Radial Head Fracture (Adult)

1. Overview

Radial head fractures represent the most common fracture of the elbow in adults, accounting for approximately 33% of all elbow fractures and 4% of all fractures. [1,2] These injuries typically result from a fall onto an outstretched hand (FOOSH) mechanism with axial loading transmitted through the pronated forearm. The radial head serves as a critical secondary stabiliser to valgus and axial forces at the elbow, and injury to this structure can have significant implications for elbow and forearm function. [3]

The management of radial head fractures ranges from conservative treatment with early mobilisation for undisplaced fractures to complex surgical reconstruction or arthroplasty for comminuted patterns, particularly when associated with ligamentous injuries. The key clinical decision revolves around identifying the presence of a mechanical block to rotation, which fundamentally alters treatment strategy. Recognition of associated injuries—particularly the Essex-Lopresti lesion and terrible triad injury pattern—is essential to prevent catastrophic long-term complications. [4,5]

Modern treatment emphasises early functional rehabilitation for simple fractures whilst maintaining a low threshold for surgical intervention in displaced or comminuted patterns, especially when elbow or forearm stability is compromised. Understanding the biomechanical role of the radial head and the consequences of its absence is fundamental to appropriate decision-making in these challenging injuries.

2. Epidemiology

Demographics

Distribution by Mason Type

Based on large-scale trauma database analysis, radial head fractures distribute as follows:

• Mason Type I (undisplaced): 60-65% [7]
• Mason Type II (displaced/angulated): 20-25% [7]
• Mason Type III (comminuted): 10-15% [7]
• Mason Type IV (with dislocation): 5-10% [8]

Associated Injuries

Radial head fractures rarely occur in isolation, particularly in higher energy mechanisms:

3. Aetiology and Pathophysiology

Injury Mechanism

The classic mechanism involves axial loading of the extended elbow with the forearm in pronation during a fall. The forces are transmitted longitudinally through the radial shaft, impacting the radial head against the capitellum. The pattern and severity of fracture depend on:

1. Energy of impact: Low energy produces simple fracture patterns; high energy results in comminution
2. Forearm position: Pronation concentrates forces on the anterolateral radial head
3. Associated valgus/varus force: Determines ligamentous injury pattern
4. Degree of elbow flexion: More extended positions increase radial head loading

Biomechanics of the Radial Head

The radial head performs several critical functions:

1. Secondary Valgus Stabiliser

• Provides approximately 30% of valgus stability with intact MCL [3]
• Becomes PRIMARY valgus stabiliser if MCL is incompetent
• This is why radial head excision is contraindicated with MCL injury

2. Axial Load Transmission

• Normally transmits 20% of axial forces across the elbow [9]
• With intact forearm, shares load with ulnohumeral joint
• With IOM disruption (Essex-Lopresti), becomes critical for preventing proximal radial migration

3. Longitudinal Forearm Stability

• Works in conjunction with the interosseous membrane (IOM)
• The central band of the IOM is the primary restraint to proximal migration
• Loss of both radial head and IOM integrity leads to proximal radial migration and wrist pathology

4. Rotation Axis

• The radial head rotates within the annular ligament during pronation/supination
• Free rotation requires smooth articular surface and intact annular ligament
• Even small step-offs (> 2mm) can produce mechanical block

Classification: Mason (Modified by Hotchkiss)

The Modified Mason classification remains the most widely used system for guiding treatment:

Limitations of Mason Classification:

• Poor inter-observer reliability, particularly for Type II vs III distinction [10]
• Does not account for associated injuries
• Does not predict mechanical block (functional criterion)

The Radial Head "Safe Zone"

A critical anatomical concept for surgical fixation is the "safe zone"—a 90-degree arc of the radial head that does NOT articulate with the sigmoid notch of the proximal ulna during forearm rotation. [11]

• Location: Corresponds to the area between lines drawn from the radial styloid and Lister's tubercle with the forearm in neutral rotation
• Clinical significance: Hardware (plates/screws) must be placed in this zone to avoid impingement during pronation/supination
• Intraoperative confirmation: Test rotation under direct vision after plate application

4. Complex Injury Patterns

The Terrible Triad of the Elbow

This injury pattern represents one of the most challenging elbow injuries, with high rates of complications and poor outcomes if not appropriately managed. [12,13]

Components:

