What is the treatment approach for radial head fractures?

Treatment of Radial Head Fractures

Treatment of radial head fractures depends on fracture displacement and stability: non-displaced or minimally displaced fractures should be managed conservatively with early mobilization, while displaced fractures require open reduction and internal fixation with headless screws, and comminuted unreconstructable fractures necessitate radial head replacement in younger patients or excision in elderly patients. 1

Initial Assessment and Classification

• Evaluate fracture displacement, stability, and associated injuries to determine the treatment pathway 1
• Obtain true lateral radiographs to assess alignment and rule out associated injuries 2
• CT scanning should be utilized when available to better characterize fracture patterns and comminution 1
• Look specifically for associated ligamentous injuries (lateral ulnar collateral ligament), cartilage damage, and other fractures, as these significantly influence management 3, 1

Treatment Algorithm

Non-Displaced or Minimally Displaced Fractures (Mason Type I)

• Treat conservatively with removable splint or minimal immobilization 4, 1
• Initiate immediate active finger motion exercises to prevent stiffness, which does not adversely affect adequately stabilized fractures 5, 4
• Avoid prolonged immobilization beyond 3 weeks, as extended immobilization increases stiffness risk and complications occur in approximately 14.7% of cases 5, 4
• Obtain radiographic follow-up at approximately 3 weeks and at time of immobilization removal 5, 4

Displaced Fractures (Mason Type II)

• Internal fixation with headless cannulated screws is the preferred treatment, providing satisfactory biomechanical stability through smaller incisions with fewer complications and less need for later hardware removal 1
• Use the extensor digitorum communis split approach to minimize risk of lateral ulnar collateral ligament injury 3
• Provisional fixation with Kirschner wires and small bone reduction clamps, followed by definitive headless low-profile screws placed in the safe zone (right angle based laterally with forearm in neutral position) 3
• Plate fixation is reserved for fractures with neck comminution, though this increases risk of motion loss in pronation-supination arc and often requires later implant removal 3, 1

Comminuted Unreconstructable Fractures (Mason Type III-IV)

• In younger patients or those with associated soft tissue/bony injuries: radial head replacement is indicated 6, 1
• In elderly patients without significant associated injuries: radial head excision is acceptable, though this results in radiographic degenerative changes that develop slowly and may be well tolerated 3, 1
• Radial head replacement is specifically indicated when Essex-Lopresti injury is suspected or longitudinal forearm instability is demonstrated on fluoroscopic "push-pull" testing 3

Critical Pitfalls to Avoid

• Do not immobilize for extended periods (>3 weeks), as this is a primary cause of poor outcomes including chronic stiffness requiring arthroscopic arthrolysis 7
• Never allow splints to obstruct full finger range of motion at any point during treatment 5
• Do not miss associated ligamentous instabilities (lateral or medial collateral ligaments), as 34 of 70 patients in one series had isolated lateral instability and 27 had combined stiffness with instability after conservative treatment 7
• Inadequate initial assessment leads to poor outcomes: in a retrospective study of 70 patients requiring revision surgery after conservative treatment, the average time to surgery was 50 months, with most suffering from stiffness, instability, or both 7

Post-Treatment Management

• Assess range of motion and confirm appropriate fixation, resection, or prosthetic position with fluoroscopy before wound closure 3
• Early motion rehabilitation protocols optimize functional outcomes, particularly for complex injuries 6
• Reevaluate any patient with unremitting pain during follow-up, as this may indicate complications requiring intervention 2
• Counsel patients undergoing plate fixation that implant removal is often necessary due to motion limitations 3
• Loss of terminal extension in the flexion-extension arc may occur and should be anticipated 3