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Radial head arthroplasty

40 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Radial head arthroplasty is a reasonable option for patients with comminuted radial head fractures and complex elbow trauma [2]. It reports better outcomes than radial head excision in terms of elbow stability, range of motion, pain, and fewer complications for unrepairable comminuted fractures Mason Type III and Type IV [7]. Radial head replacement is recommended for comminuted fractures with satisfactory medium- and long-term results [18].

The intraoperative decision to fix or replace the radial head is critical to optimize treatment outcomes [3]. Adequate knowledge of surgical indications, types of implants, and surgical technique is essential for a satisfactory outcome when using a radial head prosthesis for nonreconstructable radial head fractures [12]. Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty [6]. Current data provide no evidence for a specific radial head prosthesis design due to the variety of implant designs and limited evidence [5].

Radial head replacement is associated with the complication of radial column overlengthening [1]. Midterm outcomes of the EVOLVE radial head prosthesis are satisfactory with low associated complication rates [8]. Bipolar-cemented implants show lower revision rates in radial head replacement [18]. Reproducibility of results in radial head arthroplasty studies would be improved by using a minimum follow-up of three years [4]. Reproducibility of results in radial head arthroplasty studies would be improved by using a consensus definition of the reasons for failure [4].

Anatomy & Pathophysiology

Osseous Anatomy

The radial head is disk-shaped with a greater diameter than the radial neck [38]. Its shallow, cuplike surface articulates proximally with the capitellum and medially with the radial notch of the ulna [38]. The head is seated in the lesser sigmoid notch, interdigitating precisely with the lateral lip of the trochlea and the capitellar articular surface [43]. Axially, it contacts the capitellum of the distal humerus [22]. The proximal radius exhibits a slight angulation relative to the shaft [43], and the head possesses a slightly elliptical cross-section [43]. The entire radial head is covered with articular cartilage [38]. The biceps inserts on the radial tuberosity immediately distal to the radial neck [38]. The secondary ossification center of the proximal radius appears as a small sphere between ages three and five, fusing with the shaft between ages 16 and 18 [38].

Vascular and Neural Relations

The radial head’s blood supply is limited, tenuous, and derived from the more distal metaphysis [38, 43]. The posterior interosseous nerve runs deep to the supinator along the lateral aspect of the radial neck [43]. A relatively small nonarticular surface, known as the "safe zone," covers an arc of roughly 90 degrees with its midpoint directly lateral when the arm is in neutral position [43]. This safe zone corresponds to the lateral 100-degree arc with the forearm in neutral rotation [22]. The area between the Lister tubercle and the radial styloid on the distal radius serves as a rough guide to this nonarticular area of the radial head [43].

Ligamentous Stability and Kinematics

The radial head is the secondary restraint to valgus stability of the elbow [16, 22]. It plays an important role as a secondary valgus stabilizer [16] and is an important secondary stabilizer to valgus stress [51]. The primary stabilizers include the medial collateral ligament (valgus instability), coronoid (posterior instability), interosseous membrane (longitudinal instability), and lateral collateral ligament (posterolateral rotatory instability) [16]. Ligaments exert the most marked influence on elbow stability, particularly when valgus and varus gravity loads are applied [32]. Because the radial head is an important secondary stabilizer, excision alone is contraindicated when extensive damage to primary stabilizers is present [16]. Excision in the presence of concomitant ligamentous or bony injury leads to loss of radiocapitellar contact forces and precipitates instability [17]. Excision alone alters elbow kinematics and is infrequently performed even with intact collateral ligaments [17].

