1

CASE SUMMARY 1 RADIAL HEAD FRACTURE

INTRODUCTION Radial head fracture may represent an isolated intra-articular fracture or combined complex injury involving the ulnar collateral, interosseous or the distal radioulnar ligament. Careful and thorough assessment is needed to differentiate these two forms of injuries. The main goal of its treatment is to maintain a good elbow function and thus to

retain an ade uate elbow motion and joint stability. !ith a proper choice of treatment and rehabilitation program, this type of fractures can be managed ade uately with good functional outcome. CASE REPORT (RN 833864) ".#.!., a $1-year-old male was admitted on the $% rd &anuary $''$ with a history of fall from a flight of stairs approximately 1' feet high. (is left elbow directly hit the ground at the end of the fall. The patient has no significant past medical or surgical histories. (e wor)s as an air-conditioner mechanic and is a right-handed person. *xamination revealed a swollen left elbow with tenderness over the lateral side of the joint. +o wounds were noted on the left elbow region. There was reduced range of motion in all directions. The pulses were palpable distally and there was no neurological deficits noted. The left elbow ,- and lateral radiographs revealed fracture of the left radial head with displacement. The wrist radiographs showed that the distal radioulnar joint was intact. , diagnosis of fracture of the left radial head ./ason type 001 was made and the patient was admitted for open reduction and screw fixation. 2n admission the elbow was put on a bac)slab in the functional position and analgesics were given. (e underwent an open reduction and screw fixation of the fracture on the %' th of &anuary $''$. ,fter given a supraclavicular bloc), the upper limb was cleaned and draped. *xsanguination was followed by torni uet inflation up to $3' mm(g. The #ocher4s approach was used and the interval between the anconeus and the extensor carpi ulnaris entered. The annular ligament was noted to be intact and partial resection was done for better exposure of the radial head. The radial head was noted to be fractured into three pieces and there was also a chondral fracture fragment involving the capitellar cartilage .5 1 cm diameter1 which was impacted into the radial head fracture site. The impacted cartilage was removed and the joint was washed and cleared from any debris. The radial head was then fixed with two $.' mm cortical screws inserted under lag screw principles. The screws were inserted in the non-articulating area of the radial head .see 607C87702+ on 9The safe :one;1. -ost-screw fixation assessment for stability of the

fixation as well as the elbow joint was performed and all the ligaments were noted to be intact. The area was again washed with saline. The annular ligament and fascia was repaired with 6exon %<'. 7)in was closed with 6afilon =<' sutures. -ost-operatively the left upper limb was elevated on a drip stand to avoid excessive swelling and edema. -ost-operatively, the chec) radiograph was acceptable with stable reduction of the fracture fragments and the patient was discharged well. ,t $ wee)s post-op, the wound was healing, sutures were removed and passive elbow range of motion exercise was started. ,t > wee)s the patient had full extension, supination and pronation of the left elbow with a slightly limited flexion. -hysiotherapy was continued further. ,t 11 wee)s post-op, the elbow range of motion was full in all directions and radiographs showed that the screw fixation is stable and the fracture line disappearing. The patient was allowed to go bac) to wor) and was discharged from follow-up. DISCUSSION Radial head and nec) fractures represent approximately 1.? to 3.= @ of all fractures. Radial head fractures alone account for about 1<% of all elbow fractures and are involved in approximately $' @ of elbow trauma cases .Caputo et al. 1AAB1. Combined with olecranon fractures, they account for more than one-half of the fractures at this site ./orrey et al. 1AA31. 1'@ of cases of elbow dislocations had been found to be associated with radial head fractures .#upersmith et al. $''11. The head of radius is cylindrical in shape and is covered by hyaline cartilage. This cartilage layer is somewhat wider, whitish glistening in the area which articulates with the radial notch of the ulna .Caputo et al. 1AAB1, ma)ing it easier to identify intra-operatively in the process of recogni:ing 9the safe :one4 C which is the non-articulating area of the head .a safe place to insert<place implants1 that is more yellowish and has a thinner cartilaginous layer. The head is palpable in the depression behind the lateral side of the extended elbow, where it can be felt rotating in pronation-supination movements. The upper surface of the radial head is spherically concave to fit the capitulum.

