Proximal Radial Head Fracture

Description

The radius, located on the outside of the forearm, is the smaller of the two bones that make up the forearm. The radius is connected to the ulna, the second bone in the forearm. These two bones and their joints form the radioulnar and radiocarpal joints at the elbow and wrist, respectively.

Radius fractures include the neck of the radius and the proximal portion of the head. This type of fracture is common in adults. Proximal radius fractures occur when a fall on the outstretched hand (FOOSH) pushes the radius into the humerus or directly injures the elbow. proximal fracture The radius places the radial head at higher risk for avascular necrosis (AVN). [1]

Clinically Relevant Anatomy

The elbow joint is a synovial hinge joint made up of three joints—the humeroulnar, humeroradial, and radioulnar joints. The humerus of the arm meets the ulna and radius of the forearm to form a hinge, and the radius and ulna articulate to form a pivot joint that allows the forearm to pronate and Supination.

Prominent landmarks of the proximal radius include the radial head and tuberosity. The head is round with a flat but slightly concave surface. The plane connects to the humerus. The circumference of the head is contained within the annular ligament and rests on Pronation and supination rotate and slide the ulna. The radial tuberosity is the attachment site of the biceps brachii and rotator brevis. [2]

Epidemiology/Etiology

Epidemiology

Proximal radial head fractures most commonly occur between the ages of 20-64. [3] However, young men are more likely than women to fracture the radial head. This difference is associated with men experiencing more sports- or height-related falls, while women tend to experience fractures later in life due to Falls and weak bones. [4]

Etiology

The most common mechanism of radial head injury is a fall with the hand straight or elbow extended and the forearm pronated, which directs traumatic forces to the radial head through the wrist and forearm. Some common injuries associated with this type of fracture It can be a ligament injury, such as an injury to the lateral collateral ligament (LCL) or medial collateral ligament (MCL). Elbow dislocations can also produce what is known as the “dreaded triad” of elbow dislocation, radial head fracture, and coronoid fracture. [3]

Characteristics/Clinical Presentation

Types of Fractures

There are four grades of proximal radial head fractures commonly described using the Mason classification. The orthopedic surgeon determines the diagnosis of the different Mason’s fractures and decides on the interventions needed. Surgeon’s decision guided by diagnostic imaging radiograph MRI or CT Scan [5] Possible interventions include immobilization that may involve splint straps and/or surgery.

Mason Type 1

Mason type 1 fractures are cleft or marginal sector fractures with nondisplaced or slightly displaced radius In the management of Mason type 1 fractures of the proximal radius, mechanical limitations of supination and pronation of the forearm do not occur. [7]

Mason type 1 fractures of the proximal radius have a five percent (5%) chance of nonunion. [7] Nonunion of the proximal radius can lead to subluxation of the radial head. However, removal of associated fracture fragments does not increase the likelihood of subluxation. [7]

Mason Type 2

Mason type 2 radial head fractures are evident when the radial head is partially fractured and displaced >2 mm. [8]

Mason Type 3

A Mason type 3 fracture is completely broken or comminuted into multiple pieces or fragments. Mason type 3 fractures can be further described by subclass. Type 3a is complete displacement of the radial head from the axis and the fracture passes through the radial neck. Type 3b is joint Fracture of the head into two or more pieces. Type 3c joint fractures involving rotation and impingement. [8]

Differential Diagnosis

The high potential for other injuries in a fall with the outstretched hand (FOOSH) indicates the need for x-rays, MRI and sometimes CT scans to verify the diagnosis and demonstrate the integrity of all surrounding structures and tissues. [4]

Possible injuries that should be considered and ruled out for radial head fractures are microcephaly fractures, distal radius fractures, distal radioulnar joint dislocations, medial collateral ligament (MCL) ruptures, biceps tendon ruptures, triceps tendon ruptures, and elbow dislocations . [4]

Diagnostic Procedures

The primary diagnostic tool used to identify radial head fractures is an x-ray. Mason type 1 fractures do not always show up on radiographs. In this case, the “sail sign” may indicate a broken bone. The “sail sign” is a silhouette on a radiograph caused by an enlarged fat pad at the elbow. Current research is investigating the use of ultrasonography for faster detection of occult fractures. Current diagnostic procedures can take more than three weeks to identify a fracture. [9]

Mason type 1 fracture.

