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2005;87:76-84. doi:10.2106/JBJS.C.01323 J Bone Joint Surg Am.
Masayoshi Ikeda, Kazuhiro Sugiyama, Chonte Kang, Tomonori Takagaki and Yoshinori Oka

and Internal Fixation
Comminuted Fractures of the Radial Head. Comparison of Resection
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,o
Comminuted Fractures
of the Radial Head
COMPARISON OF RESECTION AND INTERNAL FIXATION
BY MASAYOSHI IKEDA, MD, PHD, KAZUHIRO SUGIYAMA, MD,
CHONTE KANG, MD, TOMONORI TAKAGAKI, MD, AND YOSHINORI OKA, MD, PHD
Investigation performed at the Department of Orthopaedic Surgery, Tokai University Oiso Hospital, Kanagawa, Japan
Background: Satisfactory internal fixation of comminuted radial head fractures is often difficult to achieve, and ra-
dial head resection has been the accepted treatment. In this study, we compared the results of radial head resection
with those of open reduction and internal fixation in patients with a comminuted radial head fracture.
Methods: Twenty-eight patients with a Mason type-III radial head fracture (some with associated injuries) were en-
rolled in the study. Fifteen patients underwent radial head resection as the initial treatment (Group I), and thirteen pa-
tients underwent open reduction and internal fixation (Group II). The age at the operation averaged 41.1 and 38.2
years, respectively, and the duration of follow-up averaged ten and three years, respectively. The outcomes were as-
sessed on the basis of pain, motion, radiographic findings, and strength measured with Cybex testing. The overall
outcome was rated with the functional rating score described by Broberg and Morrey and with the American Shoulder
and Elbow Surgeons Elbow Assessment Form.
Results: Elbow motion averaged 15.5 (extension loss) to 131.4 (flexion) in Group I and 7.1 to 133.8 in Group II.
The carrying angle and ulnar variance averaged 8.2 and 1.9 mm in Group I and 1.5 and 0.5 mm in Group II. Com-
pared with Group II, Group I had a loss of strength in extension, pronation, and supination (p < 0.01). The Broberg
and Morrey functional rating score averaged 81.4 points in Group I and 90.7 points in Group II (p = 0.0034). The
score on the American Shoulder and Elbow Surgeons Elbow Assessment Form averaged 87.3 points in Group I and
94.6 points in Group II (p = 0.0031).
Conclusions: The patients in whom the comminuted radial head fracture was treated with open reduction and inter-
nal fixation had satisfactory joint motion, with greater strength and better function than the patients who had under-
gone radial head resection. These results support a recommendation for open reduction and internal fixation in the
treatment of this fracture.
Level of Evidence: Therapeutic study, Level III. See Instructions to Authors for a complete description of levels of
evidence.
he treatment of displaced comminuted fractures of the
radial head is controversial, with conflicting evidence to
support either resection or open reduction and internal
fixation
1-5
. It is difficult to achieve satisfactory open reduction
and internal fixation of a fracture that is comminuted and se-
verely displaced. Improper internal fixation interferes with the
smooth congruity of the proximal radioulnar articulation, and
this limits joint motion, causes pain, and may lead to posttrau-
matic osteoarthrosis of adjacent joints. Therefore, radial
head resection has been a valid therapeutic option, with reports
of good long-term functional outcomes
6-13
. However, delayed
complications, including pain, joint instability, proximal radial
translation, decreased strength, osteoarthrosis, and cubitus
valgus, have also been reported after radial head resection
12-21
.
Radial head resection in patients with a severely comminuted
radial head fracture, which often is associated with ligament
disruption, may produce an extremely unstable elbow.
Prior to July 1996, we performed radial head resec-
tion as the primary treatment for comminuted radial head
fractures. After July 1996, we have performed internal fixation
with small implants such as mini-plates or Herbert screws
whenever possible. Thus, we were able to study two groups of
patients: those who underwent radial head resection and those
who underwent internal fixation for a similar type of commi-
nuted fracture of the radial head. The purpose of this study
was to evaluate and compare the outcomes in those two
groups to determine the better method of treatment of com-
minuted radial head fractures.
