Radial Head Fractures; Causes, Diagnosis, Treatment

Radial head fractures
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Radial head fractures represent approximately one-third of elbow fractures and 1% to 4% of fractures in adults. A few years ago, the radial head was considered of little importance in the elbow anatomy and biomechanics, so its excision was frequently indicated. Laboratory studies and long-term series outcomes have shown the undesirable consequences of this method. Associated injuries usually determine treatment and outcomes.[rx]

Radial head fractures

Anatomy Radial Head Fractures

A 180-degree arch in the pronation and supination is allowed by the articulation of the proximal end of the radius with the distal humerus (capitulum), and with the ulna in the lesser sigmoid cup (trochoid joint). Cartilage covers the radial head except for the anterolateral third that lacks subchondral bone, and it is easily fractured. It has a 40-degree central cavity, and it is oval-size-like. The head and neck are not collinear with the diaphysis and complete a 15-degree offset angle. They are closely related to the lateral ligament complex, mainly the annular ligament and radial collateral ligament.[rx]

The physiologic elbow range of movement is zero to 150 degrees of flexion and extension, and  85 degrees of pronation and  75 degrees of supination.[rx]

The radial head stabilizes in valgus when the internal ligament complex is injured, and it does not take part when being harmless (secondary stabilizer). Moreover, it is involved in longitudinal stability. [rx]

Causes of Radial Head Fractures

Colles’ fracture

  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of broken radial head fractures.
  • Sports injuries – Many radials and radial head fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause radial head fractures to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Radial Head Fractures

Common symptoms of  radial head fractures include:

  • Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
  • Swelling
  • Tenderness
  • Bruising
  • Obvious deformity, such as a bent wrist
  • Pain
  • The wrist hanging in a deformed way
  • Pain, especially when flexing the wrist
  • Deformity of the wrist, causing it to look crooked and bent.
  • Your wrist is in great pain.
  • Your wrist, arm, or hand is numb.
  • Your fingers are pale.

Diagnosis of Radial Head Fractures

Diagnosis can be made upon the interpretation of anteroposterior and lateral views alone.[rx]

The classic radial head fractures have the following characteristics:[rx]

  • Transverse fracture of the radial and ulnar shaft fractures
  • dorsal displacement and dorsal angulation, together with radial tilt[rx]

Other characteristics[rx][rx]

  • Radial shortening
  • Loss of ulnar inclination≤
  • Radial angulation of the wrist
  • Comminution at the fracture site
  • Associated fracture of the ulnar styloid process in more than 60% of cases.

Differential Diagnosis/ Associated Injuries

  • Scapholunate ligament tear
  • Median nerve injury
  • TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
  • Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
  • Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
  • Compartment syndrome
  • Ulnar styloid fracture
  • DRUJ (Distal Radial Ulnar Joint) Instability
  • Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures[rx]
X-ray of a displaced intra-articular radial head fractures in an external fixator – The articular surface is widely displaced and irregular. Diagnosis may be evident clinically when the radial head fractures are deformed but should be confirmed by X-ray. The differential diagnosis includes scaphoid fractures and wrist dislocations, which can also co-exist with radial head fractures. Occasionally, fractures may not be seen on X-rays immediately after the injury. Delayed X-rays, X-ray computed tomography (CT scan), or Magnetic resonance imaging[rx] (MRI) can confirm the diagnosis.

Medical Imaging

  • Fracture with a dorsal tilt – Dorsal is left, and volar is right in the image.
  • X-ray of the affected wrist is required if a fracture is suspected. Posteroanterior, lateral, and oblique views can be used together to describe the fracture.[rx] X-ray of the uninjured wrist should also be taken to determine if any normal anatomic variations exist before surgery.[rx]
  • A CT scan is often performed to further investigate the articular anatomy of the fracture, especially for fracture and displacement within the distal radio-ulnar joint.[rx]
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Various kinds of information can be obtained from X-rays of the wrist:[rx]

Lateral view

  • Carpal malalignment – A line is drawn along the long axis of the capitate bone and another line is drawn along the long axis of the radius. If the carpal bones are aligned, both lines will intersect within the carpal bones. If the carpal bones are not aligned, both lines will intersect outside the carpal bones. Carpal malignment is frequently associated with a dorsal or volar tilt of the radius and will have poor grip strength and poor forearm rotation.[rx]
  • Teardrop angle – It is the angle between the line that passes through the central axis of the volar rim of the lunate facet of the radius and the line that pass through the long axis of the radius. Teardrop angle less than 45 degrees indicates the displacement of the lunate facet.[rx]
  • Anteroposterior distance (AP distance) – Seen on lateral X-ray, it is the distance between the dorsal and volar rim of the lunate facet of the radius. The usual distance is 19 mm.[rx] Increased AP distance indicates the lunate facet fracture.[rx]
  • Volar or dorsal tilt – A line is drawn joining the most distal ends of the volar and dorsal side of the radius. Another line perpendicular to the longitudinal axis of the radius is drawn. The angle between the two lines is the angle of volar or dorsal tilt of the wrist. Measurement of volar or dorsal tilt should be made in true lateral view of the wrist because pronation of the forearm reduces the volar tilt and supination increases it. When the dorsal tilt is more than 11 degrees, it is associated with loss of grip strength and loss of wrist flexion.[rx]

