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Proximal Radial Head Fracture

Original Editors - Alexander Bartis, Brittney Bryan, Victoria Kunselman as part of the Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project Top Contributors - Matteo Ghezzi, Brittney Bryan, Victoria Kunselman, Alexander Bartis, Kim Jackson and Aminat Abolade

Description

The radius, located in lateral forearm, is the smaller of the two bones that form the forearm. The radius articulates with the ulna, the second bone in the forearm. These two bones and their articulations form the radioulnar and radiocarpal joints at the elbow and the wrist, respectively.

Radius fractures include the proximal portion of the radius, the neck, and head. This type of fracture is common in adults. Proximal radial fractures occur when falling on an outstretched hand (FOOSH), which pushes the radius into the humerus, or direct trauma to the elbow. Fractures at the proximal radius place the radial head at higher risk for avascular necrosis (AVN).[1]

Clinically Relevant Anatomy

The elbow is a synovial hinge joint made up of three articulations– the humeroulnar, humeroradial, and radioulnar. The arm’s humerus meets the forearm’s ulna and radius to create the hinge, while the radius and ulna articulate to create a pivot joint to allow forearm pronation and supination.

Notable landmarks of the proximal radius include the radial head, neck, and tuberosity. The head is round with a flat though slightly concave surface. The flat surface articulates with the humerus. The circumference of the head is contained within the annular ligament and against the radial notch of the ulna where it rotates and glides during pronation and supination. The radial tuberosity serves as an attachment site for the biceps brachii and supinator brevis muscles.[2]

Epidemiology and Aetiology

Epidemiology

Proximal radial head fractures are most common in ages 20-64.[3][4] However, radial head fractures are seen more in younger men than women. This discrepancy is associated with men experiencing more falls associated with sports or heights whereas women tend to experience fractures later in life due to falls and fragility of the bone.[4][5]

Aetiology

The most common mechanism of injury to the radial head is falling on an outstretched hand or falling with the elbow in extension and the forearm pronated, which directs the trauma force through the wrist and forearm to the head of the radius. Some common associated injuries with this type of fracture can be ligamentous such as a lateral collateral ligament (LCL) or medial collateral ligament (MCL) injuries. Dislocation of the elbow can also produce what is known as the “terrible triad” which consists of a dislocation of the elbow, a radial head fracture, and a coronoid fracture.[3]

Mason classification

Proximal radial head fractures, commonly described using Mason classification, have four grades[6]. The orthopaedic surgeon determines the diagnosis of different Mason fractures, and they decide the interventions needed. The surgeon’s decision is guided by the diagnostic imaging: X-Ray, MRI, or CT scans.[7]

Mason Type 1

Mason I

Mason Type 1 fractures involve fissure or marginal fractures of the radial head that are non-displaced or minimally displaced (<2mm). [8] These fractures can be difficult to detect on X-ray, so CT or MRI may be needed for accurate diagnosis. Functionally, they do not restrict supination or pronation of the forearm.[9] Type 1 fractures are treated conservatively with polysling immobilisation and immediate mobilisation. The risk of non-union is about 5%, but non-union rarely leads to radial head subluxation, and removing associated fragments does not improve the likelihood of subluxation. [9]

Mason Type 2

Mason II

Mason Type 2 fractures are identified by a partial fracture of the radial head with more than 2 mm of displacement and involvement of more than one-third of the radial head.[10] Type 2 fractures are typically managed non-surgically unless there is a mechanical obstruction or the displacement exceeds 3 mm[11].

Mason Type 3

Mason III

Mason Type 3 fractures are comminuted, displaced fractures involving the entire the radial head. [10] Type 3 fractures almost always require surgical treatment, typically through open reduction and internal fixation (ORIF) or radial head excision or replacement, particularly in cases of severe comminution[12].

Mason Type 4

Mason IV

Mason Type IV fractures involve a radial head fracture, typically classified as Type II or III, accompanied by an elbow dislocation[12]. Treatment often requires addressing both the fracture and the dislocation, with surgical intervention depending on the severity.