T
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COMMI NUTED FRACTURES
OF THE RADI AL HEAD
Materials and Methods
etween April 1984 and March 2001, we performed opera-
tions on thirty-five consecutive patients with a commi-
nuted and displaced radial head fracture. All fractures were
classified as type III according to the Mason
6
classification
system. Some patients had an associated elbow dislocation,
ligament injury, coronoid fracture, or Monteggia lesion (the
so-called Mason type-IV variations)
3
. Radial head resection
was performed prior to July 1996 by two of us (M.I. and Y.O.),
and open reduction and internal fixation was performed
after July 1996 by one of us (M.I.). Two patients underwent
prosthetic replacement of the radial head after July 1996 and
were excluded from this study. Five patients who had under-
gone radial head resection were lost to follow-up, and the re-
maining twenty-eight patients were included in the study.
Eighteen patients sustained the injury from a fall on the out-
stretched hand, and ten patients sustained the injury in a
motor-vehicle accident.
Our institutional review board approved the retrospec-
tive review, and the physical and radiographic examinations,
including the assessment protocol, were carried out after the
patients gave informed consent to participate in the study.
Group I: Radial Head Resection
Group I included fifteen patients (eleven men and four
women) who had undergone primary radial head resection.
Their average age at the time of the operation was 41.1 years
(range, twenty-five to seventy years). There were nine Mason
type-III fractures and six Mason type-IV variations. Four pa-
tients had a simple fracture of the entire radial neck with the
head completely displaced from the shaft (Fig. 1, A), seven
had an articular fracture of the entire head consisting of
more than two large displaced fragments (Fig. 1, B), and four
had a fracture with an impacted articular fragment and
small, comminuted, completely displaced fragments (Fig 1,
C). Three patients who had a Mason type-IV variation with a
posterior elbow dislocation initially underwent manipulative
reduction and immobilization in a plaster splint. The average
time from the injury to the operation was nine days (range,
one to fourteen days).
Radial head resection was carried out through a lateral
or posterolateral approach, with the head removed at the
level of the annular ligament. The lateral collateral ligament
was repaired with number-1 nonabsorbable braided sutures
or an anchoring system (Mitek GII Quick Anchor Plus; Ethi-
con, Johnson and Johnson, Westwood, Massachusetts) at
joint closure.
Four patients had a coronoid fracture. According to the
Regan-Morrey
22
classification system, three of these fractures
were type I (simple avulsion of the tip of the process), and one
was type II (a single fracture involving approximately 50% of
the process). The coronoid fracture fragment was removed in
the three patients with a type-I fracture, and the type-II frac-
ture was internally fixed. A Monteggia lesion was present in
one patient who had a posteriorly angulated fracture of the
proximal third of the ulna with a posterior dislocation of the
fractured radial head. The fracture of the ulna was internally
fixed when the radial head was resected. In five patients with a
medial collateral ligament injury, the ligament was repaired
with number-1 nonabsorbable braided sutures or an anchor-
ing system.
The average period of immobilization after the radial
head resections was eight days (range, one to fourteen days).
Active forearm rotation exercises were initiated with the arm
in a sling and the elbow at a right angle. Active range-of-
motion exercises of the elbow were started two weeks after the
operation. The five patients with a repaired medial collateral
ligament wore a long arm cylinder cast instead of a sling to
keep the elbow at a right angle in order to allow forearm rota-
tion. The cast was changed to a hinged brace, and active el-
bow movement was started two weeks postoperatively. The
brace was worn continuously for four weeks. The average pe-
riod of postoperative follow-up was ten years (range, three to
eighteen years).
B
Fig. 1
Mason type-III radial head fracture patterns. A: A fracture of the entire radial neck, with the head
completely displaced from the shaft. B: An articular fracture involving the entire head, which con-
sists of more than two large fragments. Each fragment is completely displaced from the shaft. C:
A fracture with a tilted and impacted articular segment, which must be reduced, and some artic-
ular fragments displaced from the shaft.
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COMMI NUTED FRACTURES
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Group II: Open Reduction and Internal Fixation
Group II included thirteen patients (seven men and six
women) who underwent open reduction and internal fixa-
tion. The average age at the time of the operation was 38.2
years (range, twenty to seventy-one years). There were three
Mason type-III fractures and ten Mason type-IV variations.
