Radial Head Fractures – Causes, Diagnosis, Treatment 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] 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 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] 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. History Your doctor in the emergency department may ask the following questions How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology) When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months) What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture? Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery? What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc? Physical Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain. Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing. Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function. Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function. Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint. Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill). Lab Test Laboratory tests should be done as an adjunct in overall medical status for surgical treatment. CBC, ESR test Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus. Microscopic urine examination test, and stool test. ECG, EKG test for heart abnormality is present Ultrasonography test in some cases. Normalized hemoglobin, hematocrit test Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed, Partial thromboplastin time (PTT), and platelet counts will be needed for operative intervention. Serum creatinine test, Serum lipid profile Serum uric acid test 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] 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.) 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. 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. 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. Do no HARM for 72 hours after injury Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing. Alcohol – stimulates the central nervous system that can increase bleeding and swelling and decrease healing. Running and movement – Running and walking may cause further damage, and causes healing delay. Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain. Medication The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema. NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, dexlansoprazole, etc. Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture. Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis. Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia. Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx] Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item. Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep. Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints. Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health. Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup. What To Eat and What to avoid Eat Nutritiously During Your Recovery All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat. Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again. Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon. Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation). Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives. 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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686442/ https://www.ncbi.nlm.nih.gov/books/NBK448140/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721345/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631956/ https://en.wikipedia.org/wiki/Radial_head_fracture https://orthoinfo.aaos.org/en/diseases–conditions/distal-radius-fractures-broken-wrist/ https://www.orthobullets.com/trauma/1027/distal-radius-fractures https://www2.aofoundation.org/wps/portal https://www.sciencedirect.com/topics/medicine-and-dentistry/colles-fracture https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/colles-fracture https://medlineplus.gov/ency/patientinstructions/000896.htm https://www.physio-pedia.com/Colles_Fracture Show More