What is the management plan for a patient with a nondisplaced radial head fracture at the right elbow?

Management of Nondisplaced Radial Head Fracture

For a nondisplaced radial head fracture in an adult, initiate conservative management with early mobilization: use a sling for comfort only (typically 3-7 days), begin immediate active finger motion exercises, and start gentle elbow range-of-motion exercises within 48-72 hours as pain allows. 1, 2, 3

Initial Treatment Protocol

Immobilization Strategy

• A sling is appropriate for comfort only and should be discarded as early as the patient's pain allows—typically within 3-7 days. 4, 1
• Rigid casting or prolonged immobilization is NOT indicated for nondisplaced radial head fractures, as this increases the risk of elbow stiffness, which is one of the most functionally disabling complications. 4, 5
• The primary concern with stable, nondisplaced radial head fractures is post-immobilization stiffness, not fracture displacement. 2

Early Mobilization (Critical to Prevent Stiffness)

• Begin active finger motion exercises immediately after diagnosis to prevent edema and stiffness. 4, 5
• Initiate gentle elbow range-of-motion exercises (flexion-extension and pronation-supination) within 48-72 hours as pain tolerance permits. 1, 3
• Aggressive finger and hand motion is necessary once any brief immobilization period ends to facilitate optimal outcomes. 4
• Early mobilization does not adversely affect healing of adequately stable fractures. 5

Follow-Up Imaging

• Routine serial radiographs are not necessary if the fracture remains nondisplaced and the patient is progressing clinically. 4
• Consider repeat radiographs only if clinically indicated: new trauma, pain score >6/10, loss of range of motion, or neurovascular symptoms develop. 4
• If routine imaging is preferred, obtain radiographs at approximately 2-3 weeks to confirm maintained alignment and at cessation of any protective measures. 4, 5

Red Flags Requiring Surgical Consideration

Assess for Associated Injuries (Critical Pitfall to Avoid)

• Nondisplaced radial head fractures can be associated with ligamentous injuries (lateral collateral ligament complex, medial collateral ligament) or other fractures that create elbow instability. 2, 6
• Examine specifically for: elbow joint instability on varus-valgus stress testing, mechanical block to pronation-supination, and associated coronoid or olecranon fractures. 4, 6, 7
• The presence of a large elbow joint effusion on radiographs (anterior and posterior fat pad signs) in the context of a "nondisplaced" fracture warrants careful clinical examination to exclude occult displacement or associated injuries. 4

Indications That Would Change Management to Surgical

• Mechanical block to forearm rotation (pronation-supination) despite being "nondisplaced" on static radiographs. 6, 7
• Fragment displacement >2mm on any view. 6, 7
• Associated elbow dislocation, coronoid fracture, or ligamentous injury causing instability. 2, 6
• Complete loss of cortical contact of any fracture fragment (suggests higher risk of associated injuries). 6

Rehabilitation Progression

• Progress range-of-motion exercises as tolerated, avoiding forceful passive stretching in the first 3-4 weeks. 1
• Strengthening exercises can begin at 4-6 weeks once fracture healing is evident and pain-free range of motion is improving. 1, 3
• Return to full activities typically occurs at 6-8 weeks for nondisplaced fractures managed conservatively. 3

Common Pitfalls

• Overly aggressive physical therapy in the early phase can paradoxically worsen stiffness and pain. 4
• Prolonged immobilization beyond 1 week is the most common error and leads to preventable elbow stiffness. 2, 3
• Failing to assess for mechanical block to rotation or associated ligamentous injuries can result in missed indications for surgical intervention. 6, 7