Figure 1. Anteroposterior radiograph of the right elbow.
Figure 2. Lateral radiograph of the right elbow.
A 35-year-old man presents to the office with right elbow pain after he fell 2 days ago. Anteroposterior and lateral radiographs of the right elbow (Figures 1 and 2) show a minimally displaced radial head fracture.
Which of the following is the best treatment option for this patient?
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Radial head fractures are the most common type of elbow fractures in adults.1 The mechanism of injury is usually a fall onto an outstretched hand that causes impaction of the radial head into the capitellum. An intact radiocapitellar joint helps to stabilize the elbow joint to valgus and axial forces.
The indications for surgical treatment of a radial head fracture are controversial. Fractures displaced >2 mm and involving >25% of the articular surface may be considered for operative treatment with open reduction and internal fixation. However, most radial head fractures are minimally displaced and can be treated nonoperatively. Minimally displaced fractures are treated with use of a sling for 7 to10 days, followed by early elbow motion. Patients are instructed not to lift using the arm with the affected elbow, other than for range of motion, to avoid displacement of the fracture.
The most frequent complication of radial head fracture is elbow stiffness from prolonged immobilization. Patients should be advised that early motion does not reduce the rate of healing. Patients should also be given instructions to perform full elbow extension, flexion, supination, and pronation at home. Physical therapy has not been found to have any benefit over a home exercise program for treating minimally displaced fractures.2 With similar clinical results between the two, the cost of physical therapy cannot be justified. At 2 weeks following injury, range of motion should be checked and radiographs obtained to document fracture position. At 6 weeks, final radiographic examination should be performed to document full healing and elbow range of motion.1,2
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).
1. Lapner M, King GJW. Radial head fractures. J Bone Joint Surg Am. 2013;95(12):1136-1143.
2. Egol KA, Haglin JM, Lott A, Fisher N, Konda SR. Minimally displaced, isolated radial head and neck fractures do not require formal physical therapy: results of a prospective randomized trial. J Bone Joint Surg Am. 2018;100(8):648-655.