The head is held on to the radial notch of the ulna by the annular ligament, which tapers at its lower end to hold the nec) of radius. The superior radioulnar joint is a uniaxial synovial pivot joint between the radial head and the annular ligament. The elbow joint capsule and the triangular lateral collateral ligament are attached to the annular ligament and both the elbow and the superior radioulnar joint share the same synovial membrane. The non-articulating portion of the radial head is the most common area to be fractured as it lac)s strong subchondral osseous support ./orrey et al. 1AA31. This is beneficial in the sense that it allows easier fracture fixation within the safe :one of the radial head. *lbow joint stability is maintained by the ligaments .mainly the medial and lateral collateral ligaments1, the bones and the muscles which traverse the joint. The medial collateral ligament consists of the anterior band .the anterior medial collateral ligament, ,/C"1, the posterior band .-/C"1 and the transverse band. 2ut of these three, the ,/C" is the main ligament contributing to the strength of the medial collateral ligament. The lateral collateral ligament is also triangular in shape with its apex attached to the lateral humeral epicondyle and the base fused to the annular ligament. /orrey et al. .1AA11 found out that the /C" acts as the primary constraint of the elbow joint with the radial head as the secondary constraint of the elbow joint. They found out that absence of the radial head does not significantly alter the three dimensional characteristics of motion in the elbow joint, provided that the /C" is intact. The most common mechanism of injury is fall onto an outstretched hand with the elbow extended and the forearm pronated. This causes transmission of axial load across the radiocapitellar joint and fracture of the radial head. Clinically the patient will have local swelling and tenderness over the head of radius. There is reduced movement of the elbow. -resence of echymosis along the medial elbow in a patient with radial head fracture .without ulnar bone injury1 is pathognomonic for a medial collateral injury .#upersmith et al. $''11 as the radial head is anatomically isolated from the medial side by muscle planes and fascia.

0t is necessary to assess the elbow function when examining the patient. /orrey et al. 1AA3 advocate the use of local anaesthetics that is injected into the elbow joint before examination is performed. This is preceded by joint aspiration, allowing $ benefitsD .i1 ,spiration of the joint relieves the pressure-increase due to haemarthrosis. .ii1 0nfiltration of local anaesthetics provides temporary pain relief to allow proper examination of the elbow joint. *xamination is performed to assess the ligaments .in particular the medial collateral and the distal radioulnar joint1E and the range of motion of the elbow to exclude bony bloc) to full movement. 7tandard ,- and lateral radiographs of the elbow should be obtained upon suspicion of a radial head fracture. , valgus-stress view usually helps in the diagnosis of medial collateral ligament involvement .medial joint space widening1. The radial headcapitellum view may also be helpful .#upersmith et al. $''11 Treat e!t "# radial head fractures was first described by Thomas in 1A'3. 2perative management at the time was limited to simple excision. Carstam first mentioned regarding open reduction and internal fixation in 1A3' and since his published result, 2R0F has become more popular for certain type of fractures of the radial head . uoted from Furry et al. 1AAB1. Currently, treatment of radial head fractures remains controversial and fre uently guided by the severity of the fracture as classified by /ason.

/ason4s Classification of radial head fracture is the most widely used and accepted classification system. Table 1 D /odified /ason4s Classification for Radial (ead Fractures ( Chapmans Textbook of Orthopedic Surgery)

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TYPE 0 00 000 0G

CHARACTERISTICS 8ndisplaced fracture /arginal fracture with displacementE involvement of more than %'@ of the head Comminuted fracture involving the entire radial head Fracture of radial head with associated elbow dislocation (Modified by Johnston 1 !")

/orrey et al. .1AA31 practically classified this fracture into simple and complex fractures. 7imple fractures are those without an associated injury. These fractures include those of type 0, 00 and 000 of the /ason4s classification. /ason4s type 0G injury is included into the complex group. C"!$er%at&%e treat e!t remains the choice of treatment for most type 0 and some type 00 fractures of the radial head. Treatment consists of early motion, usually within several days or as early as pain allows. This has been shown to prevent stiffness and loss of terminal extension .#uppersmith et al. $''11. *arly motion in type 0 fractures was associated with A' percent chance of a good outcome, even though complications can still occur, the most common being non-union ./orrey et al. 1AA31. /orrey et al. .1AA31 also suggested that type 00 fractures that show at least $' to 1=' degrees of flexion and ?' degrees of forearm rotation in both directions .supination and pronation1 are amenable for non-operative treatment. (owever, in these cases immobili:ation should be carried out longer .for $ to % wee)s1 before active range of motion can be started. 0ndications for "'e! re()*t&"! a!( &!ter!a+ #&,at&"! include mechanical bloc) of motion, fracture where greater than 1<% of the articular surface is involved, displacement of more than $ to % mm of the fracture fragment and more than $ to % mm of articular depression. 2ther indications are lesions involving the capitellar cartilage, an associated proximal ulnar fracture, injury to the medial collateral ligament or to the distal radio-ulnar joint .*ssex-"opresti injury1. 0n this particular patient, the indications to perform 2R0F are involvement of more than 1<% of the articular surface and also capitellar cartilage

