Radial Head Fractures

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Radial Head Fractures of the Elbow

Understanding the Elbow Joint

The elbow joint is a complex joint of the upper arm which bends and straightens like a hinge. It is also important for rotation of the forearm; that is, the ability to turn your hand in a palm up (like accepting change from a cashier) or palm down (like typing or playing the piano).

Your elbow joint is a joint made up of three bones:

• The lower end of humerus (arm bone)
• The upper end of radius (forearm bone on the thumb side)
• The upper end of ulna (forearm bone on the little finger side)

The distal humerus or the lower end of the humerus forms the upper part of the elbow and is the pivot around which the forearm bends and straightens.

The radial head or the upper end of the radius is a knobby end with a flat upper surface which glides up and down in front of the distal humerus when you bend your arm. The radial head also rotates around a groove in the upper end of ulna when you turn your wrist up or down.

The olecranon or the part of the upper part of ulna "hooks" the lower end of the humerus, creating a hinge for elbow movement. The bony "point" of the olecranon can be easily felt beneath the skin.

The elbow is held together by its bony architecture, as well as ligaments, tendons, and muscles. In addition to this, major blood vessel and nerves supplying the forearm and hand cross the elbow joint.

Elbow Fractures

For simplicity of understanding, the elbow joint can either break at the lower end of the humerus (arm bone) or at the upper end of the forearm bones (radius/ulna) either individually or in combination.

Radial Head Fractures

A radial head fracture is a break in the upper end of the thumb side forearm bone. Protecting oneself during a fall by taking the impact on your outstretched hand may seem instinctive but the force of the fall could travel up your forearm bones and dislocate your elbow. It also could break the smaller bone (radius) in your forearm. Fractures of the radius often occur in the part of the bone near the elbow, called the radial head.

Radial head fractures are common injuries, occurring in about 20% of all acute elbow injuries. Many elbow dislocations also involve fractures of the radial head. Radial head fractures are more frequent in women than in men, and are more likely to happen in people who are between 30 and 40 years of age.

What are the causes of Radial Head Fracture

Radial Head fractures are most often caused by:

• Falling directly on the outside of the elbow
• Receiving a direct blow to the elbow from some hard object
• Falling on an outstretched hand with the elbow held tightly to brace against the fall.

Symptoms

The most common symptoms of a radial head fracture include:

• Pain on the outside of the elbow
• Swelling in the elbow joint
• Difficulty in bending or straightening the elbow accompanied by pain
• Inability or difficulty in turning the forearm (palm up to palm down or vice versa)

How is a radial head fracture diagnosed

Most patients with radial head fractures experience severe difficulty and will consult the emergency department of a hospital. However, some patients may tend to neglect the injury and only visit the hospital/clinic when symptoms do not subside with home remedies. Your doctor will talk with you about your medical history and general health and ask about your symptoms. He or she will then examine your elbow to determine the extent of the injury. During the exam, your doctor will:

• Palpate (feel) all around your elbow to determine if there are any other areas of tenderness. This could indicate other broken bones or injuries, such as a dislocated elbow.
• Check your pulse at the wrist to ensure that there is good blood flow to your hand and fingers
• Check to see that you can move your fingers and wrist, and can feel things with your fingers. In some cases, the posterior interosseous nerve may be injured at the same time the fracture occurs. This can result in weakness and numbness in lifting the hand of the table.

Although you may have pain only at the elbow, your doctor may also examine your shoulder, upper arm, forearm, wrist, and hand to ensure that you do not have any other injuries.

Your doctor will order x-rays of your elbow to help diagnose your fracture and also may also order x-rays of your upper arm, forearm, shoulder, wrist, and/or hand to ensure that you do not have any other injuries based on his/her clinical judgement

What is the initial treatment for radial head fracture

In the emergency room, your doctor will apply a splint (like a cast) to your elbow and give you a sling to help keep your elbow in position. This prevents any further movements of the broken fragments and thereby limits the chances of nerve injury and also help control any increase in the swelling. Immediate treatment may also include medications to relieve pain. Whether or not your fracture requires surgery will then be determined. Some distal humerus fractures can be treated without an operation, but this is rare.