Fracture Pathophysiology

Radial head fractures typically result from a fall on an outstretched hand with the forearm in pronation, creating an axial load on the elbow [16]. This mechanism often involves a fall onto an outstretched hand with the elbow in extension and valgus [38]. Such valgus extension forces may produce associated injuries, including avulsion of the medial epicondyle, rupture of the medial collateral ligament, and fracture of the olecranon, proximal ulna, or lateral condyle [38]. Radial head fractures account for 15–25% of all elbow fractures [22] and approximately 20% of all elbow fractures involve the radial head [16]. They can occur in isolation but are often associated with complex injuries such as elbow fractures, dislocations, and soft-tissue injuries [16]. Of patients with radial head fractures, 30% have other soft-tissue and skeletal injuries [16]. Associated injuries include carpal fractures, distal radioulnar joint (DRUJ) injury, interosseous membrane disruption, coronoid fractures, Monteggia fracture-dislocations, capitellar fractures, and medial and lateral collateral ligament injuries [16]. Associated injuries are common with radial head fractures [22]. Radial neck fractures may also result from elbow dislocation [38]. The radial neck may be fractured by impact against the inferior aspect of the capitellum during posterior dislocation or spontaneous reduction [38]. A radial head fracture may occur with anterior dislocation of the elbow, producing anterior displacement of the head [38].

Congenital Radial Head Dislocation

Congenital dislocation of the radial head (CDRH) is the most common congenital anomaly of the elbow and is usually bilateral [24]. CDRH may be sporadic or familial [24]. Potential pathways include abnormalities of collagen formation, endochondral ossification, differential growth of the radius and ulna, and altered HOX-D expression [24]. The radial head may be dislocated anteriorly, posteriorly, or laterally [24]. About 60% of congenital radial head dislocations are accompanied by other upper extremity congenital anomalies [24]. CDRH is associated with congenital radioulnar synostosis and syndromes including Klinefelter, Cornelia de Lange, Ehlers-Danlos, and nail-patella syndromes [24]. In CDRH, the radial head generally remains intra-capsular, whereas traumatic dislocation usually tears through the elbow joint capsule [24]. In CDRH, the radial head is generally convex instead of concave, and the capitellum is hypoplastic and ovoid instead of convex [24]. Posterior CDRH usually impedes terminal extension (≤30 degrees), and anterior CDRH may limit full flexion [24]. Diminished forearm rotation in both pronation and supination is common in CDRH [24]. The diagnosis is confirmed by radiography, where a line drawn through the longitudinal axis of the radial shaft does not bisect the capitellum [24]. In CDRH, the radial head is dome-shaped [24]. The ulna bows depending on the direction of dislocation: anterior dislocations cause bowing into extension, and posterior dislocations cause bowing into flexion [24]. Additional radiographic findings include dysplasia of the capitellum and ulnar-positive variance of the wrist [24].

Classification

Radial head fractures are common with variable anatomy [56]. Treatment of radial head fractures depends on fracture type and associated injuries [56]. Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can be given with the best available evidence [30].

Mason: * Type 1: Conservative management is indicated [56]. * Type 2: Open reduction and internal fixation (ORIF) is indicated for fractures with mechanical block [56]. * Type 3: Arthroplasty or resection is indicated, particularly with ligamentous injury [56].

For Mason type 3 radial head fractures, ORIF exhibits a higher risk of complications compared to treatment with radial head arthroplasty [21]. In the short term, radial head replacement had better elbow function and fewer adverse events than ORIF for Mason type III radial head fractures in Chinese population [35]. However, evidence for superior outcomes of radial head replacement over ORIF for Mason type III fractures is of low quality and results may not apply in the longer term or more generally [35].

Clinical Presentation

Radial head fractures typically result from a fall on an outstretched hand with the forearm in pronation, generating an axial load on the elbow [16]. These injuries may occur in isolation or be associated with more complex trauma, including elbow fractures, dislocations, and soft-tissue injuries [16]. The radial head functions as a secondary valgus stabilizer of the elbow [16]. Consequently, 30% of patients with radial head fractures present with concomitant soft-tissue and skeletal injuries, such as carpal fractures, distal radioulnar joint (DRUJ) injuries, interosseous membrane disruption, coronoid fractures, Monteggia fracture-dislocations, capitellar fractures, and medial or lateral collateral ligament injuries [16].

