Current concepts in management of radial head fracture: An overview

Abstract

Abstract: The most frequent injury discovered so far is a radial skull fracture. The radial head fracture has become a crucial component of the elbow over the past ten years. According to a treatment plan that has evolved, the radial head fracture treatment aims to restore the wounded elbow's function and stability. A rising number of articles are available on radial head fracture. This article's goal is to give a summary of the most recent theories about the treatment of radial head fractures. Moreover, one of the most contentious elbow topics is the radial head fracture.

Full text

~ 31 ~
International Journal of Orthopaedics Sciences 2022; 8(4): 31-36
E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2022; 8(4): 31-36
© 2022 IJOS
www.orthopaper.com
Received: 22-06-2022
Accepted: 25-07-2022
Saran Malisorn
Department of Orthopedics,
Naresuan University Hospital,
Phitsanulok, Thailand
Corresponding Author:
Saran Malisorn
Department of Orthopedics,
Naresuan University Hospital,
Phitsanulok, Thailand
Current concepts in management of radial head
fracture: An overview
Saran Malisorn
DOI: https://doi.org/10.22271/ortho.2022.v8.i4a.3238
Abstract
The most frequent injury discovered so far is a radial skull fracture. The radial head fracture has become
a crucial component of the elbow over the past ten years. According to a treatment plan that has evolved,
the radial head fracture treatment aims to restore the wounded elbow's function and stability. A rising
number of articles are available on radial head fracture. This article's goal is to give a summary of the
most recent theories about the treatment of radial head fractures. Moreover, one of the most contentious
elbow topics is the radial head fracture.
Keywords: Elbow injury, elbow fracture, radial head fracture
Introduction
The most frequent type of elbow fracture is a radial head fracture [1]. The "New England"
Journal has published the first report of a radial head fracture despite it being more than 80
years old. Since then, the radial head has remained a contentious issue in both orthopedics [2]
and trauma papers (Figure 1). The stability of the elbow has become more dependent on the
radial head during the past ten years [2].
Epidemiology
Radial head fractures are predicted to occur 2.5 to 2.8 times more frequently than elbow
fractures per 10,000 people annually. The age range of patients receiving treatment for radial
head fractures ranged from 44 to 47.9 years old [3, 4]. The male-to-female ratio can range from
1:1 to 2:3 to 3:2 [5]. When compared to male patients between the ages of 48 and 54, female
patients between the ages of 37 and 41 are more prominent [3, 4]. The incidence is highest in
women between 50 and 60 and men between the ages of 30 and 40. Among patients older than
50, the number of female patients who have sustained a Radial head fracture is likely higher
than that of male patients [6]. This general classification can be explained with correlation, and
the occurrence of osteoporosis in a female patient aged 50 years old forward.
Biomechanics
The Radial head is the second important supplement in order to add the stability of the elbow.
Several studies of biomechanics actualized to find the number of the stability of the elbow
fracture model.
Also, several studies found that to cut the Radial head off, it will transform and caused to
unstable of the elbow joint and tendon around the elbow. Moreover, they found that the
stability will be better after the Radial head arthroplasty [7].
Significant reduction of the stable elbow was recorded that if the Radial head was cut off in the
elbow joint and Lateral Collateral Ligament (LCL) was injured, it will affect to the instability
of the elbow joint. Furthermore, it will affect to the loose of Varus instability of the elbow
joint [8]. These findings caused to an advice to repair LCL which is the important thing to
restore the stability of the elbow collaborate with surgery Open reduction internal fixation
(ORIF) of the Radial head or the arthroplasty in the Radial head [9].
Pomianowski also reported that the instability of the elbow is increasing after the Radial head
was cut and medial collateral ligament (MCL) was injured which will cause to valgus
instability of the elbow [10].

