What is the recommended treatment for a displaced radial head fracture in a generally healthy adult?

Treatment of Displaced Radial Head Fractures

For displaced radial head fractures in healthy adults, attempt open reduction and internal fixation (ORIF) first if stable reconstruction is achievable, as it provides superior functional outcomes compared to radial head arthroplasty (RHA); if reconstruction is not feasible due to severe comminution (≥3 fragments with inability to achieve stable fixation), proceed with radial head replacement. 1

Initial Assessment and Classification

When evaluating a displaced radial head fracture, you must:

• Obtain standard radiographs (AP, lateral, and oblique views of the elbow) to assess fracture pattern and displacement 2
• Use CT scanning to clarify fracture morphology, number of fragments, degree of comminution, and identify occult associated injuries 2, 3
• Assess for mechanical block to pronation/supination through clinical examination, as this is an absolute indication for surgery 3, 4
• Evaluate for associated injuries including lateral ulnar collateral ligament (LUCL) injury, coronoid fractures, and Essex-Lopresti injuries, as these significantly influence treatment decisions 3, 4, 5

Critical pitfall: Comminution of the radial head with complete loss of cortical contact of at least one fragment is highly associated with ligamentous injuries that may not be immediately apparent 3

Treatment Algorithm Based on Displacement and Fracture Pattern

Displacement >2mm WITHOUT Mechanical Block

• Consider either non-operative treatment with early mobilization OR ORIF - current evidence does not prove superiority of either approach for partial displaced fractures 6
• Non-operative management remains acceptable if no mechanical block exists 3, 4

Displacement >2mm WITH Mechanical Block

• Surgical intervention is mandatory 3, 4
• Proceed with ORIF if stable reconstruction is possible 1

Comminuted Fractures (≥3 Fragments)

The 2024 evidence provides the strongest guidance here:

• Primary ORIF should be attempted first regardless of fragment number, patient age, sex, or injury type, as long as stable fixation can be achieved 1
• This approach yields significantly better range of motion (flexion-extension arc 121.1° vs 108.1°; p=0.018) and functional scores (MEPS 90.1 vs 78; p=0.004) compared to primary RHA 1
• Convert to RHA only if stable reconstruction cannot be achieved during surgery 1
• Even if initial ORIF fails and requires conversion to secondary RHA, outcomes remain acceptable 1

Surgical Technique Considerations

For ORIF:

• Use headless low-profile screws when possible, as they provide satisfactory biomechanical stability, require smaller incisions, have fewer complications, and less frequently require later removal 4, 5
• Plate fixation is reserved for fractures with neck comminution where screws alone are insufficient 4
• Place implants in the "safe zone" (a right angle based laterally when forearm is in neutral position) to avoid impingement 5
• Use lateral approach via EDC split if no LUCL injury is present 5

For RHA (when ORIF not feasible):

• Indications include: unfixable comminution in younger patients, associated significant soft tissue/bony injuries, or suspected Essex-Lopresti injury 4, 6
• Elderly patients with unfixable fractures and no instability may be treated with simple excision 4

Expected Complications and Counseling Points

Implant-related complications occur at similar rates between ORIF (11.9%) and RHA (14.3%) 1

For ORIF patients:

• Loss of pronation-supination arc is particularly problematic with plate fixation 5
• Counsel patients that implant removal is often necessary 5
• Loss of terminal extension may occur 5

For RHA patients:

• Capitellar changes develop over time but are usually asymptomatic 5

For radial head excision (elderly, low-demand):

• Radiographic degenerative changes in ulnohumeral joint develop but symptoms progress slowly 5

Post-operative Management

• Early active range of motion is critical for all treatment modalities 4, 6
• Assess for longitudinal forearm instability (Essex-Lopresti) with push-pull test under fluoroscopy if not done intraoperatively 5

The key paradigm shift from older literature: The 2024 evidence 1 demonstrates that even complex radial head fractures with ≥3 fragments should undergo attempted ORIF first, contradicting older recommendations that suggested primary RHA for highly comminuted fractures 6. This represents the highest quality, most recent evidence and should guide current practice.