Summary Radial Head Fractures are common intra-articular elbow fractures that can be associated with an episode of elbow instability, a mechanical block to elbow motion, an injury to the distal radioulnar joint and/or to the interosseous membrane (Essex-Lopresti). Diagnosis can be made with plain radiographs of the elbow. CT studies can be helpful for surgical planning. Treatment may be nonoperative for non-displaced fractures without a mechanical block to motion but operative management is indicated for displaced fractures, or fractures associated with mechanical block to motion or elbow/forearm instability. Epidemiology Incidence very common fracture makes up 1-4% of all fractures in adults makes up 20-30% of all elbow fractures most common elbow fracture Demographics age the mean age is ~ 45 years 85% occur between the ages of 30-60 sex 3:2 female:male risk factors osteoporosis associated with lower energy injuries Etiology Pathophysiology mechanism of injury fall on an outstretched hand login to view 2 more bullets higher energy trauma may result in associated injuries Associated conditions incidence 30% have associated soft tissue or skeletal injuries types ligamentous/ interosseous injuries login to view 7 more bullets elbow fractures & dislocations login to view 7 more bullets carpal fractures login to view 1 more bullet Anatomy Osteology proximal radius consists of radial head radial neck radial tuberosity radial shaft radial head head-neck osteology login to view 3 more bullets articular surface login to view 1 more bullet nonarticular portion login to view 2 more bullets Arthrology radiocapitellar joint a pivot joint 60% load transfer across elbow joint login to view 1 more bullet proximal radial ulnar joint (PRUJ) ulnar portion of radial head that articulates with the lesser sigmoid notch of the ulna important for forearm pronation and supination Ligaments lateral collateral ligament complex lateral ulnar collateral ligament (LUCL) login to view 4 more bullets radial collateral ligament (RCL) login to view 1 more bullet annular ligament login to view 3 more bullets accessory lateral collateral ligament medial (ulnar) collateral ligament (MCL) three bundles login to view 4 more bullets Biomechanics radial head confers two types of stability to the elbow valgus stability login to view 1 more bullet longitudinal stability login to view 6 more bullets Classification Basic Mason Classification(Modified by Hotchkiss and Broberg-Morrey) Type I Nondisplaced or minimally displaced (<2mm), no mechanical block to rotation Type II Displaced >2mm or angulated, possible mechanical block to forearm rotation Type III Comminuted and displaced, mechanical block to motion Type IV Radial head fracture with associated elbow dislocation High interobserver variability even after advanced imaging obtained Advanced OTA Classification 2R1A Extra-articular pattern 2R1B Partial articular pattern 2R1C Complete articular pattern Presentation Symptoms common symptoms pain login to view 2 more bullets limited elbow or forearm motion login to view 1 more bullet Physical exam inspection ecchymosis/swelling possible tenderness over radial head deformity possible in setting of associated dislocation motion important to evaluate for mechanical blocks to elbow motion login to view 5 more bullets neurovascular login to view 2 more bullets stability testing elbow login to view 2 more bullets DRUJ login to view 3 more bullets interosseous membrane login to view 3 more bullets Imaging Radiographs recommended views AP and lateral elbow AP and lateral forearm/wrist additional views radiocapitellar view (Greenspan view) login to view 4 more bullets findings fracture with or without displacement/intra-articular involvement may see anterior/posterior fat pad sign indicating occult minimally displaced fracture login to view 2 more bullets must rule out concomitant involvement of forearm/wrist CT indications comminuted fractures login to view 1 more bullet complex fracture dislocations findings may be helpful in planning surgical technique/approaches login to view 1 more bullet MRI indications useful for detecting associated ligamentous injuries not routinely used findings do not typically alter management Treatment Nonoperative immobilization for 3-7 days followed by early ROM indications login to view 2 more bullets outcomes login to view 2 more bullets Operative ORIF (open reduction internal fixation) indications login to view 4 more bullets techniques login to view 2 more bullets outcomes login to view 8 more bullets fragment excision indications login to view 2 more bullets outcomes login to view 1 more bullet radial head resection indications login to view 4 more bullets contraindications login to view 4 more bullets