What is the recommended management for a stable radial head fracture in an adult?

Management of Stable Radial Head Fractures in Adults

For stable radial head fractures in adults, non-operative treatment with early mobilization is recommended as the first-line approach to optimize functional outcomes and minimize complications.

Classification and Diagnosis

Radial head fractures are the most common elbow fractures in adults, accounting for approximately 5% of all adult fractures 1. The Mason classification is typically used to guide treatment:

• Type I: Non-displaced fractures (≤2mm displacement)
• Type II: Displaced partial head fractures (>2mm)
• Type III: Comminuted fractures
• Type IV: Fractures with associated elbow dislocation

Stable fractures typically refer to Mason Type I and some Type II fractures without mechanical block to motion.

Treatment Algorithm for Stable Radial Head Fractures

Initial Management

1. Immobilization:

   • Brief immobilization (3-5 days) with a posterior splint in 90° of elbow flexion
   • Avoid prolonged immobilization as it may lead to stiffness

2. Early Active Motion:

   • Begin active range of motion exercises within the first week
   • Active finger motion should be initiated immediately following diagnosis 2
   • Early mobilization helps prevent stiffness and improves functional outcomes

Follow-up Care

• Radiographic follow-up at 1-2 weeks to ensure maintained alignment
• Continue with progressive range of motion exercises
• Return to normal activities as tolerated, typically within 6-8 weeks

Evidence Supporting Non-operative Management

Non-operative treatment with early mobilization has shown excellent outcomes for stable radial head fractures. The most recent evidence supports this approach for undisplaced or minimally displaced fractures 3, 4.

Key points from the evidence:

• Undisplaced or minimally displaced fractures should be treated non-operatively 3
• Isolated, minimally displaced fractures without mechanical block to motion can be treated with early active range of motion 4
• Brief immobilization followed by early mobilization provides optimal functional outcomes

Special Considerations

Elderly Patients

For older patients (>55 years), non-operative treatment remains the preferred approach for stable fractures. The EULAR/EFORT recommendations note that most proximal humeral fractures (which share similar principles with radial head fractures) can be treated non-operatively with good functional outcomes 2.

Associated Injuries

It's crucial to evaluate for associated injuries that may alter management:

• Ligamentous injuries (particularly to the medial collateral ligament)
• Coronoid process fractures
• Essex-Lopresti lesions (disruption of the interosseous membrane)
• Elbow dislocations

If these associated injuries are present, the treatment algorithm may need to be modified, potentially favoring surgical intervention even for otherwise stable radial head fractures.

Pitfalls and Caveats

1. Overlooking associated injuries: Always examine the entire upper extremity, including the wrist and shoulder
2. Delayed mobilization: Prolonged immobilization leads to stiffness and poorer outcomes
3. Inadequate follow-up: Ensure radiographic healing and functional improvement
4. Misclassification: What appears to be a stable fracture may be unstable if associated injuries are missed

When to Consider Surgical Management

Even with initially stable fractures, surgical management should be considered if:

• Fracture displacement increases during follow-up
• Mechanical block to motion develops
• Instability becomes apparent during rehabilitation

For displaced fractures with greater than 3 fragments, radial head replacement is generally recommended over fixation attempts 4.

By following this algorithm for stable radial head fractures, clinicians can optimize functional outcomes while minimizing complications and unnecessary surgical interventions.