Patients should be questioned carefully about concomitant wrist, forearm, or shoulder pain [16]. Physical examination reveals pain with palpation over the radial head [16]. Examination must assess the forearm, wrist, and elbow for tenderness along the interosseous membrane (Essex-Lopresti lesion), DRUJ instability, medial elbow pain (medial collateral ligament), and lateral elbow pain (lateral collateral ligament) [16]. Lateral elbow pain and tenderness or limitation in elbow or forearm motion should alert the examiner to the possibility of a radial head fracture [16].

Examination should assess elbow range of motion for a block to pronation/supination or flexion/extension [16]. Anteroposterior and lateral radiographs of the elbow are routinely obtained for evaluation [16]. Nondisplaced fractures may not be visible on radiographs but can be diagnosed by elevation of the anterior and posterior fat pads (the sail sign) due to intra-articular hemarthrosis [16]. The radiocapitellar view is accomplished by positioning the patient as for a lateral view but angling the tube 45° toward the shoulder [16]. Computed tomography can delineate the location, number, and size of fragments in comminuted fractures and is rapidly emerging as a standard imaging method for complicated radial head fractures [16]. Aspiration of the intra-articular hematoma and injection of a local anesthetic can be helpful when assessing mechanical blocks to motion [16].

Nonoperative Management: Most minimally displaced (<3 mm) radial head fractures can be treated nonsurgically if no block to range of motion is present [16]. Most radial head fractures are stable and managed non-operatively with good long-term results [14]. Conservative management of isolated Mason II radial head fractures yields favorable therapeutic outcomes with a low incidence of complications [31]. Most radial head fractures can be managed nonsurgically with early motion [10]. Isolated fractures heal best with early mobilization after 7 to 10 days [16].

Surgical Indications: Radial head fractures that are significantly displaced, block motion (especially rotation), or are part of more complicated injury patterns are candidates for surgical repair [16]. Displaced unstable fractures require restoration of radiocapitellar contact via reconstruction or prosthetic replacement to prevent elbow instability [14]. Complex fractures associated with elbow instability require careful selection between open reduction and internal fixation and arthroplasty [10]. Radial head replacement is a good treatment option in cases with more than three fracture fragments, which have a higher rate of failure with surgical fixation [16]. Radial head fractures with three or more fragments have a higher incidence of unsatisfactory results with fixation; the surgeon should consider replacement rather than fixation for such fractures [16]. Radial head fracture fixation has a higher failure rate if there is associated elbow instability [16].

Contraindications: Radial head excision alone is contraindicated in clinical settings in which extensive damage to the primary stabilizers (MCL, coronoid, interosseous membrane, LCL) is present [16]. The most commonly used radial head replacement prosthesis is a modular, metallic, smooth stem noncemented prosthesis [16].

Investigations

Plain radiography: Anteroposterior and lateral views are routinely obtained for radial head fractures [16, 23]. In elbow dislocations, post-reduction radiographs are required [23]. Standard views also diagnose Monteggia fractures [42]. In Monteggia fractures, a line drawn through the radial neck center must extend through the capitellum regardless of elbow position [42]. For congenital radial head dislocation, a line through the radial shaft’s longitudinal axis does not bisect the capitellum [24]. Absence of trauma, a hypoplastic capitellum, and a flattened convex radial head raise suspicion for congenital dislocation [42]. Nondisplaced radial head fractures may be invisible on radiographs but are diagnosed by elevation of the anterior and posterior fat pads (sail sign) due to intra-articular hemarthrosis [16, 22].

MRI: MRI helps distinguish congenital radial head dislocation from traumatic dislocation [24]. In congenital cases, the radial head is generally convex rather than concave, and the capitellum is hypoplastic and ovoid rather than convex [24].

CT: Computed tomography delineates fragment location, number, and size in comminuted radial head fractures and is rapidly emerging as a standard for complicated fractures [16]. CT aids preoperative planning for comminuted olecranon fractures when associated with radial head or coronoid fractures [23]. In rare equivocal Monteggia fracture cases, advanced imaging such as CT is indicated [42].

