The most common injury seen in adults in the forearm is the radial head fracture. It is common as it occurs due to a fall on the outstretched hand and present clinically with pain and swelling around the elbow joint.
X-ray is the basic and most important investigation for treatment of fracture, but not always clear making it difficult to see the fracture line. Various views like antero-posterior, lateral and oblique views are taken.
The radio-capitellar sign is strongly suggestive of fracture of radial head fracture. If a line is drawn through the mid shaft of radius on the X-ray, it transects to middle of capitellum and a displacement of this line is called as the radio-capitellar sign.
Clinico-radiologically correlation such as point of tenderness and painful movements along with radiological features is necessary for a correct diagnosis .
Ligament injury is tested by applying varus and valgus stress at the elbow joint and exaggerated movements are looked for by comparing it to opposite side. Ligamentous injury is ruled out if there are no exaggerated movement.
Treatment depends on severity and extent of fracture which is based on Mason classification:
Type I (Undisplaced fracture)
Type II (Large minimally displaced fracture)
To achieve a good prognosis, following goals should be met :
Depending on the fracture pattern and severity, prognosis varies. With the right approach to radial head fracture, most patients make a full recovery without any impending complications. Normal life can be resumed in weeks to months after a follow-up with physiotherapy and specialist. The prognosis for compound and complex fractures with more soft tissue damage can be poor with prolonged rehabilitation period.
The most common mode of radial head fracture is indirect trauma. During a fall, the shoulders are abducted with minimal flexion at elbow and extension of wrist and this abducting force creates a valgus stress along with associated pronation of the elbow. This abnormal movement exerts a push of the radial head against the capitellum (humerus) . Clinically on examination patients present with a history of a fall on an outstretched hand. Direct trauma to the elbow can also result in radial head fractures but is infrequent.
Radial head fracture alone is the commonest presentation, but other corresponding injuries associated with radial head fractures are :
3% of all adult fractures are radial head fractures, thereby accounting to being the most common fracture of the elbow in adults . According to a retrospective study conducted at Netherlands the incidence of radial head fracture was 2.8 per 10,000 inhabitants per year with the mean age at 43 years and showing male:female ratio of 2:3 .
The elbow joint comprises of 3 bones articulating with each other to form 3 joints.
The radial head articulates with the lesser sigmoid notch at proximal part of the ulna and has articular and non-articular surfaces. The non-articular zone can be identified by a 110° arc from 65° antero-laterally to 45° postero-laterally with the forearm in neutral rotation .
The ligamentous anatomy of the elbow plays an important part in maintaining the anatomy of the joint.
The neurovascular structures of the elbow are prone to injury in fractures and dislocations of the elbow. Structures that can be damaged most likely are:
To prevent radial head fractures, care should be taken in performing daily tasks that could lead to fracture. Some of the suggested measures are:
One of the commonly found fractures due to fall on an outstretched hand are radial head fractures. Anatomically, the radial head is disc shaped, articulating with ulna at lesser sigmoid notch. The radial head rotates over the ulna maintaining the contact with it while supinating and pronating.
Injuries to the elbow result in an isolated radial head fracture or complex fracture pattern involving other components of the elbow joint along with corresponding additional fractures of distal humerus, ulna, radius or wrist.
Anatomically, the elbow joint comprises of 3 bones and 3 joints. The joints namely are ulnotrochlear, radiocapitellar and radioulnar joint. Distal humerus, radius and ulna are the bones that participate in elbow joint.
The elbow joint articulation is maintained by medial and lateral collateral ligament, radial collateral, lateral ulnohumeral, and accessory collateral. Radial head fractures have always been a topic of discussion . According to Mason, radial head fractures are classified into 3 types :
Type I fractures
Type I fractures are nondisplaced i.e. anatomy is not disturbed. Initially fractures may not be seen on X-rays since they are very small to be picked up on imaging, but breach of trabeculae with callus formation are seen when the x-ray is taken 3 weeks after the injury.
Type II fractures
Type II fractures are fractures that have disturbed the anatomy and displaced the bone which are usually larger as compared to type I fracture. If the displacement is less, it is treated conservatively with a sling or splint for 1 to 2 weeks gradually progressing to range-of-motion exercises.
Type III fractures
Type III fractures are comminuted fractures making it difficult to treat and heal. They cannot be treated conservatively. Most type III injuries have ligamentous injury and associated other fractures causing immense damage to elbow joint.
Radial head fractures are most common fractures of the forearm that usually occur due to a fall on outstretched hand.
There are two bones in forearm, the radius and the ulna. The radius has three parts
This fracture may be caused by:
Visit a doctor for proper and complete clinical examination. An X-ray is needed to confirm diagnosis, further investigations include CT scan, MRI or bone scan which may be required in some case. These are done to assess the severity and confirm the diagnosis.
Treatment varies on severity of fracture. If there is minimal displacement with no obvious damage to underlying structure or bone, splinting is done. But in cases of unstable and displaced fractures, surgical correction is needed.