Continuing Education Activity

Radial head fractures account for approximately one in three elbow fractures and 1 to 4 percent of all fractures in adults. In the past, the radial head was deemed insignificant and felt to have little influence on elbow anatomy and biomechanics, so its excision was frequently indicated. Long-term outcomes associated with the removal of the radial head have shown undesirable consequences. Treatment and prognosis of radial head fractures are typically dependent on the associated injuries at the time of presentation. This activity reviews the causes, pathophysiology, and presentation of radial head fractures and highlights the role of the interprofessional team in their management.

Objectives:

• Identify the etiology of radial head fractures.
• Outline the presentation of a patient with a radial head fracture.
• Describe the treatment options available for radial head fractures.
• Explain interprofessional team strategies for improving care coordination and communication to advance the treatment of radial head fractures and improve patient outcomes.

Introduction

A few years ago, the radial head was considered of little importance in the elbow anatomy and biomechanics, so its excision was frequently indicated. Laboratory studies and long-term series outcomes have shown the undesirable consequences of this method. Associated injuries usually determine treatment and outcomes.[1]

Etiology

Elbow trauma is the etiology of proximal radius fractures. This trauma can be direct or indirect leading to an isolated fracture or associated with other fractures and ligaments injuries

Epidemiology

Radial head fractures represent approximately one-third of elbow fractures and 1% to 4% of fractures in adults

Pathophysiology

Anatomy and Biomechanics

A 180-degree arch in the pronation and supination is allowed by the articulation of the proximal end of the radius with the distal humerus (capitulum), and with the ulna in the lesser sigmoid cup (trochoid joint). Cartilage covers the radial head except for the anterolateral third that lacks subchondral bone, and it is easily fractured. It has a 40-degree central cavity, and it is oval-size-like. The head and neck are not collinear with the diaphysis and complete a 15-degree offset angle. They are closely related to the lateral ligament complex, mainly the annular ligament and radial collateral ligament.[2]

The physiologic elbow range of movement is zero to 150 degrees of flexion and extension, and  85 degrees of pronation, and  75 degrees of supination.[3]

The radial head stabilizes in valgus when the internal ligament complex is injured, and it does not take part when being harmless (secondary stabilizer). Moreover, it is involved in longitudinal stability. [4]

History and Physical

The fracture occurs when a patient has direct traumatic to the elbow or falls with the wrist and the hand in extension. The usual signs are pain and functional impotence, there may be blockages in the elbow. 

Evaluation

In incomplete or nondisplaced fractures, it is necessary to investigate painful spots and the presence of small petechiae. Suspecting possible associated lesions is important. The medial aspect of the elbow (LCI), the interosseous membrane, and the distal ulnar radius joint should be evaluated, especially in complex cases. When there is a doubt as to the size and displacement of the fragment, it is useful to test with a local anesthetic injection to determine if it causes mechanical blockages, which indicates the need for surgical treatment.

Associated Injuries

Most complex injuries have been associated with lateral and medial ligaments injuries and interosseous membrane (Essex Lopresti). It is useful to make the radius climbing and descending in the surgery and to identify it with the intensifier climbing at elbow level and with the distal radioulnar joint to diagnose this type of injury. Capitulum, coronoid, and olecranon are among the most frequent related fractures.

Assessing the elbow, shoulder, and wrist stability is helpful.

Images

Anteroposterior and lateral x-rays are useful. If there is pain in the wrist and comminuted fractures, it is useful to request x-rays to compare them. CT scans ease planning in complex cases.

Classification

Mason is a widely-used classification system. Type 1 is a nondisplaced fracture. Type 2 is displaced with one fragment fracture. Type 3 is a comminuted fracture.  Johnston suggests Type 4to be any fracture with elbow luxation. Lately, Morrey has included the classical description of joint fractures, those of the neck,  quantifying them to 30% approximately and displacements between 2 mm.

Hotchkiss modifies the types mentioned above with ones by therapeutic criteria. Type 1 fractures are nondisplaced or mínimum displaced fractures (below 2 mm). Type 2 fractures have a partial head displacement that blocks the pronation and supination, and repairable with internal fixation. Type 3 injuries are nonrepairable fractures with internal fixation.