~ 32 ~
International Journal of Orthopaedics Sciences www.orthopaper.com
Classification
Mason [1] listed one hundred individuals with radial head
fractures in 1954. He separated the Radial head fractures into
three groups: Mason Type I fractures (73%) of the fracture
without dislocation, Type II fractures (19%) of the head
fracture with some dislocation, and Type III fractures (8%) [11]
Of the Radial head fracture with shattering. Johnston [12]
added the Radial head fracture in conjunction with elbow
discrepancy as Type IV to the system in 1962. (Table 1). Bro
berg and Capo added additional information regarding
fracture movement type II [13]. Rineer added that the
connecting detail of the radial head could be used to
determine the fracture's stability (Cortical contact) [14].
Using three-dimensional radiography (CT scan) can help
make a more accurate diagnosis [15]. the possible potentiality
of visualization CT is to determine the location of the Radial
head fracture, which could be related to common injury and
related to the elbow instability (Figure 2) [13, 16].
Fig 1: The different classification was summarized
Associated injury
To treat the patient with a Radial head fracture, we needed to
pay extraordinary attention to the examination and the related
injury treatment. Van Riet [4] discovered up to 39% of the
occurrence and associated damage. The Radial head fracture,
the loss of the outer tissue, the comminuted fracture of the
Radial head, and the linked injury will be wounded in the
tendon or bone, for example, the capitellum, in the back
assessments of 333 individuals. This can be determined using
magnetic resonance imaging (MRI), which is performed on
76% to 96% of patients with radial head fractures [17]. Also,
Hausmann et al. [18]. Found that in 9 in 14 Mason type I
patients that have got Radial head fracture, there are some
parts of the Interosseous membrane (IOM) are torn.
Ligament injuries
Ligament injuries can be diagnosed with MRI, as 61% to 80%
of patients with Radial head fractures suffer elbow injuries
[19]. The Lateral Collateral Ligament (LCL) injury was found
in up to 11% of the patient who has got a Radial head
fracture, and Medial Collateral Ligament (MCL) was found in
1.5% of the patient who has got Radial head fracture,
including MCL and LCL injury was found 6% [4] of the
patient who has got the Radial head fracture.
Coronoid process (Elbow dislocation coronoid process
fractures)
Elbow dislocation can be found 3% up to 14% along with the
Radial head fracture. In the injury mechanisms that have
mentioned, coronoid joint that was crushed against with
trochlea of humerus can cause to coronoid fracture. The
elbow dislocation, the Radial head fracture [3], and the
coronoid fracture are called “the terrible triad of the elbow".
It caused the severe instability of the elbow and often found
the complication after injuries that related to terrible triad [20]
such as the instability of the elbow and may have a
subsequent post-traumatic OA elbow.
Ulnar fracture
Radial head fracture patients can have an ulnar fracture in
1.2% to 12% of cases [3, 4] that often found in Monteggia
fracture which is the dislocation of the Radial head
collaborated with a one-third distal fracture of ulna [21] and the
mechanism of injury is a fall in the outstretched arm with a
hand hitting the ground.
Capitellum injury
Osteochondral injury of capitellum can be found with the
Radial head fracture and from MRI we found that capitellum
injury can be found up to 39% [13, 16].
Injury related to other conditions
The radial head fracture can also be associated with other
injuries, such as injury to the interosseous membrane (IOM).
It is the joint separating the radius and ulna. The Essex-
Lopresti injury is a triangle fibrocartilage complex injury [22].
Nerve damage is a possibility. 20% of patients with elbow
injuries experience nerve damage, with the median nerve
being the most severely impacted [23]. Radial and posterior
interosseous nerve damage can also result from radial head
fractures [24] and artery injury. These can occur in the patient
who has got the elbow injury 0.3% up to 1.7% [25].
Management of Non-displaced fracture
Mason type I fractures are generally treated with a pressure
bandage and arm sling for 1-2 weeks, followed by active
mobilization physical therapy of the elbow as soon as possible
[26]. The aspirated hemorrhage in the joint will reduce the
pressure and the pain in joint [27]. Furthermore, there is no
different pain between the patients groups that only put on
arm sling compared with the patients that have got with a
bupivacaine injection in the elbow [28]. Mason type I fractures
were studied by Shulman [29] who concluded that orthopedic
surgeons are likely to treat patients with Mason type I
fractures in the Radial head by non-surgical treatment and to
follow up on X-ray results without changing treatments.
Fractures with stable partial articular displacement and
their management
There is currently no consensus on the treatment of the Radial
head fracture patients that have a partial articular displaced
fracture. The Radial head fracture surgical is popular. After
found a new surgical technique [30] there is a good treatment
report in Mason type II fractures [31] group. In another way,