Nine patients had an articular fracture of the entire head.
Three of those fractures consisted of two large fragments, and
the other six consisted of more than three large fragments
with or without marginal fragments. Four fractures included
large impacted articular fragments and two or three small
fragments. Two patients who had a Mason type-IV variation
with a posterior elbow dislocation initially underwent manip-
ulative closed reduction. A Mason type-III fracture, classified
as a type-II open fracture according to the criteria of Gustilo
et al.
23
, was treated initially with dbridement and irrigation
and the wound was closed primarily. The average time from
the injury to the operation was twelve days (range, eight to
sixteen days).
All fractures of the radial head were internally fixed with
use of low-profile mini-plates
24
(Stryker Leibinger, Freiburg,
Germany) and/or Herbert screws (Zimmer, Warsaw, Indiana)
(Figs. 2-A through 2-F). The radial head fracture was accessed
through an approach similar to that used for the radial head
resections. When the medial collateral ligament was torn, it
was anchored with a number-1 nonabsorbable braided suture
or an anchoring system prior to fracture reduction. The an-
chor suture was tied after fracture fixation. The fracture was
reduced and was held with small forceps or tenacular clamps,
or it was temporarily fixed with 1.0-mm Kirschner wires. The
low-profile mini-plate used in this series was T-shaped with
a 0.55-mm profile height and a 1.7-mm screw diameter. In
eleven patients, cancellous bone chips or graft blocks, ob-
tained from the ipsilateral olecranon in three patients and
from the iliac crest in eight, were placed between the radial
head and neck or in other areas of bone deficit of the reduc-
tion. The annular ligament was sutured with number-1 non-
absorbable braided sutures, and the lateral collateral ligament
was repaired with number-1 nonabsorbable braided sutures
or an anchoring system subsequently.
Eight fractures were fixed with low-profile mini-plates,
three fractures were fixed with Herbert screws, and two frac-
tures were fixed with a combination of the two. Bone-grafting
was performed in eleven fractures. The medial collateral liga-
ment was repaired in seven patients who had the Mason type-
IV variation, and the lateral collateral ligament was repaired in
four. A type-I fracture of the coronoid tip was present and the
fragment was removed in two patients with a Mason type-IV
variation. One patient had a small avulsion fracture of the ole-
cranon, and the triceps tendon was repaired at its insertion.
An osteochondral fracture of the capitellum in a patient with a
Mason type-IV variation was fixed with a bone peg graft ob-
tained from the olecranon crest.
Forearm rotation exercises, with the extremity in a long
arm cylinder cast and the elbow at a right angle, were started
two days (range, one to four days) after the surgery. The cast
was worn for two weeks, after which it was changed to a
hinged brace and active elbow movement was started. The
brace was worn continuously for four weeks. Of the ten pa-
tients in whom the fracture was fixed with low-profile mini-
plates, nine had the plates removed after five to seven months
to prevent deterioration of the proximal radioulnar cartilage.
One patient with a Mason type-IV variation refused to have
the plates removed. The follow-up period after the initial op-
eration averaged three years (range, two to four years).
Outcome Measures and Statistical Methods
The outcome assessment included a questionnaire inquiring
about pain, impairment, and elbow disability. The responses
were incorporated into the Broberg and Morrey functional
rating score
9
and the American Shoulder and Elbow Surgeons
Elbow Assessment Form
25
. Physical assessment included mea-
surement of the ranges of motion of the elbow and forearm
and of grip strength. A standard long-limb goniometer was
used to measure range of motion. Flexion and extension of the
elbow were measured with the forearm in neutral rotation,
and rotation of the forearm was measured with the elbow at a
right angle. Bilateral anteroposterior and lateral radiographs
of the elbow were made to assess osseous union, congruity,
Fig. 2-A
Anteroposterior radiograph demonstrating a Mason type-III
radial head fracture.
