eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Radial Head Fractures: Treatment
Updated: May 14, 2009
Treatment
Medical Therapy
Treatment options for radial head fractures or dislocations include closed reduction with casting or early motion or open reduction with internal fixation, replacement, or resection. Closed reduction and casting often has associated high rates of stiffness, and closed reduction and early motion may still have high rates of nonunion and malunion in comminuted or unstable fractures, resulting in generally poor functional results. Open treatment (including internal fixation, replacement, or excision depending on the fracture) is associated with better long-term function.Soft tissue injury. Soft tissues are as important as bone in determining functional outcome.
The condition of the soft tissues is as important as the condition of the bone in determining the eventual functional outcome (see Image 4). Schatzker's general observation concerning fracture care is especially relevant for elbow injuries: "Long term disability following a fracture is almost never the result of damage to the bone. It is the result of damage to the soft tissues and stiffness of neighboring joints."6
An isolated radial head dislocation is almost always treated with closed reduction and early motion. If closed reduction cannot be achieved, then open reduction is indicated (see Image 5). Congenital radial head dislocations do not require treatment (see Image 1).
Isolated radial head dislocation is almost always treated closed.
For isolated radial head fractures, the Mason classification guides treatment.1,3,7,8 Nonsurgical treatment of radial head fractures is indicated if minimal displacement, minimal angulation, and minimal head involvement are noted (see Image 6). Early motion with a functional brace is encouraged to minimize elbow stiffness. Adequate follow-up is essential to be sure late displacement is not missed. (If displacement occurs, operative intervention is usually indicated.)
Minimally displaced radial head/neck fractures can be treated with early motion.
In the Mason classification, the fracture is type I if it is undisplaced, type II if a single fragment is displaced, and type III if it is comminuted. Type I (nondisplaced) generally is treated nonoperatively. Type II may be treated nonoperatively if the displacement is minimal. The rule of threes is used: Nonsurgical treatment can be considered if the fracture involves less than one third of the articular surface, if there is less than 30° of angulation, and if displacement is less than 3 mm. Type III fractures usually require operative intervention but may occasionally be treated closed with early motion if the radial head is not reconstructible. If a mechanical block to motion is present, then nonsurgical treatment cannot be used.1,3,7,8
Fracture-dislocations of the radial head can rarely be treated with closed reduction and splinting, but better results are expected in most cases with operative stabilization and early motion.
Patients whose medical condition is too unstable to allow safe surgery when surgery is indicated can also be treated with splinting followed by early motion, but the prognosis is guarded for achieving optimal function.
Surgical Therapy
Surgical treatment is indicated for all unstable radial head (and neck) fractures and dislocations. As described above, the rule of threes can be used for determining the need for surgical intervention: Surgery is required if the fracture involves more than 33% of the articular surface, is angulated more than 30°, or is displaced more than 3 mm. A mechanical block to motion always requires open treatment to remove the blocking bone or osteochondral fragment or fragments. Open fractures are also surgical emergencies. They require surgical irrigation and debridement in an operating room with appropriate antibiotics even if the wound is small. At the same time, immediate stabilization of the bone injury is also performed.
Radial head excessive excision. Do not excise distal to the annular ligament because the forearm becomes unstable.
Radial head replacement, salvage with radial head spacer.
Unsuccessful open reduction of Monteggia fracture-dislocation.
Monteggia fracture-dislocations are a special type of radial head injury. Classically, Monteggia fractures are ulna fractures in the proximal one third with associated radial head dislocation. Instead of the radial head dislocation, the radial head or neck may be fractured as an equivalent injury (see Images 2-3 and Images 14-16). Classification is listed in the following table.
