**Radial Head Excision vs. Radial Head Replacement: Choosing the Right Surgical Approach for Complex Elbow Fractures**
Radial Head Excision
When a radial head fracture occurs—often from a fall onto an outstretched hand—the decision between **radial head excision (removal)** and **radial head replacement (arthroplasty)** is critical to restoring elbow stability, motion, and long-term function. While both procedures aim to relieve pain and improve mobility, they differ significantly in indications, outcomes, and risks. This review compares the two approaches to help patients and clinicians make informed, evidence-based decisions—especially in complex or comminuted fractures.
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### Understanding the Radial Head’s Role
The radial head is the upper end of the radius bone, forming part of the elbow joint alongside the humerus and ulna. It plays three key roles:
1. **Stabilizing the elbow** against valgus stress (especially when the medial collateral ligament is injured)
2. **Transmitting load** across the joint (up to 60% of force during hand use)
3. **Enabling forearm rotation** (pronation and supination)
Disrupting this structure—without proper management—can lead to chronic instability, arthritis, stiffness, or loss of grip strength.
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### Radial Head Excision: When Simplicity Works
**Radial head excision** involves surgically removing the fractured radial head without replacement. Historically common, it’s now reserved for specific cases:
#### ✅ Ideal Indications:
- **Simple, non-comminuted fractures** with minimal displacement
- **Low-demand patients** (elderly, sedentary)
- **Isolated fractures** with intact ligaments and stable elbow
#### ⚠️ Risks and Limitations:
- **Elbow instability**: Loss of radial head compromises valgus stability
- **Proximal migration of the radius**: Can cause wrist pain and ulnar impaction
- **Post-traumatic arthritis**: Due to altered joint mechanics
- **Reduced grip strength** (up to 30% loss in some studies)
Studies show excision works best in **Mason Type II fractures** with <30% articular involvement. However, in **comminuted (Mason Type III/IV) or ligament-injured elbows**, excision alone often leads to poor outcomes.
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### Radial Head Replacement: Restoring Anatomy and Function
**Radial head arthroplasty** replaces the damaged radial head with a metal or pyrocarbon implant, preserving joint alignment and biomechanics.
#### ✅ Ideal Indications:
- **Comminuted fractures** not suitable for fixation
- **Elbow dislocations with radial head fracture** (terrible triad injury)
- **Patients with high functional demands** (younger, active individuals)
- **Concomitant ligament injuries** requiring stability
#### ✅ Advantages:
- Maintains **elbow stability** and prevents proximal radius migration
- Restores **load transmission** across the joint
- Allows **early mobilization**, reducing stiffness
- Better long-term **grip strength and range of motion**
Modern implants (e.g., **press-fit titanium or modular systems**) mimic natural anatomy and integrate well with bone. A 2023 meta-analysis in *The Journal of Shoulder and Elbow Surgery* found that replacement yielded **superior functional scores** and **lower reoperation rates** compared to excision in complex fractures.
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### Key Factors Influencing the Decision
1. **Fracture Pattern**:
- Simple → fixation or excision
- Comminuted → replacement
2. **Elbow Stability**:
If the medial collateral ligament (MCL) or lateral structures are torn, **replacement is strongly preferred** to prevent chronic instability.
3. **Patient Age and Activity Level**:
- Young, active patients → replacement
- Elderly, low-demand → excision may suffice
4. **Surgeon Experience**:
Implant sizing and placement require precision. Malposition can cause stiffness or capitellar cartilage wear.
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### Complications to Consider
- **Excision**: Instability, arthritis, ulnar-sided wrist pain
- **Replacement**: Implant loosening, nerve injury, stiffness, or overstuffing (if implant is too tall)
However, modern techniques have reduced replacement complications significantly. A 10-year follow-up study (Ring et al., *JSES*) showed **85% implant survival** with good functional outcomes.
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### Rehabilitation Outlook
Both procedures require **structured physical therapy**, but protocols differ:
- **After excision**: Gentle motion starts early, but heavy lifting is restricted.
- **After replacement**: Early passive motion begins within days, progressing to active use by 4–6 weeks.
Full recovery typically takes **3–6 months**, with replacement patients often regaining near-normal function if rehab is consistent.
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### Final Recommendation
For **isolated, simple radial head fractures in low-demand patients**, excision remains a viable, low-cost option.
But for **comminuted fractures, elbow dislocations, or active individuals**, **radial head replacement is the gold standard**—offering superior stability, function, and joint preservation.
At BoneFractures.org, we emphasize that surgical success depends not just on the procedure, but on **accurate diagnosis, timely intervention, and dedicated rehabilitation**. Always consult an orthopedic elbow specialist to determine the best path to recovery.
*— Written by Dr. Attia, Orthopedic cosultant*