[10]

Mason type 3 fracture.

[11]

Sail sign.

[12]

Sail sign outline.

[13]

Outcome Measures

Disability of the arms, shoulders, and hands are the outcome measures used to determine the patient’s upper extremity capabilities. The questionnaire lists daily activities such as opening jars, carrying shopping bags, dressing, etc. Patient’s rating of difficulty with individual activities This questionnaire is on a scale of 1 to 5, where 1 means “no difficulty” and 5 means “couldn’t”. Note that some questions are worded differently, so the 1 to 5 scale is relabeled as necessary, such as ‘none’ to ‘extremely’ or ‘strongly disagree’ to ‘strongly agree. ’ Scores are calculated using the formula ([sum of n responses/n]-1)(25). n = completed projects. Scores are positively correlated with disability ratings. An additional module is provided for patients using workers’ compensation or for athletes and musicians. [14]

QuickDASH is a modified version of the DASH results measure that is shorter but has evidence to be as accurate as DASH. [15] QuickDASH contains only 11 questions and uses the same scoring scale and scoring formula.

Both outcome measures can be used for Mason type 1 type 2 and type 3 fractures regardless of the mechanism of injury. [14]

Examination

The mechanism of injury is usually a fall on the outstretched hand or a direct injury to the elbow. Radial head fractures and elbow dislocations are common. Swelling and bruising on the back of the elbow may be visible. Swelling and warmth are evident. Type III fractures may result in visible deformities. The patient had limited elbow extension/flexion and forearm pronation/supination. Some people may also have limited wrist movement. Passive range of motion (PROM) is limited due to pain. The dead-end feel of muscle protection is to be expected. Palpation of the radial head is painful. Some Patients experience numbness in their forearm hands and fingers. [16]

Medical Management

Non-Surgical Treatment

The arm should be immobilized for a brief period, mainly for Mason type 1 fractures. This can be done by the patient using a sling recommended for no more than 7 days. [3]

Surgical Treatment

• Open reduction and internal fixation (ORIF) of the radial head has been shown to be beneficial in Mason type 2 and type 3 fractures.
• Radial head resection is indicated in sedentary patients or in patients with persistent pain from a simple radial head fracture.
• Radial head arthroplasty is another effective option for comminuted Mason type 3 fractures involving more than 25% of the radial head. [3]

Physical Therapy Management

Mason Type 1 Fractures

Type 1 nondisplaced proximal radius fractures should be treated nonoperatively with the patient placed in a sling or splint for several days. [17] Ice can be used as needed to help control swelling. Patients should perform active range of motion (AROM) in the early stages, as pain permits Rehabilitation includes supination and pronation of the forearm. An important aspect of this fracture is mobilizing the joint as early as possible to reduce any complications of stiffness following joint trauma. [4] ROM should be considered cautiously when the fracture involves one third of the joint surface. If the fracture does involve one third of the articular surface, a sling or splint should be used for at least two weeks. [7]

Mason Type 2 and 3 Fractures

ORIF is used in Mason type 2 and type 3 fractures where it has been shown to provide the best recovery. Physiotherapy after immobilization is divided into three phases. In the first phase of days 0-14, the patient begins AROM with elbow flexion and extension. Elbow ROM at the end of week two It should be 15-105 degrees. After meeting these ROM requirements, the patient begins grasping exercises using putty and isometric strengthening exercises at the elbow and wrist. During the second phase, from 15 days to 6 weeks, the physiotherapist should assess shoulder and wrist strength with ROM. The patient continued with elbow AROM and active-assisted range of motion (AAROM). Elbow flexion and extension range of motion should be full by the end of six weeks. After this time, the patient begins AROM and AAROM supination and pronation maneuvers. Patients will remain isometric Strengthen the exercises in the first stage, especially the flexion and extension exercises. In the third phase, from weeks 7 to 12, patients continued with AROM and AAROM supination and pronation training. By week eight, full pronation and supination should be possible. patients should Isometric strengthening of elbow flexion and extension with wrist pronation and supination. A physical therapist will also need to assess and focus on any additional deficits caused by fractures and/or surgery. [18]

