Fractures, Sprains and Strains

Radial Head Fractures of the Elbow

Anatomy

The elbow is a complex joint that allows bending and straightening (flexion and extension), and forearm rotation (pronation, palm down; and supination, palm up). The elbow is formed by the joining of three bones: the upper arm (humerus), the forearm on the pinky finger side (ulna), and the forearm on the thumb side (radius). The radius bone goes from the wrist to the elbow. The radial head is at the top of the radius bone, nearest the elbow.

The surfaces of these bones, where they meet to form the joint, are covered with articular cartilage, a smooth substance that protects the bones and acts as a natural cushion to absorb forces across the joint. A thin, smooth tissue, called synovial membrane, covers all remaining surfaces inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction as you bend and rotate your arm.

Held together by muscles, ligaments and tendons, the elbow is a combination hinge and pivot joint. The hinge part of the elbow allows the arm bend like the hinge of a door, while the pivot part makes it possible for the lower arm to twist and rotate. There are several muscles, nerves and tendons that cross at the elbow.

Description

Although attempting to break a fall with outstretched hands may be an instinctive response, the force of the impact can travel up the forearm and result in a dislocated elbow or break in the radius, which often occurs in the radial head. Many elbow dislocations also involve fractures of the radial head. Radial head fractures occur in approximately 20% of all acute elbow injuries, are more frequent in women than in men, and are more likely to occur between 30 and 40 years of age.

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

Diagnosis

Fractures are classified by type, according to the degree of displacement, or how far out of normal position the bones are.

• Type I—Generally small or crack-like, and the pieces of bone remain fitted together. Type I fractures may not be visible on initial X-rays, but can typically be seen on X-rays taken 3 weeks after the injury.
• Type II—Slightly displaced, involving a larger piece of bone.
• Type III—Multiple pieces of broken bone which cannot be put back together for healing. Most type III radial head fractures also include significant damage to the elbow joint and surrounding ligaments.

Nonsurgical Treatment

Your orthopaedic surgeon will determine the appropriate treatment based on the type of fracture. Type I fractures typically require use of a splint or sling for several days, followed by an early, gradual increase in elbow and wrist movement, depending on the level of pain experienced. Type II fractures require use of a splint or sling for 1-2 weeks, followed by range-of-motion exercises.

For type I and type II fractures that are treated without surgery, axial loading activities should be avoided for the first 6 weeks after the injury. Axial loading activities involve pushing with the hand because this directs the force up through the forearm and into the elbow, putting pressure and force against the injured radial head. Examples of axial loading activities include: pushups, bench pressing weights, pushing heavy carts or objects, and using the hand to help push up, or stand up from a seated position.

Surgery

• Type II fracture surgical treatment—If there are small fragments of bone that prevent normal elbow movement or have the potential to cause long-term problems with the elbow, they may need to be surgically removed. If fragments are large and far out of place, surgery may include the use of screws, or a plate and screws, to hold the bones together. If this is not possible, the orthopaedic surgeon will remove the broken pieces of the radial head. Torn ligaments or any other soft-tissue injuries will also be corrected during surgery.
• Type III fracture surgical treatment—Surgery is frequently required to fix or remove pieces of broken bone and repair soft-tissue damage. When damage is severe, the entire radial head may need to be removed. In some cases, an artificial radial head may be put in place to improve long-term function.
• Risks and complications—With any surgery, there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.

Recovery

Even the simplest of fractures may result in some loss of movement in the elbow. Depending on your fracture and treatment, your orthopaedic surgeon may recommend early movement to stretch and bend the elbow to help avoid stiffness. Discomfort, especially with certain movements, often lasts for months after a radial head fracture to the elbow, however, it should gradually fade with time.

Regardless of the type of fracture or the treatment used, exercises to restore movement and strength will be needed before resuming full activities.