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COMMI NUTED FRACTURES
OF THE RADI AL HEAD
and posttraumatic osteoarthrosis. Bilateral anteroposterior ra-
diographs of the wrist and elbow were made in supination to
measure the carrying angle and ulnar variance. Osteoarthrosis
in the elbow was classified, according to the Broberg and Mor-
rey system
9
, as grade zero (absent; normal elbow), grade one
(mild, with slight joint space narrowing or minimum osteo-
phyte formation), grade two (moderate, with moderate joint
space narrowing or moderate osteophyte formation), or grade
three (severe, with severe degenerative change and joint de-
struction). The strength of flexion and extension of the elbow
and of pronation and supination of the forearm was measured
with the Cybex 770-NORM (Cybex International, Ronkon-
koma, New York). The peak torques of flexion and extension
of the elbow and pronation and supination of the forearm
were measured at 60/sec and 30/sec, respectively.
Twenty normal subjects were studied to determine the
normal variation in grip strength and the results of Cybex
testing between dominant and nondominant sides, as de-
scribed by Morrey et al.
12
. The ratio of the nondominant to
the dominant side was 0.87 for grip strength, 0.89 for exten-
sion, 0.91 for flexion, 0.78 for pronation, and 0.72 for supi-
nation. These values were used to calculate and normalize
the loss of strength on the dominant or nondominant ex-
tremity independently.
The outcome was rated with the Broberg and Morrey
functional rating score
9
and the American Shoulder and El-
bow Surgeons Elbow Assessment Form
25
.
Standard statistical methods were employed. Descrip-
tive statistics, including means and standard deviations,
were calculated and Groups I and II were compared. The
Fig. 2-C
Fixation was achieved with two Herbert screws and two low-profile mini-plates.
Fig. 2-D
Fig. 2-B
Intraoperative photograph showing a Mason
type-III fracture consisting of two large frag-
ments and a marginal fragment.
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COMMI NUTED FRACTURES
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Mann-Whitney U test was used to evaluate the significance
of intergroup differences, and a p value of <0.01 was con-
sidered significant.
Results
ll fractures in Group II had osseous union. When the
plates were removed after five to seven months in nine
patients, they were covered by synovial tissue and they did not
seem to interfere with the function of the proximal radioulnar
joint. One patient who had no symptoms refused to have the
plates removed. One patient with an open Mason type-III
fracture had a delayed union, and it took eleven months until
osseous union was evident radiographically.
Pain
Visual-analog-scale scores in the American Shoulder and El-
bow Surgeons Elbow Assessment Form were used to compare
the patients perception of pain, with 25 points representing
the best possible score. The average score was 19.3 points
(range, 12 to 25 points) in Group I and 22.4 points (range, 17
to 25 points) in Group II (p = 0.0226) (Table I). Five patients
in Group I and one in Group II had mild pain in the elbow
with strenuous use that required forearm rotation. Three pa-
tients in Group I complained of a dull ache and numbness
along the ulnar aspect of the forearm.
Motion
Flexion contracture of the elbow averaged 15.5 (range, 5 to
46) in Group I compared with 7.1 (range, 0 to 23) in
Group II (p = 0.0254). The ranges of motion in the two
groups were similar. Flexion of the elbow averaged 131.4
(range, 111 to 142) in Group I compared with 133.8 (range,
116 to 143) in Group II (p = 0.2790). Pronation of the fore-
arm averaged 74.8 (range, 32 to 84) in Group I compared
with 73.3 (range, 63 to 81) in Group II (p = 0.0653). Supi-
nation of the forearm averaged 82.1 (range, 69 to 89) in
Group I compared with 85.3 (range, 75 to 90) in Group II
(p = 0.0226).
Strength
The average loss of grip strength was 15.0% (range, 2% to
34%) in Group I compared with 10.4% (range, 0% to 24%) in
Group II (p = 0.1971). Group I lost, on the average, 28.6%
(range, 6.5% to 40.0%) of strength in extension, 17.9% (range,
6.2% to 35.0%) in flexion, 26.4% (range, 7.1% to 54.7%) in
A
Fig. 2-F
The plates were removed five months after internal fixation. One Her-
bert screw was removed and the other was left in situ.
Fig. 2-E
Postoperative anteroposterior radiograph.
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COMMI NUTED FRACTURES
OF THE RADI AL HEAD
pronation, and 38.3% (range, 14.3% to 55.5%) in supination.
