Surgical Management and Post-Operative Rehabilitation of Radial Head Fractures

Radial head fractures are a common injury, representing a significant portion (approximately 33%) of all elbow fractures in adults 1. The estimated incidence is 2.5-2.8 per 10,000 inhabitants per year, with older females and younger males being more commonly affected 3. These fractures typically occur due to a fall on an outstretched hand with the forearm in pronation, resulting in axial load, valgus and/or rotating forces across the elbow 3. This force is transmitted through the hand and forearm, causing the radial head to impact the capitellum 3. Radial head fractures can significantly affect upper limb function due to the crucial role the radial head plays in elbow joint stability 3. This article provides a comprehensive overview of the surgical management of radial head fractures and discusses post-operative rehabilitation protocols.

Anatomy and Biomechanics of the Radial Head

The radial head is the proximal end of the radius. Cartilage covers the radial head except for the anterolateral third, which lacks subchondral bone and is easily fractured 2. It has a 40-degree central cavity and is oval-shaped. The head and neck are not collinear with the diaphysis and form a 15-degree offset angle 2. The radial head articulates with the capitellum of the humerus and the ulna in the lesser sigmoid notch, forming a trochoid joint 2. This articulation allows for 180 degrees of pronation and supination of the forearm 2. The radial head is an important secondary stabilizer of the elbow in almost all directions 3. It plays a crucial role in elbow stability, acting as a secondary stabilizer after the collateral ligaments and coronoid process 3. It also contributes to longitudinal stability 2.

Classification of Radial Head Fractures

Several classification systems are used to categorize radial head fractures. The Mason classification system, introduced in 1954, remains the most widely used 2. It categorizes radial head fractures based on the degree of displacement and comminution:

  1. Type I: Non-displaced fracture.
  2. Type II: Displaced fracture with one fragment.
  3. Type III: Comminuted fracture.
  4. Type IV: Any fracture with elbow dislocation (added by Johnston) 2.

The Mason classification has been modified over time to improve its accuracy and clinical relevance. Morrey included joint and neck fractures in the classification, quantifying them to approximately 30% and displacements between 2 mm 2. Hotchkiss further modified the types by therapeutic criteria:

  1. Type I: Non-displaced or minimally displaced fractures (below 2 mm).
  2. Type II: Partial head displacement that blocks pronation and supination, repairable with internal fixation.
  3. Type III: Non-repairable fractures with internal fixation 2.

Another important concept in fracture assessment is the stability of the fracture, which can be determined by the presence or absence of cortical contact between the fragments 4. When evaluating angulation in radial neck fractures, several factors need to be considered, including the patient's skeletal maturity, the true degree of angulation, translation, and associated injuries 5.

Evaluation of Radial Head Fractures

Proper evaluation of radial head fractures is essential for determining the appropriate treatment strategy. This includes a thorough clinical examination, imaging studies, and assessment of associated injuries.

  1. Assessment of associated injuries: Radial head fractures are often accompanied by other injuries. These can include injuries to the lateral and medial collateral ligaments, the interosseous membrane (Essex-Lopresti lesion), and fractures of the capitellum, coronoid, and olecranon 2. The Essex-Lopresti lesion is a specific injury pattern involving a radial head fracture, disruption of the distal radioulnar joint (DRUJ), and interosseous membrane disruption 6. This injury requires fixation or replacement of the radial head to restore stability and prevent proximal migration of the radius, which can lead to ulnocarpal impaction 6. It is important to note that comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries 3.
  2. Imaging: Anteroposterior and lateral X-rays are typically used for initial evaluation 2. In some cases, a "sail sign" on the X-ray, which is an enlarged fat pad at the elbow, may indicate a fracture that is not readily visible 7. CT scans are helpful in complex cases for surgical planning and can provide valuable information about fracture location and associated injuries 2. MRI can also be used to assess for associated injuries, particularly ligamentous injuries and bone bruises 4. While MRI may reveal a high incidence of associated injuries (76% to 96%), the clinical relevance of these findings may be limited in some cases 4.
  3. Clinical examination: Physical examination should include assessing for pain, swelling, range of motion, and stability of the elbow, shoulder, and wrist 2. It is crucial to assess forearm rotation (pronation/supination) as an inability to perform this movement, either due to mechanical obstruction or severe pain, may indicate a more complex injury pattern 5.

