Management of radial head fracture
Primary care physicians encounter numerous types of fractures. Many of these fractures are easily managed with minimal need for consultation. Physicians who wish to manage these fractures should be familiar with the “personality” of each type of fracture. This article reviews radial head fractures and basic principles of fracture healing and treatment, focusing on care for type I radial head fractures.
Healing and Repair
A fracture involves disruption of bone and soft tissues (muscle, tendon, ligament, nerves and vessels). Healing occurs in three phases, which the practitioner can influence to optimize the patient’s healing potential. These three phases are the inflammatory phase, the repair phase and the remodeling phase.
The first stage of healing, the inflammatory phase, lasts two to seven days. It is characterized by swelling, erythema, pain and increased skin temperature. Blood from damaged soft tissue forms a hematoma. A progression of cells, beginning with inflammatory cells, removes necrotic tissue. These cells also influence the proliferation of mesenchymal cells that start the repair process.
Rest, ice, elevation, immobilization, medications and pain control are prescribed during the first healing stage. This treatment limits the formation of the hematoma and necrotic “debris.” Cryotherapy decreases neural conduction, vasoconstricts vessels and slows the metabolism or enzymatic process of inflammation. This controls pain, decreases blood flow and limits inflammation. Elevation of the extremity limits blood flow and controls tissue distention, which is a cause of pain. Rest and immobilization further limit pain and blood flow by restricting muscle activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for short periods of seven to 10 days. At appropriate doses, NSAIDs provide analgesia and chemically inhibit the inflammatory cascade by limiting prostaglandin production.
The second stage of healing is the repair phase. It occurs from the second to eighth week after injury. Mesenchymal cells differentiate into cell types that replace damaged tissue in bone and soft tissue. The dilemma facing the physician in this stage is how long to immobilize the injury. Motion and tension forces around the joint help to orient the collagen fibers in the new soft tissue. On the other hand, most fractures need immobilization for the bone to heal properly. Immobilization should be prescribed only as long as needed, and movement of the injured site should be initiated as soon as treatment of the particular fracture permits. Radial head fractures require immobilization for comfort only. Gentle, active range of motion can begin in the first two to three weeks.
The remodeling phase occurs last. In this healing phase, the excess repair tissue is reshaped to its normal anatomy. This phase may last from months to years. Aggressive rehabilitation to restore range of motion, strengthen supporting musculature and restore proprioception should be the standard of care. Inappropriate rehabilitation can predispose the injured site to reinjury.
Fracture healing does not have a set time frame, although six to eight weeks can be used as an estimate. Healing time can be affected by the type of fracture, age, nutritional status, disease, medications and genetically determined differences (e.g., Ehlers-Danlos syndrome, osteogenesis imperfecta, Marfan’s disease, osteoporosis).
The Radial Head Fracture
The treatment of a grade I fracture of the radial head can be managed by the primary care physician. The following sections review the clinical and radiologic appearance of a grade I fracture.
CLASSIFICATION AND BIOMECHANICS
A classification of radial head fractures based on the amount of head involvement and the degree of displacement is shown in Figure 1.
[Figure 1 ILLUSTRATION OMITTED]
The treatment of type I fractures is nonoperative. Type I radial head fractures involve either the neck or the head and have less than 2 mm of displacement and minimal angulation or impaction. The treatment of type II through IV fractures is less clear and usually requires orthopedic consultation.
The radial head is intraarticular at the elbow joint where it rotates on the capitellum throughout a range of motion that includes flexion, extension, supination and proration. Pushing, gripping and twisting are forces that stress the radial head. Falling on an outstretched hand transfers a significant amount of force to the radial head.
The transfer of force from the hand and the wrist up the forearm can result in injury to the following structures: the distal radioulnar joint at the wrist, the interosseous membrane, and the capitellum. Complete disruption of these structures, along with the fracture, can result in radioulnar dissociation, called the Essex-Lopresti fracture. The medial collateral ligament can also be injured, resulting in an unstable elbow. Injury to the articular surfaces of the radial head and capitellum can also present as an occult injury.
Patients with isolated fractures of the radial head have pain located over the lateral side of the elbow. A radial head fracture can commonly result from a fall onto an outstretched hand or a direct blow to the side of the elbow. The patient usually holds his or her arm gently against the chest with the elbow flexed. Effusion is usually present, with distention of the elbow joint. Associated injuries should be suspected if the patient has wrist pain or medial elbow pain, or forearm swelling, ecchymosis or neurovascular injury.
The radial head can be palpated with the fingers just distal to the lateral epicondyle, where tennis elbow commonly occurs. Crepitation can sometimes be felt over the radial head. Inability to fully supinate or prorate should be noted. This finding could indicate that a displaced piece of radial head is causing a mechanical block. If the elbow is too painful to examine, a local anesthetic and aspiration of the hematoma from the joint can aid the examination and help with pain relief.
Routine radiographs for elbow pain include anteroposterior and true lateral views. If a fracture is not seen and fat pads are abnormal, then radial head views can be added. If a fracture is still not apparent, then a radiocapitellar view may be helpful. The radial head should be aligned with the capitellum in all views. If not, then a dislocation or fracture may have occurred.