~ 33 ~
International Journal of Orthopaedics Sciences www.orthopaper.com
conservative treatment article of Mason type II fractures also
reported a good result [32]. Lindenhovius [33] reported a long-
term result of ORIF for the partial articular displaced fracture
of Radial head that have an average for 22 years of follow-up.
Although the result was good, but 44% of patients have the
complication. Additionally, they compared their results with
those of Akesson et al. who performed the same fracture
follow-up [32], which is the 19 years of getting the
conservative treatment. A long-term comparison of ORIF and
ORIF was not found to be superior. These results are the same
as the study a retrospective by Yoon [34]. Getting a non-
operative treatment compared with ORIF, they found that
there is no significant differences in clinical in ROM elbow
and a muscle strength during the treatment groups [34].
However, there might be the additional complication; for
example, Hardware loosening and heterotopic ossification
(HO) after treated ORIF.
Management of comminuted factures
Mason [1] advised that we carry out the operation and ORIF
for the comminuted radial head fracture. Over the past ten
years, the differences between various surgical procedures
have been explained. Following that, ORIF has gained
popularity, and patients who received it for a fractured radial
head have reported positive outcomes. Compared to shattered
bones with only two or three parts, Mason type III fractures
with more than three pieces are more likely to generate
favorable results, according to Ring [35]. Moro [36] discovered
that unstable fractures are challenging to repair and are more
likely to result in hardware loosening or nonunion than stable
fractures, such as a severe radial head fracture. Therefore, if
there is unable to fix by ORIF method, there is an advice to
use Radial head prosthesis (RHP) for getting the stable Radial
head. Chen [37] compared ORIF with the Radial head
prostheses (RHP) for the unstable Radius head fracture. After
two years of follow-up the patient, in the Radial head
prosthesis (RHP) group significantly had a better symptom,
but there is additional complications; for example (stiffness
joint, nonunion, malunion, or infection) with the ORIF group
(11 in 23 cases was found) compared to the Radial head
prostheses (3 in 23 cases was found) [37] Concluded that
Radial head prostheses (RHP) is more effective than the
ORIF. However, they have observed fairly that Radial head
prosthesis (RHP) have a problem about a lifespan and wear
which did not find in short-term follow-up of the study that
have mentioned. Nowadays, Radial head prosthesis (RHP)
effected only short-term but for the results of a middle-term,
there still have no information.
Management of associated injuries
Two ideas serve as the foundation for treating complex elbow
injuries [38]. Osteosynthesis (ORIF) involves repairing the
ulnohumeral joint, coronoid fractures, olecranon, or distal
humerus to maintain elbow functionality. The stable elbow
needs to be shielded for the subsequent one. As previously
stated, the radial head is a crucial elbow component. Since
radial head fractures frequently accompany ligament injuries,
the LCL and MCL should also be treated simultaneously.
Fig 2: The radiographic pre-operative
Fig 3: The radiographic post-operative

~ 34 ~
International Journal of Orthopaedics Sciences www.orthopaper.com
Table 1: The different classification was summarized
Table 2: Summary of treatment of Radial head fracture
Conclusion
The Radial head is one of important part that could help the
elbow joint be stable. Also, the Radial head fracture and the
associated injuries may cause the pain, osteoarthritis after
injury, and defective elbow functions. Therefore, there should
be the Radial head fracture management to obtain the stable
and functional elbow (Table 2).
Non-displacement fracture (Mason type I) should be treated
by moving elbow joint as soon as possible. The best treatment
of partial articular displaced fracture that is stable (Mason
type II) is unclear and can be treated by conservative
treatment by fast moving or ORIF. The unstable fracture
(Mason type III) which consist of 2 or 3 pieces can manage by
the ORIF but the ORIF is unstable, or the Radial head fracture
are more than.
Three pieces, the Radial head prosthesis (RHP) gives a better
result in short-term. There is still no information about the
long-term results of radial head prostheses (RHPs). The
coronoid, olecranon, and ligament injuries associated with
radial head fractures must be assessed and treated adequately.
The summary case study report
Summary of case history, the patient aged 36 years old having
pain and swelling right elbow, and the right elbow hit the
ground.
 Diagnosed in this patient: (Closed fracture right Radial
head) Mason type III.
 Guidelines for treatment in this patient.
The method employed to achieve the best results is influenced
by the nature of the radial head fracture. The type and extent
of the therapy are determined by Mason's categorization,
which is used in medicine and depends on how severe the
radial head and neck fractures are. Mason classified three
types of radial head fractures: a non-moving fracture, a
dislocation fracture, and a fracture that broke into two or more
pieces. The fourth kind is then introduced, which includes any
radial head fractures associated with humero-ulnar joint
dislocations.
In the patient that have got the third type fracture, there
should be treat by the ORIF with locking plate and screw
fracture to hold the Radial head in place.
In the operating room, the elbow stability should be checked
whether it has Varus or Valgus instability characteristics. In
this patient, he does not have one (Figure 3).
Acknowledgments
Not applicable
Author’s contribution
SM performed study design, data collection and analyses, and
manuscript writing.
Funding
The authors declare that no funds, grants, or other support
were received for the research work.
Availability of data and materials
The datasets used and/or analysed during the current study are
available from the corresponding author upon reasonable
request.