Indications for prompt orthopedic consultation include:

  1. Fractures requiring reduction (displaced radial head, Monteggia equivalent, or articular surface involvement)
  2. An associated fracture in the same upper limb
  3. Extreme swelling/compartment syndrome
  4. Mechanical obstruction to (or severe pain with) gentle pronation/supination 5

Surgical Management of Radial Head Fractures

The decision to perform surgery on a radial head fracture is often not dictated by the fracture pattern alone but also by the presence of associated injuries 3. Surgical intervention is often necessary for displaced or comminuted radial head fractures, especially those causing a mechanical block to pronation/supination 3. The goals of surgical management are to restore articular congruity, provide stability, and allow for early mobilization 2. Patient-related aspects, such as age, bone quality, functional demand, comorbidities, fracture extension, location, displacement, and related injuries, should be considered when making treatment decisions 2. Surgical options include:

  1. Open Reduction and Internal Fixation (ORIF): This involves surgically exposing the fracture and stabilizing it with screws or plates 8. ORIF is generally preferred for Mason type II and some type III fractures where anatomical reduction and early motion can be achieved 10. It is important to note that outcomes from fixation are poorer, and complication rates are higher if more than three fragments are present 6. Studies have shown that screw osteosynthesis may provide better functional outcomes compared to plate osteosynthesis 11.
  2. Radial Head Excision: This involves removing the fractured radial head. It is typically reserved for patients with low functional demands, those with continued pain due to an isolated radial head fracture, or when internal fixation is not feasible 2. However, radial head excision can lead to instability, particularly in the presence of ligamentous injuries 12. It may also lead to an increased carrying angle and proximal radial migration, potentially causing pain at the elbow and wrist due to ulnar impaction 6.
  3. Radial Head Arthroplasty: This involves replacing the radial head with a prosthesis. It is indicated when internal fixation is not possible or in cases of severe comminution 8. Radial head arthroplasty aims to reconstruct the native head and is indicated when internal fixation is not feasible and in the presence of complex elbow injuries 10. Modular designs improve the surgeon's ability to reconstruct the native joint and have been shown to improve clinical outcomes and lower complication rates compared to internal fixation in some studies 10. However, overstuffing of the radiocapitellar joint is a frequent technical error that can have adverse effects on elbow biomechanics 10.

Specific treatment approaches for different fracture types are as follows:

  1. Type I: These fractures are generally small cracks, and the bone pieces remain fitted together. Non-surgical treatment involves using a splint or sling for a few days, followed by an early and gradual increase in elbow and wrist movement 8.
  2. Type II: These fractures are slightly displaced and involve a larger piece of bone. If displacement is minimal, treatment may involve wearing a sling or splint for 1 to 2 weeks, followed by range-of-motion exercises. Small fragments of broken bone may be surgically removed if they prevent normal elbow movement. If a fragment is large and out of place, the surgeon will first attempt to hold the bones together with screws or a plate and screws. If this is not possible, the surgeon will remove the broken pieces of the radial head 8.
  3. Type III: These fractures have multiple broken pieces of bone that cannot be put back together. Surgery is always required to either fix or remove the broken pieces of bone and repair any soft-tissue damage. If the damage is severe, the entire radial head may need to be removed, and an artificial radial head may be placed to improve long-term function 8.

Outcomes of surgical treatment can vary based on the Mason classification. Studies have shown that patients with Mason II fractures generally have better functional results compared to those with Mason III fractures 11.

Surgical Approaches

Two common surgical approaches for radial head fractures are the Kocher and Kaplan approaches.

  1. Kocher approach:

  2. Pros: Less risk of posterior interosseous nerve (PIN) injury compared to the Kaplan approach, more extensile 6.

    1. Cons: Risk of destabilizing the elbow if the capsule incision is too posterior and the lateral ulnar collateral ligament (LUCL) is violated 6.

  3. Kaplan approach:

  4. Pros: Less risk of disrupting the LUCL and destabilizing the elbow compared to the Kocher approach, improved exposure of anterior fractured fragments 6.