Fat pad signs are usually apparent with radial head fractures. Their presence, though, is not pathognomonic. In one study,6 the anterior fat pad sign was more sensitive than the posterior fat pad sign for diagnosis of elbow fracture. The anterior fat pad is normally seen on lateral view but resembles a “sail” with effusion. The posterior fat pad is not normally seen. It is thin and hides in the olecranon fossa. When there is an effusion, the posterior fat pad may be seen on lateral views; however, this is not always true (Figure 2). It is possible that a tense hemarthrosis may further stretch and thin the posterior fat pad, making it difficult to visualize on radiograph.
[Figure 2 ILLUSTRATION OMITTED]
It is not uncommon to see a fat pad sign but no fracture. If a fracture is suspected clinically, then the elbow should be treated as if a radial head fracture exists. Radiographs and examination should be repeated in two weeks. Nonfractured injuries will improve rapidly in this time frame. Or, the physician may order a computed tomographic (CT) scan to try to clearly delineate a fracture.
RADIAL HEAD FRACTURES IN CHILDREN
In the skeletally immature child, the radial head or epiphysis is rarely fractured. However, fractures around the elbow can pose a diagnostic challenge both radiographically and clinically. The growth plates have many variations that the physician needs to recognize. If the clinical examination is suspicious for a fracture of the elbow, then referral to an orthopedic surgeon is recommended.
Treatment of nondisplaced (type I) fractures of the radial head is nonoperative and, in most cases, is managed by the primary care physician.
Sling immobilization with active motion is a well-documented treatment of choice. The addition of a posterior splint for a few days may add comfort for the patient. An anesthetic and acute aspiration of the hemarthrosis can relieve pain and improve initial motion but is not necessary for healing (Figure 3). Initial pain control includes ice therapy for two to five days, NSAIDs and pain medication. Protection of the radial head from accidental bumping can be accomplished by elastic wrapping or loosely taping molded thermoplast over the lateral elbow.
Gentle active range of motion can begin as soon as pain permits. Flexion and extension of the elbow and supination and pronation of the forearm should be taken to the point where mild pain just begins. Patients should be followed weekly for the first three to four weeks; range of motion should be noted, and pain should be assessed.
Most healthy patients can be out of the sling and performing more aggressive physical therapy in about three weeks. With appropriate rehabilitation, they can expect good to excellent function in two to three months. If pain and range of motion do not show weekly improvement, an associated injury or complication should be suspected.
Significant contractures of the elbow can develop in a short period of time. The treatment of type I fractures allows for early active range of motion to prevent the development of contractures and loss of motion.
Patients with a type I radial head fracture should show weekly improvement in pain and in range of motion. Associated injuries should be suspected if improvement is not seen. In these cases, tomographic or CT visualization may be necessary and orthopedic consultation should be considered. Osteochondral fractures of the capitellum may initially go unnoticed and cause poor recovery.
Other complications include increased sensitivity to cold, which may persist for up to a year and is especially evident on cold days. Long-term pain is a rare complication.
The most important aspect of rehabilitation of an elbow injury is restoration of range of motion. As range of motion improves, strength and flexibility exercises can be added. If range of motion is not progressing on a weekly basis and occult injury is ruled out, then formal physical therapy should be prescribed to hasten recovery of motion.
Elderly patients may heal more slowly than younger patients and require longer treatment time. These patients should undergo directed rehabilitation with a physical therapist.
The author thanks Mary Zavadil, M.D., for her help with revisions of the manuscript.
REFERENCES[1.] Hatch RL, Rosenbaum CI. Fracture care by family physicians. J Fam Pract 1994;38(3):238-44.[2.] Buckwalter JA, Cruess RL. Healing of musculoskeletal tissues. In: Rockwood CA Jr, et al, eds. Rockwood and Green’s Fractures in adults. 3d ed. Philadelphia: Lippincott-Raven, 1991:181-222.[3.] Davidson PA, Moseley JB Jr, Tullos HS. Radial head fracture. Clin Orthop 1993;297:224-30.[4.] Hotchkiss RN, Green DP. Fractures and dislocations of the elbow. In: Rockwood CA Jr, et al, eds. Rockwood and Green’s Fractures in adults. 3d ed. Philadelphia: Lippincoth-Raven, 1991:805-25.[5.] Quinton DN, Finlay D, Butterworth R. The elbow fat pad sign. J Bone Joint Surg Br 1987;69:844-5.[6.] Hall-Craggs MA, Shorvon PJ, Chapman M. Assessment of the radial head-capitellum view and the dorsal fat-pad sign in acute elbow trauma. AJR Am J Roentgenol 1985;145:607-9.[7.] Holdsworth BJ, Clement DA, Rothwell PN. Fractures of the radial head–the benefit of aspiration. Injury 1987;18:44-7.
GREG GUTIERREZ, M.D. is in private practice at the Denver Center for Sports and Family Medicine and is director of sports medicine education at the St. Joseph Hospital Family Practice Residency, Denver. He is also a volunteer clinical faculty member at the University of Colorado Health Sciences Center, Denver. Dr. Gutierrez received a medical degree from the University of California, Irvine, School of Medicine and completed a residency m family practice at the St. Joseph Hospital, Denver. He also holds a Certificate of Added Qualification in Sports Medicine.
Address correspondence to Greg Gutierrez, M.D., The Denver Center for Sports and Family Medicine, 210 University Blvd., Suite 210, Denver, CO 80206; e-mail: firstname.lastname@example.org.
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