Examination

The mechanism of injury is often falling on an outstretched hand or direct trauma to the elbow. Radial head fractures are common alongside elbow dislocation. Swelling and bruising of the posterior elbow may be visible. Swelling and heat are palpable. Type III fractures may cause visible deformity. The patient has limited active elbow extension/flexion and forearm pronation/supination. Some may experience limited wrist movement as well. Passive range of motion (PROM) is limited due to pain. Empty end feels of muscle guarding can be expected. Palpation of the radial head is painful. Some patients experience numbness in the forearm, hands, and fingers.[13]

Differential Diagnosis

The high probability of other injuries occurring with a fall on an outstretched hand (FOOSH) suggests radiographs, MRI, and sometimes CT scan are required to verify the diagnosis and to certify the integrity of all surrounding structures and tissues.[5]

Possible injuries that should be considered and ruled out with a radial head fracture are capitellum fractures, distal radius fractures, distal radio-ulnar joint dislocations, medial collateral ligament (MCL) ruptures, biceps tendon ruptures, triceps tendon ruptures, and elbow dislocations.[5][14]

Diagnostic Procedures

The primary diagnostic tool used for identifying radial head fractures is radiograph. Mason Type 1 fractures do not always show on radiographs[15]. In such cases, a ‘sail sign’ might indicate a fracture. A ‘sail sign’ is a silhouette on a radiograph caused by an enlarged fat pad at the elbow. Current studies are looking at the use of sonography in detecting occult fractures more quickly[15]. Current diagnostic procedures can take upward of three weeks before identifying fracture.[16]

Sail Sign
Sail Sign Outline

Surgical Management

  •   An open reduction internal fixation (ORIF) of the radial head has been shown to be beneficial for Mason Type 2 and 3 fractures.[14]
  •    Radial head resection is an option for sedentary patients or when there is continued pain due to an isolated radial head fracture.[14]
  •    Radial head arthroplasty for comminuted Mason Type 3 fractures that involve greater than 25% of the radial head is another valid option.[3]

Rehabilitation

Non-surgical rehabilitation

The patient is provided with a polysling for a few days, to use mainly for comfort. Early active and active-assisted range of motion (AROM, AAROM) exercises, including elbow extension/flexion and forearm pronation/supination, are vital for mitigating the impact of immobilisation on the capsule, ligaments, muscles, and osteochondral tissues[17]. Initiating mobilisation early also helps prevent swelling and thickening of inflammatory fluids, which can lead to joint adhesion formation.[17]

For AROM/AAROM, the overhead position, as described by Wolff and Hotchkiss, is ideal for early mobilisation because it optimises elbow stability by reducing ulnohumeral distraction[18]. Additionally, this position minimises biceps activity and increases triceps activity, which helps improve elbow extension range and reduces pain in stiff elbows.[18]

AROM/AAROM exercises should be performed for the first six weeks to increase range of motion and support fracture healing. Early triceps isometric exercises can be introduced from week two, using a percentage of maximum voluntary isometric contraction (MVIC) to ensure the exercises are pain-free.

Isotonic strengthening exercises can be started 6 to 8 weeks after the injury, with examples including overhead triceps extensions (both supine and standing) and biceps curls. Additionally, following elbow fractures, cortical changes occur in the sensory and motor cortices[17]. Therefore, integrating weight-bearing exercises into the kinetic chain is advised to improve proprioception and enhance elbow stability.[17]

Complications of proximal radius fractures can include loss of active elbow extension, minor reductions in forearm pronation and supination, and occasional fatigue or pain from overuse. [9] Furthermore, If excessive stress is applied too early, it may lead to further shifting or displacement of the fracture.[19]

The following videos from the British Elbow Shoulder Society provide examples of AROM and strengthening exercises performed in the overhead position.

[20]
[21]
[22]
[23]


Surgical rehabilitation

Surgical rehabilitation protocols can differ from one country to another and even among hospitals within the same country. Thus, the following information may not be applicable to every patient, and it is important to follow the specific local protocol.

After surgery, the arm is usually immobilised for up to 1 week a for simple fractures and up to 3-6 weeks with a long-arm splint for complex fractures[24]. Then, post-surgery physical therapy consists of three phases:

  • Phase 1 (0-14 days): The patient starts AROM exercises for elbow flexion and extension in the overhead position. Additionally, isometric gripping and strengthening exercises for the elbow are initiated, with the percentage of maximum voluntary isometric contraction (MVIC) adjusted to match the patient's pain level[24].
  • Phase 2 (15 days to 6 weeks): Continue AROM exercises for elbow flexion and extension, and consider adding AAROM exercises to provide additional end-of-range stretching. AROM exercises for supination and pronation can begin, although some protocols may include these movements in Phase 1. Full elbow flexion and extension should be achieved by the end of week 6[24].
  • Phase 3 (week 7 to 12): The patient continues AROM/AAROM exercises for supination and pronation, targeting full range of motion by week eight. Isotonic and weight-bearing strengthening exercises are introduced during this phase. [24]

Patient Education

For the first six weeks, the patient should avoid:

  • Overusing the elbow or arm, which can impede the healing process
  • Heavy lifting, pushing and pulling
  • Placing the arm in extreme positions
  • Weight-bearing through the arm
  • Activities that causes excessive discomfort