lesion. Contraindications to 2R0F include older age patient, an underlying osteoarthritis and injury to the bony capitellum. 7tudies have shown that 2R0F is the treatment of choice for /ason type 00 fractures. #ing et al. .1AA11 treated 1= elbows with type 00 injury and revealed that all patients showed good or excellent results after an average of %$ months of follow-up. #halfayan et al. .1AA$1 reviewed $A cases of /ason type 00 fractures .1' were treated by 2R0F, 1A conservatively1 and found out that patients treated conservatively have higher incidence of pain, functional limitations, loss of strength and radiographic evidence of arthritis. The same group also showed higher incidence of articular depression, displacement and joint narrowing radiographically. The use of fibrin adhesive seal was advocated by ,rce et al. .1AA31 when they fixed 13 type 00 fractures with the Fibrin ,dhesive 7ystem .F,71. ,fter operation, the elbows were immobili:ed for a mean of $.% wee)s. 2n follow-up .ranged from $' to =B months1, no patient had any pain, = patients showed limitation of full extension while one patient showed limitation of supination. The reconstruction was, in all cases, practically anatomical by radiographic evaluation. (owever, they advised against the use of F,7 for comminuted radial head fractures of more than two fragments. Houlas and /orrey .1AAB1 studied %> fractures .type not mentioned1 treated in = different ways - 2R0F, excision, silastic head replacement and conservative. They found out that the grip strength of patients treated with 2R0F was significantly better compared to other groups even though all groups showed comparative results in Clinical -erformance 0ndex and elbow motions. Furry et al. .1AAB1 concluded that fractures of the radial head which were treated by 2R0F had a low reported incidence of avascular necrosis and non-union. (e suggested that the radial head should be preserved when technically feasible and replaced if otherwise. 246riscoll et al. .$'''1 suggested that small fragments not suitable for screw fixation can be fixed with threaded #irschner wires as an alternative. 7mooth #-wires should be avoided as they have a tendency to migrate post-operatively.

0n this patient, the fracture was a three part fracture and was noted to be displaced with involvement of more than %'@ of the circumference of the head which puts it into the /ason type 00 fracture. The fragments were noted to be reducible and stable to be fixed with $ screws inserted under lag screw principles. ,s suggested by Furry et al. .1AAB1, fractures noted intra-operatively to be feasible for 2R0F should be treated as such. 0t was also noted during operation that the ligaments were not involved in the injury. This carries a good prognosis in the context of union of the fracture as studied by Ring and &upiter .$'''1. The main danger in exposure and fixation of radial head fractures is possibility of the posterior interosseus nerve .-0+1 injury. The close proximity of this nerve to the operative field ma)es it vulnerable to iatrogenic injury and the resultant paralysis of the muscles of the extensor compartment is one of the dreaded complications in this type of surgery. 0n the classical #ocher4s approach, the plane between the anconeus and the extensor carpi ulnaris, *C8 is utili:ed. 0ncision is made starting from the posterior surface of the lateral humeral epicondyle and this is continued longitudinally about 3 cm down to the level of the lower aspect of the radial head. The interval between the anconeus .supplied by the radial nerve1 and the extensor carpi ulnaris, *C8 .supplied by the -0+1 is identified and separated using a retractor. The forearm is fully pronated to move the -0+ away from the operative field. /orrey et al. .1AA%1 suggested that the capsule should be divided anterior to the lateral ligamentous complex that attaches to the ulna. !itt and #amineni .1AAB1 studied $1 cadaver-elbows and observed that the first branches of the -0+ at ris) .in the posterolateral approach1 were situated about > cm from the articular surface of the radial head. This corresponds to the distal aspect of the bicipital tuberosity on the radius. 6iliberti et al. .$'''1 found out that for the posterolateral approach of the lateral aspect of the radial head, the -0+ is safest with the forearm in pronation. -lacement of implant on the non-articulating portion of the radial head .the safe :one1 is crucial as it prevents hardware impingement during pronation and supination. This :one can be recogni:ed by theD-

