Fracture, Radial Head
Keith A. Stuessi
Ryan C. Fowler
BasicsAs classified by modified Mason classification (Johnston adding type IV and Morey adding displacement and percentage affected):
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Type I: Nondisplaced or minimally displaced fracture of head or neck:
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Intra-articular displacement of the fracture <2 mm and fragment size ≤30% of articular surface
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Forearm rotation (pronation/supination limited only by acute pain and swelling
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Nonoperative treatment
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Type II: Displaced fracture of the head or neck:
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Fracture displaced >2 mm and fragment size >30% of articular surface
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Motion may be mechanically limited.
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If fracture involves more than a marginal lip of the radial head and is not severely comminuted, repair by open reduction with internal fixation should be considered.
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Type III: Severely comminuted fracture of the radial head and neck:
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Not reconstructible
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Requires excision, with or without arthroplasty
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Type IV (added to Mason's classifications by Johnston):
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Radial head fracture with an associated elbow dislocation
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Description
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Fracture of the head of the radius, most often caused by direct axial loading, as with a fall on outstretched hand (FOOSH) injury
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Can also be caused by posterior lateral rotary force, any injury causing posterior dislocation to the elbow that may result in radial head fracture (such as Monteggia fracture or coronoid fracture-dislocation), or rarely, a direct blow.
Epidemiology
Radial head fractures are the most common fracture about the elbow, accounting for about 30% of all elbow fractures in adults and 1.7–5.4% of all adult fractures (1). Uncommon in children, accounting for only 1% of all fractures.
Commonly Associated Conditions
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∼1/3 of patients will have a concomitant injury.
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Essex-Lopresti lesion: Disruption of triangular fibrocartilage complex of the wrist and interosseous membrane of the forearm resulting in instability of the forearm and subluxation of the distal radioulnar joint
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Concomitant capitellar, olecranon, and coronoid fractures (often associated with elbow dislocation)
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Posterior Monteggia fractures: Proximal 1/3 ulna fracture with radial head dislocation
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The terrible triad is known as posterior dislocation of the elbow with radial head fracture and associated coronoid process fracture.
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Medial collateral ligament tear
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Presence or absence of mechanical block with rotation. Examination achieved after aspiration of hematoma, with or without intra-articular injection of anesthetic. Mechanical block associated with displaced fragment of radial head and affects surgical treatment.
DiagnosisHistory
Determining the mechanism of injury (FOOSH vs. direct trauma to elbow) may help differentiate radial head fracture versus other fractures of the elbow.
Physical Exam
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Patient usually holds injured arm gently against the chest with elbow flexed.
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Typically there is pain and moderate swelling over the lateral side of the elbow.
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Any attempt to flex or extend the elbow or rotate the forearm may accentuate pain.
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Of note, a recent study reaffirmed that preservation of active elbow range of motion (ROM) was 97% specific for absence of a fracture.
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Well-localized tenderness over the radial head (located just distal to the lateral epicondyle)
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Palpation of radial head with passive rotation of the forearm typically elicits pain and occasionally crepitation.
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Forearm and wrist always need to be palpated. Rule out associated injuries such as acute radioulnar dissociation and injury to the interosseous ligament of the forearm.
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Palpation of medial ligament necessary for signs of possible disruption
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Neurovascular status checked distally, especially with history of elbow dislocation
Diagnostic Tests & Interpretation
Imaging
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Anteroposterior and lateral radiographs of the elbow are usually sufficient.
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If fat pad sign present (either anterior “sail sign” or posterior fat pad sign) and fracture not apparent, radiocapitellar views are helpful, taken with forearm in neutral rotation and x-ray beam angled 45° cephalad.
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CT scans are helpful in estimating fracture size, degree of fragmentation, and displacement.
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If wrist or forearm pain present, x-rays of the wrist in neutral rotation view should be taken.
Diagnostic Procedures/Surgery
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Patient may have limited ROM due to pain and effusion. It is important to perform an intra-articular joint aspiration and subsequent ROM testing to ensure no mechanical block (although uncommon) is found, which may change treatment.