Driving is only permitted once authorised by the surgeon, usually 4-6 weeks after surgery. Returning to work will depend on the nature of the patient’s job duties and must be approved by the surgeon. [7]

In case of surgery, the splint should remain in place until the patient’s first postoperative visit, which typically occurs 1-2 weeks after the procedure. Showering is allowed starting on the second day, but it is important to keep the splint clean and dry. The elbow should not be submerged in water for at least four weeks following the surgery.[7]

Some swelling around the arm is expected post-surgery. However, the patient should contact the surgeon immediately if there are any signs of infection, such as skin changes, discharge, or a fever above 101°F. [7]

During the first postoperative visit, the surgeon will remove stitches or staples, examine the wound, and take X-rays to ensure proper healing. The surgeon will then provide instructions on the next steps and the recovery plan for the following weeks.[7]

Pain Management

Patients who experience heightened pain during the early phases of rehabilitation or sustain nerve injuries tend to be at greater risk of developing joint contractures [25]. To manage the pain and swelling linked to radial head fractures, it can be helpful to apply ice packs, take NSAIDs like ibuprofen or paracetamol, and use a sling for added comfort. Effective pain management is pivotal, as it allows the patients to begin early mobilisation, which is essential for preventing stiffness and ensuring a full range of motion during recovery[26]

Outcome Measures

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire assesses upper extremity function through daily activities like opening jars and dressing. Patients rate the difficulty of each activity from 1 (No Difficulty) to 5 (Unable). Some questions use different scales, such as ‘None’ to ‘Extreme.’ The score is calculated with the formula ([sum of responses/n] - 1) × 25, where n is the number of completed items. Higher scores indicate greater disability. T score and level of disability have a positive correlation. [27]

The QuickDASH is a modified version of the DASH outcome measure that is shorter but with evidence of being as precise as the DASH.[28] The QuickDASH contains only 11 questions and utilises the same rating scale and scoring formula.

These two outcome measures can be utilised with Mason type I, II and III fractures.[27]

Key Research

Swensen et. al discuss outcomes in current treatment of radial head fractures.[29] ORIF of simple fractures is supported by the literature, but optimal treatment of more complex fractures is controversial.

Hacki et. al discuss complications of radial head fracture treatment and detail revisions required.[30]