.11 Color and thic)ness of the cartilage .$1 7mith-(otch)iss techni ue .%1 Caputo techni ue 7mith and (otch)iss .1AA>1 described a method for locali:ing this safe :one by mar)ing the side of the radial head in various positions of rotation of the forearm. The limitation of this method is that it is only applicable for lateral approach and re uires full forearm rotation .,ndrew et al. 1AAB1. Caputo et al. .1AAB1 studied $= elbows in 1$ cadavers and described that the arc of the safe :one encompassed the A' o angle between the radial styloid and "ister4s tubercle, and this findings are constant in all three surgical approaches .anterior, lateral and posterolateral1. Treatment of type 000 fractures remain a challenge to surgeons. 6ecision has to be made whether to perform an open reduction and internal fixation or to remove the head completely with or without radial head prosthetic replacement. #ing et. al. .1AA11 internally fixed six type 000 radial head fractures in a study comparing type 00 and 000 fractures. Type 00 showed 1''@ good to excellent results while type 000 only showed %%@ good to excellent results. They suggested that the degree of comminution should be evaluated radiographically and intra-operatively, and the decision whether to reconstruct or excise the radial head depends on whether anatomic reduction is achievable or not. /orrey et al. .1AA31 did not recommend 2R0F for type 000 fractures, as it is a difficult procedure to perform. Furthermore, approximately 1'@ of type 000 fractures are associated with an elbow dislocation, a combination that constitutes one of the most difficult management problems. Ring and &upiter .$'''1, in a retrospective review of ?% patients, found out that 2R0F of complex, comminuted fractures of the radial head may lead to nonunion in upwards of 1%@ of patients. 2n the contrary, *sser et al. .1AA31 had seven excellent and two good results out of nine type 000 fractures fixed with using ,2 screws, (erbert screws and < or mini ,2 T-plates. (owever the number of patients in this study is uite small. The controversial issue on the best treatment option for non-reconstructable radial

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head fractures remains. First comes the

uestion of stability following radial head

excision. 0t has been shown that, with excision alone .with the ligaments intact1, the radius migrates proximally $.> times farther than an intact radius under a given mechanical load .Furry et al. 1AAB1. 7tudies demonstrated that with removal of the radial head alone, proximal radial migration is '.= mm. Combined with interosseous membrane injury, the migration increased to =.= mm. Radial head resection with TFCC division causes $.$ mm of proximal radial migration. Combining all three, the migration increased to 1>.B mm . uoted from Hernstein et al. $'''1. /orrey et al. .1AA11 found out that the radial head plays an important stabili:ing role in resisting valgus stress only when the medial collateral ligament is disrupted. Therefore radial head excision alone in these circumstances will not suffice with regards to the stability of the elbow to valgus force and replacement of the head should be done. 7hepard et al. .$''11 in a cadaveric study of the effects of radial head excision on the load-sharing capacity of the radius and ulna found out that radial shortening causes slac)ening of the interosseous membrane, thereby negating its ability to transmit load across the forearm. The resultant ulnar-positive wrist created a shift of applied load from the distal radius to the distal ulna and thus increased distal ulnar loading .load is increased approximately 1'@ with every millimeter of radial shortening1. (is study also concluded that damage of the interosseous membrane will shift nearly the entire applied wrist force to the ulna. +ext comes the issue of whether to remove the head completely or to replace it with prosthesis. Furry et al. .1AAB1 concluded that excision with radial head replacement is useful for those fractures with associated ligamentous injury as it provides temporary or permanent lateral stability .for associated /C" injury1 and axial stability .for interosseous or distal radioulnar joint injury1. (e also suggested that multi-fragmentary fractures not amenable for 2R0F should be replaced with prosthesis, especially in young patients. Furthermore, elderly patients and those patients who are very ill or polytraumati:ed that could not tolerate prolonged anaesthesia should benefit from radial head replacement which can often be performed with less operative time compared to 2R0F.

