Radial head fractures: operative or conservative treatment? The Greek temple model

An important point in any communication on fracture treatment is agreement on classification of the fracture to be discussed. for fractures of the radial head there are several useful classification systems. The well-recognized Mason classification is particularly useful in the treatment of radial head fractures. It is however important to realize that the usefulness of this classification system is limited to radial head fractures without associated injury. In deciding on operative or conservative treatment it is therefore essential to subdivide fractures of the radial head into simple or complex fractures. As stated, the Mason classification system is most useful in deciding on treatment of simple fractures, that is to say fractures without an additional fracture or ligamentous injury. Type I fractures should be treated conservatively because of their excellent prognosis. The treatment of type II fractures is still controversial. The decision for osteosynthesis is not only based on the fracture configuration but certainly also on the talent of the surgeon involved. Immediate resection is not considered acceptable in this type of fracture. In type III fractures however, immediate excision is an acceptable method of treatment as long as there is no associated fracture or ligamentous injury. In deciding whether or not there is a complex injury the "Greek Temple" model is very useful. In this model the ulna and radius are seen as two "pillars" which support the "roof" of the distal humerus. The connection between the roof and the pillar on the ulnar side is formed by a ligament, on the radial side there is only the tension of the muscles. With this model it is easy to memorize which associated injuries form the basis of a complex injury, in which excision of the radial head or conservative treatment can cause ulnohumeral subluxation or late radioulnar instability. Treatment in these complex injuries should therefore in principle consist of reconstruction or temporary fixation of the radial pillar, and if necessary temporary stabilization of the ulnar pillar.