Treatment

Your surgeon will distinguish the radial head fractures according to the degree of displacement (how far out of normal position the radial head is, in relation to the remaining intact radial bone). Treatment is determined by the type of fracture.

Type I Fractures

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together

• The fracture may not be visible on initial x-rays, but can usually be seen if the x-ray is taken 3 weeks after the injury.
• Nonsurgical treatment involves using a splint or sling for a few days, followed by an early and gradual increase in elbow and wrist movement (depending on the level of pain).
• If too much motion is attempted too quickly, the bones may shift and become displaced.

Type II Fractures

Type II fractures are slightly displaced and involve a larger piece of bone.

• If displacement is minimal, a sling or splint may be used for 1 to 2 weeks, followed by range-ofmotion exercises.
• Small fragments of broken bone may be surgically removed if they prevent normal elbow movement or could cause longterm problems with the elbow
• If a fragment is large and out of place enough, the orthopaedic surgeon will first attempt to hold the bones together with screws, or a plate and screws. If this is not possible, the surgeon will remove the broken pieces of the radial head.
• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

Type III Fractures

Type III fractures have multiple broken pieces of bone which cannot be put back together for healing.

• In most Type III radial head fractures, there is also significant damage to the elbow joint and the ligaments that surround the elbow.
• Surgery is always required to either fix or remove the broken pieces of bone and repair the softtissue damage. If the damage is severe, the entire radial head may need to be removed. In some cases, an artificial radial head may be placed to improve long-term function.

Even the simplest of fractures may result in some loss of movement in the elbow. Regardless of the type of fracture or the treatment used, exercises to restore movement and strength will be needed before resuming full activities.

How will my pain be controlled

It is common to experience pain due to the injury. This can be controlled with medications. In severe cases, your doctor may suggest giving a nerve block by referring to a anaesthetist colleague. Most fractures hurt moderately for a few days to a couple of weeks after the injury. Many patients find that using ice after the slab/stitch removal, elevation (holding their arm up above their heart), and simple, nonprescription medications for pain relief are all that are needed to relieve pain. If your pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids.

Rehabilitation

Whether your treatment is surgical or nonsurgical, recovery from a radial head fracture requires work. During rehabilitation, your doctor or a physical therapist will provide you with exercises to help:

• Improve range of motion
• Decrease stiffness
• Strengthen the muscles within the elbow

Rehabilitation in Nonsurgical Treatment

Because nonsurgical treatment can sometimes require long periods of splinting or casting, your elbow may become very stiff. For this reason, you may need a longer period of physical therapy if you are treated conservatively. You will not be allowed to lift, push, or pull anything with your injured arm for a period of time till there is a clinical sign of the fracture uniting.

Rehabilitation in Surgical Treatment

Depending on the complexity of the fracture and the stability of the repair, your elbow may be splinted or casted for a period of time after surgery. Most patients will begin exercises to improve elbow and forearm motion shortly after surgery, sometimes as early as the next day. It is extremely important to perform the exercises as often as directed. The exercises will only make a difference if they are done regularly

What are the complications of surgery

There are risks associated with all surgery. If your doctor recommends surgery, he or she thinks that the possible benefits outweigh the risks. However, there is rare risk of complications with elbow fracture surgery

• Infection - There is a risk of infection with any surgery. Your doctor will take specific measures to help prevent infection.
• Damage to nerves and blood vessels - There is a minor risk of damage to nerves and blood vessels around the elbow. Temporary numbness in the hand, forearm or weakness in lifting the hand and wrist may occur. This is caused by stretching of the posterior interosseous nerve during surgery and may take weeks or months to go away. In rare cases, the nerve may be injured during surgery, and further surgery may be required to help the nerve recover.