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.
- Patient presents with a history of fall on an outstretched hand, rarely blunt trauma or penetrating injury.
- Pain over the wrist, swelling or resistance to move the joint.
- Numbness, tingling or burning sensation with pins and needles is a sign for nerve injury or vascular damage.
- Severe pain should arise suspicion of compartment syndrome.
- Active bleeding suggests open fracture.
Entire Body System
Eighty percent of the patients had clinically asymptomatic distal subluxation of the radioulnar joint. In most cases of isolated radial head fracture, complete resection yields satisfactory long-term results. [ncbi.nlm.nih.gov]
IF mechanical block to motion, or joint instability or displacement 3mm ORIF ; if stable, 82% of patients are asymptomatic at 19yrs with non-op treatment (Akesson T, JBJS 2006;88A:1909). [eorif.com]
Three months after surgery ( Fig. 5 and Fig. 6 ), the patient was completely asymptomatic, with ROM in flexion-extension of 0-140 degrees and 90-80 degrees of pronosupination. Radiographs showed complete fracture healing ( Fig. 7 and Fig. 8 ). [scielo.br]
However, they did note a 5-degree increased valgus carrying angle and early asymptomatic degenerative changes of the ulnohumeral joint with a mean of about 4.5 years surveillance ( Fig. 24-16 ). [clinicalgate.com]
- Forearm Pain
Signs and symptoms of a radial head fracture Patients with this condition typically experience a sudden onset of sharp, intense elbow or forearm pain at the time of injury. [physioadvisor.com.au]
If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint. Investigations AP and lateral X-ray views of the elbow are usually sufficient. [patient.info]
Collapse of the radial head may lead to loss of radial length and accompanying valgus instability. The anterolateral aspect of the radial head contains an arc of bone that does not articulate with either the humerus or the ulna. [ncbi.nlm.nih.gov]
- Flexion Contracture
Patients with Essex-Loprestic injuries are held in full supination for 3-4 weeks. 6 Weeks: Consider static progressive nightime extension splinting if a flexion contracture is present 6 weeks after injury. 10 to 15 flexion contractures are not uncommon [eorif.com]
Over 90% of people report good to excellent results, and the elbow regains full function (although it may never completely straighten out, with about 10-15 degrees of a persistent flexion contracture). [bonetalks.com]
Regular progressive exercise can be started after callus formation is on X-ray and in cases of flexion contractures, consider static progressive nigh time extension splinting 6 weeks after injury. [symptoma.com]
The mean flexion contracture was 15 degrees (range, 0 degrees to 42 degrees ), with an average loss of 10 degrees (range, 0 degrees to 25 degrees ) of full flexion compared with that of the contralateral elbow. [opnews.com]
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.
- Antero-Posterior view: It is difficult to appreciate the fracture line on this view but abnormal fat pad sign that is caused by effusion following trauma is evident. It is not a highly sensitive sign.
- Lateral view: Abnormal fat pad tends to be more appreciated posteriorly on lateral view.
- Oblique view: This view is gives better visibility of the displaced radial head or radial head fractures.
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)
- Conservative treatment: Sling or splinting is preferred during conservative approach. The posterior splint or sling is given for 1 week followed by early active range of motion.
- If the joint is difficult to examine due to pain and swelling, consider aspiration of the swelling which could be a hematoma and inject local anesthetic agent to reduce pain.
- Regular progressive exercise can be started after callus formation is on X-ray and in cases of flexion contractures, consider static progressive nigh time extension splinting 6 weeks after injury .
Type II (Large minimally displaced fracture)
- Examination under anesthesia helps to determine the mode of treatment and rules out ligamentous laxity (joint stability). If the fracture fragment is displaced >3mm open reduction with internal fixation should be planned. If the displacement is <3mm, then conservative treatment is followed as mentioned above.
- About 82% of patients that underwent conservative management are asymptomatic at 19yrs .
- In few cases, radial head replacement option should also be considered.
- Surgical dilemma whether to excise , or consider radial head replacement .