    1. Cons: Greater risk of PIN and radial nerve injury, less extensile 6.

In both approaches, the forearm should be pronated to protect the PIN 6.

Fragment Excision:

If the fracture involves less than 25% of the radial head's surface area and does not compromise elbow stability, the fragment can be excised 6. This is typically done through either the Kocher or Kaplan approach. However, it is important to avoid excising a fragment that is too large, as this can lead to elbow instability 6.

Post-Operative Rehabilitation

Post-operative rehabilitation is crucial for restoring elbow function and preventing complications such as stiffness and instability 8. Early motion after surgery is essential to prevent stiffness and promote healing 10. Rehabilitation protocols vary depending on the type of surgical procedure performed and the individual patient's needs. However, some general principles apply:

  1. Early Mobilization: Early active and active-assisted range of motion exercises are essential to prevent stiffness and promote healing 7.
  2. Pain Management: Adequate pain control is necessary to facilitate participation in rehabilitation exercises 13. This may involve over-the-counter pain medications, ice packs applied indirectly to the area, and elevation of the elbow 13.
  3. Progressive Strengthening: Strengthening exercises are gradually introduced as the fracture heals 7.
  4. Functional Activities: Rehabilitation should focus on restoring functional activities and returning the patient to their desired level of activity 8.

Non-Surgical Rehabilitation

For non-displaced or minimally displaced fractures treated non-surgically, early mobilization is key. Patients are typically provided with a polysling for a few days for comfort, to use mainly for comfort 7. They should reduce the wearing of the sling as pain settles and aim to completely remove it as soon as they feel able 13. Early active and active-assisted range of motion (AROM, AAROM) exercises, including elbow extension/flexion and forearm pronation/supination, are vital for mitigating the impact of immobilization on the capsule, ligaments, muscles, and osteochondral tissues 7. Patients should gently stretch their elbow to regain full movement and take simple, over-the-counter pain relief as needed to keep their elbow moving 13. It is important to avoid forcibly stretching the elbow, as this may cause pain and delay recovery 13.

Examples of exercises that can be done immediately after injury include:

  1. Exercise 1: Sit with your elbow tucked in at your side. Slowly turn your palm to the floor as far as you can. Then turn your palm to the ceiling as far as you can. Repeat 10 times or as many as you can comfortably tolerate 13.
  2. Exercise 2: Lie on your back. Bend your arm and point your elbow to the ceiling. Slowly straighten your elbow as if you are pointing to the ceiling, then lower back down, trying to get your thumb down to the pillow. Repeat 10 times or as many as you can comfortably tolerate 13.
  3. Exercise 3: Keep your wrist mobile by moving it forwards and back and side to side 13.
  4. Exercise 4: Raise your arm overhead as far as you can comfortably. You can do this in any position, for example, lying/sitting/standing. You can have your elbow bent and/or in a sling for this exercise if it makes it more comfortable 13.

It is more effective to do small amounts of exercise regularly throughout the day rather than doing a lot of exercises all at once 13. This should mean your exercises are bearable and your arm does not stiffen up between sets 13. Some pain after exercising is normal and may take several months to settle completely 13. However, it should not be severe pain, and any pain after exercising should be bearable 13. Your elbow should not feel hot, inflamed, or develop a lot of swelling after exercising 13. If pain following exercise does not settle down within 30 minutes of exercising, you should consider doing shorter bursts of exercises, not pushing into your pain too much, and discussing your pain relief with your GP 13.

Isotonic strengthening exercises can be started 6 to 8 weeks after the injury 7.

Surgical Rehabilitation

Post-surgical rehabilitation typically involves three phases:

  1. Phase 1 (0-14 days): The focus is on pain management, edema control, and early AROM exercises for elbow flexion and extension in the overhead position. Additionally, isometric gripping and strengthening exercises for the elbow are initiated, with the percentage of maximum voluntary isometric contraction (MVIC) adjusted to match the patient's pain level 7.
  2. Phase 2 (15 days to 6 weeks): Continue AROM exercises for elbow flexion and extension, and consider adding AAROM exercises to provide additional end-of-range stretching. AROM exercises for supination and pronation can begin, although some protocols may include these movements in Phase 1 7. Full elbow flexion and extension should be achieved by the end of week 6 7.
  3. Phase 3 (week 7 to 12): The patient continues AROM/AAROM exercises for supination and pronation, targeting full range of motion by week eight. Isotonic and weight-bearing strengthening exercises are introduced during this phase 7.