Group II lost an average of 11.8% (range, 2.3% to 29.7%) of
strength in extension, 21.3% (range, 5.5% to 37.5%) in flex-
ion, 13.6% (range, 0% to 42.3%) in pronation, and 7.7%
(range, 0% to 30.1%) in supination. Loss of strength in ex-
tension (p = 0.0002), pronation (p = 0.0046), and supination
(p < 0.0001) was greater in Group I than it was in Group II
(Fig. 3). There was no significant difference between the
groups with regard to strength in flexion (p = 0.3841).
Radiographic Assessment
In comparison with the value for the contralateral limb, the
average increase in the carrying angle was 8.2 (range, 0 to
20) in Group I and 1.5 (range, 0 to 5) in Group II (p <
0.0001) (Table II). The average increase in ulnar variance was
1.9 mm (range, 0 to 5 mm) in Group I and 0.5 mm (range, 2
to 3 mm) in Group II (p = 0.0075) (Table II). Degenerative
changes in Group I were grade zero in four elbows, grade one
in six, and grade two in five (Figs. 4-A and 4-B). Degenerative
changes in Group II were grade zero in seven elbows and
grade one in six. Varying degrees of osteoarthrosis were recog-
nized in Group I but not in Group II.
Functional Assessment
The Broberg and Morrey functional rating score averaged 81.4
points (range, 57 to 92 points) in Group I and 90.7 points
(range, 73 to 100 points) in Group II (p = 0.0034) (Table I).
According to this scoring system, the result was rated as good
for nine patients, fair for five, and poor for one in Group I.
The result was rated as excellent for three patients, good for
nine, and fair for one in Group II. The average score according
to the American Shoulder and Elbow Surgeons Elbow Assess-
ment Form was 87.3 points (range, 70 to 97 points) in Group I
and 94.6 points (range, 77 to 100 points) in Group II (p =
0.0031) (Table I).
Discussion
cceptable long-term functional outcomes have been re-
ported after primary or delayed radial head resection
performed as a salvage operation for Mason type-III frac-
tures
6,7,9-11,26
. Radial head resection has been associated with
long-term complications, including wrist and forearm pain,
increased valgus elbow deformity, degenerative osteoarthro-
sis, and decreased strength. However, these complications
are not considered serious as long as joint mobility is
preserved
6-10,12,19
.
Many authors
10,12-16,18,20
have reported a 2 to 3-mm in-
crease in proximal translation of the radius and an increase in
ulnar variance after radial head resection. These changes can
cause wrist, forearm, and elbow pain with resultant ulnar
A
TABLE I Pain Scores and Functional Assessment Scores
Measure* Group I Group II P Value
VAS pain score of ASES (points) 19.3 3.5 22.4 2.7 0.0226
Broberg and Morrey functional
rating score (points)
81.4 8.2 90.7 7.7 0.0034
ASES score (points) 87.3 7.6 94.6 6.0 0.0031
*Pain was assessed with the visual-analog-scale (VAS) of the American Shoulder and Elbow Surgeons Elbow Assessment Form (ASES)
25
, with
25 points representing the best possible score. Function was assessed with the Broberg and Morrey functional rating score
9
and the ASES
score. The values are given as the mean and standard deviation.
Fig. 3
Loss of strength, expressed as a per-
centage of the strength on the uninjured
side, in elbow extension and flexion and
forearm pronation and supination. The
values are given as the mean and stan-
dard deviation, and the difference be-
tween the dominant and nondominant
sides has been normalized.
8:
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COMMI NUTED FRACTURES
OF THE RADI AL HEAD
abutment, subluxation of the distal radioulnar joint, or
stretching of the interosseous membrane
14,16,18
. A 5 to 20 in-
crease in the carrying angle of the elbow has also been re-
ported
10,13,16-19
. This valgus elbow deformity can result in the
development of ulnar nerve symptoms. Although the condi-
tions under which strength was measured were not uniformly
normalized in previous studies, loss of strength in elbow flex-
ion and extension and in forearm rotation may approach
30%
8,9,12,18,27
. Our study demonstrated less elbow extension and
forearm rotation strength after radial head resection than after
open reduction and internal fixation. The main mechanism
for loss of strength is probably related to the decreased
proximal support of the radius, which normally acts as a load-
bearing fulcrum to transmit forces across the radiocapitellar
articulation. Other contributing factors may include restricted
joint mobility, valgus instability, functional discomfort, and
psychologic factors.
