Radial head fracture
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Radial head fractures are, together with the radial neck fractures, relatively common injuries, especially in adults, although they can be occult on radiographs. Radial head fractures are the most common elbow fractures 5.
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Although fractures of the radial head are seen in all age groups, they usually occur in adults (85% between 20-60 years of age) and more frequently in women (M: F 1:2) 2.
Radial head fractures usually occur as a result of indirect trauma, with most resulting from a fall on an abducted arm with minimal or moderate flexion of the elbow joint (0 - 80°) 2. This results in valgus pronation stress with the radial head forcibly pushed against the capitulum of the humerus 1,2. In practice, the history is often a fall onto an outstretched arm. A direct blow to the elbow can cause a radial head fracture but is uncommon.
While the majority of radial head fractures are isolated, a number of other injuries may also be seen 2:
fracture of the coronoid process of the ulna
medial collateral ligament tear
interosseous membrane injury
triangular fibrocartilage complex injury at the wrist (Essex-Lopresti fracture-dislocation)
The Mason-Johnston classification can be used to further classify radial head fractures, although, in practice, most radiologists merely describe the injury.
The elbow is typically radiographed in AP and lateral projections, although an external oblique view is very frequently also obtained to better visualize the radial head. When a fracture is not seen but there is clinical suspicion, a Coyle's view can be performed.
Radial head fractures can be subtle and easily missed on radiographs. It is important to assess the radiograph for a joint effusion and where one exists, to take extra care in the assessment of the radial head. Even when a fracture cannot be identified, the presence of joint effusion in adults should be treated as a non-displaced radial head fracture.
Elbow effusions are best appreciated on a lateral projection, where fluid in the joint capsule elevates the pericapsular fat, seen as anterior or posterior fat pad sign. A minimally elevated anterior fat pad may be seen on normal elbow radiographs. However, posteriorly, the pericapsular fat is usually hidden in the olecranon groove and fossa, and its presence is indicative of fluid in the joint.
CT is increasingly being obtained in joints with intra-articular involvement, as it is far superior in assessing articular contour and presence of intra-articular fragments.
Treatment and prognosis
Treatment depends on the degree of displacement and involvement of the articular surface (as well as associated injuries).
Non-operative management has good results in undisplaced fractures without a mechanical block 5.
In general, type I (see Mason classification) injuries can be treated conservatively whereas type II injuries require open reduction and internal fixation (ORIF) 4. Type III injuries often require early complete excision of the radial head 2.
Radial head replacement is also an option, to help stabilize the elbow joint and prevent proximal migration of the radius 2. Radial head replacement shows favorable outcomes compared to ORIF in patients with complete articular fracture and more than three displaced fragments 5.
Generally, patients can expect a good outcome although secondary osteoarthritic change is certainly encountered in patients with intra-articular fractures.
In addition to reporting the presence of a radial fracture, a number of specific features should be sought +/- commented upon:
involvement of the articular surface
displacement and impaction
evaluate rest of elbow for
coronoid process fractures
capitulum osteochondral injuries
ligamentous injury (widening of joint space due to medial collateral tear)
wrist x-rays should be obtained if any clinical suspicion exists or where assessment is difficult to assess for the presence of Essex-Lopresti fracture-dislocation
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