Radial head fractures of the elbow
What is a Radial head fracture of the elbow?
Radius is a forearm bone that runs from the elbow to wrist. It is one of the bones of the elbow joint that articulates with ulna (another forearm bone) and humerus (arm bone) to form the elbow joint. Radius is essential for elbow flexion/extension and also forearm rotation. Fractures in the head of the radius are common among all elbow injuries. The main cause of these fractures is falling on the outstretched hand when the force of the fall goes from wrist to the head of the radial head.
33 % of elbow fractures are the fractures are radial head fractures. It accounts for 20% of all injuries of elbow and 1.5 to 4 % of all fractures. It is usually associated with the injuries to the adjacent ligaments, elbow dislocation, elbow fractures and rarely carpal fractures. These fractures are commonly seen in women than men, more prevalent in the age of 30-40 years.
What are the symptoms of Radial head fractures of the elbow?
The common symptoms of these fractures are the pain, swelling, and tenderness outside of the elbow. It becomes difficult to bend or straighten the elbow. You may also feel difficulty in turning the forearm. Stiffness and bruising are also common in the elbow.
How is it diagnosed?
Your orthopedic surgeon will investigate your medical history including history of your injury. He will perform a physical exam of your elbow to assess the range of motion and your symptoms. He will also order X-ray and CT scan in selected cases to find out the exact location and damage to the elbow.
What happens if nothing is done?
If it is left untreated, there can be non-union or malunion of the bone fragments leading to elbow stiffness and pain.
How is it treated?
It can be treated conservatively or surgically. Minimally displaced radial head fractures (Mason type I) is treated with conservative or non-operative treatment. It involves ice packs, rest, immobilization by a sling, medications, and physiotherapy
Surgery is indicated in
- Type II and type III radial head fractures
- Open fractures
- Displaced fractures
- Multiple fractures
- Associated injuries to nerves and ligaments
- Complex fractures with dislocations
What are the non-operative treatments?
The non-operative methods involve –
- Rest– the elbow of the patient is rested in a polysling for 1-2 weeks.
- Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first two days of the injury as it can relieve pain and swelling.
- Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate swelling in the elbow for few days as long-term consumption of these medicines may cause damage to your kidneys and stomach.
- Physical therapy- early motion exercises are started after 1 to 2 weeks of immobilization to prevent stiffness and maintain the good mobility in your elbow. Your elbow is prone for getting stiff and extra bone formation. Early physiotherapy under the supervision of your surgeon and physiotherapist is paramount for optimal outcome.
What does the operation involve?
The main goal of the surgical operation is to realign the bone fragments, repair the damaged ligaments and restore the normal function of the elbow. It is also focussed on the stabilization of the joint.
- It is usually done as a day case under general anaesthetic, a small incision is made on the skin of affected site to realign the bone fragments and repair the other damaged tissues.
- The bone fragments are internally fixed by pins, plates or screws to keep the bones in position while healing. If small fragments of bones are present, they are removed. If the radial head is severely broken, then it is removed and an artificial head is implanted to improve the long-term function of the joint. In some cases, with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap.
- The skin is stitched using absorbable sutures and a sling is applied. The surgical time is usually 1-2hrs and the majority of the patients go home the same day
What happens after surgery?
- The local anaesthetic ends in 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Initially, the aims are the comfort and rest the arm in a sling for a couple of days.
- Before discharge, you may see a physiotherapist, who will teach you gentle exercises of your fingers, wrist, and elbow. You may be able to start these gentle exercises on the day of your operation and they are essential to reduce stiffness and pain.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You could start a gentle range of movement (ROM) exercises after surgery and progress to more strenuous activities around six weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and clinical union of the fracture. It is advisable to avoid sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
Are there any risks?
- Stiffness in elbow
- Displacement of fractures (rarely in 5% of cases)
- Nerve injury
- Fixation failure
- Elbow instability
- Loss of forearm rotation
- Hardware failure
- Complex regional pain syndrome
- Joint arthritis
- Myositis ossificans
What are the results of the operation?
The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the injury, associated injuries, treatment involved and adherence to physiotherapy. However, is more predictable in the author’s experience.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury. You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
- CT scan showing comminuted radial head fracture
- Radial head replacement and ligament reconstruction with anchors
- ORIF with headless compression screws and ligament reconstruction