Functional Outcomes of Fixation Versus Replacement for Comminuted Radial Head Fractures in Adults: A Systematic Review

Akash Patel, Lily Li, Abbas Rashid

Akash Patel, FRCS, Orthopaedic registrar, Department of Trauma & Orthopaedics, St Mary’s Hospital, London, W2 1NY, the United Kingdom
Lily Li, MRCS, Orthopaedic registrar, Department of Trauma & Orthopaedics, St Mary’s Hospital, London, W2 1NY, the United Kingdom
Abbas Rashid, FRCS, Upper Limb Fellow, Upper Limb Unit, Wrightington Hospital, Wigan, the United Kingdom

Correspondence to: Lily Li, MRCS, Department of Trauma and Orthopaedics, Salton House, St Mary’s Hospital, London, W2 1NY, the United Kingdom.
Email: XL228@doctors.org.uk
Telephone: +442033127974
Fax: +442033126034
Received: March 9, 2016
Revised: April 15, 2016
Accepted: April 17, 2016
Published online: June 23, 2016


AIM: The purpose of this systematic review was to search for and critically appraise articles directly comparing functional outcomes and complications for fixation (ORIF) versus arthroplasty for comminuted radial head fractures (Mason type 3) in adults.

MATERIAL AND METHODS: A comprehensive search of Medline, Embase and Cochrane databases using specific search terms and limits was conducted. Strict eligibility criteria were applied to stringently screen resultant articles. Three comparative studies were identified and reviewed.

RESULTS: Two studies found significantly better functional scores after replacement compared with ORIF in Mason type 3 fractures. The third study found no significant differences in functional score or range of motion, but did find that grip strength was better after ORIF. Complication rates were too heterogenous for conclusion.

CONCLUSION: Fixation with good reduction may be attempted in unstable Mason type 3 fractures, and arthroplasty may be considered if this is not possible. Further randomised comparative trials are required to clarify the decision-making between fixation and replacement. Functional outcomes and complications were conflicting in the studies included here. Ideally, treatment decision should take into account elbow stability and degree of comminution.

Key words: Radial head fractures; Fixation; Arthroplasty; ORIF

© 2016 The Authors. Published by ACT Publishing Group Ltd.

Patel A, Li L, Rashid A. Functional Outcomes of Fixation Versus Replacement for Comminuted Radial Head Fractures in Adults: A Systematic Review. International Journal of Orthopaedics 2016; 3(3): 557-563 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/1635


Radial head and neck fractures account for 1.7% to 5.4% of all fractures seen[1]. They are the most common fractures involving the elbow[2,3] representing 33% of all elbow fractures[4]. 85% of radial head fractures occur in patients aged between 20 and 60 years[1]. Treatment is influenced by fracture characteristics such as fragment number, displacement, joint stability, and associated injuries[5]. Options include early motion, fragment excision, radial head excision, fixation, or replacement[2]. Studies of the optimal treatment of comminuted, unstable radial head fractures has been hindered by their relative infrequency and limited comparative data[6].

Radial head fractures usually result from a fall onto the outstretched hand with the elbow extended and forearm pronated[5]. Axial, valgus and postero-lateral rotational patterns of loading are responsible for these fractures[3]. The radial head plays an important role in elbow stability. Several radial head fracture classification systems have been developed. The Mason classification[7] is widely referenced to categorise radial head fractures[6]. Mason type 1 is an undisplaced fracture; type 2 displaced marginal fractures; and type 3 comminuted fractures involving the entire radial head. Johnston[8] also added type 4, which categorises radial head fracture with an ulno-humeral dislocation. Broberg and Morrey[9] further modified Mason’s classification by including fractures of the radial neck and stratifying them based on articular segment displacement and fragment size. The Hotchkiss[10] modification includes clinical examination and provides treatment guidelines for radial head fractures.

The goal of treatment of radial head fractures is preservation of elbow stability, motion and maintenance of radial length[11]. There is a consensus that Mason type 1 fractures without mechanical block should be managed non-surgically with early active motion[5,12]. Good results have been reported in 86-100% patients with type 1 fractures[13]. Mason type 2, minimally displaced, isolated fractures with no block to motion may also be managed non-surgically with early active motion[12]. Studies have shown 85-95% good results[14]. Isolated Mason type 2 fractures with significant displacement or mechanical block should be reduced and internally fixed if possible[15]. Options for fixation include Herbert screws, K-wires, plates, fibrin glue and bio-absorbable pins[16]. Fragment excision may be considered if secure fixation cannot be achieved in patients with block to motion[2].