After surgery to repair a radial head fracture, the surgeon will recommend no weight-bearing through the arm and no lifting objects heavier than a few pounds for 6 to 12 weeks 8. Depending on the fracture pattern and other associated elbow injuries, you may be placed in a splint or cast for a period of time 8. All fractures of the radial neck should have follow-up arranged in a fracture clinic within one week of injury, with an X-ray at that visit taken with the plaster removed 5.

For the first six weeks after surgery, the patient should avoid:

  1. Overusing the elbow or arm, which can impede the healing process
  2. Heavy lifting, pushing, and pulling
  3. Placing the arm in extreme positions
  4. Weight-bearing through the arm
  5. Activities that cause excessive discomfort 7

Patients should avoid contact sports for at least 6 weeks after injury 15.

Complications

Potential complications of radial head fractures and their management include:

  1. Stiffness: This can occur due to prolonged immobilization, prominent hardware, or capsular contracture 2. Early mobilization and appropriate rehabilitation are crucial for preventing stiffness 2. Many patients may have residual stiffness even with optimal treatment 5.
  2. Aseptic necrosis: This is a rare complication that can occur after osteosynthesis failure. It may require further surgery 2.
  3. Nonunion: This can also occur after osteosynthesis failure and may require revision surgery 2.
  4. Malunion: This is less frequent after osteosynthesis compared to non-surgical treatment 2.
  5. Arthritis: Post-traumatic arthritis can develop in the long term, but it may not always be clinically significant 2. A higher percentage of arthritis has been observed in patients who underwent radial head excision compared to those who had ORIF 6.
  6. Instability: This is less frequent but can occur with inadequate management of associated injuries 2.
  7. Nerve injury: PIN injury is a risk with both the Kocher and Kaplan approaches, although the risk is greater with the Kaplan approach. Radial nerve injury is also a potential complication, particularly with the Kaplan approach 6.
  8. Elbow instability: Excessive capsule incision during the Kocher approach can destabilize the elbow by violating the LUCL 6.

Late complications of radial head fractures can include frozen elbow, chronic instability, and early joint wear 12.

Conclusion

Radial head fractures are common injuries that require careful evaluation and management by an elbow specialist to avoid complications 12. Treatment decisions are based on the fracture classification, associated injuries, and patient-specific factors, including age, bone quality, functional demand, and comorbidities 2. Surgical options include ORIF, radial head excision, and radial head arthroplasty, each with its own indications, advantages, and potential complications. Post-operative rehabilitation is essential for restoring elbow function and preventing complications. Early mobilization, pain management, and progressive strengthening are key components of rehabilitation. It is important to note that even with optimal treatment, some patients may experience residual stiffness 5. Most radial head fractures take around 6 weeks to heal completely 15. During this time, patients should avoid activities that put excessive stress on the elbow and follow their surgeon's recommendations for weight-bearing and activity restrictions.

While significant advancements have been made in the management of radial head fractures, there are still areas of ongoing debate and research. These include the optimal treatment for Mason type II fractures, the role of radial head arthroplasty in complex injuries, and the long-term outcomes of different surgical techniques. Future research should focus on refining surgical techniques, improving implant design, and developing individualized rehabilitation protocols to optimize patient outcomes.

It is crucial for surgeons to engage in shared decision-making with their patients, considering individual factors and preferences when developing a treatment plan. By combining the latest evidence with a patient-centered approach, healthcare providers can help individuals with radial head fractures achieve the best possible outcomes and return to their desired level of activity.

Parents of children with radial neck fractures should be advised that while most undisplaced fractures do well, many can have residual stiffness (loss of forearm rotation) even with optimal treatment 5. Close follow-up, including serial X-rays without overlying plaster, is important 5.

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