Does a patient with a subtle impacted fracture of the radial head require surgical intervention?

From the Guidelines

Surgery is typically not needed for a subtle, non-displaced radial head fracture, and conservative management is usually the preferred treatment approach. These fractures can usually be managed conservatively with a brief period of immobilization (1-2 weeks) in a posterior splint or sling, followed by early range of motion exercises. Pain management with acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for 5-7 days is often sufficient 1. Physical therapy may be beneficial after the initial rest period to restore function.

Key Considerations

• Surgery becomes necessary only if the fracture is significantly displaced (>2mm), involves more than 30% of the articular surface, blocks forearm rotation, or if there is associated elbow instability 1.
• The radial head is crucial for elbow stability and forearm rotation, but most subtle fractures heal well without surgical intervention.
• Close follow-up with repeat imaging at 1-2 weeks is important to ensure the fracture remains stable and properly aligned during the healing process.

Treatment Approach

• Conservative management is the preferred approach for subtle, non-displaced radial head fractures.
• Surgical fixation may be considered for fractures with significant displacement or instability, but this is not typically the case for subtle, non-displaced fractures 1.

Important Factors

• The size of the fracture fragment and the amount of displacement or angulation may affect treatment options 1.
• Isolated radial head fractures, Essex-Lopresti injuries, and Monteggia fractures with dislocation of the elbow can be diagnosed with CT scans.
• The American Academy of Orthopaedic Surgeons (AAOS) and the American Society for Surgery of the Hand (ASSH) have developed evidence-based clinical practice guidelines for the treatment of distal radius fractures, which may be relevant to the treatment of radial head fractures 1.

From the Research

Treatment Options for Radial Head Fractures

The treatment for radial head fractures depends on the severity and type of fracture.

• Undisplaced or minimally displaced fractures can be treated non-operatively 2.
• Displaced fractures may require internal fixation, such as open reduction and internal fixation or prosthetic replacement 2, 3, 4.
• The decision to operate on a radial head fracture also depends on the presence of associated injuries, such as ligamentous or cartilaginous injuries 2, 3.

Subtle Impacted Radial Head Fractures

For subtle impacted radial head fractures, the treatment approach may be more conservative.

• If the fracture is stable and there is no mechanical block to motion, non-operative treatment may be recommended 3, 4.
• However, if the fracture is unstable or there is a mechanical block to motion, surgical intervention may be necessary 3, 4.

Factors Influencing Treatment

The treatment of radial head fractures is influenced by several factors, including:

• The type and severity of the fracture 2, 3, 4.
• The presence of associated injuries 2, 3.
• The patient's age, nutritional and health status, and medication use 5.
• The goal of treatment is to restore radiocapitellar contact and achieve coronal plane and longitudinal stability of the elbow and forearm 4.