1. Posterior elbow dislocation
2. Radial head fracture (usually Mason II-III)
3. Coronoid fracture (usually Regan-Morrey Type I-II)

Pathomechanics: The injury occurs through a posterolateral rotatory force, sequentially disrupting:

• Lateral ulnar collateral ligament (LUCL)
• Radial head fracture from impact
• Coronoid shearing as the ulna subluxates posteriorly
• Possible MCL injury in severe cases

Fixation Sequence (Critical for Exam):

1. First: Restore osseous stability
   • Fix or replace radial head (restores lateral column height)
   • Fix coronoid (restores anterior buttress)
2. Second: Repair lateral ligaments
   • Repair LUCL (lateral collateral ligament complex)
3. Third: Assess stability
   • Check range of motion under fluoroscopy
   • Repair MCL only if persistent instability (usually unnecessary)
4. Fourth: External fixator (if needed)
   • Reserved for persistent instability after above steps

Outcomes:

• Early ROM critical to prevent stiffness (most common complication) [13]
• Some loss of extension expected (10-15°)
• Post-traumatic arthritis develops in 20-30% long-term [12]

The Essex-Lopresti Injury

First described in 1951, this injury represents longitudinal radioulnar dissociation with devastating consequences if missed. [14,15]

Classic Triad:

1. Comminuted radial head fracture
2. Disruption of the interosseous membrane (IOM), particularly the central band
3. Distal radioulnar joint (DRUJ) disruption

Diagnosis: Often missed acutely—requires high index of suspicion:

• Wrist pain or tenderness in patient with radial head fracture (KEY FINDING)
• DRUJ instability on clinical examination (piano key sign)
• Radiographic signs:
  • Ulnar variance > 2mm compared to contralateral side
  • Widened DRUJ space on PA wrist radiograph
  • Proximal migration of radius relative to ulna

Advanced Imaging:

• MRI of forearm: Demonstrates IOM disruption (sensitivity ~85%) [15]
• Radioulnar axial load (RAIL) test: Dynamic assessment under fluor oscopy—proximal radial migration > 3mm with axial loading suggests IOM injury [16]

Management Principles:

1. NEVER excise the radial head → leads to progressive proximal radial migration and wrist destruction
2. Acute management:
   • Radial head ORIF if possible
   • Radial head replacement if non-reconstructable
   • DRUJ stabilisation (K-wires temporary fixation)
   • IOM reconstruction controversial in acute setting
3. Chronic management (if missed):
   • IOM reconstruction with tendon graft
   • Possible ulnar shortening osteotomy
   • Outcomes generally poor

Prognosis:

• Even with appropriate treatment, many develop chronic wrist pain and limited forearm rotation
• Missed diagnosis leads to progressive radioulnar dissociation and wrist arthrosis

5. Clinical Presentation

Symptoms

Cardinal Symptoms:

• Lateral elbow pain: Localised to radial head region
• Inability to rotate forearm: Particularly painful in pronation/supination
• Reduced range of motion: Especially terminal extension
• Mechanical symptoms: Clicking, catching, or locking suggests displaced fragment or loose body

Red Flag Symptoms (Suggest Complex Injury):

• Wrist pain or tenderness → Think Essex-Lopresti
• Severe instability feeling → Think terrible triad
• Finger drop → Think posterior interosseous nerve injury

Signs

Inspection:

• Elbow effusion (loss of olecranon fossa contour)
• Bruising over lateral elbow
• Deformity if associated dislocation

Palpation:

• Point tenderness over radial head (best palpated just distal to lateral epicondyle)
• Confirmatory test: Tenderness moves with forearm rotation (confirms radial head origin)
• DRUJ tenderness: Palpate wrist—tenderness suggests Essex-Lopresti
• Soft tissue crepitus: May indicate IOM injury

Range of Motion Assessment:

Critical Test: Aspiration-Injection Test

This test differentiates pain-limited motion from true mechanical block:

Technique:

1. Identify "soft spot": Triangle bounded by radial head, lateral epicondyle, olecranon
2. Aspirate hemarthrosis (typically 10-30ml of blood)
3. Inject 10ml of 1% lidocaine
4. Re-examine rotation after 5-10 minutes

Interpretation:

• Full rotation achieved → Functional block (pain) → Mason I, conservative treatment
• Hard stop persists → Mechanical block (bone) → Surgery indicated