Education

If surgery is performed, the splint should be left in place until the patient’s first postoperative visit, which usually occurs 1-2 weeks after surgery. You can shower the next day, but care must be taken to keep the splint clean and dry. Immersion in the elbow area is limited to At least four weeks after surgery. [5]

After returning home, the patient can walk as needed. Patients are allowed to drive a car once they are authorized by the surgeon, which is usually four to six weeks after surgery. Return to work is contingent on the patient’s duties required to perform the job and must be approved by the surgeon before returning to work employment responsibilities. [5]

Patients should expect to see some swelling in/around the arm after surgery. Patients should contact their surgeon immediately if they notice skin changes around the incision site with or without discharge or bleeding, or if a fever exceeds 101°. [5]

Things patients should not do during the first 6 weeks are:

• Use your arms to push yourself onto the bed or chair.
• Use the strong contraction of the muscles needed to push off.
• Overuse of the elbow/arm can make the healing process difficult.
• Lift an object heavier than a glass of water.
• Position the arms in extreme positions, including reaching out to the side or back of the patient’s body.

Patients should seek help with mobility when needed.

At the first post-op visit with the surgeon (1-2 weeks), the patient’s staples/sutures are removed, the wound is inspected and x-rays are taken to ensure proper healing. After everything has been assessed, the patient will be given instructions on next steps and plans for the next few weeks. [5]

Pain Management

Applying ice packs and using a sling to the injured area while taking NSAIDs such as ibuprofen or acetaminophen can help manage pain and swelling associated with radial head fractures. [19]

Rehabilitation

Non-Surgical Rehabilitation

Early ROM in nonsurgical simple and complex radial head fractures and early AROM and AAROM in the elbow help prevent the collection of edema stiffness and the formation of adhesions in the joint capsule and annular ligament. Patients must also pay attention to surrounding joints such as Acts as shoulder-wrist-hand and shoulder-thorax joints to ensure ROM and arm use is maintained. [10]

Surgical Rehabilitation

With regard to surgical intervention, there are two types of fractures: simple and complex. Simple radial head fracture refers to an isolated radial head fracture [10]. According to Mason’s classification, type 2 and type 3 radial head fractures require surgical intervention to stabilize the radius. A sort of Complex radial head fractures are classified as additional instability due to factors other than the radial head fracture. [10] In both cases, immobilization of the arm is recommended in favor of protecting and supporting the arm after surgery. However, immobilization of the arm can only be Use a long arm splint for up to 1 week after surgery for simple fractures and up to 3-6 weeks for complex fractures. [10]

Recovery

Mason Type 1 Fractures

Nonsurgical treatment consists of a splint or sling for several days, followed by early and gradual increases in elbow and wrist motion depending on pain level. [17] Possible complications of Mason type 1 proximal radius fractures may include loss of active elbow extension, mild loss of Forearm pronation and supination and occasional fatigue and pain from overuse of the forearm. [7] If excessive movement is promoted prematurely, it can move and displace bones. [17]

Mason Type 2 Fractures

If displacement is minimal, treatment involves the patient wearing a sling or splint for 1 to 2 weeks and ROM exercises should be done. [17]

Mason Type 3 Fractures

Early extension and elbow flexion are necessary to avoid elbow contracture or elbow ROM stiffness. [17]

Some type 3 fractures require the patient to be placed in a splint or sling for a short time. The surgeon will advise the patient not to bear or lift anything heavier than a few pounds by the arm or wrist for 6 to 12 weeks. [17] Proximal fractures Partial radial head can cause loss of elbow ROM. Patients should perform exercises to restore ROM and strength to restore their functional activities. A second surgery may be required to remove any scar tissue that forms and limits elbow ROM. [17]

Key Research

Svensson et al. al Discusses current outcomes in the management of radial head fractures. [20] ORIF for simple fractures is supported by the literature, but optimal management of more complex fractures is controversial.

Harkey et al. al discusses the complications and detailed revisions required in the management of radial head fractures. [twenty one]