References

  1. ↑ Proximal radius (radial neck) fractures [Internet]. POSNA. 2022 [cited 2022Apr13]. Available from: https://posna.org/Physician-Education/Study-Guide/Proximal-Radius-(Radial-Neck)-Fractures
  2. ↑ Gray H. Barnes & Noble. 15th ed. New York, New York: Barnes & Noble; 2010.
  3. ↑ 3.0 3.1 3.2 Wang JH, Rajan PV, Castaneda J, Gokkus K. Radial head fractures [Internet]. Orthobullets. 2022 [cited 2022Apr13]. Available from: https://www.orthobullets.com/trauma/1019/radial-head-fractures
  4. ↑ 4.0 4.1 Al-Tawil K, Arya A. Radial head fractures. Journal of Clinical Orthopaedics and Trauma. 2021 Sep;20:101497.
  5. ↑ 5.0 5.1 5.2 Radial head fractures [Internet]. Radial Head fractures - Musculoskeletal Medicine for Medical Students - OrthopaedicsOne. [cited 2022Apr13]. Available from: https://www.orthopaedicsone.com/display/MSKMed/Radial+Head+fractures
  6. ↑ Iannuzzi NP, Leopold SS. In Brief: The Mason Classification of Radial Head Fractures. Clinical Orthopaedics &amp; Related Research. 2012 Jun;470(6):1799–802.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Patient education radial head fracture - the Core Institute [Internet]. The Core Institute. 2019 [cited 2022Apr14]. Available from: https://thecoreinstitute.com/wp-content/themes/the-core/documents/patient-education/Radial-Head-Fracture-Patient_Education_PE_ELB_%207-09-2019.pdf
  8. ↑ Krupko T. Core Curriculum V5 Radial Head and Neck Fractures. Orthopaedic Trauma Association;
  9. ↑ 9.0 9.1 9.2 Type I radial head fracture [Internet]. Wheeless' Textbook of Orthopaedics. 2020 [cited 2022Apr13]. Available from: https://www.wheelessonline.com/joints/type-i-radial-head-fracture/
  10. ↑ 10.0 10.1 Weerakkody Y. Mason classification of radial head fractures: Radiology reference article [Internet]. Radiopaedia Blog RSS. Radiopaedia.org; 2022 [cited 2022Apr13]. Available from: https://radiopaedia.org/articles/mason-classification-of-radial-head-fractures-1?lang=us
  11. ↑ Patiño JM, Saenz VP. Radial Head Fractures.
  12. ↑ 12.0 12.1 Swensen SJ, Tyagi V, Uquillas C, Shakked RJ, Yoon RS, Liporace FA. Maximizing outcomes in the treatment of radial head fractures. Journal of Orthopaedics and Traumatology. 2019 Dec;20:1-9.
  13. ↑ Radial head fracture: Causes, symptoms, diagnosis, treatment [Internet]. OrthoTexas. 2022 [cited 2022Apr13]. Available from: https://www.orthotexas.com/radial-head-fracture-causes-symptoms-diagnosis-treatment/
  14. ↑ 14.0 14.1 14.2 Kodde IF. Current concepts in the management of radial head fractures. World Journal of Orthopedics. 2015;6(11):954.     
  15. ↑ 15.0 15.1 Pavić R, Margetić P, Hnatešen D. Diagnosis of occult radial head and neck fracture in adults. Injury. 2015 Nov;46:S119–24.
  16. ↑ Malahias M-A, Manolopoulos P-P, Kadu V, Shahpari O, Fagkrezos D, Kaseta M-K. Bedside ultrasonography for early diagnosis of occult radial head fractures in emergency room: a CT-comparative diagnostic study. Arch Bone Jt Surg. 2018Nov;6(6):539–46.
  17. ↑ 17.0 17.1 17.2 17.3 Jones V. Conservative management of the post-traumatic stiff elbow: a physiotherapist’s perspective. Shoulder & elbow. 2016 Apr;8(2):134-41.
  18. ↑ 18.0 18.1 Lee AT, Schrumpf MA, Choi D, Meyers KN, Patel R, Wright TM, Hotchkiss RN, Daluiski A. The influence of gravity on the unstable elbow. Journal of Shoulder and Elbow Surgery. 2013 Jan 1;22(1):81-7.
  19. ↑ Nonunions - orthoinfo - Aaos [Internet]. OrthoInfo. [cited 2022Apr13]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/nonunions/
  20. ↑ BESS - British Shoulder & Elbow Society. Improving Elbow Stiffness: Overhead Flexion Extension Range Exercises. Available from: https://www.youtube.com/watch?v=3cyp2fStCbw
  21. ↑ BESS - British Shoulder & Elbow Society. Improving Elbow Stiffness: Overhead Forearm Rotation Exercises. Available from: https://www.youtube.com/watch?v=togSRnKIsWc
  22. ↑ BESS - British Shoulder & Elbow Society. How to Strengthen Your Elbow After Injury. Available from: https://www.youtube.com/watch?v=q-WyKM6GAGs
  23. ↑ BESS - British Shoulder & Elbow Society. Improving Elbow Range and Strength After Injury. Available from: https://www.youtube.com/shorts/Jq7Z6m8Npqo
  24. ↑ 24.0 24.1 24.2 24.3 Kerns GJ. Dr. Garrett Kerns [Internet]. Dr Garrett James Kerns | Orthopaedic Surgery Specialist Saginaw, MI. [cited 2022Apr13]. Available from: https://www.drgarrettkerns.com/pdfs/office-forms/physical-therapy-protocols/elbow/radial-head-orif-protocol.pdf.
  25. ↑ Monument MJ, Hart DA, Salo PT, Hildebrand KA, Befus AD. Posttraumatic elbow contractures: targeting neuroinflammatory fibrogenic mechanisms. Journal of Orthopaedic Science. 2013 Nov 1;18(6):869-77.
  26. ↑ Radial head fracture - aftercare: Medlineplus medical encyclopedia [Internet]. MedlinePlus. U.S. National Library of Medicine; [cited 2022Apr13]. Available from: https://medlineplus.gov/ency/patientinstructions/000561.htm
  27. ↑ 27.0 27.1 About the DASH [Internet]. DASH. [cited 2022Apr13]. Available from: https://www.dash.iwh.on.ca/about-dash
  28. ↑ Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the ARM, shoulder and hand questionnaire (Quick Dash): Validity and reliability based on responses within the full-length dash. BMC Musculoskeletal Disorders. 2006;7(1).
  29. ↑ Swensen SJ, Tyagi V, Uquillas C, Shakked RJ, Yoon RS, Liporace FA. Maximizing Outcomes in the treatment of radial head fractures. Journal of Orthopaedics and Traumatology. 2019;20(1):1–9.
  30. ↑ Hackl M, Wegmann K, Hollinger B, El-Zayat BF, Seybold D, Gühring T, et al. Surgical revision of radial head fractures: A Multicenter retrospective analysis of 466 cases. Journal of Shoulder and Elbow Surgery. 2019;28(8):1457–67.
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