Neurovascular Examination

Posterior Interosseous Nerve (PIN):

• Motor: Finger extension at MCPJ (EPL, ED indices, EDM)
• Note: No sensory component—purely motor
• Risk: Injured in ~5-10% of cases, usually neurapraxia from traction
• Documentation essential: Must document pre-operatively for medicolegal protection

Radial Nerve (Superficial Branch):

• Sensory over first dorsal web space
• Rarely injured in isolated radial head fractures

Ulnar Nerve:

• May be injured in terrible triad patterns (stretched during dislocation)
• Test intrinsic muscle function and sensory to little finger

6. Investigations

Plain Radiography

Standard Views:

1. AP Elbow: Assess displacement, comminution
2. True Lateral Elbow: Identify fat pad signs, assess joint alignment
3. Radiocapitellar View (Greenspan View):
   • Beam angled 45° cephalad
   • Removes coronoid overlap
   • Best view for marginal radial head fractures

Radiographic Signs:

• Posterior Fat Pad Sign: Always abnormal—indicates hemarthrosis, very sensitive for fracture
• Elevated Anterior Fat Pad: "Sail sign"—suggests effusion
• Radiocapitellar Line: Should bisect capitellum on all views—disruption suggests dislocation

Additional Views if Concern for Associated Injuries:

• Wrist PA and Lateral: Mandatory if DRUJ tenderness (Essex-Lopresti)
• Forearm Views: Look for ulnar variance, IOM calcification

Computed Tomography (CT)

Indications:

• Mason II fractures if surgery considered (surgical planning)
• All Mason III fractures (assess reconstructability)
• Suspected coronoid fracture (terrible triad workup)
• Preoperative planning for ORIF or arthroplasty

Information Provided:

• Fragment size, number, and displacement
• Articular step-off measurement
• Coronoid involvement
• Capitellum shear fractures (often occult on plain films)

Protocol:

• 1mm slice thickness
• Multiplanar reconstructions (coronal, sagittal, axial)
• 3D reconstruction useful for surgical planning

Magnetic Resonance Imaging (MRI)

Indications:

• Suspected Essex-Lopresti injury (IOM assessment)
• Suspected lateral collateral ligament injury
• Capitellar osteochondral injury assessment
• Discordance between clinical and radiographic findings

Findings in Essex-Lopresti:

• Central band IOM disruption (high signal T2)
• DRUJ capsule disruption
• TFCC tears
• Distal radial signal changes

Stress Radiography

Valgus Stress Views:

• Assess MCL competency
• Widening > 3mm suggests MCL incompetence
• Indicates radial head excision is contraindicated

7. Management

Conservative (Non-Operative) Management

Indications:

• Mason Type I fractures (less than 2mm displacement, no mechanical block)
• Selected Mason Type II fractures without mechanical block and cooperative patient
• Contraindications to surgery (severe medical comorbidities)

Protocol:

1. Immediate phase (0-7 days):

   • Broad arm sling for comfort ONLY
   • Ice, elevation, analgesia
   • Remove sling after 3-5 days maximum (prolonged immobilisation causes stiffness)
   • Active gentle ROM encouraged from day 1-2

2. Early mobilisation phase (Week 1-6):

   • Active ROM only (no passive stretching—risk of HO)
   • Progress as pain allows
   • Avoid heavy lifting or valgus stress activities
   • Physiotherapy focused on regaining rotation first, then flexion/extension

3. Strengthening phase (Week 6-12):

   • Progressive resistance exercises
   • Return to functional activities
   • Most recovery complete by 3 months

Follow-up:

• Clinical review at 1 week (ensure mobilising)
• Radiographs at 1 week (exclude displacement)
• Further review at 6 weeks
• Discharge if asymptomatic with functional ROM

Expected Outcomes:

• Excellent in 85-90% of Mason I fractures [7]
• Mild loss of terminal extension (5-10°) common but rarely symptomatic
• Return to full activities typically 8-12 weeks

Surgical Fixation (ORIF)

Indications:

• Mason Type II with mechanical block
• Simple Mason III (single large fragment, amenable to lag screw fixation)
• Articular step-off > 2mm affecting > 30% of articular surface

Surgical Approach: Kocher (Posterolateral) Interval

• Between anconeus and extensor carpi ulnaris (ECU)
• Advantage: Avoids PIN (stays anterior to dissection)
• Danger: Do NOT place retractors anterior to radial neck (PIN runs in supinator at this level)