Classification of Monteggia fracture-dislocations
Open table in new window
Table
| Type | Description | Equivalent(s) | % |
|---|---|---|---|
| Type I | Anterior dislocation of the radial head and anterior angulation of the ulna fracture | Radial head or neck fracture instead of dislocation | 60 |
| Type II | Posterior dislocation of the radial head and posterior angulation of the ulna fracture | Posterior elbow dislocation Radial head or neck fracture instead of dislocation | 105 |
| Type III | Lateral dislocation of the radial head with proximal ulna fracture | Radial head or neck fracture instead of dislocation | 20 |
| Type IV | Anterior dislocation of the radial head and proximal shafts of both bones fractured at same level | Radial head or neck fracture instead of dislocation | 5 |
| Type | Description | Equivalent(s) | % |
|---|---|---|---|
| Type I | Anterior dislocation of the radial head and anterior angulation of the ulna fracture | Radial head or neck fracture instead of dislocation | 60 |
| Type II | Posterior dislocation of the radial head and posterior angulation of the ulna fracture | Posterior elbow dislocation Radial head or neck fracture instead of dislocation | 105 |
| Type III | Lateral dislocation of the radial head with proximal ulna fracture | Radial head or neck fracture instead of dislocation | 20 |
| Type IV | Anterior dislocation of the radial head and proximal shafts of both bones fractured at same level | Radial head or neck fracture instead of dislocation | 5 |
The injury pattern is similar to both-bone forearm fractures. Monteggia fracture-dislocations are included here because of the importance of not missing either injury. The isolated injuries (radial head dislocation by itself or ulna [nightstick] fracture by itself) are often treated by closed treatment with good results, but the combined injury can almost never be treated by closed methods if good results are expected. Appropriate treatment requires diagnosing both (see Workup, Imaging Studies, above, and Images 2-3).
Floating elbow. Combined Monteggia fracture with dislocation and supracondylar humerus fractures. Treatment of a floating elbow requires fixation of both fractures.
Floating elbow injuries are another special case that can include radial head injury. Floating elbow injuries include associated ipsilateral forearm and humerus fractures. They are severe high-energy injuries. The best outcome almost always requires fixation at both levels. Standard fixation methods for the individual fractures are used (see Image 7). Surgical treatment options include open reduction and internal fixation with plates and screws, excision of fragments, or radial head replacement.
Preoperative Details
Adequate preoperative planning is essential. If replacement is a possibility based on imaging studies demonstrating excessive comminution with distal radioulnar joint instability, then the surgeon needs to be sure an adequate stock of radial head replacement implants is available. Similarly, a wide range of minifragment plates and screws should be available to accomplish fixation.
Intraoperative Details
The radial head is approached posteriorly. The surgeon must be aware of the posterior interosseous nerve, which winds around the neck of the radius and lies directly on the bone. During the approach (and throughout the case), the surgeon should attempt to use indirect reduction techniques preserving soft-tissue attachments. Periosteal stripping must be minimized. Narrow retractors are used, and the surgeon must avoid penetration of the interosseous membrane to avoid the complication of synostosis, which can cause severe limitation of motion that is difficult or impossible to treat (see Complications, below).
For isolated radial head dislocations, reduction of the head is usually stable and no specific repair is necessary. If unstable, the annular ligament is repaired (if unstable, the surgeon should look for a missed forearm fracture).
Once the fracture is opened, the final decision is made regarding fixation, replacement, or excision. When possible, best results are obtained with anatomic reduction and fixation. As with any surgical fracture treatment, if fixation is chosen, the first step is reduction of the bone fragments. The surgeon reduces and provisionally fixes the intra-articular fragments first and then attaches the construct to the shaft. In some cases, the radial head is removed and assembled on the back table, but if possible, fixing the fracture in place is preferable to preserve the blood supply provided through the remaining soft-tissue attachments.
Fixation options include minifragment plates and screws and Herbert screws.9 Usually, 2.7-mm implants are used with interfragmentary lag screw fixation of individual fragments. Bone graft is included if the bone is significantly comminuted or if bone loss is preventing stable fixation. If more than 33% of the cortical circumference is lost, interfragmentary compression becomes impossible. Examples of radial head fracture fixation in an adult are presented in Images 8-9 and in Images 17-19. Images 10-11 show treatment of a radial head fracture in a child. Children require anatomic reduction with the same indications as adults, but additionally, the surgeon must be aware of potential growth plate injury and late deformity.
Displaced radial head fracture.
Radial head fracture fixation.
Radial head fracture in a child.
Radial head fracture in a child.
Displaced radial head fracture.
Fixation with hardware pain.
If repair is not possible, excision of comminuted radial head fragments can be considered. The surgeon must test for valgus instability and, if necessary, repair the medial collateral ligament to restore stability if excision is chosen. If instability persists, replacement with a radial head spacer is the appropriate treatment instead of excision alone (see Images 12-13). The surgeon must also be aware of the Essex-Lopresti lesion (ipsilateral injury to the distal radioulnar joint) and repair or fixate the distal radioulnar joint as necessary.