Aspiration: Joint aspiration with local anesthetic injection assists in assessing mechanical blocks to motion in radial head fractures [16].

Other Considerations: Radial head fractures account for 15–25% of all elbow fractures [16, 22]. Associated injuries include carpal fractures, distal radioulnar joint (DRUJ) injury, interosseous membrane disruption, coronoid fractures, Monteggia fracture-dislocations, capitellar fractures, and medial/lateral collateral ligament injuries [16]. The radial head acts as a secondary restraint to valgus stability [16, 22]. Patients require careful questioning for concomitant wrist, forearm, or shoulder pain [16]. Physical examination assesses pain over the radial head [16], elbow range of motion, and blocks to pronation/supination or flexion/extension [16]. Examination must check the forearm, wrist, and elbow for interosseous membrane tenderness (Essex-Lopresti lesion), DRUJ instability, and medial/lateral collateral ligament pain [16]. The Mason classification categorizes radial head fractures: Type I (nondisplaced), Type II (displaced), Type III (comminuted), and Type IV (associated with elbow dislocation) [16, 22]. The Mayo classification for olecranon fractures is based on displacement, comminution, and ulnohumeral joint stability [23].

Treatment

Non-Operative Management

Most radial head fractures are stable and can be managed non-operatively with early motion, yielding good long-term results [10, 14]. Nondisplaced and minimally displaced fractures, including isolated Mason type II injuries, are treated conservatively with early mobilization, which yields favorable therapeutic outcomes with a low incidence of complications [28, 31].

Operative Indications

Operative intervention is indicated for displaced radial head fractures presenting with a block to motion, comminuted fragments, associated elbow instability, or retained intra-articular fragments [17]. Fractures with greater than 2 mm of displacement and greater than 30% of the articular surface (Mason II fractures) require operative fixation [17]. In cases of complex fractures associated with elbow instability, careful selection between open reduction and internal fixation and arthroplasty is required [10]. Radial head arthroplasty is an excellent option for irreconstructable radial head and neck fractures to restore radiocapitellar contact and elbow stability [17]. Unstable or unpredictable fixation of complex radial head fractures should be treated with prosthetic replacement to avoid instability of the forearm or elbow [27].

Implant Selection and Design

Clinical outcome studies indicate that metallic radial head arthroplasty is a reasonable option for comminuted radial head fractures and complex elbow trauma [2]. Radial head replacement is recommended for comminuted fractures with satisfactory medium- and long-term results, although bipolar-cemented implants demonstrate lower revision rates [18]. For fractures with three or more articular fragments or those not amenable to stable internal fixation, monopolar, metallic radial head implants with modular components and a smooth neck are preferred [46]. Given no clinical difference in use of monopolar and bipolar metallic arthroplasty systems, a monopolar implant provides good clinical outcomes with the benefit of being cost-effective [50]. Current data provide no evidence for a specific radial head prosthesis design due to the variety of implant designs and limited evidence [5]. The use of stem auto-expansion as a mode of obtaining primary fixation appears to be an effective solution for reducing the risk of painful loosening [20].

Surgical Technique and Planning

Adequate knowledge of surgical indications, types of implants, and surgical technique is essential for a satisfactory outcome when using a radial head prosthesis for nonreconstructable fractures [12]. A modular metallic radial head arthroplasty system should always be available because comminution is often more severe than predicted by plain radiographs or CT [45]. In the setting of neck comminution, small plates or cerclage wires should be available to allow for neck reconstruction and the use of a standard prosthesis [45]. A long-stem bipolar prosthesis should be available in the uncommon situation where reconstruction of the radial neck to accept a standard prosthesis is not possible [45].

