Radial Head Fracture

By admin On Feb 26, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Radial Head Fracture

Radial Head Fracture

John H. Wilckens MD

Michelle Cameron MD

Basics

Description

Radial head fractures:
- Occur in the proximal 2–3 cm of the radius
- Are intra-articular fractures (The radial head articulates with capitellum.)
Classification (1):
- Type 1: Nondisplaced fractures
- Type 2: Partial head fractures
- Type 3: Complete head fractures
Radial head fractures often are associated with other injuries to the elbow or the forearm.

Epidemiology

Incidence

Fractures can occur in any age group.
In 1 series of 333 fractures (2):
- 67% of fractures were Mason type 1, 14% were type 2, and 19% were type 3.
- Ligamentous injuries requiring repair were found in 13% of patients.

Etiology

This fracture generally results from a fall on the outstretched hand with the forearm in pronation.
The position of the elbow and forearm at the time of injury directly affects the injury pattern (3).

Associated Conditions

Elbow dislocation
Carpal fractures
Wrist fractures
Olecranon fracture dislocation (the posterior Monteggia lesion)
Radial head dislocation
Rupture of the MCL
Elbow instability secondary to extensive damage to soft-tissue restraints

Diagnosis

Signs and Symptoms

Tenderness or swelling over the lateral surface of the elbow
Painful ROM of the elbow
Elbow hemarthrosis

Physical Exam

Examine for range of supination and pronation and for elbow flexion and extension.
Because of the mechanism of injury, include examination of the wrist and hand.
Assess carefully the neurovascular status of the forearm and hand.
If the patient has tenderness of the
interosseous membrane and distal radioulnar joint, an Essex-Lopresti
injury should be considered.
- This injury involves a radial head
  fracture combined with an intraosseous membrane disruption and distal
  radial ulnar joint dislocation.
- The radius pull test may help diagnose ligamentous injury (4).
If a fracture occurs with an elbow dislocation, determine the ROM at which the elbow is stable.

Tests

Imaging

Radiography:
- Obtain routine AP and lateral radiographs of the elbow.
  - Occult or nondisplaced radial neck fractures may have no bony findings.
  - A “posterior fat pad sign” and “anterior sail sign” suggest a hemarthrosis and radial head/neck injury (5).
- A radiocapitellar view may be necessary
  to identify nondisplaced fractures or to characterize additionally
  displaced or comminuted fractures.
Comminuted fractures with associated
injury may require a CT or MRI scan for identification of the
abnormality and for preoperative planning.

Diagnostic Procedures/Surgery

It is important to determine whether the fracture blocks motion of the elbow.
Aspiration of the joint with injection of lidocaine gives pain relief and allows for examination.
- For aspiration, insert a needle on the
  lateral side of the elbow in the center of a triangle formed by the
  radial head, the tip of the olecranon, and the lateral epicondyle.

Differential Diagnosis

Distal humerus fracture
Radial head dislocation

Treatment

General Measures

For nondisplaced or minimally displaced fractures: Early mobilization (6)
Fractures involving >1/3 of the articular surface: Splint for 1–2 weeks, followed by protected ROM for 7–10 days.
Moderately displaced or comminuted
fractures or those with fragments blocking ROM at the elbow: Surgical
repair (open reduction with internal fixation or excision of the radial
head)

Activity

For nondisplaced or minimally displaced fractures, active and passive ROM should begin shortly after injury.
Patients with moderately displaced or severely comminuted fractures should begin active and passive ROM as soon as tolerated.

Special Therapy

Physical Therapy

Decreased ROM and muscle strength are common sequelae of elbow immobilization after radial head fractures.
Therefore, it is important to begin active and passive ROM exercises as soon as tolerated.

Medication

First Line

NSAIDs and acetaminophen

Second Line

Narcotics

Surgery

Fixation of moderately displaced fractures usually is accomplished with the use of small-diameter screws.
Comminuted fractures are treated with internal fixation, if possible.
- Results after internal fixation have been shown to be better than those after resection (7).
- With >4 fracture fragments, fracture fixation is more difficult and results are poorer (8).
If resection is necessary, it may be performed early or late (9).
- In general, results of resection are good except when other injuries or elbow dislocation have occurred.
- A prosthetic head may be placed in the presence of an elbow fracture/dislocation.
Complex elbow dislocations with
ligamentous injury and radial head fracture should be treated with
ligament repair, coronoid repair, and either repair or replacement of
the radial head fracture so that early mobilization can be achieved (10).

