Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Radial Head Fracture

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 :
    • 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 :
    • 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 .
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 .
  • 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 .
    • 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  
  • 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 .
    • With >4 fracture fragments, fracture fixation is more difficult and results are poorer .
  • If resection is necessary, it may be performed early or late.
    • 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.
Follow-up
Prognosis
  • Nondisplaced fractures treated with mobilization have a good prognosis.
  • Displaced fractures:
    • Results usually are good.
    • Excellent results have been reported with mobilization and no surgery if fracture displacement is <4 mm.
    • Long-term results after fixation of displaced fractures with few fracture fragments are good.
  • 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.
  • Radial head replacement also gives good results.
    • The exact sizing of the replacement is important for reconstruction of the radiohumeral joint.
  • Long-term results in children after radial head fracture treatment are good.
Complications
  • Decreased elbow ROM
  • Elbow arthritis
  • Malunion
  • Nonunion
  • Elbow instability
Patient Monitoring
It is important to document preoperative and postoperative neurovascular status and ROM.
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.

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