weeks and radiation within 24 hours |
| Implant prominence and painful hardware (10-20% incidence) | Pain with forearm rotation, mechanical catching or crepitus, point tenderness over hardware, fluoroscopy during rotation shows impingement on PRUJ, loss of terminal rotation | Bury screws beneath articular cartilage (countersink), use low-profile plates in safe zone (110° anterolateral arc), smooth plate contouring, intra-op rotation testing with fluoroscopy, avoid hardware in posterior 250° arc | Hardware removal once healed (6-12 months minimum) if symptomatic and affecting function. Confirm fracture union before removal. May need plate replacement with buried screws if early (less than 6 months). Warn patient stiffness may not fully resolve after removal |
| Loss of reduction and fixation failure (5-10% incidence) | Recurrent mechanical symptoms, loss of ROM, radiographs show displacement, hardware loosening or breakage, articular step-off on CT | Adequate fragment size for fixation (greater than 25% of head circumference), stable construct (plate for comminution, minimum 2 screws for large fragments), protected early motion (active only), bone graft if comminution or bone loss | Revision ORIF if early (less than 6 weeks) and reconstructable with good bone quality. Radial head excision if late, small fragment, and stable elbow (no LUCL or MCL injury, no Essex-Lopresti). Radial head arthroplasty if late, unstable elbow, or Essex-Lopresti injury |
| Stiffness and loss of rotation (10-30% incidence) | Progressive loss of flexion-extension (normal 0-145°) or forearm rotation (normal 75° pronation, 85° supination), firm capsular endpoint, radiographs may show HO or joint space narrowing | Anatomic articular reduction (less than 1mm step-off), stable fixation allowing early motion, aggressive PT from week 1-2 (active ROM only), brief splinting (48-72 hours maximum), avoid passive stretching first 6 weeks, HO prophylaxis if high risk | Continue aggressive active ROM and stretching for minimum 6 months. Static progressive splinting after 3 months if plateau. Arthroscopic or open capsular release and heterotopic ossification excision after 6-12 months if severe (functional arc less than 30-100°) with failed conservative management |
| Post-traumatic arthritis (15-30% long-term incidence) | Chronic pain with use, mechanical symptoms (catching, locking), crepitus, loss of motion, radiographs show joint space narrowing, osteophytes, subchondral sclerosis, articular collapse | Anatomic articular reduction (less than 1mm step-off), stable fixation, early motion, bury screws beneath cartilage to avoid mechanical wear, low-profile hardware, address all instability (ligament repair) | Non-operative initially: NSAIDs, activity modification, physiotherapy for ROM and strengthening. Steroid injection for symptomatic relief. Radial head excision if isolated radial head arthritis and stable elbow (no LCL/MCL injury, no Essex-Lopresti). Radial head arthroplasty if arthritis with instability. Total elbow arthroplasty if pan-elbow arthritis and low demand patient |
Practice these scenarios to excel in your viva examination
"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?"
"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?"
"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?"
High-Yield Exam Summary
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
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
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
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
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
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
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
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
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
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