Early studies advocated excision of Mason type 2 and 3 fractures[16,17,18]. However, the biomechanical understanding of the radial head as a stabiliser and axial weight-bearing structure led to an appreciation of its functional importance. Excision has become less popular due to concerns about delayed sequelae and improvements in instrumentation for internal fixation and arthroplasty[19]. Also, not all radial head fractures are amenable to simple excision because of concomitant injuries[16]. Complications associated with excision include wrist pain, elbow stiffness, loss of strength, cubitus valgus, synostosis, instability, proximal radial migration, and degenerative arthritis[20]. Broberg and Morrey[21] reported that late excision is equally effective as early excision and may be used as a salvage procedure. Excision can also be considered in patients with isolated, displaced comminuted radial head fractures that are not amenable to fixation[2]. Most comminuted radial head fractures, however, are not isolated[22], and therefore excision alone is often contraindicated.

Choosing to re-establish radio-capitellar mechanics[20] in Mason type 3 fractures by radial head arthroplasty or to preserve the radial head by internal fixation techniques remains controversial. Ring[6] has discussed elbow stability and associated injuries which may be important in determining whether to fix or replace comminuted fractures. As advent of techniques and implants for internal fixation of comminuted radial head fractures developed, it became more popular to attempt to save complex fractures[15]. Some authors have suggested fixation of all comminuted radial fractures, except those with greater than three fragments and where stable fixation may be difficult to achieve[2]. However, combined with increased availability and use of radial head prostheses for comminuted fractures[23,24], the role of fixation is being re-defined. A wide variety of radial head implants have been used since Speed published the first series of ferrule caps for the radial head in 1941[25]. These include acrylic, cobalt-chromium, titanium and silicone[26]. Many surgeons believe that it is important to preserve the native radial head, whereas others believe that reliable restoration of radio-capitellar contact with a prosthetic radial head may better address the goals of treatment for comminuted fractures[27].

Numerous reviews evaluating fixation versus replacement for Mason type 3 radial head fractures have been published[6,27]. However, none of these have been systematic in terms of search strategy. They all recommend the need for prospective randomised controlled and comparative studies. Therefore in this review, search criteria specifically included comparative studies evaluating fixation versus replacement in adults with Mason type 3 radial head fractures.


The Pubmed and Embase databases were searched on 18th June 2014 using keywords and strict eligibility criteria. The studies identified were further limited by selecting “English language articles” only. Duplicate studies were removed. The strategies for these searches are detailed in Tables 1 and 2. Only comparative studies evaluating fixation versus replacement for comminuted (Mason type 3) radial head fractures were included. The critical appraisal checklist (adapted from Critical Appraisal Skills Programme CASP, Oxford)[28,29] and the revised CONSORT checklist[30] for reporting randomised trials were used to guide assessment of the studies identified from the literature search. The full inclusion and exclusion criteria are detailed in Table 3.

Participants: Adults (over 18 years) with Mason type 3 radial head fractures.

Intervention: Surgical fixation with open reduction internal fixation.

Comparator: Radial head replacement.

Outcomes: Primary: functional outcome.

Secondary: complications.


A total of 92 studies were identified from the literature search (38 Medline, 47 Embase, 7 Cochrane). Of 23 relevant titles 10 were selected for full-text review after assessment of the abstracts. Three articles met inclusion criteria on full-text review (Figure 1). A summary of these three studies comparing fixation and replacement of Mason type 3 radial head fractures in adults is described in Table 4, and critique of the studies follows on Table 5.


The purpose of this systematic review was to determine whether fixation or replacement provides better functional outcomes for Mason type 3 radial head fractures. Chen et al[31] concluded that metallic radial head replacement gave better joint function that ORIF. Ruan et al[32] concluded that bipolar radial head replacement was better than ORIF. Boulas[33] concluded that, when possible, ORIF provided better functional results than silastic replacement.

A number of methodological deficiencies were found in these studies. These included: small sample sizes; limited follow-up period; no controlling for confounding factors; no power calculation to determine probability of type II error; no observer blinding.