- In cases where medial collateral ligament or interosseous membrane are damaged, replacement of radial head or reconstruction is indicated. Excision is contraindicated.
- Instability of distal ulna if present should be pinned to radius in supination.
- Type II and III can be determined mostly only intraoperatively.
- Radial head fracture with ulno-humeral dislocation.
- Consider reconstruction, replacement of radial head or excision if not reconstructable.
To achieve a good prognosis, following goals should be met :
- Attain stability: The main goal is to avoid any more damage and allow the bone to heal which is achieved either by manual reduction or internal fixation.
- Healing: To attain sufficient healing of the bone by reducing the anatomic damage done to the bone and try to maintain the biology of the bone as close to normal as possible also looking out for any damage to soft-tissues.
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.
- Distal humerus
- Proximal ulna
- Proximal radius
- Ulnotrochlear joint: Ulnotrochlear joint comprises of olecranon process (ulna) and medial condyle (distal humerus). Flexion and extension are the only movements that take place here since the joint is restricted.
- Radiocapitellar joint: It comprises of radial head and lateral condyle (distal humerus). This joint is less restricted as compared to ulnotrochlear joint and hence movements like flexion, extension and rotation occur.
- Radioulnar joint: It comprises of radial head and sigmoid notch (ulna) permitting free movement including rotation i.e. supination and pronation.
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.
- Medial collateral ligament: It is divided into three parts, well-defined anterior, posterior, and transverse bundles
- Lateral collateral ligament: It is poorly defined. The medial and lateral collateral ligaments are the main constraints of the ulnotrochlear joint
- Other ligaments: (Radial collateral, lateral ulnohumeral, and accessory collateral ligaments): These provide additional stability to the joint.
- Radioulnar joint: It is constrained by the annular ligament.
- Ulnar nerve: Special caution should be paid to injury to ulnar nerve as it passes posterior the medial epicondyle and maintains a very close proximity to it.
- Posterior interosseous nerve: It wraps around the radial neck, and is most likely to be damaged with radial head fractures or dislocations or during intervention to correct these injuries.
- Median nerve injury: It can be injured due to the anatomical location i.e lying anterior to the elbow joint.
- Brachial artery injury: A tear or rupture pose a threat as it lies anteriorly to the elbow joint.
To prevent radial head fractures, care should be taken in performing daily tasks that could lead to fracture. Some of the suggested measures are:
- Appropriate safety gear.
- Use of wrist and knee guards while cycling, mountain biking.
- Calcium rich foods (milk, yoghurt, cheese) and exposure to sunlight for vitamin D.
- Post-menopausal women and men above 50 years should take their daily recommended dose of calcium supplements.
- Regular diet plays an important role in maintaining calcium homeostasis and bone strength.
- Weight bearing exercises helps maintain bone regulation and thus bone strength is maintained.
- Regular evaluation helps prevent osteoporosis.
- Treatment of osteoporosis.
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.
- Ulnotrochlear joint comprises of olecranon process (ulna) and medial condyle (distal humerus). Flexion and extension movements take place here.
- The radiocapitellar joint comprises of radial head and lateral condyle (distal humerus). Movements at this joint are flexion, extension and rotation.
- Radioulnar joint comprises of radial head and sigmoid notch (ulna). It allows rotation i.e supination and pronation.
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
- Radial head and neck (near the elbow)
- Shaft (middle part)
- Distal end up to styloid (wrist part)
This fracture may be caused by:
- Direct cause: When you get directly injured at that part during fall or injury during fights or due to collision with an fast moving objects etc.
- Indirect cause: When you fall on an outstretched hand during activities like skateboarding or snowboarding.
- Sharp excruciating pain over the elbow.
- Swelling, bruising around the elbow.
- Not able to bend and extend the elbow joint.
- Not able to push.
- Not able to turn keys (rotating movements).
- Not able to pick up weights (carry bag or hand bag) with the affected side.
- Pin and needles type of tingling sensation.
- Obvious deformity at the elbow joint.
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.
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