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A recent study found no benefit in ROM, pain, or function comparing arthrocentesis alone vs arthrocentesis followed by anesthetic instillation (1).
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Joint aspiration is performed at the lateral elbow in the soft spot at the center of the dorsal olecranon, radial head, and lateral epicondyle.
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If diagnostic hemarthrosis is avoided, serial exams may be helpful.
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Any questions should be referred for orthopedic consideration.
Differential Diagnosis
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Other fractures of the elbow, including capitellar, olecranon, and coronoid
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Supracondylar fractures much more prevalent in children
P.245
Treatment-
Aspiration alone may provide some pain relief vs aspiration with local anesthetic instillation.
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Type I:
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Treated nonoperatively
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Sling for pain control no longer than 3–4 days
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Active ROM can begin as soon as pain permits. Flexion and extension of the elbow and supination and pronation of the forearm should be taken to the point where mild pain begins.
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Ice therapy for 2–5 days
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Acetaminophen and oral narcotics as necessary for pain control
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Type II:
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Orthopedic consultation should be obtained with any type II patient, as there is still considerable controversy as to proper treatment and no specific criteria have been defined to differentiate who responds better to which treatment. Recent studies show better results with specific type II injuries as below with nonoperative vs open reduction internal fixation (ORIF), but randomized trials are still lacking.
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Without associated injuries and moderate displacement (2–5 mm), can be treated nonoperatively such as type I
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With associated injuries, especially causing elbow instability or with mechanical block, should be referred for orthopedic consultation and possible open ORIF
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Type III:
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ORIF vs resection and arthroplasty vs resection alone
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Type IV:
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Treated as above, with obvious attention paid to reduction of dislocation and surgical repair of both fractures and associated ligamentous injuries
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Additional Treatment
Additional Therapies
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Initiate ROM exercises early.
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More aggressive strength and flexibility exercises added progressively as tolerated
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If ROM does not improve on a weekly basis, a mechanical block should be excluded. Once excluded, formal therapy may be needed.
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Only mild restriction of extension and rotation should be expected at 6 wks.
Ongoing Care-
Contractures and loss of motion may develop if early active ROM is not initiated.
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Increased sensitivity to cold, which may persist for up to 1 yr
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Long-term pain is rarely a complication.
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Nonunion is possible, but is frequently asymptomatic.
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Nerve injuries in the form of partial ulnar nerve and posterior interosseus nerve injury have been documented, mainly associated with surgical exploration.
Follow-Up Recommendations
Early orthopedic input is essential in all but type I fractures due to potential need for surgical correction and controversy surrounding treatment.
Reference
1. Kaas L, et al. The incidence of associated fractures of the upper limb in fractures of the radial head. Strategies Trauma Limb Reconstr, 2008.
Additional Reading
Akesson T, et al. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am. 2006;88:1909–1914.
Chalidis BE, Papadopoulos PP, Sachinis NC, et al. Aspiration alone versus aspiration and bupivacaine injection in the treatment of undisplaced radial head fractures: A prospective randomized study. J Shoulder Elbow Surg. 2009.
Darracq MA, et al. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26:779.
Herbertsson P, et al: Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg Am. 2004;86-A:569.
Pike JM, Athwal GS, Faber KJ, et al. Radial head fractures—an update. J Hand Surg [Am]. 2009;34(3):557–565.
Ring D. Fractures and dislocations of the elbow: radial head fractures. In: Rockwood CA, Green DP, Bucholz RW, et al. Rockwood and Green's fractures in adults, 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2006;1011–1019.
Rosenblatt Y, et al. Current recommendations for the treatment of radial head fractures. Orthop Clin North Am. 2008;39:173.
CodesICD9
813.05 Fracture of head of radius, closed
Clinical Pearls
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In type I fractures, typically athletes can return to play as early as 6–8 wks, depending on pain, ROM, and strength.
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Protection of the elbow may be needed if returning to contact sports. In type II–IV fractures, return to play is based on extent of associated injuries and surgical correction.