Treatment / Management

Objectives are to achieve an appropriate range of motion with an early rehabilitation start, elbow and forearm stability, and to avoid immediate and long-term complications (arthritis). Aspects to keep in mind for therapeutical decisions are patient-related and include age, bone quality, functional demand, comorbidities, fracture-related extension, location, displacement, and related injuries.[5][6][7][8]

Non-surgical Treatment

Most isolated fractures. Indication for non-displaced fractures, displaced with a joint step under 2 mm, a joint surface condition under 30%, and angling under 30 degrees. However, some authors extend the indication to all fractures which do not block the joint (test through anesthesia) in spite of their having further displacements that evolve toward non-strengthening, and the fragment is to be dried similarly.

The local anesthesia test is used to search for mechanical occlusion which could determine surgical resolution. The initial immobilization may be carried out by plaster or sling in functional position. It is to be worn for two or three weeks and followed by an x-ray evaluation seven days later.

It is convenient, attempt active elbow flexion and extension while the humerus is on a flat surface.

Surgical Treatment

Radial head excision: Indication in severe pain in selected cases for instance older adults with a low demand with complex fractures but no associated fractures which compromise stability. One option is the differed excision with the same indication as the mentioned one or to enhance pronation-supination. [4]

Open or arthroscopic: Fragment excision may be indicated in cases where these can obstruct joints and are too small for osteosynthesis and should not be part of the proximal radio-ulnar joint.

Osteosynthesis: As regards isolated fractures, it is an absolute indication when they cause a joint blockage. (Mason type 2) Step over 2 mm, joint fragment over 30%, neck fractures with angling over 30 degrees.[9]

Low profile plates and screws implants or cannulated are applied.

Surgical approach: (Kocher) between the anconeus and extensor carpi ulnaris (ECU), it provides good access to the back fragments and safety to the posterior interosseous nerve. Another option is extensor digitorum comunis (EDC) splinting to avoid iatrogenic injuries. 

Osteosynthesis should be placed in the safe interval to avoid interference with the proximal radio-ulnar joint which is located 110 external degrees with the elbow in neutral pronation-supination.

In complex fractures, osteosynthesis or prosthesis? It is convenient not to get more than three fragments with no impaction or deformity with enough bone quality and without metaphyseal bone loss to achieve stable internal fixation. In many cases, these fracture features are determined at surgery time.

Arthroplasty: Indication for non-repairable fractures. A prosthesis-sized appropriate choice is important to avoid articular stiffness. [10]

Differential Diagnosis

The simple and incomplete fractures could be mistaken with others lateral elbow pain etiologies like tennis elbow, and osteochondritis

Prognosis

The main objectives in radial head fractures are fracture healing with a functional elbow range of motion. The prognosis is in relationship with associated injuries like lateral and medial ligaments and complex fractures.

Complications

Stiffness due to prominent hardware in osteosynthesis or to the oversized prosthesis in arthroplasties.

It can also be found due to capsular contracture and ossification.

Aseptic necrosis and nonunion after osteosynthesis failure. Malunion is less frequent post osteosynthesis than in nonsurgical treatment.Arthritis according to clinical x-ray studies but with no clinical correlation.

Instability is less frequent. It is important to manage injuries to avoid this complication adequately.

Aseptic necrosis and nonunion after osteosynthesis failure. Malunion is less frequent post osteosynthesis than in nonsurgical treatment.

Arthritis according to clinical x-ray studies but with no clinical correlation.

Deterrence and Patient Education

Patients must follow postoperative care and rehabilitation.

Enhancing Healthcare Team Outcomes

Radial head fractures are best managed by an interprofessional team that includes physical therapists and orthopedic nurses. The management for nondisplaced and mild fractures is usually conservative. Severe cases usually require surgery. An orthopedic specialty nurse can be an invaluable asset for these cases, assisting during surgery/reduction, answering patient questions, and helping coordinate therapy postoperatively, while serving as a bridge to the treating clinician and other ancillary providers.

The outlook for most patients is good after treatment but arthritis, aseptic necrosis, joint stiffness, and capsular contraction are not uncommon problems in the long run.