Radial Head Fractures: A Comprehensive Clinical Overview

Radial head fractures are among the most common elbow injuries encountered in clinical practice. Proper diagnosis and management are essential to restore function, maintain joint stability, and prevent long-term complications.

Epidemiology

Radial head fractures account for 1.7% to 5.4% of all fractures and approximately one-third of all elbow fractures. Notably, about one-third of patients present with associated injuries, including fractures or ligamentous damage involving the shoulder, humerus, forearm, wrist, or hand.

Anatomy and Biomechanics

The radial head plays a critical role in elbow and forearm function:

• The radial head and capitellum are reciprocally curved, enabling smooth articulation.
• Force transmission across the radiocapitellar joint occurs throughout elbow motion and is greatest in full extension.
• Accurate positioning of the radial head within the lesser sigmoid notch is essential for full forearm rotation.
• The radial head contributes to:
  • Valgus stability (secondary restraint)
  • Load sharing across the elbow
  • Longitudinal forearm stability in conjunction with the interosseous membrane

Loss of radial head integrity—especially when combined with ligament injury—can result in instability and proximal migration of the radius.

See Also: Elbow Anatomy

Mechanism of Injury

Most radial head fractures occur due to:

• Fall onto an outstretched hand (FOOSH)
• Higher-energy trauma such as:
  • Falls from height
  • Sports injuries

Biomechanical patterns:

• Axial loading with the elbow between 0–80° flexion → radial head fracture
• Combined forces (axial + rotational) may lead to:
  • Posterolateral rotatory injuries
  • Fracture-dislocations (e.g., Monteggia or olecranon fracture-dislocations)

These injuries are frequently associated with ligamentous damage and, less commonly, capitellar fractures.

Clinical Evaluation

Symptoms:

• Elbow pain
• Limited range of motion (especially rotation)
• Pain with passive forearm rotation

Signs:

• Localized tenderness over the radial head
• Elbow effusion
• Reduced flexion-extension and pronation-supination

Important Assessments:

• Examine wrist and distal radioulnar joint (DRUJ)
  → Wrist pain may indicate an Essex-Lopresti lesion
• Evaluate medial collateral ligament (MCL) stability
• Joint aspiration with local anesthetic may:
  • Reduce pain
  • Help detect mechanical block to motion

Radiographic Evaluation

Standard Imaging:

• Anteroposterior (AP) and lateral elbow X-rays

Special Views:

• Greenspan (radiocapitellar) view improves visualization of the radial head

Key Findings:

• Fat pad sign (especially posterior) suggests occult fracture
• Subtle fractures may not be immediately visible

Advanced Imaging:

• CT scan for:
  • Comminution
  • Surgical planning
• MRI if soft tissue injury or occult fracture is suspected

See Also: Elbow X-ray Views

Classification (Modified Mason Classification)

• Type I: Nondisplaced fractures
• Type II: Displaced marginal fractures
• Type III: Comminuted fractures of the entire head
• Type IV: Radial head fracture with elbow dislocation

Treatment

Treatment Goals

• Restore forearm rotation
• Achieve early mobilization
• Maintain elbow and forearm stability
• Prevent long-term complications such as arthrosis

Nonoperative Treatment

Indications:

• Nondisplaced fractures (Type I)
• Displaced fractures without mechanical block

Approach:

• Sling for comfort
• Early mobilization within 24–48 hours
• Optional joint aspiration for pain relief

Operative Treatment

1. Open Reduction and Internal Fixation (ORIF)

Indications:

• Type II fractures with mechanical block to motion
• Large displaced fragments (>2 mm or >25% of head)

Technique highlights:

• Lateral approach (Kocher or Kaplan)
• Fixation with screws or plates in the safe zone

2. Radial Head Replacement

Indications:

• Comminuted fractures (Type III)
• Unstable elbow or forearm injuries

Notes:

• Metallic prostheses (titanium/vitallium) preferred
• Avoid oversizing, which can impair joint mechanics

3. Radial Head Excision

• Rarely used in acute settings
• Contraindicated in unstable injuries
• May be considered in chronic cases with good outcomes

Essex-Lopresti Lesion

A complex injury involving:

• Radial head fracture
• Interosseous membrane disruption
• DRUJ instability

Key point:

• Do NOT excise the radial head
  → leads to proximal radial migration

Management:

• Radial head repair or replacement
• Stabilization of DRUJ

See Also: Essex-Lopresti Injury

Postoperative Care

• Early mobilization is critical:
  • Begin active or assisted motion within 5–7 days
• Avoid prolonged immobilization

Complications

• Elbow stiffness (contracture)
• Heterotopic ossification
• Chronic wrist pain (missed ligament injury)
• Proximal migration of radius
• Posttraumatic osteoarthritis
• Complex regional pain syndrome (CRPS)
• Chronic instability (rare, often due to missed injuries)

Key Clinical Insights

• Always assess the entire upper limb, not just the elbow
• Wrist pain in radial head fractures is a red flag for Essex-Lopresti injury
• Early motion is essential to prevent stiffness
• Preservation or replacement of the radial head is critical in unstable injuries

References & More

1. Pappas N, Bernstein J. Fractures in brief: radial head fractures. Clin Orthop Relat Res. 2010 Mar;468(3):914-6. doi: 10.1007/s11999-009-1183-1. PMID: 19967474; PMCID: PMC2816766. Pubmed
2. Patiño JM, Saenz VP. Radial Head Fractures. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: Pubmed
3. Al-Tawil K, Arya A. Radial head fractures. J Clin Orthop Trauma. 2021 Jul 8;20:101497. doi: 10.1016/j.jcot.2021.101497. PMID: 34307018; PMCID: PMC8283329. Pubmed
4. Egol KA. Handbook of fractures. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2019.
5. Campbel’s Operative Orthopaedics 12th edition Book.