What is the appropriate treatment for an elbow radial head fracture?

Treatment for Elbow Radial Head Fracture

The majority of radial head fractures should be managed nonoperatively, with surgical intervention reserved for displaced fractures where open reduction internal fixation (ORIF) is preferred over radial head arthroplasty (RHA) in most cases, particularly in younger patients. 1

Initial Management Algorithm

Non-displaced Fractures

• Nonoperative management is the standard treatment for non-displaced radial head fractures. 2, 3
• Approximately 85% of all radial head fractures are managed nonoperatively in current practice. 1
• Early mobilization should be initiated once pain allows to prevent stiffness. 2

Displaced Fractures Requiring Surgery

When surgical intervention is indicated (only 5.1% of cases), the decision tree follows this hierarchy: 4

Primary Choice: Open Reduction Internal Fixation (ORIF)

• ORIF is the preferred surgical treatment for displaced radial head fractures when stable fixation is achievable. 1, 4
• ORIF accounts for 57.1% of surgically treated radial head fractures. 4
• Use headless low-profile screws when possible, placed in the "safe zone" (a right angle based laterally with forearm in neutral position). 2
• Plate fixation may be necessary but carries higher risk of loss of pronation-supination and often requires later implant removal. 2

Key Technical Points for ORIF: 2

• Approach via split in extensor digitorum communis (EDC) origin to minimize lateral ulnar collateral ligament injury
• Provisional fixation with K-wires and reduction clamps
• Confirm appropriate fixation with fluoroscopy and range of motion testing

When to Consider Radial Head Arthroplasty (RHA)

RHA should be considered in specific circumstances: 4, 5, 6

• Severely comminuted fractures (Mason III/IV) that preclude stable fixation 5
• Older patients with multiple comorbidities 1
• Associated coronoid fracture (64.2% treated with arthroplasty) 4
• Elbow dislocation present (54.3% treated with arthroplasty) 4
• Suspected Essex-Lopresti injury with longitudinal forearm instability on push-pull fluoroscopic testing 2

Critical technical considerations for RHA: 5

• Proper implant sizing is essential
• Optimal implantation height must be determined—excessively high placement causes capitellar overloading, stiffness, and pain
• Treatment of concomitant ligamentous injuries is crucial for success

Radial Head Excision

• Rarely used as definitive treatment (4.9% of surgical cases). 4
• May be considered in older, lower-demand patients when replacement is not available. 7
• Avoid in younger patients due to risk of elbow/forearm instability and ulnohumeral degenerative changes. 2, 5

Special Considerations for Complex Injuries

Terrible Triad Injury (TTI)

When radial head fracture occurs with elbow dislocation and coronoid fracture: 7

• For Mason type III fractures in TTI, resection may provide better outcomes than ORIF (better ROM in extension, pronation, supination, and better Mayo Elbow Performance Scores). 7
• However, overall ORIF demonstrates better ROM across all fracture types in TTI. 7
• RHA is frequently chosen in this setting when comminution is severe. 4

Outcomes and Revision Rates

ORIF has higher revision surgery rates compared to arthroplasty: 4

• ORIF: 12.7% at 1 year, 14.4% at 2 years
• RHA: 8.6% at 1 year, 10.7% at 2 years
• Excision: 8.3% at 1 year, 8.4% at 2 years

RHA provides satisfactory clinical outcomes in 60-80% of cases. 5

Common Pitfalls to Avoid

• Do not perform RHA in young, active patients unless absolutely necessary—surgeons demonstrate clear preference for fixation in this population. 6
• Avoid radial head excision as primary treatment in the presence of ligamentous instability or Essex-Lopresti injury. 2, 5
• Do not overlook associated injuries—coronoid fractures, elbow dislocations, and ligamentous injuries significantly alter treatment algorithms. 8, 4
• Prevent capitellar overloading with RHA by ensuring proper implant height—this is the most common complication requiring implant removal. 5

Imaging for Surgical Planning

When radiographs are indeterminate and fracture is suspected: 8

• CT without contrast is the preferred advanced imaging modality to clarify fracture morphology, fragment size, displacement, and angulation
• CT identifies occult fractures in 12.8% of patients with positive elbow extension test
• MRI is not indicated for osseous injury assessment