Fixation Techniques:

1. Headless Compression Screws:

   • Ideal for single large fragment
   • Fully buried, no prominence
   • 2.5mm or 3.0mm screws typically used
   • Must achieve compression and stable fixation

2. Low-Profile Plate Fixation:

   • For more complex Type II fractures
   • Must be placed in "safe zone" (see above)
   • Pre-contoured anatomic plates available
   • Test rotation intraoperatively to ensure no impingement

Intraoperative Checklist:

• Anatomic reduction confirmed under direct vision
• Articular surface smooth (no step-off)
• Rotation tested through full ROM (no catching on hardware)
• Assess elbow stability (valgus/varus stress)
• If unstable, address ligamentous injuries

Post-operative Protocol:

• Remove drain at 24 hours
• Immediate active ROM (no splinting unless unstable repair)
• Avoid heavy lifting 6-8 weeks
• Return to normal activities 12 weeks

Outcomes:

• Good-excellent in 75-85% of well-selected cases [17]
• Complications: hardware prominence (10-15%), stiffness (20%), heterotopic ossification (5-10%)

Radial Head Arthroplasty

Indications:

• Comminuted Mason III fractures (> 3 fragments, non-reconstructable)
• Mason IV (fracture-dislocation) with non-reconstructable radial head
• Failed ORIF
• Essex-Lopresti injury (absolute indication to preserve radial head replacement)
• Terrible triad with comminuted radial head

Why NOT Excision? Radial head excision is now rarely performed due to:

• Proximal radial migration (especially if IOM injury)
• Valgus instability (if MCL incompetent)
• Reduced load transmission across elbow
• Wrist pain and instability

Implant Types:

• Metallic (Cobalt-Chrome): Most common, durable
• Pyrocarbon: Good outcomes but higher cost
• Modular vs Monoblock: Modular allows intraoperative sizing
• Unipolar vs Bipolar: Bipolar may improve kinematics

Surgical Technique Key Points:

1. Sizing: Critical—too large causes capitellar erosion; too small allows instability

   • Template from largest fragment
   • Trial components available
   • Final check: elbow should reduce easily, no excessive tightness

2. Height: Match native radial head height

   • Line of posterior cortex of radius
   • Level with coronoid tip on lateral view
   • Overlengthening causes pain, capitellar wear, limited motion

3. Stem Orientation: Align with radial shaft axis

Post-operative Management:

• Early ROM (no immobilisation)
• Avoid varus/valgus stress for 6 weeks (ligament healing)
• Strengthening from 8-12 weeks

Outcomes:

• Good outcomes in 70-80% at medium-term follow-up [18]
• Complications (20-40%):
  • Implant loosening (5-10%)
  • Capitellar erosion (if overlengthened or oversized)
  • Stiffness (most common)
  • Heterotopic ossification
  • Implant failure/dislocation (rare)

Radial Head Excision

Indications (Now Limited):

• Comminuted fracture in low-demand elderly patient
• Intact MCL and IOM confirmed
• Patient unsuitable for arthroplasty
• Chronic malunion causing painful clicking (secondary procedure)

Contraindications (Absolute):

• MCL injury or valgus instability
• Essex-Lopresti injury (any IOM injury)
• Terrible triad or complex instability
• Active/young patient

Technique:

• Excise only neck and head (preserve annular ligament insertion on ulna)
• Smooth bone edges
• Repair annular ligament and capsule

Outcomes:

• Reasonable pain relief initially
• Long-term problems common:
  • Wrist pain (proximal migration)
  • Valgus drift
  • Elbow instability
  • Post-traumatic arthritis

8. Complications

Early Complications

1. Stiffness (Arthrofibrosis)

• Incidence: Most common complication (40-50% have some stiffness)

• Risk factors:

  • Prolonged immobilisation
  • High-energy injury
  • Complex fracture patterns
  • Terrible triad injuries
  • Patient non-compliance with physiotherapy

• Prevention:

  • Early active mobilisation (within 48 hours)
  • Avoid passive stretching initially (first 6 weeks)
  • Avoid prolonged splinting

• Expected losses:

  • 10-15° terminal extension loss is NORMAL and rarely affects function
  • 10-20° rotation loss common

• Management if severe:

  • Intensive physiotherapy
  • Dynamic splinting (after 3 months if no progress)
  • Arthroscopic or open arthrolysis (last resort, after 9-12 months)

2. Heterotopic Ossification (HO)

• Incidence: 5-10% overall; up to 40% in terrible triad or after head injury

• Risk factors:

  • Delayed treatment (> 2 weeks)
  • Associated head injury
  • Terrible triad pattern
  • Forceful passive ROM
  • Genetic predisposition

• Prevention:

  • Indomethacin 75mg OD for 6 weeks post-surgery
  • "Alternative: Single-dose radiation therapy (700 cGy within 72 hours of surgery)"
  • Avoid aggressive passive stretching

• Management:

  • Allow to mature (usually 12-18 months)
  • Excision only if functionally limiting after maturation
  • Repeat prophylaxis with excision surgery

3. Nerve Injury

PIN Protection During Surgery:

• Keep forearm pronated during Kocher approach (moves PIN anteriorly away from field)
• Never place retractors anterior to radial neck
• Identify and protect during dissection

Late Complications

1. Post-Traumatic Arthritis

• Incidence: 20-30% long-term (> 5 years), especially terrible triad [12]

• Risk factors:

  • Articular surface injury
  • Residual incongruity
  • Capitellar damage
  • Associated injuries (coronoid, capitellum)

• Management:

  • "Conservative: NSAIDs, activity modification, physiotherapy"
  • "Surgical (if severe symptoms):"
    • Debridement and loose body removal (early arthritis)
    • Radial head excision (if source of pain and stable elbow)
    • Total elbow arthroplasty (severe, low-demand patient)

2. Malunion/Nonunion

• Malunion: Usually asymptomatic if less than 20° angulation and no mechanical block
• Nonunion: Rare (less than 5%), usually requires revision ORIF or conversion to arthroplasty
• Symptomatic malunion: May require corrective osteotomy or conversion to arthroplasty

3. Hardware-Related Complications

• Prominent screws/plates: 10-15% require removal
• Hardware failure: Rare with modern low-profile implants
• Management: Remove after fracture union (usually > 6 months)

4. Proximal Radial Migration (Post-Excision)

• Develops in Essex-Lopresti or if excessive radial head excision
• Leads to wrist pain, DRUJ arthritis, reduced grip strength
• Prevention better than cure—avoid excision, preserve radial head

9. Prognosis

Overall Outcomes by Mason Type

Functional Outcomes

Expected Range of Motion Post-Treatment:

• Flexion: Usually returns to near-normal (130-140°)
• Extension: Loss of 5-15° terminal extension is expected and functionally insignificant
• Pronation/Supination: Usually 80-90% of contralateral side
• Functional arc: Most activities require only 100° flexion-extension and 50° rotation each direction

Factors Predicting Poor Outcome:

1. Complex injury patterns (terrible triad, Essex-Lopresti)
2. Delayed treatment (> 2 weeks)
3. Associated injuries (MCL, IOM, coronoid)
4. High-energy mechanism
5. Poor patient compliance with rehabilitation
6. Development of heterotopic ossification

Return to Activities

10. Evidence and Guidelines

Landmark Studies

1. Mason (1954) [1]

• Original description and classification
• Established principle of early mobilisation for undisplaced fractures
• Remains foundation of modern management

2. Ring et al. (2002) [17]

• Demonstrated high failure rate of ORIF for comminuted (> 3 fragments) radial head fractures
• Established threshold for considering arthroplasty over attempted fixation
• Key finding: Arthroplasty superior to ORIF for comminuted patterns

3. Guitton et al. (2011) [10]

• Assessed inter-observer reliability of Mason classification
• Finding: Substantial variation even with 3D CT
• Highlighted need for additional functional criteria (mechanical block) in decision-making

4. Heijink et al. (2016) [18]

• Systematic review of radial head arthroplasty outcomes
• Finding: 70-80% good-excellent results; 20-30% complication rate
• Metallic implants superior to older silastic designs

5. Fahs et al. (2024) [12]

• Comprehensive review of terrible triad management
• Key recommendations:
  • Radial head fixation or replacement mandatory
  • Lateral ligament repair improves stability
  • Early mobilisation critical despite repair

Current Guidelines

British Orthopaedic Association (BOA) / British Elbow and Shoulder Society (BESS):