~ 35 ~
International Journal of Orthopaedics Sciences www.orthopaper.com
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The author declares no competing interests.
Author details
Saran Malisorn is a certified orthopedics and a lecturer at the
Department of Orthopedics, Faculty of Medicine, Naresuan
University, Phitsanuloke, Thailand.
References
1. Mason ML. Some observations on fractures of the head
of the radius with a review of one hundred cases. British
Journal of Surgery. 1954;42:123-132.
2. Jones SG. Fractures of the Head and Neck of Radius -
Separation of Upper Radial Epiphysis. The New England
Journal of Medicine. 1935;212:914-917.
3. Kaas L, Van Riet RP, Vroemen JPAM, Eygendaal D. The
epidemiology of radial head fractures. Journal of
Shoulder and Elbow Surgery. 2010;19:520-523.
4. Van Riet RP, Morrey BF, O’ Driscoll SHW, Van
Glabbeek F. Associated injuries complicating radial head
fractures. a demographic study Clinical Orthopaedics and
Related Research. 2005;441:351-355.
5. Jackson JD, Steinmann SP. Radial head fractures. Hand
Clinics. 2007;23:185-193.
6. Kaas L, Sierevelt IN, Vroemen JPAM, Van Dijk CN,
Eygendaal D. Osteoporosis and radial head fractures in
female patients: a case control study. Journal of Shoulder
and Elbow Surgery. 2012;21:1555-1558.
7. Morrey BF, Tanaka S, Kai-Nan A. Valgus stability of the
elbow. A definition of primary and secondary constraints.
Clinical Orthopaedics and Related Research.
1991;265:187-195.
8. Beingessne RDM, Dunning CE, Gordon KD, Johnson,
JA, King GJW. The effect of radial head excision and
arthroplasty on elbow kinematics and stability. The
Journal of Bone and Joint Surgery American volume.
2004;86-A:1730-1739.
9. Jensen SL, Olsen BS, Søjbjerg JO. Elbow joint
kinematics after excision of the radial head. Journal of
Shoulder and Elbow Surgery. 1999;8:238-241.
10. Pomianowski S, Morrey BF, Neale PG, Park MJ, O’
Driscoll SW, Kai-Nan A. Contribution of mono block
and bipolar radial head prostheses to valgus stability of
the elbow. The Journal of Bone and Joint Surgery
American volume. 2001;83-A:1829-1834.
11. Kodde IF, Kaas L, Van ESN, Mulder PGH, Van Dijk C.
N, Eygendaal D. The effect of trauma and patient related
factors on radial head fractures and associated injuries in
440 patients. BMC Musculoskeletal Disorders.
2015;16:135.
12. Johnston GW. A follow-up of one hundred cases of
fracture of the head of the radius with a review of the
literature. Ulster Medical Journal. 1962;31:51-56.
13. Capo JT, Shamian B, Francisco R, Tan V, Preston JS,
Uko L, Yoon RS, Liporace FA. Fracture pattern
characteristics and associated injuries of high-energy,
large fragment, partial articular radial head fractures: a
preliminary imaging analysis. Journal of Orthopaedics
and Traumatology. 2015; 16:125-131.
14. Rineer CA, Guitton TG, Ring D. Radial head fractures:
loss of cortical contact is associated with concomitant
fracture or dislocation. Journal of Shoulder and Elbow
Surgery. 2010;19:21-25.
15. Guitton TG, Brouwer K, Lindenhovius ALC, Dyer G,
Zurakowski D, et al. Diagnostic accuracy of two-
dimensional and three-dimensional imaging and
modeling of radial head fractures. Journal of Hand and
Microsurgery. 2014;6:13-17.
16. Van Leeuwen DH, Guitton TG, Lambers K, Ring D.
Quantitative measurement of radial head fracture
location. Journal of Shoulder and Elbow Surgery.
2012;21:1013-1017.
17. Kaas L, Turkenburg JL, Van Riet RP, Jos Vroemen
PAM, Eygendaal D. Magnetic resonance imaging
findings in 46 elbows with a radial head fracture. Acta
Orthopaedica. 2010;81:373-376.
18. Hausmann JT, Vekszler G, Breitenseher M, Braunsteiner,
T, Vécsei V, Christian G. Mason type-I radial head
fractures and interosseous membrane lesions--a
prospective study. The Journal of Trauma. 2009;66:457-
461.
19. Kaas L, Van Riet RP, Turkenburg JL, Jos Vroemen PA.
M, Van Dijk CN, Denise E. Magnetic resonance imaging
in radial head fractures: most associated injuries are not
clinically relevant. Journal of Shoulder and Elbow
Surgery. 2011;20:1282-1288.
20. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of
the elbow with fractures of the radial head and coronoid.
The Journal of Bone and Joint Surgery American volume.
2002;84-A:547-551.
21. Somford MP, Wiegerinck JI, Hoornenborg Daniël, Van
den BMPJ, Denise E. Eponyms in elbow fracture surgery.
Journal of Shoulder and Elbow Surgery. 2015;24:369-
375.
22. Essex-Lopresti P. Fractures of the radial head with distal
radioulnar dislocation; report of two cases. The Journal of
Bone and Joint Surgery British volume. 1951;33B:244-
247.
23. Morrey BF. The elbow and its disorders. 4th ed.
Philadelphia, PA: Saunders/Elsevier. c2009. p.1211.
24. Sudhahar TA, Patel ADA. Rare case of partial posterior
interosseous nerve injury associated with radial head
fracture. Injury. 2004;35:543-544.
25. Ayel JE, Bonnevialle N, Lafosse JM, Pidhorz L, Al H.
M, Mansat P, Chaufour X, Rongieres M, Bonnevialle P.
Acute elbow dislocation with arterial rupture. Analysis of
nine cases. Orthopaedics & Traumatology: Surgery &
Research. 2009;95:343-351.
26. Mahmoud SSS, Moideen AN, Kotwal R, Mohanty K.
Management of Mason type 1 radial head fractures: a
regional survey and a review of literature. European
Journal of Orthopaedic Surgery & Traumatology.
2014;24:1133-1137.
27. Ditsios KT, Stavridis SI, Christodoulou AG. The effect of
haematoma aspiration on intra-articular pressure and pain
relief following Mason I radial head fractures. Injury
2011;42:362-365.
28. Chalidis BE, Papadopoulos PP, Sachinis NC, Dimitriou
CG. Aspiration alone versus aspiration and bupivacaine
injection in the treatment of undisplaced radial head
fractures: a prospective randomized study. Journal of
Shoulder and Elbow Surgery. 2009;18:676-679.
29. Shulman BS, Lee JH, Liporace FA, Egol KA. Minimally

