Radial Head Fracture

Aka: Radial Head Fracture, Radial Neck Fracture

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II. Epidemiology

  1. Radial Head Fractures account for >5% of all Fractures and one third of elbow Fractures

III. Etiology

  1. Fall on Outstretched Hand with elbow extended and Forearm pronated
  2. Direct blow to lateral elbow

IV. Exam

  1. See Elbow Exam
  2. See Forearm Fracture
  3. Evaluate elbow stability with valgus and varus stress testing (see Elbow Exam)
    1. Assess for Medial or lateral collateral ligament injury

V. Symptoms

  1. Painful and limited Forearm movement (esp with extension and supination)

VI. Signs

  1. Tenderness over radial head (distal to the lateral epicondyle)
  2. Local swelling
  3. Pain on Forearm rotation or elbow flexion
  4. Elbow joint effusion is typically present

VII. Imaging

  1. Elbow XRay
    1. See Elbow XRay
    2. Sail Sign (Anterior Fat Pad Sign)
    3. Posterior Fat Pad
    4. XRays are often normal initially (have a high index of suspicion)
  2. Special Views
    1. Radial Head-Capitellum View
      1. Isolates radial head without overlapping shadows
  3. Diagram
    1. elbowRadialHeadFracture.png

VIII. Complications

  1. Lateral Elbow Instability
    1. Medial or lateral collateral ligament injury in >50% of Fractures (esp. if displaced)

IX. Evaluation: Mason Classification

  1. Mason Fracture Type I
    1. Nondisplaced Fracture without mechanical obstruction
  2. Mason Fracture Type II
    1. Fracture wirth displacement >2 mm or angulation >30 degrees
  3. Mason Fracture Type III
    1. Comminuted Fracture of entire radial head
  4. Mason Fracture Type IV
    1. Fracture with Elbow Dislocation

X. Indications: Orthopedic Referral

  1. Mason Type 2-4
  2. Abnormal varus or valgus testing
    1. Suggests medial or lateral collateral ligament injury

XI. Management: Adult

  1. Displaced or comminuted Radius Fracture (Mason Type II or more)
    1. Surgical excision of radial head or ORIF (preferred within 24-48 hours)
  2. Non-displaced or minimally displaced Radius Fracture (Mason Type I)
    1. Conservative Management
      1. Initial Option 1: Immobilize for 3-7 days with elbow at 90 degrees
        1. Light posterior splint or
        2. Sling with comfort
      2. Initial Option 2: Immediate mobilization
        1. Associated with decreased pain and better initial function
        2. Similar healing rates to option 1
      3. Continue Sling for 1-2 weeks after splint removed
    2. Exercises
      1. Early elbow range of motion Exercises and later strengthening Exercises
      2. Home programs for elbow rehabilitation appear to be as effective as physical therapy
        1. Egol (2018) J Bone Joint Surg Am 100(8): 648-55 +PMID:29664851 [PubMed]
    3. Relief of severe pain from swelling
      1. May aspirate Elbow joint at posterolateral triangle, but lack of evidence for benefit
      2. Foocharoen (2014) Cochrane Database Syst Rev (11): CD009949 [PubMed]
    4. Follow-up at 3-4 weeks
      1. Repeat Elbow XRay
      2. Expect return to full use at 3-4 weeks
      3. Indications for extended restrictions for additional 2-3 weeks
        1. Medial or lateral collateral ligamentous instability
        2. Less than full range of motion
        3. Decreased strength
        4. XRay with incomplete healing

XII. Management: Child

  1. Non-displaced Fracture and <15-30 degrees angulation
    1. Management as for non-displaced Fracture in adults
  2. Displaced Fracture >50% or >15-30 degrees angulation (60 degrees may be acceptable in some cases)
    1. Reduction
      1. Closed
      2. Open reduction and internal fixation (ORIF)
    2. Radial head is never excised in growing child
      1. Epiphysis removal results in unequal Forearm growth

XIII. Prognosis

  1. Non-displaced Fracture or effective early reduction
    1. Expect some loss of elbow extension
    2. Minimal or no functional Impairment expected
  2. Delayed effective management of displaced Fracture
    1. Permanently restricted elbow Range of Motion
    2. Traumatic Arthritis
      1. Fracture fragments act as nidus for calcification
      2. Myositis Ossificans ensues in anterior elbow region

XIV. References

  1. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
  2. Liow (2002) Injury 33(9): 801-6 [PubMed]
  3. Patel (2021) Am Fam Physician 103(6): 345-54 [PubMed]

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