Radial head replacement, Monteggia variant and the radial head could not be salvaged.
Radial head replacement, temporary spacer.
Radial head excessive excision. Do not excise distal to the annular ligament because the forearm becomes unstable.
Radial head replacement, salvage with radial head spacer.
When radial head excision is chosen, the surgeon must not excise distal to the annular ligament because this results in an unstable proximal radioulnar joint (see Images 14-15). If comminution extends distal to the annular ligament, then replacement with a spacer should be strongly considered. The spacers shown in these figures are silicone. Newer recommended implants use titanium. The silicone implants were easier to place because of their flexibility, but concerns over silicone synovitis, late fragmentation, and loosening led to the development of the metal implants.7,10
For Monteggia fracture-dislocations, best treatment includes open reduction internal fixation of the ulna diaphyseal fracture (see Images 2-3 and Image 7). The ulna fracture is approached and reduced first. The radial head dislocation then usually reduces indirectly and is stable. (More than 90% of radial head dislocations are stable after fixation of the ulna.) If it is stable, then the radial head dislocation is treated closed. An irreducible radial head usually occurs because the diaphyseal ulna fracture has been poorly reduced, and this should be reassessed carefully, both radiographically and clinically. If it is unstable or irreducible (and the ulna is anatomic), then open reduction of the joint is required. The annular ligament is repaired during the open reduction.
Failure of the radial head to reduce with the ulna reduction is usually due to interposed annular ligament or, rarely, to interposed radial nerve. Image 16 shows a patient who presented after an unsuccessful attempt at open reduction of both components of the injury. If the radial head or neck is fractured and stable, then the choice of open versus closed treatment can be made as if the radial head injury were isolated, using the indications for open surgery as described above. If the radial head or neck is fractured and unstable, then it is approached and dealt with by open surgery as described above (see Images 14-15 and Images 22-23).
Unsuccessful open reduction of Monteggia fracture-dislocation.
Monteggia variant with radial head fracture.
Fixation of both radial head and ulna.
Elbow fracture-dislocations are usually due to more violent trauma and are usually unstable after reduction. They require open reduction and internal fixation. All efforts should be made to salvage the radial head because it is a secondary stabilizer of the elbow. The goal is stable fixation for early motion.
Postoperative Details
The wound can usually be closed, or skin grafts may be used for open wounds within 3-5 days.
Follow-up
Rehabilitation with range-of-motion exercises is begun as soon as the wound is healed, depending on the type of fracture and stability of fixation. The typical time to union is 6-8 weeks. Casting with the elbow in 90° of flexion is rarely needed to maintain the radial head reduction, but if the radial head is unstable, the surgeon needs to search for other causes, such as interposed annular ligament or osteochondral fragment or poorly reduced fracture.
Complications
Early complications of radial head or neck fractures or dislocations include compartment syndrome, neurovascular injury, and infection. Late complications include nonunion, hardware failure, malunion, infection, synostosis, and persistent pain.
Compartment syndrome after isolated radial head fracture is unlikely but could occur with Monteggia fractures, floating elbow injuries, and associated crush injuries to the forearm. Compartment syndromes usually occur in high-energy trauma but can occur with prolonged low-energy injuries and gunshot injuries. Predisposing factors include vascular injury, coagulopathy, and limb compression. Prevent iatrogenic compartment syndrome during surgery by obtaining good hemostasis and by not closing the fascia at surgery.
Early diagnosis is necessary. The treating physician needs to have a high index of suspicion, remembering the standard signs and symptoms of increased compartment pressure: pain on passive stretch, palpable firmness or tightness of the compartment, altered sensation or paresthesias, pain out of proportion to that expected, pallor, pulselessness, and less than 30 mm Hg difference between compartment pressure and diastolic pressure. All affected compartments should be released.
Neurovascular injury after radial head fracture or dislocation is not common but occurs more often if the fracture is open. Iatrogenic injury is more frequent. The surgeon needs to remember the location of the posterior interosseous nerve as it travels along the neck of the radius. If no recovery occurs, the nerve usually is explored at 3 months.
