Ortho Dx: Elbow Pain Following a Fall - Clinical Advisor

Ortho Dx: Elbow Pain Following a Fall

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  • Figure 1. Anteroposterior radiograph of the left elbow.

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  • Figure 2. Lateral radiograph of the left elbow.

A 28-year-old woman presents with pain in her left elbow after a fall 2 days earlier. The patient reports that she tripped and landed on her outstretched hand with her elbow extended. Since then she has had significant pain with any motion of the elbow. On physical examination of the left elbow, the patient has tenderness to palpation over the radiocapitellar joint. Anteroposterior and lateral radiographs of the left elbow are obtained (Figures 1 and 2).

The radial head articulates with the capitellum of the distal humerus and forms the radiocapitellar joint in the elbow. The radiocapitellar joint, along with the ulnar collateral ligament, provides stability to the elbow against valgus forces. A depressed or significantly...

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The radial head articulates with the capitellum of the distal humerus and forms the radiocapitellar joint in the elbow. The radiocapitellar joint, along with the ulnar collateral ligament, provides stability to the elbow against valgus forces. A depressed or significantly displaced radial head fracture can cause painful clicking and loss of mobility (mechanical blockade) when extending the elbow.  

Radial head fractures are most commonly impacted articular fractures.1 Fractures displaced <2 mm are considered minimally displaced; those displaced >2 mm often require surgery.2 The decision for surgical treatment is also based on patient factors including age and overall health.

The patient in this case has a displaced fracture >2 mm and given her age would be at increased risk for radiocapitellar arthritis if treated conservatively. The ideal treatment for this fracture is open reduction and internal fixation (ORIF) with small screws. This surgical procedure requires arthrotomy of the elbow in order to visualize reduction of the radial head; low-profile headless screws are then placed parallel to the articular surface.3,4

Small, displaced radial head fracture fragments involving <25% of the articular surface can often be excised to prevent mechanical block of elbow range of motion. Radial head fractures with significant comminution are typically unrepairable; therefore, radial head excision or radial head replacement is the best treatment option. Head excision and replacement carry a higher risk of postoperative elbow arthritis compared with ORIF.3,4

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.

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.
  2. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5:1-10.
  3. Adams JE, Sems SA, Steinmann SP. Open treatment of radial head fractures. JBJS Essent Surg Tech. 2017;7(4):e35.
  4. Lapner M, King GJ. Radial head fractures. J Bone Joint Surg Am. 2013;95(12):1136-1143.
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