Radial Head Fracture

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Physical Therapy Videos - Elbow

Basic Anatomy

The elbow is the joint between your upper arm and your forearm. It is made of several joints. One of these is called the radial-capatellar joint. The disc-shaped radial head moves and rotates against a round part of the humerus called the capitellum. As your radial head moves against the capitellum, it allows you to turn your palm up (supination) and down (pronation), as well as allowing you to bend and straighten your elbow. The elbow allows you to move your hand in space and put it where you want it. The radial head is the key to this motion.

The elbow joint is surrounded by a thick capsule. There are lots of ligaments (tissues that connect bone to bone) that make the elbow stable and not "floppy." Lots of muscles are attached to the bone on both sides of the elbow joint, but the thickest parts of the muscles aren’t at the elbow itself. That’s why when you touch your elbow you can feel the bones easily under the skin. That also means it can be easy to break the elbow, because there isn’t much padding.

There are also nerves and blood vessels that cross the elbow. These are located mostly in the front of the elbow and on the inside. The ulnar nerve is located on the inside of the elbow close to the bone. When you hit this nerve, it is very painful and is commonly called hitting your "funny bone."

Skeleton model showing the elbow joint and the three bones that form the joint
Figure 1: Skeleton model showing the elbow joint and the three bones that form the joint. The blue arrows point to the radial head.

 

X-rays of a normal elbow
Figure 2: X-rays of a normal elbow, showing the elbow joint and the bones that form the joint. The white boxes are around the radial head.

Mechanism and Epidemiology

Most elbow fractures, including radial head fractures, happen when you fall onto your outstretched hand. As you try to catch yourself, the impact goes up your bones, from your wrist to your forearm to the elbow and up the humerus to your shoulder. At some point, the bones may not resist the weight and break. A common place for this to happen is at the radial head or neck. Other accidents such as direct hits or getting the arm caught in something can cause the radial head or neck to break.

The blue arrow points to a crack in the radial head
Figure 3: The red arrow points to a crack in the radial head. The surface of the bone, which is covered with cartilage, no longer lines up.

 

Radial head broken in several places
Figure 4: Sometimes the radial head is broken in lots of places, or is broken and out of place (dislocated or subluxed). The blue arrow points to where the radial head should be. The yellow line points to where the radial head is. The radial head has been outlined with red lines.

Initial Treatment

If you break your radial head, you will typically go to an emergency room. The pain and swelling after is generally bad enough that it hurts when you try to move your elbow. X-rays will be ordered to look at your elbow. Sometimes the break in the radial head or neck may not have moved out of place and can be hard to see. Other times the break may be in lots of pieces and easy to see. Many radial head breaks can be treated without surgery.

The emergency room physician may want to see if the broken piece of bone blocks motion of your elbow joint. This can be critical information to determine if you need surgery or not. To do this, a needle will be placed into your elbow joint to remove blood and to inject numbing medicine. The numbing medicine typically takes away your pain for a short time, so the physician can gently move your elbow to see if the broken bones are blocking motion. If the broken pieces limit the motion of your elbow, you may require surgery to fix this, and you should see an orthopaedic surgeon who treats broken bones as soon as possible.

You may receive a sling to make you more comfortable, told not to lift anything heavy, and be given an appointment with your physician or an orthopaedic surgeon. It is important to make this appointment to figure out what your best long-term treatment will be.

General Treatment

Most radial head fractures are treated without surgery. This requires the pieces to be lined up well and for there to be good motion at the elbow. Non-operative treatment usually means a short period of rest in a sling followed by gentle motion. Lifting, pushing and pulling more than a few pounds with the injured arm is limited for 6-12 weeks. Depending on your pain level, you may be able to get back to light activities such as typing early in the healing process. Your physician will typically get x-rays when you follow up with them to make sure that the break is healing or at least has not moved. You may be given a prescription for physical therapy to help regain motion.

If your bones are not lined up or the broken piece(s) block motion of your elbow joint, and/or if your bone is in multiple pieces, you may need surgery . This is done with a cut or incision on the outside of the elbow. In general, if the bones can be repaired they are fixed with screws, plate and screws, or very small wires. Your surgeon will make sure your bones line up well, and that the plates and screws don’t limit your elbow motion. If the radial head is broken into many small pieces, it may not be fixable. In those cases, a radial head replacement may be used. This is where the radial head fragments are removed, and a metal replacement is placed to substitute for the part of the bone that was removed.

A splint or brace may be used after surgery to limit motion. Pushing, pulling, and lifting more than 5 pounds is limited for 6-12 weeks to allow the bone and wound to heal. Your surgeon may recommend physical therapy to help prevent elbow stiffness. You will likely see your surgeon several times after your injury to make sure you are healing well.

Radial head fracture fixed with screws only
Radial head fracture fixed with plates and screws
Radial head fracture fixed with a radial head replacement
Figures 5-7: Radial head fractures fixed in different ways (from top to bottom): screws only, plates and screws, and a radial head replacement.

Post-operative Care

After surgery, you may have a splint or a cast to help protect your elbow as it heals. At some point, this will be removed. What you are allowed to do and when you can do it depends on your specific injury and your surgeon’s advice. After an elbow injury, it is common to start physical therapy early to try to prevent stiffness. It will likely be several weeks to months before you can lift, push, or pull more than 1-3 pounds. However, many people can get back to doing light activities such as writing and typing earlier. Your surgeon will see you to make sure you are progressing appropriately. X-rays will be taken periodically to check healing.

Long Term

Long-term issues after a radial head fracture include stiffness, arthritis, and pain. Stiffness is very common. You may not be able to get your elbow all the way straight or bend it as much as the other side. Fortunately, the typical amount of stiffness doesn’t greatly affect the use of your arm.

Arthritis can form in any joint that has had a break or an injury. Either stiffness or arthritis can cause pain. Sometimes extra bone forms around the elbow after a radial head fracture. Fortunately, this rarely happens unless you injuries are more extensive. It is more common when multiple bones in the elbow are injured. If this does happen, it can affect the motion of your elbow. Surgery or therapy may be needed. Radial head replacements can wear out over time and may need to be replaced or removed.

Physical Therapy Videos - Elbow

More Information

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Christopher Domes, MD
Edited by the OTA Patient Education Committee and Steven Papp, MD (section lead)
All x-rays and pictures taken from the personal collections of Dr. Domes and Christopher Doro, MD