Is a splint or sling more appropriate for a potential displaced radial head or neck fracture, and is an urgent orthopedic (ortho) referral necessary?

Management of Suspected Radial Head or Neck Fracture

For a suspected displaced radial head or neck fracture, immobilize the extremity with a splint in the position found and arrange urgent orthopedic referral within 24-48 hours, as displaced fractures often require operative management to restore radiocapitellar contact and prevent elbow instability. 1, 2

Immediate Immobilization Strategy

Splint vs. Sling Decision

• Use a splint rather than a sling alone for suspected radial head or neck fractures, as splinting stabilizes the extremity and prevents further injury while reducing pain 1
• Do not attempt to straighten or realign an angulated fracture—splint in the position found 1, 3
• The splint should be padded to cushion the injury 1
• If immediate medical care is unavailable and you are far from definitive healthcare, stabilization with a splint is recommended 1

Critical Assessment Before Immobilization

• Check for vascular compromise immediately: if the injured extremity is blue or extremely pale, activate EMS immediately as this represents a medical emergency 1
• Cover any open wounds with a dressing before splinting 1

Urgency of Orthopedic Referral

Displaced Fractures Require Urgent Referral

• Displaced radial head or neck fractures warrant urgent orthopedic consultation within 24-48 hours because these injuries often require operative intervention 4, 2
• Displaced unstable fractures are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement is necessary to prevent subluxation or dislocation of the elbow and forearm 4
• Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm 2

Factors Indicating Need for Operative Management

• Fragment displacement >4mm and angulation >30 degrees impair outcome and typically require surgical intervention 5
• Fractures with three or more fragments, unstable partial articular fractures, or those with metaphyseal comminution often require radial head replacement rather than fixation 2
• In pediatric patients, Judet type III and IV injuries or those demonstrating mechanical block to motion require closed or open reduction under anesthesia 6

Common Pitfalls to Avoid

Do Not Delay Mobilization Unnecessarily

• While initial immobilization is appropriate, prolonged rigid immobilization beyond what is necessary leads to joint stiffness, which is functionally disabling and difficult to treat after healing 3
• For simple, minimally displaced fractures confirmed by imaging, early mobilization after 48 hours of initial immobilization produces better functional outcomes than prolonged casting 5

Do Not Assume All Radial Head Fractures Need Surgery

• Most simple, undisplaced or minimally displaced (<2mm) partial fractures are stable and can be managed non-operatively with short-term immobilization followed by early mobilization 4, 2
• However, you cannot definitively determine displacement without imaging, so urgent orthopedic evaluation with radiographs is essential 4

Definitive Management Pathway

• Arrange orthopedic evaluation within 24-48 hours for radiographic assessment and treatment planning 4, 2
• The orthopedic surgeon will determine if the fracture is stable (can be managed with brief immobilization and early mobilization) or unstable (requires operative fixation or radial head replacement) 5, 4, 2
• Radiographic follow-up at approximately 3 weeks is recommended to assess healing 7, 3