Fractures of the radial head and coronoid process

Challenges of conservative therapy

Conservative management of intra-articular fractures of this localization is associated with a number of significant drawbacks. The patient requires limb immobilization in a forced position of full forearm extension for a prolonged period — from 4 to 6 weeks, which is extremely uncomfortable and reduces quality of life.

At the same time, the traumatologist faces a serious dilemma when choosing the timing for initiating rehabilitation:

• Too early initiation of motion inevitably leads to secondary displacement of bone fragments due to muscle traction.
• Late initiation of joint mobilization guaranteed to result in persistent stiffness — elbow joint contracture, which is extremely difficult to treat.

For this reason, even with minimal diastasis (up to 5 mm) that tends to resolve, osteosynthesis is recognized as the most optimal, predictable, and safe method for joint function.

Surgical tactics: indications and limitations

An absolute indication for surgical intervention is a diastasis between fragments exceeding 5 mm. The surgeon has two main options: performing osteosynthesis or, in cases of severe comminution, resecting a part of the olecranon (strictly up to 1/3 of its original volume).

There is a critically important absolute contraindication to olecranon resection: the presence of an associated anterior dislocation of the forearm. If this rule is ignored and even a comminuted fragment is excised in the setting of dislocation, the patient will suffer a severe complication in the form of chronic recurrent forearm dislocations due to the loss of the bone stabilizer.

Regardless of the chosen technique, a mandatory step in any operation is the careful anatomical restoration of the triceps brachii tendon expansion (musculus triceps brachii). Without adequate repair of this tendon, the patient will permanently lose the ability to actively and fully extend the arm at the elbow.

Weber osteosynthesis: technique and biomechanics

For simple (non-comminuted) fractures, the method of choice is dynamic osteosynthesis using a Weber figure-of-eight tension band wire. This elegant method is based on converting tensile muscle forces into compressive forces at the fracture site.

Surgical technique:

1. Two guide Kirschner wires are inserted from the fragment into the ulna, positioned strictly parallel to each other.
2. A strong wire is passed through the bone tunnel and over the free ends of the pins, forming a figure-8 configuration.
3. The loop is tightly twisted, ensuring firm compression of the bone fragments.
4. The protruding free ends of the pins are carefully bent into hooks over the wire and buried deep into the bone tissue to prevent soft tissue irritation.

The unique biomechanics of the method lie in the following: the applied wire loop creates a powerful compressive force on the outer cortical layer of the bone. Simultaneously, the physiological traction of the triceps brachii muscle, which usually displaces the fragments, works to advantage in this construct — it compresses the inner (articular) cortical layer. As a result, absolute stability is achieved.

Such reliability allows patients to be managed in the postoperative period without any external plaster immobilization at all. In extreme cases, short-term fixation for the acute period (from 5 to 10 days) is permitted, exclusively necessary for the uneventful healing of the surgical wound.

Tactics for complex fracture types

If the fracture pattern differs from a simple transverse one, the surgical technique requires modification:

• Oblique fractures: the basic construct is reinforced with a lag screw, which must be inserted strictly perpendicular to the fracture plane to achieve interfragmentary compression.
• Comminuted fractures: in cases of severe bone destruction where it is technically impossible to properly place parallel pins, either a complex modification of the figure-of-eight loop or fixation with a robust plate and screws is used.

After plate osteosynthesis is performed, the general rules of postoperative management change. External immobilization with a plaster splint or brace is mandatory (with the forearm fixed in a flexion position from 90° to 110°). After immobilization is removed, the patient is prescribed an intensive course of physical therapy (PT) to restore the full range of motion.

Class and exam questions

What else to study on this topic

• Biomechanics of tension band wiring at various joint flexion angles.
• Surgical approaches to the elbow joint and protection of the ulnar nerve.
• Criteria for choosing between a wire loop and an anatomical locking plate in multi-comminuted fractures.
• Protocols for early rehabilitation and physical therapy after removal of the plaster splint.

Other topics in the "Specialized Adult Traumatology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.