Radial head replacement of elbow

Radial head replacement surgery is undertaken on a patient’s elbow following a complex fracture to the radial head where fixation by means other than with screws or a plate is not suitable or feasible. During surgery, the fractured bone and joint surface of the radius is removed and replaced with an artificial implant. Ligament damage surrounding the elbow, commonly associated with an injured radial dial, may also be repaired during the surgery.

 

Following surgery, patients will have an incision on the outer aspect of their elbow. It will be sutured closed and protected by a waterproof dressing. A back-slab plaster might also be present if the associated ligament injuries were significant.

The following is an xray of a patient who has had a radial head replacement.

radial head replacement 1
radial head replacement 2

Post-operative rehabilitation (developed in conjunction with Melbourne Hand Therapy)

Rehabilitation of the radial head replacement is largely dependent on the associated ligament injuries and repairs. Generally, in the case of a complex fracture, the lateral ulnar collateral ligament (LUCL) is injured necessitating surgical repair. Successful recovery is dependent on these ligaments being well protected.

 

Post-operatively, a patient’s arm will be in a sling and, more often-than-not, a back-slab.  All dressings and bandages need to remain intact and dry until the next post-operative review. In the meantime, patients can be advised to shower using a plastic bag tied above their elbow to prevent the wound from getting wet. Alternatively, a one-handed bath can be suggested to patients at least until Kemble has reviewed the wound and assessed that it is safe to resume normal showering or bathing.

 

The artificial radial head should be protected at all times in order for it to integrate successfully with the bone. A patient is therefore limited to the weight-bearing of “cup of tea” for the initial six weeks. Following this period, it is recommended patients bear no more weight than 5kg on the elbow for a further six months post-operatively.

 

Initial Phase (0-4 weeks)

Initial appointment (10-14 days post-operatively)

  • Remove post-operative dressing and primary dressing of wound

  • Apply tubigrip (or similar) to elbow to reduce post-operative swelling

  • Commence scar management if suitable

  • Fashion posterior shell elbow splint

    • splint at 120 deg of flexion to approximate radial head to coronoid process​

    • forearm pronation to minimise lateral stress

    • wrist in neutral flexion/extension

    • splint all time except for hygiene and overhead exercises exercises 

  • Commence overhead elbow protocol in supine position:

    • shoulder flexed to 90 deg, adducted, and in neutral to slightly externally rotated position

      • ​This position minimizes the effect of gravity, decreases posteriorly directed forces, and allows the triceps to function as an elbow stabilizer. By avoiding abduction and internal rotation, the gravitational varus force is eliminated thereby allowing the lateral collateral ligament to heal in an isometric fashion.

    • With the arm in above position, following exercises are performed: 

      • Active assisted forearm pronation and supination, with elbow in 90 deg flexion​

      • Active assisted elbow flexion with no limit

      • Active/active-assisted elbow extension, limited to 30 deg short of full extension

  • Elbow Varus Precautions (for first 6 weeks)

    • avoid shoulder abduction and internal rotation

    • avoid full elbow extension, especially combined with forearm supination

    • when sleeping a pillow is placed between the affected arm and torso (when lying on back) or several pillows placed under elbow when side lying (on opposite side)

  • if excessive pain or unexpected stiffness in motion – suggest xrays to check for subluxation of joint

 

Intermediate Phase (4-6 weeks post-operatively)

  • Remold posterior splint to 90 deg of elbow flexion at 4 weeks, and forearm now in neutral rotation rather than pronation

  • Continue supine overhead exercises as above

  • Shoulder internal rotation is still avoided to minimize gravitational varus strain

 

Advanced Phase (6+ weeks post-operatively)

  • Wean out of splint

  • Start all seated range of motion exercises, capsular stretching

  • Increase strength and endurance​

  • Commence gradual weightbearing exercises, but nothing >5kg until 6 months post surgery. 

  • Static progressive splinting if needed after 8 weeks

 

Return to activity / sports:

  • The rate of healing and the readiness of a patient to return to sport or normal activities, differs from one to another.  It is also highly dependent on a therapist's input.

  • Bone healing is determined via X-ray and Kemble will advise when sufficient healing as occurred for a patient to be able to return to specified activities. Most commonly, this occurs 12 weeks post operatively. However, factors such as age and general health an impact on this timeline.

  • Once the bone has healed sufficiently, therapists can encourage patients to increase weight-bearing through the arm and gradually return to sports.

 

Signs to look for:

  • Continued drainage from the wounds that does not stop after one week;

  • Sudden deterioration in a patient’s pain level when previously it had been improving;

  • Sudden locking of the elbow and inability to bend/straighten or rotate the forearm;

  • If any of the above is noted, please contact Kemble's team immediately.

 

General post-operative things to be aware of:

  • It is normal to have some tingling, numbness or weakness following the procedure. This is often due to a nerve block performed pre-operatively to help with pain management or associated with a local anaesthesia which is injected postoperatively. This should wear off in a day or two.

Possible Complications:

  • Early subluxation of radial head/elbow joint (posterolateral rotatory instability)

  • Elbow flexion contracture (capsular tightness of anterior capsule, or posterior/lateral bony block)

  • Elbow extension contracture (triceps tightness and/or posterior capsule, or anterior bony block)

  • late posterolateral rotatory instability