Radial Head Fractures

What is the Radial Head?
The radial head is a round disc of bone with cartilage cap which articulates with the humerus as part of the elbow joint.

A fracture of the radial head

How is the radial head injured?
The radial head is usually injured as a result of a fall onto the outstretched hand. When a force is applied to the hand, the force is transmitted up the arm and dissipates. When this force is considerable, it will produce a particular pattern of fractures in the upper limb depending on age and bone quality. This is the most common history reported for a radial head fracture.

What are the symptoms of a radial head fracture?
Pain – Pain in the elbow is often difficult to localise immediately after an injury, but with time the pain localises to the outside of the elbow.

Restriction of movement – There is usually considerable discomfort on attempting to straighten or bend the elbow. In addition, rotating the forearm may be painful, or may be impossible because of the fracture.

Usual area of pain in a radial head fracture

What treatment is required?
The treatment of a radial head fracture depends on the type of injury seen:

STABLE INJURIES – In a stable fracture of the radial head, the fracture fragments move as one piece and the soft tissues around the elbow remain intact, even if bruised or sprained. The vast majority of radial head injuries are stable.

Collar and cuff – A sling is recommended initially in order to help alleviate pain.
Analgesia – Painkillers are usually necessary for the first week or two.

Mobilisation – Early mobilisation of the elbow helps prevent stiffness in the elbow. In addition, mobilisation of the shoulder, wrist and hand are key to regaining early function in the arm (see below).

It is very safe to use the arm as normally as possible in a stable radial head fracture. Although the elbow may hurt when it is used, this will not cause harm.

DISPLACED STABLE INJURIES – In some radial head fractures, the bony fragments are displaced, even although the soft tissues around the elbow are intact. Although the fracture fragments may move separately from the main bone, there is no risk of the elbow becoming partly or completely dislocated by the injury. There is, however, a risk of the displaced bone fragments interfering with normal elbow joint movement, particularly forearm rotation. Occasionally, review of the xrays will identify a bone fragment likely to significantly impair movement, and in this case early surgery will usually be recommended to remove the interfering bone fragment. Otherwise, these injuries are usually treated in the same way as a stable injury, with the potential for surgery to be recommended if movement remains restricted.

Collar and cuff – A sling is recommended initially in order to help alleviate pain.
Analgesia – Painkillers are usually necessary for the first week or two.

Mobilisation – Early mobilisation of the elbow helps prevent stiffness in the elbow. In addition, mobilisation of the shoulder, wrist and hand are key to regaining early function in the arm (see below).

Evaluation of Movement – This is recommended at around 2-4 weeks following the injury. If there is ongoing impairment of rotation then surgery may be recommended to remove the bone fragments of to remove the radial head itself.

UNSTABLE INJURIES – Many fractures of the radial head are associated with injuries to other bony parts of the elbow or to the ligaments around the elbow. The elbow may partly or fully dislocate, making early movement of the elbow unsafe. This type of injury is usually one where the surgeon will recommend an operation to convert the injury into a STABLE injury and allow early movement.

How should I mobilise my elbow?
The best way to mobilise the elbow is to use the arm normally for light everyday activity. Unlike the other joints in the arm such as the shoulder or wrist, it is virtually impossible to do anything without moving the elbow, because of its key function in positioning the hand. Using a fork, drinking from a glass, tying laces, washing, using a telephone are all things that need the hand to be positioned by the elbow in order to accomplish.

Take the arm out o the sling every half hour and gently bend and straighten the elbow within the limits of what is reasonably comfortable. Remember to keep the shoulder, wrist and hand moving as much as possible to prevent generalised stiffness in the arm. As the pain settles over the first week, it is safe to use the arm for all everyday activity, and this will build up quickly over the first few weeks.

Week 1
Pain in the elbow can be intrusive but bearable. Concentrate on mobilising the shoulder, wrist and hand, with gentle movement of the elbow every half an hour.

Weeks 2-4
The pain should rapidly subside during these weeks such that the elbow is painfree at rest by week 4. Build up use of the arm by using it for everyday activity, slowing down and adapting the way you do things to accommodate the elbow.

Week 6
The elbow should now be fairly comfortable other than when using it for anything heavy. Office workers should be able to return to full duties. The elbow will probably not straighten out just yet.

3 Months
Normal function should have returned, although residual loss of movement may still be a problem. Manual workers should have now returned to full duties.

6 Months
By now you should have forgotten about your fracture! If there is ongoing loss of movement preventing you from doing things, then it is worth discussing surgery.

What are the complications of a radial head fracture?
Restriction of movement – It usually takes between 6 and 12 months for movement to return following a radial head fracture, and this makes it very frustrating for people, as they can have trouble seeing light at the end of the tunnel in the first few months following injury. When the radial head breaks, the bone bleeds into the joint, and this causes the thin capsule at the front of the joint to react by thickening up and scarring. With time, the scar tissue remodels and becomes more pliable, just like a scar from a skin wound which can be thick and red to begin with, becoming fine and white with time.

It is normal for a radial head fracture to result in a loss of full extension of the elbow leaving a long term slight bend at the elbow. Occasionally, this loss of movement interferes with function, and under these circumstances, surgery may be recommended with the aim of improving range of movement (arthrolysis surgery).

Radio-capitellar Osteoarthritis – This sounds complex but just means arthritis between the radial head and the capitellum on the outside of the elbow (see illustration at top of page!) This condition is characterised by the findings on an xray of reduced joint space from loss of cartilage in the joint. It is usually asymptomatic, but can give rise to pain from the joint around the outside of the elbow.

The decision making processes are summarised in this graphic:

© Fife Hand Service 2021

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