The small sample sizes in the studies may indicate selection bias, reporting bias, or both. The varying follow-up might indicate a significant amount of “missing” events and complications occurring after the follow-up period. Surgical methods were different in all three papers and no clear explanations were given for the types of fixation chosen. Fixation can be obtained with various implants, the goal being stable articular surface fixation and restoration of the head-neck relationship[2]. Currently, fixation has become popular, since contemporary techniques have improved surgical outcomes[15,36]. Good surgical outcomes have been shown in selected Mason type 3 radial head fractures and fracture dislocations stabilized with internal fixation[37]. Complications of fixation include metalwork failure, irritation, non-union and poor forearm motion.

Most radial head implants in use today are metal, consisting of cobalt-chrome or titanium. These have been found to restore axial and valgus stability, whereas silicone implants cannot[26]. Comparative clinical evidence supporting a particular design concept for radial head arthroplasty, such as bipolar versus monopolar, cemented versus uncemented, and anatomic versus asymmetric head shape is not yet available[2]. However, good to excellent results can be anticipated when radial head replacement is used for the correct indications and when care is taken to understand concomitant injuries[25]. Recent clinical outcome studies of metallic radial head arthroplasty systems indicate it is a reasonable option to offer patients with comminuted radial head fractures[19]. Specific complications include synostosis formation, heterotopic ossification, loosening and stiffness[26].

The study by Boulas[33] compared fixation to silastic replacement. Evidence has shown that silicone radial head implants have multiple complications[38,39]. These include implant fractures and silicone synovitis. These complications and biomechanical studies showing the inability of silicone implants to support the radius functionally have lead to their disuse[19]. However recently other authors have argued that the silastic implant can be used in a stable elbow with good functional and radiographic results[40]. Therefore Boulas’ paper[33] has been included in this systematic review. The inclusion of this study could be seen to be a limitation of this systematic review.

Important factors in considering operative treatment for Mason type 3 radial head fractures include elbow stability, associated injuries and number of fragments. None of the studies identified in this systematic review gave this important baseline patient information. Recent studies have discussed the principles that guide decision-making in the management of comminuted radial head fractures[2,22,27]. Pike et al[2] recommended ORIF when feasible for all displaced (> 2 mm) radial head fractures consisting of less than four fragments. They recommended radial head arthroplasty if ORIF was not feasible and in the presence of elbow instability or if greater then three fragments were present. Clembosky and Borretto[27] attempted to repair all comminuted radial head fractures, as they concluded radial head arthroplasty could not restore valgus stability when the medial collateral ligament was deficient. However, they stated that if stable fixation could not be achieved, there was a definite risk of early failure and non-union. They therefore recommended arthroplasty in these complicated comminuted fractures as it produced consistent results and was more straightforward than fixation. Considering these reviews, it is evident that the lack of detail regarding baseline characteristics of patients in the studies by Chen[31], Ruan[32] and Boulas[33] is a major weakness. This is another limitation of this search strategy.

There are other factors that may have affected the findings of this systematic review. Firstly, only English language articles were included and this may have limited the breadth of literature review. Secondly, the search strategy was based on a computer search process. Computer searches may omit some articles, and consequently, limit the scope of the literature search[41].

In conclusion, in our systematic review two studies found significantly better Broberg and Morrey functional scores after replacement compare with ORIF for Mason type 3 radial head fractures. The third study found no significant difference in functional score (Mayo performance index) or range of motion, but did find that grip strength was better after ORIF. Complication rates were too heterogenous for conclusion. Considering the small numbers of studies, limitations of the search strategy and methodological weaknesses within the studies included in this systematic review, it is not definitively possible to clarify whether fixation or replacement has better functional outcomes in patients with Mason type 3 radial head fractures. As discussed, the principles that guide decision making in the treatment of Mason type 3 radial head fractures include elbow stability and degree of comminution. Each individual case should take these factors into account and only then a decision on fixation or replacement should be made. To help clarify the decision making, randomised studies comparing the two treatment methods and taking stability into account are needed. This may be difficult as many unstable, comminuted fractures are difficult or impossible to fix[6]. Future studies should also compare the various types of radial head implants in randomised comparative studies. Also, better data is required regarding the long-term outcome of metal radial head replacements.


The authors declare no conflict of interest in the writing of “Functional outcomes of fixation versus replacement for comminuted radial head fractures in adults: a systematic review”.

No author has received internal or external funding or grants that assisted in this study.

Ethical statement

This article does not contain any studies with human participants or animals performed by any of the authors.


The authors would like to thank Gill Jones for her help in compiling the literature search.


The authors declare no conflicts of interest.


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