History
A patient with radial head fracture-dislocations usually presents with a history of a fall on the outstretched hand. Blunt or penetrating trauma rarely causes radial head injury. The wrist, especially the distal radioulnar joint, may be damaged simultaneously, and the presence of wrist pain, grinding, or swelling should be determined.
The presence of bleeding, even with small puncture wounds, should alert the examiner to the possibility of open injury. Neurovascular symptoms of numbness, tingling, or loss of sensation should be identified to rule out nerve or vascular injury. The presence of severe pain should alert the examiner to the possibility of compartment syndrome.
Physical Examination
Patients with radial head fractures and dislocations present with localized swelling, tenderness, and decreased motion. The physician must carefully examine any wounds to make sure that no open fractures are present. Evaluating wounds over the subcutaneous border of the ulna is especially important in fracture-dislocations for ensuring that open fractures are not missed. The examiner should palpate the elbow, especially the radial head, feeling for deformity, and should also examine the wrist, especially feeling for stability of the distal radioulnar joint.
Because all three major nerves of the forearm are in danger with elbow fractures and dislocations, the examiner should also carefully assess neurovascular function for all of the nerves of the forearm and hand. Radial nerve function is especially important to assess with displaced fractures through the neck of the radius. The motor (posterior interosseous) branch provides extension for the fingers and wrist (see Anatomy).
The examiner must also assess the firmness of all compartments, check for pain with passive stretch, and measure compartment pressures if in doubt to avoid missing compartment syndromes. Elbow stability needs to be assessed even with seemingly nondisplaced radial neck fractures. The elbow is tested with valgus stress at 30° of flexion to determine the competency of the medial collateral ligament.
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Congenital radial head dislocation.
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The radial head must be aligned with the capitellum on all views. Simple ulna fracture on anteroposterior view; radial head appears in place but see Image below.
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The radial head must be aligned with the capitellum on all views. Dislocated radial head is observed on the lateral radiograph.
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Soft tissue injury. Soft tissues are as important as bone in determining functional outcome.
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Isolated radial head dislocation is almost always treated closed.
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Minimally displaced radial head/neck fractures can be treated with early motion.
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Floating elbow. Combined Monteggia fracture with dislocation and supracondylar humerus fractures. Treatment of a floating elbow requires fixation of both fractures.
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Displaced radial head fracture.
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Radial head fracture fixation.
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Radial head fracture in a child.
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Radial head fracture in a child.
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Radial head replacement, Monteggia variant and the radial head could not be salvaged.
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Radial head replacement, temporary spacer.
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Radial head excessive excision. Do not excise distal to the annular ligament because the forearm becomes unstable.
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Radial head replacement, salvage with radial head spacer.
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Unsuccessful open reduction of Monteggia fracture-dislocation.
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Displaced radial head fracture.
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Fixation with hardware pain.
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Same patient as in Image above. Pain was resolved after hardware removal.
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Synostosis after Monteggia fracture-dislocation; see Image below.
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Improved motion after synostosis resection.
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Monteggia variant with radial head fracture.
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Fixation of both radial head and ulna.
Tables
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 |