• Mason I: Conservative management with early mobilisation
• Mason II: Surgery if mechanical block or articular incongruity > 2mm
• Mason III: Arthroplasty preferred over excision unless low-demand elderly
• Radial head preservation (ORIF or arthroplasty) mandatory if MCL injury, IOM disruption, or terrible triad

American Academy of Orthopaedic Surgeons (AAOS):

• Limited evidence for optimal treatment of Mason II fractures
• Strong recommendation for early mobilisation in non-operative cases
• Moderate evidence supporting arthroplasty over excision for unstable injuries

11. Examination Pearls (Viva Preparation)

Opening Statement

"Radial head fractures are the most common elbow fracture in adults, representing 33% of elbow injuries. They result from a fall onto an outstretched hand with axial loading. Management depends on fracture displacement, presence of mechanical block, and critically, the status of associated structures—particularly the MCL and interosseous membrane. The radial head is a secondary valgus stabiliser and contributes to longitudinal forearm stability, so preservation through ORIF or replacement is preferred over excision in most cases."

Key Exam Questions and Model Answers

Q1: How do you assess for a mechanical block to rotation?

Model Answer: "The key is to differentiate pain-limited motion from a true mechanical block. I would perform an aspiration-injection test. After aspirating the hemarthrosis through the 'soft spot'—the triangle between the radial head, lateral epicondyle, and olecranon—I inject 10ml of local anaesthetic. After waiting 5-10 minutes for the anaesthetic to take effect, I re-examine rotation. If the patient achieves full pronation and supination, it was a functional block due to pain, and conservative management is appropriate. If there's a hard end-point preventing full rotation despite adequate analgesia, there's a mechanical block from a bone fragment, and surgery is indicated."

Q2: What is the Safe Zone and why is it important?

Model Answer: "The Safe Zone is a 90-degree arc of the radial head that does not articulate with the sigmoid notch of the proximal ulna during forearm rotation. It corresponds to the area between the radial styloid and Lister's tubercle with the forearm in neutral. This is critical for hardware placement during ORIF—plates and screws must be positioned entirely within this zone to avoid impingement during pronation and supination. If hardware is placed outside the safe zone, patients will have painful clicking and limited rotation. Intraoperatively, after plate fixation, I would test full rotation under direct vision to ensure no catching."

Q3: Describe the Terrible Triad and the sequence of surgical fixation.

Model Answer: "The Terrible Triad, as described by Hotchkiss, consists of posterior elbow dislocation, radial head fracture, and coronoid fracture. It represents high-energy posterolateral rotatory instability with sequential failure of lateral structures. The surgical sequence is critical:

First, restore osseous stability by fixing or replacing the radial head and fixing the coronoid. This restores the lateral column height and anterior buttress.

Second, repair the lateral ulnar collateral ligament complex to prevent posterolateral rotatory instability.

Third, assess stability through full ROM under fluoroscopy. The MCL usually does not require repair if osseous and lateral structures are addressed.

Finally, if there's still instability, consider a hinged external fixator, though this is rarely necessary.

The keys to outcome are anatomic restoration and early mobilisation. Patients typically still lose 10-15 degrees of extension but achieve functional range."

Q4: What is an Essex-Lopresti injury and why is it catastrophic if missed?

Model Answer: "An Essex-Lopresti injury is longitudinal radioulnar dissociation with three components: radial head fracture, interosseous membrane disruption—particularly the central band—and distal radioulnar joint injury. It's catastrophic if missed because if you excise the radial head in this setting, the radius migrates proximally, leading to ulnar impaction at the wrist, DRUJ arthritis, and severe functional impairment.

The key to diagnosis is examining the wrist in any patient with a radial head fracture. Tenderness over the DRUJ should raise suspicion. Radiographically, look for increased ulnar variance or DRUJ widening. MRI can confirm IOM disruption.

Management requires radial head preservation—either ORIF if possible or arthroplasty. The radial head acts as a buttress preventing proximal migration when the IOM is torn. Even with appropriate treatment, outcomes are often poor, with chronic wrist pain and limited rotation."

Q5: When would you excise vs. replace a radial head?

Model Answer: "Radial head excision is now very limited in its indications. I would only consider it in a low-demand elderly patient with a comminuted radial head fracture where I have confirmed intact MCL and interosseous membrane stability. The patient must accept the risk of late wrist pain and possible instability.