outcomes login to view 4 more bullets radial head arthroplasty indications login to view 8 more bullets outcomes login to view 2 more bullets intramedullary nail fixation indications login to view 1 more bullet technique login to view 1 more bullet outcomes login to view 1 more bullet Techniques Nonoperative management Sling (preferred) or posterior long arm splint 3-7 days only to prevent stiffness early ROM exercises Hematoma aspiration and intraarticular anesthetic injection may help with acute pain No follow up radiographs if nondisplaced fracture and clinically improving Outcomes Excellent with near normal ROM Type II with no mechanical block may have persistent symptoms and early failure rate up to 12% ORIF (open reduction internal fixation) positioning supine, lateral, or prone with a tourniquet login to view 1 more bullet approaches Kocher approach login to view 16 more bullets Kaplan approach login to view 11 more bullets extensor digitorum communis (EDC) split login to view 5 more bullets posterior approach login to view 10 more bullets technique screw(s) login to view 4 more bullets plate(s) + screws login to view 9 more bullets complications PIN injury destabilization of lateral ligament complex articular surface penetration with screws mechanical block to motion by hardware Fragment Excision approach Kocher or Kaplan approach as described technique if fracture is <25% of surface area of radial head and does not compromise elbow stability, fragment can be excised complications elbow instability if fragment excised is too large Radial Head Resection approach Kocher or Kaplan approach technique remove enough head to fully remove comminuted aspects of radial head attempt to keep annular ligament intact complications muscle weakness wrist pain valgus elbow instability heterotopic ossification elbow arthritis proximal radial migration decreased strength cubitus valgus Radial head arthroplasty approach Kocher Kaplan EDC split technique metal prostheses login to view 10 more bullets pyrocarbon prostheses login to view 2 more bullets silicon replacements (Sylastic) login to view 4 more bullets implant design monoblock login to view 1 more bullet modular login to view 1 more bullet complications overstuffing of joint that leads to capitellar wear problems and malalignment instability login to view 7 more bullets loosening login to view 2 more bullets implant dissociation login to view 2 more bullets synovitis login to view 1 more bullet Complications Surgical Site Infection incidence rare after isolated ORIF or arthroplasty risk factors high energy injuries, open fracture, significant soft-tissue injury treatment incision and drainage consider radial head excision if osteomyelitis present consider hardware/implant removal when infection complicates ORIF or radial head replacement six weeks of intravenous antibiotics, possibly followed by oral antibiotics if hardware/prosthesis retained Nonunion/Malunion incidence common after nonsurgical and surgical management frequently asymptomatic treatment if symptomatic, may consider excision or arthroplasty Secondary displacement of fracture incidence occurs in < 5% of fractures initially treated nonoperatively treatment fixation may be necessary serial radiographs do not change management Posterior interosseous nerve injury (with operative management) risk factors high energy injury and associated elbow dislocations dissection distal to biceps tuberosity in ORIF overaggressive retraction at radial neck treatment if neuropraxia suspected, begin conservatively login to view 3 more bullets Elbow stiffness & loss of forearm rotation incidence 3-20% loss of supination most common risk factors prolonged immobilization login to view 1 more bullet intra-articular fracture involvement malunion/nonunion heterotopic ossification treatment nonoperative login to view 3 more bullets operative login to view 2 more bullets Elbow instability incidence uncommon if radial head not excised and associated injuries appropriately managed Radiocapitellar joint arthritis incidence common radiographic finding but does not correlated with poor outcomes risk factors fracture with intra-articular displacement use of metallic radial head replacement login to view 1 more bullet treatment nonoperative login to view 3 more bullets operative login to view 5 more bullets Heterotopic ossification (HO) risk factors CNS injury burns elbow fracture/dislocation with significant soft tissue injury treatment prevention login to view 3 more bullets operative removal login to view 3 more bullets Loss of hardware fixation incidence rare lucency around noncemented smooth stems is common but not associated with pain treatment revision fixation radial head replacement radial head removal