Infection after radial head fracture can occur either early or late. Treatment requires irrigation and debridement and appropriate antibiotics, usually by IV. If the fracture is healed or the hardware is loose, the hardware should be removed. If the fracture has not healed and the hardware is stable, the hardware is maintained.
Persistent pain after radial head fracture may be due to the hardware, intra-articular cartilage injury and posttraumatic arthritis, adhesions, malalignment, or associated nerve or muscle injuries. Hardware removal may be helpful, but potential complications, including iatrogenic nerve injury when dissecting through scar, may outweigh the benefits. Persistent pain may be due to nonunion. Images 17-19 show a patient who had persistent painful clicking after his radial head fixation, which resolved after hardware removal.
Displaced radial head fracture.
Fixation with hardware pain.
Same patient as in Image above. Pain was resolved after hardware removal.
Nonunion and resultant hardware failure after radial head fracture are usually due to poor biomechanics. Poor biology is the result of poor initial fracture characteristics and damage to the soft tissue envelope. An open injury or an extensive surgical reconstruction with periosteal stripping predisposes to slow healing. Poor surgical technique with overaggressive iatrogenic damage to soft tissues is a contributing factor. Poor mechanics occurs when the surgeon is unable to obtain a stable construct. (This occurs with too few screws or failure to obtain interfragmentary compression.) Treatment of nonunion requires restoration of normal biomechanics with stable internal fixation or radial head excision or replacement, depending on the fracture and wrist and elbow stability.
Stiffness is common after elbow injuries, especially if they have been immobilized. Motion is difficult to recover even with extensive physical therapy, dynamic bracing, manipulation, or open release of adhesions. Avoiding the problem by early motion is preferable to trying to deal with it after contracture has already occurred.
Unsuccessful open reduction of Monteggia fracture-dislocation.
Synostosis after Monteggia fracture-dislocation; see Image below.
Improved motion after synostosis resection.
Synostosis after radial head fracture or dislocation can be a disabling complication because it limits motion, especially rotation of the forearm. Risks include closed head injury, surgical delay longer than 2 weeks, and penetration of the interosseous membrane by bone graft or screws, bone fragments, or surgical instruments. Treatment by resection with an interposition spacer restores motion in about 50% of patients. Generally, the surgeon should wait at least a year or until the bone is metabolically inactive on bone scanning. Surgery should generally be completed before 3 years. Image 16 shows an example of a patient who developed synostosis. Image 20 shows the synostosis. The synostosis was resected, and an interposition fat spacer was used with early motion. Significantly increased motion was obtained and maintained (see Image 21).
More on Radial Head Fractures |
| Overview: Radial Head Fractures |
| Workup: Radial Head Fractures |
 Treatment: Radial Head Fractures |
| Follow-up: Radial Head Fractures |
| Multimedia: Radial Head Fractures |
| References |
| Further Reading |
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References
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Moro JK, Werier J, MacDermid JC, et al. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. Aug 2001;83-A(8):1201-11. [Medline].
Rabin SI, Rabin SL. Indications for radial head replacement following elbow trauma. Medscape Orthopaedics and Sports Medicine eJournal [serial online]. September 1997;1(5). Available at: http://www.medscape.com.
Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. Apr 2002;84-A(4):547-51. [Medline].
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Further Reading
Related eMedicine topics
Fracture, Elbow (Emergency Medicine)
Elbow Dislocation (Sports Medicine)
Dislocation, Elbow (Emergency Medicine)
Elbow, Fractures and Dislocations - Adult (Radiology)
Elbow Trauma, Pediatric (Radiology)
Capitellar Fracture (Orthopedic Surgery)
Distal Humerus Fractures (Orthopedic Surgery)
Forearm Fractures (Orthopedic Surgery)
Clinical guidelines
Elbow disorders.
Evidence-based care guideline for loss of elbow motion following surgery or trauma in children aged 4 to 18.
Clinical study
ExploR™ Modular Radial Head Data Collection
Safety and Effectiveness Study of Ascension's PyroCarbon Radial Head Compared to Ascension's Metal Radial Head
Unstable Fractures of the Distal Radius: Randomised Controlled Trial of Volar Plate Versus Dorsal Nail Plate Fixation
Keywords
radial head fractures, radial neck fractures, broken arm, broken elbow, radial dislocation, proximal radial migration, displaced radial head and neck fractures, Monteggia fracture-dislocation