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Radial head excision alone can be performed to treat non-reconstructable radial head fractures, provided that the ligaments responsible for elbow stability are intact. !allenboc) and -otsch .1AA?1 retrospectively studied $% patients with radial head resection without implant insertion .average 1? years follow-up1 and found out that all patients had very good to satisfactory outcome without a single case of poor outcome. (owever it was not mentioned whether these patients had associated ligamentous injury or not. Furry et al. .1AAB1 and /oro et al. .$''11 mentioned that radial head excision may lead to complications such as pain, instability, new-bone formation around the resection site, proximal radial migration and cubitus valgus. -revention of these complications can be achieved by replacing the head with prosthesis. 6ifferent prosthetic materials have been used and studied. ,crylic, siliconerubber, Gitallium, cobalt-chromium and titanium had been used and described in literatures. Gitallium prosthesis was studied by #night et al. .1AA%1 and they found out that the metal4s rigidity improves elbow stability when there has been gross soft tissue tearing. This implant also has a low incidence of symptomatic loosening and erosion. The use of this metal avoids some disadvantages experienced with silicone-rubber heads .sensitivity reactions, implant fractures and capitellar osteopenia from reduced load transfer1. 0t also helps to share and balance the forces acting across the elbow and allows earlier mobili:ation. /orrey .1AA31 seemed to agree with #night et al. .1AA%1 when he mentioned that a metal implant is a viable solution when radial head resection is indicated and the elbow is unstable. 7ilicone-rubber implants had been all but abandoned in the 8nited 7tates ./orrey 1AA31. This is due to complications associated with this implant. 2ther than those already mentioned above, mechanical studies had shown that silicone-rubber allows proximal radial migration $.% times farther than an intact radial head. /orrey .1AA31 found out that silicone-rubber implants had no functional advantage over other types of prostheses in the context of inhibiting proximal radial migration after radial head excision.

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&udet et al. .1AA>1 reported a series of patients who received articulating cobaltchromium prosthesis with cemented stem and polyethylene articulation with the head component .the so-called 9floating prosthesis41 and found out that all patients rated their outcome as fair .$1, good .?1 or excellent .%1 using the Hroberg and /orrey .1AB>1 elbow functional scoring system .Table $1. They concluded that this implant can overcome the complications of silicone-rubber implants. Furthermore, they found out that there was no radiographic evidence of lucency surrounding the cemented stems. Their report also suggested indications for immediate insertion of this implant were /ason type 000 fractures with ligamentous instability or associated destabili:ing fractures such as coronoid process fractures. #upersmith et al. .$''11 suggested that the choice of implant to be used may depend on the mechanism of injury of the radial head. (e mentioned that for *ssex"opresti injury, where the instability is mainly in the longitudinal and axial direction, a metallic implant should be used to counteract the resultant supra-physiologic loads on the proximal radius. 0f the injury has been caused by a valgus stress, silastic implant insertion .which is easier1 can be carried out along with the more important reconstruction of the /C". 0f the /C" reconstruction cannot be done, then a metallic implant is a better choice as it resists excessive valgus force on the elbow better while allowing the /C" to heal.

Table $ D /odified Functional 7coring 7ystem by Hroberg and /orrey .1AB>1 (J#JS$%&# 1 ! ' p "(&)

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Range of movements .1D Flexion contracture Flexion 7upination Irade *xcellent Iood -ain /ild 7trength .@1 +ormal B' - 1'' -ronation Full J$' KA' K=3 K3' Fair /oderate B' $' A' =3 3' -oor 6isabling JB' K$' JA' J=3 J3' 8nstable +ormal or slight instability 7tability +ormal +ormal

7urgical timing for radial head excision is another debated issue. #night et al. .1AA%1 suggested that early radial head excision for unstable fractures should be protected by means of spacer insertion, the most suitable being the metal radial head. This allows soft tissue healing and earlier mobili:ation. /orrey .1AA31 stated that type 000 fractures are best treated with complete excision within =B hours after injuryE the reason being late excision in type 000 injuries has been less successful in outcome as compared to that for

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the persistently symptomatic elbow after a type 00 injury. (e recommended that delayed excision can be carried out for persistent residual symptomatic elbow after 2R0F. 6elayed excision can also follow failed conservative management of radial head fractures with ?>@ reduction of pain and B1@ of improvement in strength. CONCLUSION Radial head fractures should be treated accordingly to ensure a good functional outcome. Reconstruction .if possible1 should be performed in order to restore the articular surface and to enable satisfactory range of motion of the elbow post-operatively. The important supporting ligaments .especially the /C"1 should be managed as well in order to maintain a stable elbow joint. *xcision of the radial head with or without arthroplasty is indicated for non-reconstructable fractures of the radial head.