P.355

Follow-up

Prognosis

Nondisplaced fractures treated with mobilization have a good prognosis (11).
Displaced fractures:
- Results usually are good.
- Excellent results have been reported with mobilization and no surgery if fracture displacement is <4 mm (12).
- Long-term results after fixation of displaced fractures with few fracture fragments are good (13).
The prognosis for recovery of full elbow
function is inversely proportional to the degree of comminution and the
extent of associated ligamentous injuries.
In patients treated with radial head excision, the more severe injuries had a worse prognosis (14).
Radial head replacement also gives good results (15).
- The exact sizing of the replacement is important for reconstruction of the radiohumeral joint (16).
Long-term results in children after radial head fracture treatment are good (17).

Complications

Decreased elbow ROM
Elbow arthritis
Malunion
Nonunion
Elbow instability

Patient Monitoring

It is important to document preoperative and postoperative neurovascular status and ROM.

References

1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123–132.

2. van Riet RP, Morrey BF, O’Driscoll SW, et al. Associated injuries complicating radial head fractures: a demographic study. Clin Orthop Relat Res 2005;441:351–355.

3. McGinley JC, Hopgood BC, Gaughan JP, et al. Forearm and elbow injury: the influence of rotational position. J Bone Joint Surg 2003;85A:2403–2409.

4. Smith AM, Urbanosky LR, Castle JA, et al. Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg 2002;84A:1970–1976.

5. O’Dwyer
H, O’Sullivan P, Fitzgerald D, et al. The fat pad sign following elbow
trauma in adults: its usefulness and reliability in suspecting occult
fracture. J Comput Assist Tomogr 2004;28:562–565.

6. Unsworth-White
J, Koka R, Churchill M, et al. The non-operative management of radial
head fractures: a randomized trial of three treatments. Injury 1994;25:165–167.

7. Ikeda M, Sugiyama K, Kang C, et al. Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg 2005;87:76–84.

8. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg 2002;84A:1811–1815.

9. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg 1986;68A:669–674.

10. Pugh
DMW, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat
elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg 2004;86A:1122–1130.

11. Herbertsson
P, Josefsson PO, Hasserius R, et al. Displaced Mason type I fractures
of the radial head and neck in adults: a fifteen- to thirty-three-year
follow-up study. J Shoulder Elbow Surg 2005;14:73–77.

12. Akesson
T, Herbertsson P, Josefsson PO, et al. Displaced fractures of the neck
of the radius in adults: an excellent long-term outcome. J Bone Joint Surg 2006;88B:642–644.

13. Herbertsson
P, Josefsson PO, Hasserius R, 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 2004;86A:569–574.

14. Herbertsson P, Josefsson PO, Hasserius R, et al. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg 2004;86A:1925–1930.

15. Ashwood
N, Bain GI, Unni R. Management of Mason type-III radial head fractures
with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg 2004;86A:274–280.

16. Van
Glabbeek F, van Riet RP, Baumfeld JA, et al. Detrimental effects of
overstuffing or understuffing with a radial head replacement in the
medial collateral-ligament deficient elbow. J Bone Joint Surg 2004;86A:2629–2635.

17. Malmvik
J, Herbertsson P, Josefsson PO, et al. Fracture of the radial head and
neck of Mason types II and III during growth: a 14–25 year follow-up. J Pediatr Orthop B 2003;12:63–68.

Additional Reading

McKee
MD, Jupiter JB. Trauma to the adult elbow and fractures of the distal
humerus. In: Browner BD, Jupiter JB, Levine AM, et al., eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia: WB Saunders, 2003: 1404–1480.

Tashjian RZ, Katarincic JA. Complex elbow instability. J Am Acad Orthop Surg 2006;14: 278–286.

Miscellaneous

Codes

ICD9-CM

813.05 Radial head fracture
832.00 Elbow dislocation

Patient Teaching

Elbow stiffness can occur even with a perfect surgical result.

Activity

Early ROM should be used.
Care should be taken to mobilize the shoulder, wrist, and hand to avoid stiffness.

Prevention

The use of protective elbow pads is encouraged with skating and other sports in which falls are likely.

FAQ

Q: How long should patients with a nominally displaced radial head be immobilized?

A:
In general, if the elbow is stable, early ROM as tolerated is advocated
with the use of a sling and/or posterior splint for early pain control.

Q:
If a patient has a comminuted radial head fracture that cannot be
stabilized with internal fixation, when should head excision be
considered?

A:
Such a patient may have associated elbow instability or an
Essex-Lopresti injury. Early head excision may complicate these 2
conditions. Because the results of late radial head excision are
superior to those of early excision, delay in excision is recommended.
In the context of a grossly unstable elbow or Essex-Lopresti lesion in
a patient for whom early excision is indicated because of motion
problems, a radial head prosthesis should be inserted.