The importance of the radial head and radiocapitellar
contact has been noted both clinically and experimentally, es-
pecially after radial head fractures associated with ligament
injuries
27-33
. The most common cause of failure of open reduc-
tion and internal fixation has been the inability to achieve
rigid internal fixation
5,30
. The advent of the Herbert screw and,
more recently, the mini-plate system has created the possi-
bility of reducing and internally fixing radial head fractures
that previously would have required resection
24,28-31,34-38
. Al-
though repair of severely comminuted fractures is technically
demanding and not all radial head fractures are amenable to
open reduction and internal fixation, our results justify an ef-
fort to preserve the radial head.
TABLE II Radiographic Assessment of Valgus Deformity of the Elbow and Proximal Translation of the Radius
Measure Group I* Group II* P Value
Increase in carrying angle (deg) 8.2 1.4 1.5 1.8 <0.0001
Increase in ulnar variance (mm) 1.9 1.1 0.5 1.3 0.0075
*The values are given as the mean and standard deviation. Compared with the value on the contralateral side.
Fig. 4-B
Anteroposterior (Fig. 4-A) and lateral (Fig. 4-B) radiographs of the el-
bow, showing moderate degenerative changes thirteen years after
radial head resection. There is severe osteophyte formation at the
coronoid and olecranon processes.
Fig. 4-A
8,
THE JOURNAL OF BONE & JOI NT SURGERY J BJ S. ORG
VOLUME 87-A NUMBER 1 JANUARY 2005
COMMI NUTED FRACTURES
OF THE RADI AL HEAD
Ideally, all comminuted radial head fractures should be
treated with internal fixation with small implants. Since we
started using small implants for internal fixation of commi-
nuted fractures, we have fixed all but two successfully. The two
patients in whom the fracture was not fixed would not accept
the bone-grafting and the postoperative protocol for internal
fixation, including plate removal; they underwent prosthetic
radial head replacement primarily without an attempt at open
reduction and internal fixation.
While there was no bias in this study with regard to pa-
tient selection according to fracture severity or technical dif-
ficulty, the study did have several limitations. First, it was a
longitudinal study comparing a cohort of patients who had un-
dergone radial head resection prior to July 1996 with a group that had
been treated more recently with open reduction and internal
fixation. Thus, there is an obvious difference in the duration of
follow-up between the two groups (ten years in Group I com-
pared with three years in Group II), although all patients were
followed for a minimum of two years. This discrepancy may
have had a substantial effect on the reported prevalence of
degenerative elbow changes, which was greater in the patients
who had had the radial head resection. Second, we attribute
our good results to meticulous surgical technique, especially
the use of low-profile mini-plates and bone-grafting. A third
limitation of the study is the difference in postoperative pro-
tocol between the groups, but the final ranges of motion of
the two groups were similar and the follow-up period was suf-
ficient to evaluate strength. Although the average ages of the
patients in the two groups were similar at the time of the oper-
ation, the patients in Group I were, on the average, older than
those in Group II at the final evaluation.
Despite these limitations, we concluded that open re-
duction and internal fixation results in satisfactory joint
mobility and provides better strength and a better overall
functional outcome than does radial head resection. There-
fore, open reduction and internal fixation should be pursued
in the treatment of comminuted fractures of the radial head
unless extenuating factors, such as poor general health or ad-
vanced age, prevent the patient from participating in the post-
operative rehabilitation protocol.
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Masayoshi Ikeda, MD, PhD
Kazuhiro Sugiyama, MD
Chonte Kang, MD
Tomonori Takagaki, MD
Yoshinori Oka, MD, PhD
Department of Orthopaedic Surgery, Tokai University Oiso Hospital,
21-1 Gakkyo, Oiso, Naka-gun Kanagawa, 259-0198, Japan. E-mail
address for M. Ikeda: zenryo@oiso.u-tokai.ac.jp
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive pay-
ments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit
organization with which the authors are affiliated or associated.
doi:10.2106/JBJS.C.01323
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VOLUME 87-A NUMBER 1 JANUARY 2005
COMMI NUTED FRACTURES
OF THE RADI AL HEAD
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