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Radial Head Fracture

Fractured Head Radial

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.


Presentation

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]
Neglect
  • These injuries can be easily missed by the attending physician, more so if the symptoms are more severe on one side, thus neglecting the other. Neglect or inability to diagnose and treat such a pathology early can lead to severe debility later.[webmedcentral.com]
Stroke
  • Feet Carpal Tunnel Syndrome Diet and Nutrition Emergency Supplies Fall Prevention Fibromyalgia Fitness and Health Hearing Loss Home Health Care and Safety Industrial and Public Health Safety Occupational Health Safety Sight Impaired Sleeping - COPD Stroke[activeforever.com]

Workup

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.

In case of swelling and to distinguish mechanical blockage during passive joint movement from pain and muscle spasm, arthrocenthesis may be done. 

Clinico-radiologically correlation such as point of tenderness and painful movements along with radiological features is necessary for a correct diagnosis [9].

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

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 [7].

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 [10].
  • In few cases, radial head replacement option should also be considered.

Type III

  • Surgical dilemma whether to excise [9], or consider radial head replacement [11].
  • 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.

Type IV

  • Radial head fracture with ulno-humeral dislocation. 
  • Consider reconstruction, replacement of radial head or excision if not reconstructable.

Prognosis

To achieve a good prognosis, following goals should be met [8]:

  1. 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.
  2. 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.

Etiology

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) [3]. 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 [4]:

  • Fracture of the coronoid process of the ulna
  • Medial collateral ligament tear
  • Interosseous membrane injury
  • Rupture of intraosseous membrane with distal wrist fractures with triangular fibrocartilage complex injury at the wrist (Essex-Lopresti fracture-dislocation)

Epidemiology

3% of all adult fractures are radial head fractures, thereby accounting to being the most common fracture of the elbow in adults [5]. 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 [6].

Sex distribution
Age distribution

Pathophysiology

The elbow joint comprises of 3 bones articulating with each other to form 3 joints.

Bones

  1. Distal humerus
  2. Proximal ulna
  3. Proximal radius

Joints

  1. 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.
  2. 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.
  3. 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 [7].

The ligamentous anatomy of the elbow plays an important part in maintaining the anatomy of the joint.

Ligaments

  1. Medial collateral ligament: It is divided into three parts, well-defined anterior, posterior, and transverse bundles
  2. Lateral collateral ligament: It is poorly defined. The medial and lateral collateral ligaments are the main constraints of the ulnotrochlear joint
  3. Other ligaments: (Radial collateral, lateral ulnohumeral, and accessory collateral ligaments): These provide additional stability to the joint.
  4. Radioulnar joint: It is constrained by the annular ligament.

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:

  1. 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.
  2. 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.
  3. Median nerve injury: It can be injured due to the anatomical location i.e lying anterior to the elbow joint.
  4. Brachial artery injury: A tear or rupture pose a threat as it lies anteriorly to the elbow joint.

Prevention

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.

Summary

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 [1]. According to Mason, radial head fractures are classified into 3 types [2]:

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.

Patient Information

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)

Causes

This fracture may be caused by:

  1. 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.
  2. Indirect cause: When you fall on an outstretched hand during activities like skateboarding or snowboarding.

Symptoms

  • 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.

Diagnosis

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

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.

References

Article

  1. Guitton TG Ring D. Science of Variation Group. Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. J Bone Joint Surg Am. 2011 Nov 2; 93(21):2015-21.
  2. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954 Sep; 42(172):123-32.
  3. John SD, Wherry K, Swischuk LE, et-al. Improving detection of pediatric elbow fractures by understanding their mechanics. Radiographics. 1996; 16(6):1443-60.
  4. Mirzayan R, Itamura JM. Shoulder and Elbow Trauma. Thieme Medical Pub. 2004; ISBN:1588902196.
  5. Duckworth AD,Clement ND, Jenkins PJ, et al. The epidemiology of radial head and neck fractures. J Hand Surg Am. 2012 Jan; 37(1):112-9.
  6. Kaas L van, Riet RP, Vroemen JP, et al. The epidemiology of radial head fractures. J Shoulder Elbow Surg. 2010 Jun; 19(4):520-3.
  7. Smith GR, Hotchkiss RN . Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg. 1996 Mar-Apr; 5(2 Pt 1):113-7.
  8. O'Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003; 52:113-34.
  9. Hume MC, Wiss DA. Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res. 1992; 229-35.
  10. Liow RY, Cregan A, Nanda R, et al. Early mobilisation for minimally displaced radial head fractures is desirable. A prospective randomised study of two protocols. Injury. 2002 Nov; 33(9):801-6.
  11. 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 Sep; 88(9):1909-14.

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Last updated: 2018-06-22 03:51