~ 36 ~
International Journal of Orthopaedics Sciences www.orthopaper.com
displaced radial head/neck fractures (Mason type-I, OTA
types 21A2.2 and 21B2.1): are we “over treating” our
patients. Journal of Orthopaedic Trauma. 2015;29:31-35.
30. Esser RD, Stanton D, Tala T. Fractures of the radial head
treated by internal fixation: late results in 26 cases.
Journal of Orthopaedic Trauma. 1995;9:318-323.
31. King GJW, Evans DC, Kellam JF. Open reduction and
internal fixation of radial head fractures. Journal of
Orthopaedic Trauma. 1991;5:21-28.
32. Akesson T, Herbertsson P, Josefsson P-O, Hasserius R,
Besjakov J, Karlsson MK. Primary nonoperative
treatment of moderately displaced two-part fractures of
the radial head. The Journal of Bone and Joint Surgery
American volume. 2006;88:1909-1914.
33. Lindenhovius ALC, Felsch Q, Ring D, Kloen P. The
long-term outcome of open reduction and internal
fixation of stable displaced isolated partial articular
fractures of the radial head. The Journal of Trauma.
2009;67:143-146.
34. Yoon A, King GJW, Grewal R. Is ORIF superior to
nonoperative treatment in isolated displaced partial
articular fractures of the radial head. Clinical
Orthopaedics and Related Research. 2014;472:2105-
2112.
35. Ring D, Quintero J, Jupiter JB. Open reduction and
internal fixation of fractures of the radial head. The
Journal of Bone and Joint Surgery American volume
2002;84:1811-1815.
36. Moro JK, Werier J, MacDermid JC, Patterson SD, King
GJW. Arthroplasty with a metal radial head for
unreconstructible fractures of the radial head. The Journal
of Bone and Joint Surgery American volume.
2001;83:1201-1211.
37. Chen X, Si-cheng W, Lie-hu C, Guo-qing Y, Li M, Jia-
can S. Comparison between radial head replacement and
open reduction and internal fixation in clinical treatment
of unstable, multi-fragmented radial head fractures.
International Orthopaedics. 2011;35:1071-1076.
38. Morrey BF. Current concepts in the management of
complex elbow trauma. Surgeon. 2009;7:151-161.