Posteroanterior view

  • Radial inclination – It is the angle between a line drawn from the radial head fractures to the medial end of the articular surface of the radius and a line drawn perpendicular to the long axis of the radius. Loss of radial inclination is associated with loss of grip strength.[rx]
  • Radial length – It is the vertical distance in millimeters between a line tangential to the articular surface of the ulna and a tangential line drawn at the most distal point of radius (radial styloid). [rx]
  • Ulnar variance – It is the vertical distance between a horizontal line parallel to the articular surface of the radius and another horizontal line drawn parallel to the articular surface of the ulnar head. Positive ulnar variance (ulna appears longer than radius) disturbs the integrity of triangular fibrocartilage complex and is associated with loss of grip strength and wrist pain.[rx]

Oblique view

  • Pronated oblique view of the distal radius helps to show the degree of comminution of the radial and ulnar shaft fractures, depression of the radial styloid and confirming the position the screws at the radial side of the distal end radius. Meanwhile, a supinated oblique view of shows the ulnar side of the distal radius, accessing the depression of dorsal rim of the lunate facet, and the position of the screws on the ulnar side of the distal end radius.[rx]

Treatment of Radial Head Fractures

Non-Surgical

Treatment available can be broadly

  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Radial head fractures cause significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness and tingling in the arm/hand.
  • Apply ice to your radial head fractures – After you get home from the hospital radial head fractures (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your radial head fractures  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
    Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the radial head fractures so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your distal radius fractures need to move a little bit during the later phases of the injury to stimulate complete recovery.
  • Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Get a supportive arm sling – Due to their anatomical position, radial head fractures can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both shoulders and the base of your neck in order to support the injured shoulder and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
  • Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and radial head fractures movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
  • Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with radial and ulnar shaft locking plate, coracoclavicular screws, Knowles pin fixation.
  • Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vicryl tape, dacron arterial graft for coracoclavicular ligament reconstruction.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
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Rest your Hand

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your radial head fractures and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
  • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
  • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the radial head fractures.
  • Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
  • Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the clavicle injury.

Eat nutritiously during your recovery

All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal broken bones of all types, including ulnar styloid. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your radial and ulnar shaft fractures. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

Physical therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  After a radial head fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.
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Follow-up care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

  • To elevate breathing problem or remove the lung congestion if needed.

Medication

Surgical Treatment

  • Radial head excision – Indication in severe pain in selected cases for instance older adults with a low demand with complex fractures but no associated fractures which compromise stability. One option is the differed excision with the same indication to the mentioned one or to enhance pronation-supination. [rx]
  • Open or arthroscopic – Fragment excision may be indicated in cases where these can obstruct joints and are too small for osteosynthesis and should not be part of the proximal radio-ulnar joint.
  • Osteosynthesis – As regards isolated fractures, it is an absolute indication when they cause a joint blockage. (Mason type 2) Step over 2 mm, joint fragment over 30%, neck fractures with angling over 30 degrees.[rx] Low profile plates and screws implants or cannulated are applied.
  • Surgical approach – (Kocher) between the anconeus and extensor carpi ulnaris (ECU), it provides good access to the back fragments and safety to the posterior interosseous nerve. Another option is extensor digitorium comunis (EDC) splinting to avoid iatrogenic injuries.
  • Osteosynthesis – should be placed in the safe interval to avoid interference with the proximal radio-ulnar joint which is located 110 external degrees with the elbow in neutral pronation-supination.
  • In complex fractures – osteosynthesis or prosthesis? It is convenient not to get more than three fragments with no impaction or deformity with enough bone quality and without metaphyseal bone loss to achieve stable internal fixation. In many cases, these fracture features are determined at surgery time.
  • Arthroplasty – Indication for non-repairable fractures. A prosthesis-sized appropriate choice is important to avoid articular stiffness. [rx]

Complications of Radial Head Fractures

  • Nonunion (1-5%)
  • Infection (~4.8%)
  • 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
  • Bleeding
  • Problems with wound healing
  • Blood clots
  • Damage to blood vessels or nerves
  • Reaction to anesthesia
  • Hardware prominence
  • Malunion with cosmetic deformity
  • Restriction of ROM
  • The difficulty with bone healing
  • Hardware irritation
  • Fracture comminution (Z deformity)
  • Fracture displacement
  • Increased fatigue with overhead activities
  • Dissatisfaction with appearance
  • The difficulty with shoulder straps, backpacks and the like
  • ~30% of patient request plate removal
  • Superior plates associated with increased irritation
  • Superior plates associated with increased risk of subclavian artery or vein penetration

References

Radial head fractures

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