Radial head replacement is indicated when:

1. The fracture is comminuted and non-reconstructable (more than 3 fragments)
2. There's any associated ligamentous instability—MCL injury, terrible triad, or Essex-Lopresti
3. The patient is young or active

The contraindications to excision are absolute: any MCL injury, any IOM disruption, terrible triad patterns, or active patients. In modern practice, with improved implants and outcomes, arthroplasty is the standard for non-reconstructable fractures in most cases."

12. Patient Communication

Initial Explanation (Emergency Department)

"You've broken the top part of one of the bones in your forearm, just below the elbow—we call it the radial head. This usually happens from falling on your outstretched hand. The good news is that many of these heal well without surgery. What we need to work out is whether a piece of broken bone is blocking the normal rotation of your forearm. To test this, I'm going to drain the blood from your elbow joint and put in some local anaesthetic to numb it. Once it's numb, we'll see if you can turn your hand palm-up and palm-down. If you can, you won't need surgery. If it gets stuck, a piece of bone is blocking movement and we'll need to operate to fix or remove it."

Conservative Treatment Counselling

Expected Recovery: "With non-surgical treatment, most people recover very well. Here's what to expect:

First week: Your elbow will be painful and swollen. Use a sling for comfort but take it off several times a day to gently move your elbow. It's really important not to let it stiffen up.

First 6 weeks: Pain gradually settles. Focus on getting your rotation back—turning your palm up and down. Don't lift anything heavy.

3 months: Most people are back to normal activities. You might notice you can't quite straighten your arm those last few degrees compared to the other side, but this rarely affects what you can do day-to-day.

About 85-90% of people have excellent results with no long-term problems."

Surgical Treatment Counselling

For ORIF: "Surgery involves making a small cut on the outer side of your elbow, putting the bone fragments back together, and holding them with small screws or a plate. We start moving your elbow the day after surgery—it's important to move it early even though it's uncomfortable. You'll wear a sling for comfort for a few days only. Most people get back to desk work in 6-8 weeks and heavier activities in 12-16 weeks. The main risks are stiffness, infection (less than 5%), nerve injury affecting finger movement (uncommon), and a small chance of needing metalwork removal if it becomes prominent."

For Arthroplasty: "Because your radial head is shattered into multiple pieces, we can't fix it back together. Instead, we'll replace it with a metal spacer—like a small joint replacement. This allows your elbow to move normally and keeps your forearm stable. We remove your own radial head and put in the metal replacement sized to match. You'll start moving it immediately after surgery. Recovery is similar to having it fixed—about 12-16 weeks to full activities. About 70-80% of people are happy with the result, though some stiffness is common and you may notice some difference compared to your other arm."

Long-term Expectations

"Most people regain good function but it's common to have minor limitations:

• You might not get those last 5-10 degrees of straightening your arm fully
• Your rotation might be 80-90% of your other arm
• Heavy manual work may always cause some discomfort
• Contact sports may need to be avoided or modified
• There's a small chance of developing arthritis in the elbow in the future, especially if the injury was severe

The key to best outcomes is following the physiotherapy programme and accepting that full recovery takes time—usually 3-6 months."

13. References

1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42(172):123-132. doi:10.1002/bjs.18004217203

2. Patel DS, Statuta SM, Ahmed N. Common Fractures of the Radius and Ulna. Am Fam Physician. 2021;103(6):345-354.

3. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5(1):1-10. doi:10.5435/00124635-199701000-00001

4. Guss MS, Rettig ME. The Essex-Lopresti Injury. Bull Hosp Jt Dis (2013). 2019;77(1):33-38.

5. Ohl X, Siboni R. Surgical treatment of terrible triad of the elbow. Orthop Traumatol Surg Res. 2021;107(1S):102784. doi:10.1016/j.otsr.2020.102784

6. de Muinck Keizer RJ, Walenkamp MM, Goslings JC, Schep NW. Mason Type I Fractures of the Radial Head. Orthopedics. 2015;38(12):e1147-1154. doi:10.3928/01477447-20151123-06

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Document Information:

• Topic: Radial Head Fracture (Adult)
• Specialty: Orthopaedics, Trauma Surgery
• Target Audience: MRCS, FRCS (Tr\u0026Orth), FRACS (Ortho) candidates
• Last Updated: 6 January 2026
• Citations: 18 peer-reviewed sources
• Word Count: ~8,500 words
• Line Count: 878 lines