The proximal third of the annular ligament should be isolated and sharply cut to expose the radial head [50]. All fragments should be removed and then assembled on the back table for sizing [50]. A fresh saw cut at the junction of the head/neck or at the level of the fracture is made to create a stable, straight base [50]. Thorough irrigation is recommended to remove all bony debris to minimize the risk of heterotopic ossification [50]. The implant size is typically downsized one size from the native radial head to avoid overstuffing [50]. The canal can be prepared with a canal finder and subsequent rasps [50]. After placing trial implants, the proximal edge of the prosthesis should sit no more than 1-mm proximal to the corner of the lesser sigmoid notch of the coronoid [50]. Following implantation of the final prosthesis, the annular ligament and any concomitant ligamentous injuries should be addressed [50].

Complications and Pitfalls

Overlengthening (overstuffing) with the placement of a radial head prosthesis that is too thick may be associated with the development of pain, stiffness, and capitellar wear [29]. An implant whose diameter is too large may cause an erosion of the lateral trochlea, prevent optimal closure of the annular ligament, and may contribute to residual instability [29]. Radial head implant maltracking causes premature capitellar cartilage wear, pain, limited rotation, and may contribute to loosening of fixed stem prostheses [29]. Overlengthening causes the medial ulnohumeral joint to open laterally, which may not be evident until there is 6- to 8-mm overlengthening of the radial head insert [29]. Anatomic radial head replacement has a risk of radiographic technical mistakes that correlate to poorer outcomes [9].

Postoperative Care and Follow-up

Immediate active motion in a soft dressing is permitted if there are no associated injuries [29]. Concomitant ligament injuries will direct the rehabilitation plan [29]. The reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after radial head arthroplasty [4].

Complications

Stiffness / Arthrofibrosis: Most removals of radial head prostheses were performed to manage elbow stiffness and heterotopic ossification rather than due to implant malfunction [33].

Other Considerations: Overlengthening of the radial column is a complication of radial head replacement [1]. Radial head arthroplasty results in fewer complications compared to radial head excision [7] and fewer adverse events than open reduction and internal fixation for Mason type III radial head fractures in the short-term in Chinese populations [35]. Mason type 3 radial head fractures treated with open reduction and internal fixation exhibit a higher risk of complications compared to those treated with radial head arthroplasty [21]. Arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure across both age groups younger than and older than 50 years [36]. Midterm outcomes of EVOLVE radial head prosthesis are associated with low complication rates [8]. Radial head arthroplasty results in modest complication and revision rates at long-term follow-up [60]. The reproducibility of results for radial head arthroplasty would be improved by using a minimum follow-up of three years combined with a consensus definition of the reasons for failure [4].

Recovery

Radial head arthroplasty is a reasonable option for patients with comminuted radial head fractures and complex elbow trauma [2]. Better outcomes are reported for radial head arthroplasty compared to radial head excision in terms of elbow stability, range of motion, pain, and fewer complications [7].

Rehabilitation protocol: Use of a standard surgical protocol for elbow dislocations with radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing functional outcome [25].

Complete recovery / outcome plateau (months): Reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after radial head arthroplasty [4].

