What is the management approach for a radial head fracture?

Management of Radial Head Fractures

The management of radial head fractures should be based on fracture type, displacement, and patient factors, with non-operative treatment recommended for undisplaced or minimally displaced fractures and surgical intervention for complex, displaced fractures that cause mechanical blocks to motion or instability.

Classification and Initial Assessment

• Mason classification is commonly used to guide treatment:

  • Type I: Undisplaced fractures
  • Type II: Displaced partial fractures
  • Type III: Comminuted fractures (≥3 fragments)
  • Type IV: Fractures with elbow dislocation

• Initial radiographic evaluation:

  • Standard 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique) 1
  • CT scan for complex fractures to better assess fragment number, displacement, and associated injuries 2

Treatment Algorithm

Non-operative Management

• Indicated for:

  • Undisplaced or minimally displaced fractures (Mason type I) 2, 3
  • Displaced fractures without mechanical block to motion 3

• Protocol:

  1. Brief immobilization (1-2 weeks) during inflammatory phase 4
  2. Early active range of motion exercises to prevent stiffness 1, 4
  3. Gradual return to activities during repair phase (2-8 weeks) 4
  4. Rehabilitation during remodeling phase (several months) to restore strength and motion 4

Surgical Management

• Indications for surgery:

  • Displaced fractures with mechanical block to motion
  • Comminuted fractures (Mason type III)
  • Fractures with associated ligamentous injuries or elbow instability
  • Failed conservative management 5

• Surgical options:

  1. Open Reduction and Internal Fixation (ORIF):

     • First-line treatment for reconstructable fractures regardless of fragment number 6
     • Preferred for younger patients with good bone quality
     • Headless cannulated screws preferred for most displaced fractures 2
     • Plate fixation for fractures with neck comminution 2

  2. Radial Head Arthroplasty (RHA):

     • For unreconstructable fractures (severely comminuted)
     • When stable fixation cannot be achieved
     • In elderly patients with poor bone quality 2
     • When associated with significant soft tissue or bony injuries 2

  3. Radial Head Excision:

     • Limited role in modern treatment
     • May be considered for unreconstructable fractures in elderly, low-demand patients 2

Outcomes and Complications

• Recent evidence shows ORIF provides superior outcomes compared to RHA when stable reconstruction is possible 6:

  • Better range of motion (flexion/extension: 121.1° vs 108.1°)
  • Better functional scores (MEPS: 90.1 vs 78)
  • Similar complication rates (ORIF: 26.2% vs RHA: 23.8%)

• Common complications:

  • Elbow stiffness
  • Chronic instability
  • Cartilage damage
  • Hardware-related issues

Special Considerations

• Associated injuries are important determinants of management and should be carefully assessed 2
• For distal radius fractures in patients >65 years, non-operative treatment is generally preferred as surgical fixation does not lead to improved outcomes 1
• For patients <65 years with distal radius fractures, operative fixation is supported for post-reduction radial shortening >3mm, dorsal tilt >10°, or intra-articular displacement >2mm 1
• Patients with radial head fractures should perform active finger motion exercises to prevent stiffness 1

Follow-up

• Radiographic follow-up may be reduced to minimize radiation exposure without affecting outcomes 1
• Patients with unremitting pain during follow-up should be reevaluated for potential complications 1
• Consider arthroscopic arthrolysis for patients with persistent stiffness after conservative treatment 5