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Radial Head Fracture
The two bones in the forearm are the radius and the ulna. The radius is the bone nearest your thumb and the ulna nearest the little finger. A fall onto an outstretched arm can result in a fracture of the upper end of the radius (the radial head). Radial head fractures are relatively uncommon injuries that can happen in isolation but frequently occur during an elbow dislocation, when the realignment of the humerus and ulna cause a piece of the radial head to be broken off.
At the proximal (upper) end of the bones, the ulna articulates with the radius and the humerus (upper arm bone) to form the hinge-like elbow joint. At the furthest (distal) end of the forearm, the radius articulates with the ulna and three of the wrist bones. A strong membrane between the radius and ulna holds the bones close together but allows them to rotate around each other to a certain degree so that we can turn our palms up and down.
Radial head fractures are classified according to their severity and the degree of separation between the bone pieces:
Type I:
These fractures are typically stable in that the bone is not displaced. The fractures tend to be small and crack-like.
Type II:
The bone pieces are slightly separated. The fracture involves a larger piece of bone, and there may be fragments broken off.
Type III:
The entire radial head has been broken into pieces (a comminuted fracture).
Type IV:
These comminuted fractures are often combined with a dislocation and affect associated soft tissues such as ligaments. A Monteggia fracture-dislocation with the radial head fractured is an example of a Type IV injury.
Causes:
A fall onto an outstretched arm, with the forearm angled, is the most usual cause of a radial head fracture. Rarely, this type of injury occurs as a result of a heavy blow, such as during a motor vehicle accident. In some cases, deterioration of the bone due to osteorarthritis or rheumatoid arthritis may result in a fracture.
Symptoms:
- Pain, sometimes severe, on the outer, upper or lower side of the elbow
- Desire to guard the elbow
- Holding the elbow in a flexed (bent) position
- Swelling and tenderness of the outer side of the elbow
- Loss of range of motion. Difficulty bending or straightening the arm, and difficulty turning the palm up or down.
- Possible numbness or tingling sensation
- Depending on injury, visible deformity of the elbow
Diagnosis:
The doctor will ask you about the circumstances of your injury. He or she will gently palpate (touch) your elbow, feeling for signs of fracture or dislocation. You will be asked to try to straighten your arm and move your hand. The doctor will probably do some passive tests (the doctor moves your arm for you) to assess the stability of the elbow joint ligaments. Your wrist will be checked for injury as wrists are often damaged at the same time as an elbow injury.
The blood and nerve supply will be carefully checked as several nerves and blood vessels pass through the elbow joint.
X-rays show bone structure very clearly. Several will taken of the elbow from different angles to aid diagnosis and ensure that any other bone injuries are discovered. If damage to soft tissues such as ligaments is suspected, CT (computed tomography) scans of the elbow may also be taken.
Treatment:
The aim of treatment is to regain maximum function and stability of the elbow joint. The method used will depend on the type of fracture.
First aid will consist of applying ice to the elbow to relieve swelling, and administering pain medication. The elbow will be placed in a splint and supported in a sling. If a bone fragment has pierced the skin (a compound fracture) there is a serious risk of infection so surgery would be immediate. The wound would be thoroughly cleaned and any repair to the bone or soft tissues performed at the same time.
Type I fractures are usually treated conservatively (non-operatively). If the patient is an adult and the degree of bone displacement is less than 2 mm, the doctor will attempt to realign the bone without the need for surgery. This is called a closed reduction. If there is no displacement, there is no need for manipulation. Following reduction, the elbow would be placed in a sling, with perhaps a few days wearing a splint as well. Pain medication, non-steroidal anti-inflammatory drugs (NSAIDs) and icing of the elbow would continue to provide relief.
Type II, III, and IV fractures require surgery. The best results are achieved with a technique called open reduction internal fixation. During surgery the bone pieces are realigned and held in position with orthopedic fixing devices such as screws, pins or plates. Damaged soft tissues would be trimmed or reattached as necessary. After surgery the arm would be placed in a long arm cast with the elbow bent at 90 degrees. This would be worn for two weeks and then changed to a hinged brace to allow range of motion exercises to begin.
Your doctor or physical therapist will develop a program of rehabilitation exercises, starting at the correct time for your particular injury. Because of the complexity of the elbow joint it is important to follow medical advice and to perform the recommended exercises regularly. Physical therapy may include massage, initial passive movement of the elbow, ultrasound, and exercises to restore range of motion and strength.
Prognosis:
With any bone fracture there is a risk of developing arthritis, particularly if the articular surface of the bone has been damaged. Stiffness in the joint, even with physical therapy, may be a long-term problem, but will be minimized with proper attention to rehabilitation.
Exercises:
You should only begin rehabilitation exercises when your doctor has confirmed that the fracture is stable enough for you to do so. Try to do the exercises three times a day. You should not feel any pain when doing these exercises. If you do, stop.
Elbow Flex and Extend:
Standing, simply bend and straighten your elbow as far as it will go without force. You should not feel any pain. Repeat 10 times.
Rotations:
With your elbow by your side and bent to 90 degrees, carefully turn your hand up and down as far as it will go without force. Repeat 10 times.
Ball Squeeze:
Hold a soft ball, about the size of a tennis ball, in your hand. Squeeze the ball as hard as possible with causing yourself pain. Hold for 5 seconds. Repeat 10 times.
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