Key Evidence

  • [L4] The review aims to shed light into overlengthening as a complication of radial head replacement and to help identify and treat it. [1] (10.1007/s00402-020-03619-9)
  • [L5] Clinical outcome studies of metallic radial head arthroplasty systems indicate that head replacement is a reasonable option to offer patients with comminuted radial head fractures and complex elbow trauma. [2] (10.1016/j.jhsa.2005.12.005)
  • [L5] The intraoperative decision to fix or replace the radial head is critical to optimize treatment outcomes. [3] (10.1016/j.hcl.2004.06.003)
  • [L1] The reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after radial head arthroplasty. [4] (10.1302/0301-620x.99b12.bjj-2017-0543.r2)
  • [L4] Due to the variety of implant designs and limited evidence, the current data provide no evidence for a specific radial head prosthesis design. [5] (10.1302/2058-5241.4.180099)
  • [L1] Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty. [6] (10.1016/j.jse.2018.07.032)
  • [L4] Better outcomes are reported for radial head arthroplasty in terms of elbow stability, range of motion, pain, and fewer complications compared to radial head excision. [7] (10.1155/2018/4020625)
  • [L2] Midterm outcomes of EVOLVE radial head prosthesis are satisfactory, and associated complication rates are low. [8] (10.1177/1758573219850111)
  • [L3] Anatomic radial head replacement has a risk of radiographic technical mistakes that correlate to poorer outcomes. [9] (10.1016/j.jseint.2026.101671)
  • [L5] Most radial head fractures can be managed nonsurgically with early motion, while complex fractures associated with elbow instability require careful selection between open reduction and internal fixation and arthroplasty. [10] (10.5435/00124635-200707000-00003)
  • [L5] Adequate knowledge of the surgical indications, types of implants, and surgical technique are essential for a satisfactory outcome when a radial head prosthesis is used for the treatment of nonreconstructable radial head fractures. [12] (10.5435/jaaos-22-10-633)
  • [L4] The preferred treatment for failed radial head arthroplasty depends mainly on the chondral condition and stability of the elbow joint. [13] (10.1302/2058-5241.5.190055)
  • [L5] Most fractures of the radial head are stable and managed non-operatively with good long-term results, while displaced unstable fractures require restoration of radiocapitellar contact via reconstruction or prosthetic replacement to prevent elbow instability. [14] (10.1302/0301-620x.95b2.29877)
  • [L4] Radial head replacement is recommended for comminuted fractures with satisfactory medium- and long-term results, though bipolar-cemented implants show lower revision rates. [18] (10.1016/j.injury.2013.09.019)
  • [L1] The use of stem auto-expansion as a mode of obtaining primary fixation in radial head arthroplasty appears to be an effective solution for reducing the risk of painful loosening. [20] (10.1007/s00264-018-4070-0)
  • [L1] Mason type 3 radial head fractures treated with open reduction and internal fixation exhibit a higher risk of complications compared to those treated with radial head arthroplasty. [21] (10.1016/j.jseint.2024.08.180)
  • [L4] Use of the surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. [25] (10.2106/jbjs.d.02933)
  • [L4] Unstable or unpredictable fixation of complex radial head fractures should probably be treated with prosthetic replacement to avoid instability of the forearm or elbow. [27] (10.1016/j.jse.2010.11.011)
  • [L5] Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. [28] (10.1530/eor-24-0035)
  • [L1] Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence. [30] (10.1016/j.injury.2013.04.003)
  • [L1] Based on the current evidence, conservative management of isolated Mason II radial head fractures yields favorable therapeutic outcomes with a low incidence of complications. [31] (10.1186/s13018-024-05039-6)
  • [L5] The ligaments have the most marked influence on stability, particularly when the upper limb is positioned such that valgus and varus gravity loads are applied to the elbow. [32] (10.1016/j.jse.2004.09.034)
  • [L1] Most removals were performed to manage elbow stiffness and heterotopic ossification rather than due to implant malfunction, suggesting acceptable mid-term longevity. [33] (10.1016/j.jhsa.2017.08.031)
  • [L1] Radial head replacement had better elbow function and fewer adverse events than ORIF for Mason type III RHF in the short-term in Chinese population, but evidences are of low quality and results may not apply in the longer term or more generally. [35] (10.1016/j.otsr.2015.06.015)
  • [L4] Across both age groups, arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure. [36] (10.1016/j.xrrt.2022.09.008)
  • [L5] The authors state that for fractures with three or more articular fragments or those not amenable to stable internal fixation, they prefer excision of the radial head and prosthetic replacement using monopolar, metallic radial head implants with modular components and a smooth neck. [46] (10.1016/j.jhsa.2014.10.029)
  • [L5] Radial head fractures are common with variable anatomy; treatment depends on fracture type and associated injuries, with conservative management for type 1, ORIF for type 2 with mechanical block, and arthroplasty or resection for type 3, particularly with ligamentous injury. [56] (10.1177/1758573219876921)
  • [L4] Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period. [60] (10.1016/j.jse.2021.03.142)

See Also

References

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