Radial head fractures
Radial head fractures are, together with the radial neck fractures, relatively common injuries, especially in adults, although they can be occult on radiographs.
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 degrees) 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 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 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 oblique view is very frequently also obtained to better visualise the radial head (see elbow radiography).
Radial head fractures can be subtle and easily missed on radiographs. It is important to assess the film 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 a joint effusion in adults should be treated as a non-displaced radial head fracture.
Elbow effusions are best seen on lateral projection where fluid in the joint capsule elevates the pericapsular fat. 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 seen as a sail sign.
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). 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 stabilise the elbow joint and prevent proximal migration of the radius 2.
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
- articular step-off/gap
- displacement and impaction
- associated injuries
- evaluate rest of elbow for
- coronoid process fractures
- capitulum osteochondral injuries
- elbow dislocations
- olecranon fracture
- ligamentous injury (widening of joint space due to medial collateral tear)
- evaluate rest of elbow for
- evaluate wrist
- 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
- elbow anatomy
- elbow radiography
- MRI of the elbow - an approach
- distal humeral fracture
- Panner disease (osteochondrosis of the capitellum)
- 1. John SD, Wherry K, Swischuk LE et-al. Improving detection of pediatric elbow fractures by understanding their mechanics. Radiographics. 1996;16 (6): 1443-60. Radiographics (abstract) - Pubmed citation
- 2. Mirzayan R, Itamura JM. Shoulder and Elbow Trauma. Thieme Medical Pub. (2004) ISBN:1588902196. Read it at Google Books - Find it at Amazon
- 3. Bhandari M. Evidence-Based Orthopedics. Wiley-Blackwell. (2012) ISBN:1405184760. Read it at Google Books - Find it at Amazon
- 4. Pappas N, Bernstein J. Fractures in brief: radial head fractures. Clinical orthopaedics and related research. 468 (3): 914-6. doi:10.1007/s11999-009-1183-1 - Pubmed