Lateral elbow x-ray of a 60-year-old woman following a fall
Anteroposterior elbow x-ray
A 60-year-old woman presents with elbow pain after a fall 2 days earlier. She remembers falling on her wrist with her arm extended and has had severe pain with elbow motion since the fall. X-rays taken after the injury show a displaced radial neck fracture with more than 30 degrees of angulation.
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The radial head and neck comprise the most proximal portion of the radius. The radial head lies at the proximal end. It is disc-shaped with a slightly concave end that articulates with the capitellum of the distal humerus. The radial head also articulates with the lesser sigmoid notch of the ulna medially. Just distal to the head but proximal to the tuberosity is the radial neck. The neck is enclosed by the lower end of the annular ligament. Both the head and neck are free from capsular attachment and can rotate freely.
An intact articulation between the radial head and the capitellum is crucial for elbow stability. The radiocapitellar joint stabilizes the elbow with valgus stresses and provides load sharing with weight-bearing activities at the wrist.1 The radiocapitellar joint, along with the interosseous membrane, distal radioulnar joint, and triangular fibrocartilage complex prevent proximal migration of the distal radius. A longitudinal force, such as a fall on an outstretched arm that causes the radial head to collide with the capitellum, is the most common mechanism of injury for radial neck fractures.
Indications for surgical treatment of radial head fractures have been defined in the literature as greater than 30% involvement of the radial head and more than 2 mm of displacement.2 However, treatment of isolated radial neck fractures is determined by several factors, including fracture stability, degree of angulation, and the patient’s functional status. The radiocapitellar joint must be restored to anatomic alignment to avoid potential complications such as elbow instability, further displacement, and late arthrosis.
Angulation of the radial neck fracture greater than 30 degrees should be corrected surgically. The 3 options for surgical treatment of radial head and neck fractures are open reduction and internal fixation, radial head excision, and replacement. Open reduction and internal fixation should be performed whenever possible to restore joint articulation and facilitate early active range of motion. Low-profile precontoured plates provide an excellent option for fixation. Radial head and neck fractures that are not amenable to open reduction and internal fixation should be treated with radial head arthroplasty, or in some cases, radial head excision.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Ruchelsman DE, Christoforou D, Jupiter JB. Fractures of the radial head and neck. J Bone Joint Surg Am. 2013;95(5):469-478.
- Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts and management. J Am Acad Orthop Surg. 2007;15(7):380-387.