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Basics ⬇

Author(s): Ryan C.Fowler, MD, CAQSM and Keith A.Stuessi, MD, CAQSM

As classified by modified Mason classification (Johnston adding type IV, Morey adding displacement and percentage affected for type II, and Rineer trying to establish stability for type II):

Description

  • Fracture of the head of the radius, most often caused by direct axial loading, as with a fall on outstretched hand (FOOSH) injury
  • 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 1/3 of all elbow fractures in adults, with an estimated incidence of 2.5 to 2.8 per 10,000 inhabitants per year (1); uncommon in children, accounting for only 1% of all fractures

Commonly Associated Conditions

  • 1/3 of patients will have a concomitant injury.
  • 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
  • Concomitant capitellar, olecranon, and coronoid fractures (often associated with elbow dislocation)
  • Posterior Monteggia fractures: proximal 1/3 ulna fracture with radial head dislocation
  • The “terrible triad” includes posterior dislocation of the elbow with radial head fracture and associated coronoid process fracture.
  • Medial collateral ligament tear
  • Lateral collateral ligament tear
  • 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
  • Neurologic injuries can occur rarely with isolated radial head fracture but are more commonly associated with dislocation. Ulnar and median nerve are more commonly injured than the radial and posterior interosseous nerve.
  • Brachial artery injuries can occur but are rare.

Diagnosis ⬆ ⬇

History

Determining the mechanism of injury is extremely helpful in differentiating from other elbow fractures. The typical mechanism of injury is a fall onto an outstretched hand in a pronated position, thus creating an axial load to the elbow (2).

Physical Exam

  • Patient usually holds injured arm gently against the chest with elbow flexed.
  • Typically, there is pain and moderate swelling over the lateral side of the elbow.
  • Any attempt to flex or extend the elbow or rotate the forearm may accentuate pain.
  • Preservation of active elbow range of motion (ROM) was 97% specific for absence of a fracture.
  • Focal tenderness over the radial head (located just distal to the lateral epicondyle)
  • Palpation of radial head with passive rotation of the forearm typically elicits pain and occasionally, crepitation.
  • Forearm and wrist examination required to rule out associated injuries such as acute radioulnar dissociation and/or injury to the interosseous ligament of the forearm
  • Palpation of medial ligament necessary for signs of possible disruption
  • Neurovascular status checked distally, especially with history of elbow dislocation

Differential Diagnosis

  • Other fractures of the elbow, including capitellar, olecranon, and coronoid
  • Supracondylar fractures (much more prevalent in children)
  • Radial head or other bone contusion
  • Elbow sprain
  • Elbow effusion

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Anteroposterior and lateral radiographs of the elbow are usually sufficient.
  • 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 degrees cephalad.
  • Computed tomography (CT) scan considered for estimating fracture size, degree of fragmentation, and displacement
  • If wrist or forearm pain present, x-rays of the forearm and/or wrist in neutral rotation view should be taken.
  • Magnetic resonance imaging (MRI) is helpful if there is concern for other soft tissue injury.

Diagnostic Procedures/Other

  • Patient may have limited ROM due to pain and effusion.
  • Joint aspiration for pain control is performed at the lateral elbow in the soft spot at the center of the dorsal olecranon, radial head, and lateral epicondyle (3)[A].
  • If arthrocentesis is avoided, serial exams may be helpful (3)[A].
  • Concerns for fracture orientation, severity, or healing should be referred to orthopedics (3)[A].

Treatment ⬆ ⬇

General Measures

  • Aspiration alone may provide some pain relief versus aspiration with local anesthetic instillation (3)[A].
  • Type I:
    • Treated nonoperatively (4)[A]
    • Sling for pain control for 48 hr and followed by active mobilization. Mobilization should be supported by physical therapy as needed (4)[A].
    • 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.
    • If required, hematoma aspiration is safe and effective for pain relief (3)[A].
    • Cast immobilization should be avoided (4)[A].
    • Ice therapy for 2 to 5 days
    • Acetaminophen and oral narcotics as necessary for pain control
  • Type II:
    • Orthopedic consultation should be obtained with any type II fracture. There is still considerable controversy on proper treatment and no specific criteria for surgical versus nonsurgical treatment. A randomized controlled trial (RCT) is awaiting publication Radial Head Amsterdam Amphia Boston Others (RAMBO trial).
    • Without associated injuries and moderate displacement (2 to 5 mm), can be treated nonoperatively such as type I. Recent retrospective study in athletes showed good outcomes with nonsurgical treatment (5)[A]. Another retrospective study showed no difference in open reduction and internal fixation (ORIF) versus nonoperative (6)[A].
    • Associated injuries, especially causing elbow instability or mechanical block, should be referred for orthopedic consultation and possible ORIF.
  • Type III:
    • ORIF versus resection and arthroplasty versus resection alone
    • Best treatment strategy for types III and IV is controversial. However, many studies are attempting to address this as new techniques become available.
  • Type IV:
    • Treated as above, with obvious attention paid to reduction of dislocation and surgical repair of both fractures and associated ligamentous injuries

Additional Therapies

  • Initiate ROM exercises early.
  • More aggressive strength and flexibility exercises added progressively as tolerated
  • If ROM does not improve on a weekly basis, a mechanical block should be excluded. Once excluded, formal therapy may be needed.
  • Only mild restriction of extension and rotation should be expected at 6 wk.

Ongoing Care ⬆ ⬇

  • Contractures and loss of motion may develop if early active ROM is not initiated.
  • Increased sensitivity to cold, which may persist for up to 1 yr
  • Long-term pain is rarely a complication.
  • Nonunion is possible but is frequently asymptomatic.
  • Nerve injuries in the form of partial ulnar nerve and posterior interosseous 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.

Additional Reading ⬆ ⬇

  • Akesson T, Herbertsson P, Josefsson PO, et al. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am. 2006;88(9):1909–1914.
  • Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26(7):779–782.
  • 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 Am. 2004;86-A(3):569–574.
  • Kaas L, van Riet RP, Vroemen JP, et al. The incidence of associated fractures of the upper limb in fractures of the radial head. Strategies Trauma Limb Reconstr. 2008;3(2):71–74.
  • 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: RockwoodCA, GreenDP, BucholzRW, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1011–1019.
  • Rosenblatt Y, Athwal GS, Faber KJ. Current recommendations for the treatment of radial head fractures. Orthop Clin North Am. 2008;39(2):173–185.

References ⬆ ⬇

  1. Kodde IF, Kaas L, Flipsen M, et al. Current concepts in the management of radial head fractures. World J Orthop. 2015;6(11):954–960.
  2. Jordan RW, Jones AD. Radial head fractures. Open Orthop J. 2017;11:1405–1416.
  3. 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;18(5):676–679.
  4. de Muinck Keizer RJ, Walenkamp MM, Goslings JC, et al. Mason type I fractures of the radial head. Orthopedics. 2015;38(12):e1147–e1154.
  5. Guzzini M, Vadalà A, Agrò A, et al. Nonsurgical treatment of Mason type II radial head fractures in athletes. A retrospective study. G Chir. 2017;37(5):200–205.
  6. Yoon A, King GJ, Grewal R. Is ORIF superior to nonoperative treatment in isolated displaced partial articular fractures of the radial head?Clin Orthop Relat Res. 2014;472(7):2105–2112.

Clinical Pearls ⬆

  • In type I fractures, typically, athletes can return to play as early as 6 to 8 wk, depending on pain, ROM, and strength.
  • Protection of the elbow may be needed if returning to contact sports. In types II to IV fractures, return to play is based on extent of associated injuries and surgical correction.