REFERENCE 1. Ar*e A-A-. /ar&! M-D-. /ar*&a M-0-. et a+- Treatment of radial head fractures using a Fibrin ,dhesive 7eal - a review of 13 cases. J) #one Joint Surg) 1 *+ %%$

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# ' (""$() $. 1er!$te&! A-D-. 2a34ar& L-M-. R"5&t" A-S-. et a+- *lbow joint biomechanics basic science and clinical applications. Orthop) ",,,+ "- ' 1" -$-,-) %. 1")+a$ H-2-. M"rre6 1-F-- Hiomechanical evaluation of the elbow following radial head fracture - Comparison of open reduction and internal fixation vs. excision, silastic replacement, and non-operative management. Chirurgie de .a Main) 1 & + 1% ' -1($", (Section description))

=. Ca')t" A-E-. Ma33"**a A-D-. Sa!t"r" 0-M- The non-articulating portion of the radial head - anatomical and clinical correlations for internal fixation. J) /and Surg) 1 &+ "-$0 ' 1,&"$ ,)

3. D&+&7ert& T-. 1"tte M-D-. A7ra $ R-A- ,natomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J) #one Joint Surg) ",,,+ &"$0 ' &, $1-) >. E$$er R-D-. Da%&$ S-. Taa%a" T- Fractures of the radial head treated by internal fixation - late results in $> cases. J) Orthop) Trauma) 1 *+ ' -1&$"-)

?. F)rr6 8-L-. C+&!5$*a+e$ C-M- Comminuted fractures of the radial head arthroplasty versus internal fixation. C.in) Orthop) 1 &+ -*- ' (,$*")

B. 2)(et T-. /arrea) D-L-. P&r&") P-. et a+- , floating prosthesis for radial head fractures. J) #one Joint Surg) 1 ! + %&$# ' "(($ )

A. 89a+#a6a! E-E-. C)+' R-:-. A+e,a!(er A-H- /ason type 00 radial head fractures - operative versus non-operative treatment. J) Orthop) Trauma) 1 1'. 8&!; /-2-. E%a!$ D-C-. 8e++a "+ ! ' "&-$ )

2-F- 2pen reduction and internal fixation of

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radial head fractures. J) Orthop) Trauma) 1

1+ * ' "1$&)

11. 8!&;9t D-2-. R6 a$3e4$5& L-A-. A &$ A-A- -rimary replacement of the fractured radial head with a metal prosthesis. J) #one Joint Surg)1 !) 1$. 8)'er$ &t9 L-M-. Ha)$ a! M-R- Fracture-dislocations of the elbow. Curr) Opin) Orthop) ",,1+ 1" ' -*!$!-) 1%. M"r" 2-8-. :er&er 2-. Ma*Der &( 2-C-. et a+- ,rthroplasty with a metal radial head for unreconstructible fractures of the radial head. J) #one Joint Surg) ",,1+ &-$0 ' 1",1$11) 1=. M"rre6 1-F- 0nstructional Course "ectures, The ,merican ,cademy of 2rthopaedic 7urgeons - current concepts in the treatment of fractures of the radial head, the olecranon and the coronoid. J) #one Joint Surg) 1 *+ %%$0 ' -1!$"%) -+ %*$# ' *%"$

13. M"rre6 1-F-. Ta!a5a S-. A! 8-N- Galgus stability of the elbow - , definition of primary and secondary constraints. C.in) Orthop) 1e.) 1esearch) 1 *) 1>. O<Dr&$*"++ S-:- The unstable elbow. J) #one Joint Surg) ",,, + &"$0 ' %"($-&) 1?. R&!; D-. 2)'&ter 2-1- +onunion following 2R0F of radial head fractures. J) Orthop) Trauma) ",,,+ 1( ' 11 $",) 1B. S9e'ar( 2- *ffects of radial head excision and distal radial shortening on loadsharing in cadaver forearms. J) #one Joint Surg) ",,1+ &-$0 ' "$1,,) 1A. S &t9 /-R-. H"t*95&$$ R-N- Radial head and nec) fractures - anatomic guidelines for proper placement of internal fixation. J) Shou.der 2.bo3 Surg) 1+ "!* ' 1&%$

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!+ * ' 11-$%)

$'. :a++e!7"*5 E-. P"t$*9 F- Resection of the radial head - an alternative to use of a prosthesisL J) Trauma) 1 %+ (-' * $!1)

$1. :&tt 2D-. 8a &!e!& S- The posterior interosseous nerve and the poster lateral approach to the proximal radius. J) #one Joint Surg) 1 &+ &,$# ' "(,$")