FRACTURES OF THE HEAD OF THE RADIUS

CONSERVATIVE TREATMENT

INDICATIONS Start by treating all fractures of the head of the radius this way.

METHOD Make sure that the patient’s elbow is not also dislocated. If it is, reduce it first.

Aspirate the blood in his elbow joint (Fig. 72-4), inject 2 ml of local anaesthetic solution. You will now be able to flex, extend, and supinate his elbow. Start active movements (69.10) and encourage easy movements, especially rotation. Don’t apply plaster. Observe him carefully.

If he improves, over the next few days, good. If not, refer him for operation as early as possible. By the time 5 days have elapsed you should know if conservative treatment is going to succeed or mot. It is more likely to succeed in fractures A, and B, in Fig. 72-20 than it is in C, and D. Most skilled surgeons would operate immedIately on C, or D, without attempting conservative treatment; you would probably be wise to try conservative treatment first. If the fragment in fracture E, is not much dIsplaced, it may have to be removed at open operation. But if it is widely displaced, it may be not be restricting elbow movement, so conservative treatment may succeed.

If the patient improves under conservative treatment, so much the better, but warn him that full recovery will be slow.

OPEN OPERATION ON THE HEAD OF THE RADIUS

If possible refer the patient. This is not an operation for the beginner, or one to do if you have not seen it done. It you decide to operate, the sooner you do so the better. Try to operate within 5 days before dense scar tissue forms.

INDICATIONS Failure of conservative treatment. There is no need to remove a loose fragment (E) unless it is interfering with the movement of the elbow joint. Don’t remove the head of the radius in a child, because this will interfere with the growth of the bone, and cause a severe valgus deformity.

TOURNIQUET Exsanguinate the patient’s arm with an Esmarch bandage, and place a tourniquet (3.8) round his upper arm. Operating without a tourniquet will place the deep branch of his radial nerve in greater danger.

POSITION Lie him on his back and bring his arm over the front of his chest, so that the posterior surface of his elbow is uppermost. Leave his hand free so that you can rotate his wrist, and so turn the head of the radius. If necessary, attach a weight to his wrist, or tie it.

INCISION Make a 5 cm incision (A, in Fig. 72-20) over the posterolateral surface of the patient’s elbow, extending downwards from his lateral epicondyle to his ulna over the interval between his extensor carpi–ulnaris and his anconeus muscles.

Deepen the incision through the fascia between anconeus and extensor carpi ulnaris (B), to expose the joint capsule. If there is much bruising, and you cannot define these muscles, incise them between his lateral epicondyle and his olecranon.

CAUTION! The deep branch of the radial nerve (posterior interosseus nerve) arises from the radial nerve 2 or 3 cm below the elbow. It winds round the lateral side of the neck of the radius, 1 cm below its head, between the two planes of the fibres of supinator. Don’t dissect deeply in front of the radius, or distal to the annular ligament posteriorly. Unfortunately, its course may vary considerably.

Make a longitudinal incision in the capsule (C) to expose the head of the patient’s radius and his capitulum (D). Syringe away the blood clot from the joint.

Find his annular ligament and divide the periosteum immediately proximal to it. Don’t strip any of the perlosteum from the bone.

Cut away the head of his radius with nibblers immediately proximal to the annular ligament (E). Don’t cut this ligament.

Remove all loose pieces of bone (F). Reassemble the head of his radius to make sure that no pieces are still missing inside the joint.

If possible, close the soft tissues over the broken neck of his radius with a purse string suture (G). This is not easy, and is not essential.

If his elbow has been dislocated, redislocate it to remove any loose fragments of the radial head that may be lying in other parts of the joint. Fragments are sometimes driven through the capsule and lie outside it. Inspect his capitulum for injury.

Rinse the wound forcibly with Ringer’s lactate, or saline, and if possible insert a suction drain. Close the capsule and the muscle with one layer of interrupted sutures. Release the tourniquet and control bleeding.

POSTOPERATIVE CARE Flex the patient’s elbow to 90. Apply a pressure dressing to the wound and give him a collar and cuff.

Next day, encourage him to start exercising his fingers and shoulders. After a week encourage him to move his elbow. Avoid vigorous exercise or forced passive movement.

If he is in much pain or spasm, immobilize his elbow again for a few weeks, and then try again to mobilize it.

DIFFICULTIES WITH FRACTURES OF THF HEAD OF THF RADIUS

If a patient PRESENTS LATE with a fracture like that in D Fig. 72-20, refer him. There is however little to be done.

If he has a STIFF ELBOW, watch the progress of his movements carefully. An Injured elbow takes a long time to recover. The tissues round it sometimes ossify. If movements become fewer, stop them completely for a few days, then start them again cautiously. Don’t push exercises if recovery is slow, because it increases the risk of post–traumatic ossification. X–ray his elbow and look for this.

MAKE SURE YOU REMOVE ALL THE FRAGMENTS