Radial Head Fractures

Radial head fractures are the most common fracture of the elbow. Most commonly, they are minimally displaced (ie. not moved very much). While minimally displaced radial head fractures don’t require surgery, they can still cause problems.

Far and away, the most common problem people have following radial head fractures is stiffness. Many generalists or emergency room physicians have a knee-jerk reaction, and splint all fractures. And while there’s nothing wrong with splinting a minimally displaced radial head fracture for a few days, if the elbow is immobilized for over a week or two it becomes much tougher for many patients to regain full motion. Permanent elbow stiffness may result.

I much prefer to put patients in a sling for comfort and to begin range of motion exercises within 2-5 days after the fracture. If motion is painful, it’s often best to aspirate the blood clot that’s collected inside the elbow joint. This decreases the pressure inside the elbow, making it easier and less painful to move. It’s analogous to letting some water out of a water balloon to make it easier to bend. If it’s difficult to regain motion, physical therapy will usually be prescribed.

Some radial head fractures are displaced or comminuted (many pieces) and require surgical fixation or even replacement with a metal radial head. This is where it’s very important to be seen by an experienced elbow specialist, as the more severe radial head fractures are often associated with severe elbow ligament injuries and/or other small but important fractures about the elbow. Bad radial head fractures may even be associated with severe ligament injuries about the wrist. If these other associated ligament or bony injuries are missed or ignored, permanent instability, pain, stiffness, weakness and compromise of elbow function may result. As well as further complex reconstructive surgeries to try to salvage the elbow.

If the radial head fracture is displaced and in only 2 or 3 pieces, it is often best to fix it with screws, if possible. While plates are sometimes necessary, plates often lead to pain, stiffness and swelling, and are usually removed after 4-6 months.

Radial head fractures that split the head into 4 or more pieces do better with replacement. Subspecialty knowledge and experience is extremely important here. While seemingly straightforward to many surgeons, it is quite common for inexperienced surgeons to ‘overstuff’ the elbow joint by implanting too large a radial head replacement, leading to residual pain, stiffness, weakness and arthritis. More experienced upper extremity surgeons are far less likely to make this technical error.

In addition, if associated lateral collateral ligament injuries, medial collateral ligament injuries, coronoid fractures, or wrist and forearm injuries are missed, the initial surgery may not be sufficient, and further complex reconstruction surgeries may be required to salvage the elbow and minimize future problems.

Expertise is also important following surgery. Certain ligament injuries will require special post-operative care that is best performed by an experienced therapist. Be forewarned: I am extremely picky about which therapist patients work with following elbow ligament repair and reconstruction. Simply put, not all therapists have the knowledge and experience to safely rehabilitate complex elbow ligament surgeries without stressing those structures, potentially compromising the results of an otherwise well-done surgery. A good therapist can often help regain full or nearly full motion and function following successful elbow surgery. A knowlegeable therapist combined with an experienced elbow surgeon and a motivated patient is the best team possible for restoring optimum motion and function to the severely injured elbow.

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