Radial Head Fracture in the Adult

Case: 62 year old woman presents after tripping on sidewalk and falling on outstretched hand. No LOC. Left elbow hurts to move. No other injuries or complaints.

Tapa: Radial head fractures are common in adults falling on outstretched hands, but can be difficult to detect on x-ray.

A focused physical exam should include:

• Distal skin examination, capillary refill, radial/ulnar pulses.
• Upper extremity sensation, motor, strength testing
• Upper extremity nerve function can be tested as follows: A-OK (median), crossed fingers (ulnar), thumbs up (radial)
• Active/Passive ROM testing including: pronation/supination, wrist & elbow extension/flexion
• Palpation feeling for point tenderness and/or displacement in entire upper extremity (a rule of thumb with orthopedic injuries is to always check the joints proximal and distal to the site of suspected injury).

At this point you will most likely need an x-ray to confirm your suspicions. Radial head fractures can be classified into three types radiographically. For the purposes of this conversation we will focus on Type 1 fractures, as they are non-displaced, and often the most difficult to detect.

Here you can see a "normal" lateral film of the elbow. The fat pad lines the sinovial fluid in the joint. After trauma to the elbow, the synovial fluid can cause this area to expand, and thus the fat pad can be an indirect marker of type 1 radial head fractures (especially if no fracture in the bone can be appreciated).

Here is an example of displacement of the anterior fat pad, otherwise known as the "sail sign". Remember, this is an indirect sign of trauma, and does not confirm a diagnosis of radial head fracture. Use wisely with your clinical suspicion!












In this example, you can again see the "sail sign". Additionally, you can see a posterior fat pad (marked with arrow). Presence of a posterior fat pad is always abnormal and is the most sensitive radiographic finding for a radial head fracture.













Any suspicions of distal radial/ulnar injuries should warrant wrist films as well.

After examination and radiographs you may still be unsure as to whether the patient has a type 1 radial head fracture or not. Rest assured, the treatment is the same. The patient should be given medication for their pain, placed in a sling, and instructed to mobilize their arm with range of motion exercises after 1 week. They should follow up with an orthopedist, and if any suspicion lingers as to whether or not their is a fracture, radiographs can be repeated at this time as evidence of a fracture will be more apparent.

(Images courtesy of: http://www.wikiradiography.com/)