Initial Management of Nondisplaced Radial Neck Fractures
Nondisplaced radial neck fractures should be treated with immobilization in a cast or splint for 3 weeks, combined with appropriate pain control to facilitate early mobilization. 1, 2
Immobilization Strategy
The primary treatment is conservative management with short-term immobilization:
- Use either a cast or removable splint for immobilization 2, 3
- Duration should be 3 weeks, as this provides equivalent outcomes to longer immobilization periods while minimizing stiffness 4
- No closed reduction is required for nondisplaced fractures 3
The evidence strongly supports shorter immobilization periods. A randomized controlled trial demonstrated that 3 weeks of immobilization produces better patient-reported outcomes compared to 5 weeks, with no increase in complications or secondary displacement 4. This is particularly important because prolonged immobilization increases the risk of stiffness, which is one of the most functionally disabling complications 5.
Pain Management
Provide aggressive analgesia from the outset:
- Multimodal pain control is essential to enable early mobilization and prevent stiffness 1
- Adequate pain relief allows patients to participate in rehabilitation once immobilization is discontinued 1
Follow-Up Protocol
Radiographic monitoring should be minimal for truly nondisplaced fractures:
- Obtain radiographs at approximately 3 weeks (at time of immobilization removal) to confirm healing 5
- Avoid excessive radiographic follow-up if the fracture remains stable, as this leads to unnecessary radiation exposure and costs without changing management 6
A retrospective study of 56 nondisplaced radial head/neck fractures found that no patient developed complications requiring intervention beyond physical therapy, yet an average of 4.4 additional x-rays were obtained per patient without modifying treatment 6. This represents significant overtreatment.
Early Mobilization and Rehabilitation
Once immobilization is removed:
- Begin aggressive mobilization immediately with early physical training and muscle strengthening 1
- Active finger motion exercises should be performed throughout the immobilization period to prevent stiffness 5
- Early wrist and elbow motion exercises should commence after cast removal 1
Special Considerations
For patients over 50 years:
- Systematically evaluate for osteoporosis risk and consider secondary fracture prevention measures including calcium, vitamin D, and pharmacological treatment if indicated 1, 7
Red flags requiring surgical consideration:
- Any displacement >2-3mm warrants consideration for closed or open reduction 6, 3
- Mechanical block to motion requires operative intervention 3
- Judet type III or IV fractures (>30-60 degrees angulation) should undergo closed reduction 3
Common Pitfalls to Avoid
- Do not over-immobilize: Periods longer than 3 weeks increase stiffness without improving outcomes 4
- Do not order excessive follow-up radiographs: If the fracture is truly nondisplaced and stable, one follow-up x-ray at 3 weeks is sufficient 6
- Do not delay pain control: Inadequate analgesia leads to stiffness and poor functional outcomes 1
- Do not skip osteoporosis screening in older adults: These patients require systematic evaluation for secondary fracture prevention 1, 7