Radial head fractures are the most common fracture of the elbow in adults, comprising 30–50% of all elbow fractures, and are classified using the Mason classification (Types I–IV). [1-2] The majority occur from a fall onto an outstretched hand (FOOSH) with axial loading through the forearm. [1-2]
1. History
- Mechanism: FOOSH with elbow extended and forearm pronated is the classic mechanism; less commonly, a direct blow to the lateral elbow [1-2]
- Pain characterization: Lateral elbow pain, worse with forearm rotation (pronation/supination); pain can be severe even with occult fractures due to capsular distension from hemarthrosis [1]
- Timing: Acute onset after trauma; ask about time of injury, prior attempts at treatment, and ability to use the arm since injury
- Associated symptoms: Swelling, ecchymosis, limited ROM (especially extension and supination), mechanical catching or locking (suggests loose body or block to motion) [1][3]
- Important negatives: Wrist pain (Essex-Lopresti), forearm pain along interosseous membrane, numbness/tingling (neurovascular compromise), prior elbow injuries or surgeries
2. Alarm Features
- Mechanical block to motion after aspiration/injection → suggests displaced fragment requiring surgical intervention [4]
- Crepitation with ROM → concerning for comminution or intra-articular loose body [4]
- Tenderness over the DRUJ or dorsal forearm (interosseous membrane) → suspect Essex-Lopresti injury (radial head fracture + IOM disruption + DRUJ instability) [5-6]
- Elbow dislocation → Mason Type IV / "terrible triad" (dislocation + radial head fracture + coronoid fracture) — requires urgent orthopedic consultation [7]
- Neurovascular compromise or open fracture → emergent orthopedic referral [3]
- High-energy mechanism (MVC, fall from height) → higher risk of associated ligamentous and bony injuries [2]
3. Medications
- Acute pain management: Acetaminophen and NSAIDs are first-line [8]
- Opioids: Brief course (few days) for severe pain inadequately controlled by NSAIDs [8]
- NSAID caution: Some concern about delayed fracture healing with prolonged NSAID use, though short-term use is generally accepted [8]
- Aspiration with local anesthetic: Intra-articular bupivacaine after hemarthrosis aspiration provides significant pain relief and allows better ROM assessment [1]
4. Diet
- No specific acute dietary modifications
- Adequate calcium and vitamin D intake for bone healing in the subacute/chronic phase
- Ensure adequate protein intake to support fracture healing
5. Review of Systems
- MSK: Wrist pain (DRUJ/Essex-Lopresti), shoulder pain (ipsilateral injury), forearm pain
- Neurologic: Numbness/tingling in hand (ulnar, median, or radial nerve distribution)
- Vascular: Coolness, pallor, or diminished pulses distally
- Constitutional: Mechanism-related — syncope, dizziness, or other cause of fall (especially in elderly)
6. Collateral History and Family History
- Witnessed mechanism details (height of fall, surface, position of arm)
- Dominant hand — impacts treatment decisions and functional goals [4]
- Occupation and activity level — manual labor, overhead athletes, or high-demand occupations may influence surgical thresholds [4]
- History of osteoporosis or metabolic bone disease
- Family history of osteoporosis (relevant for fragility fractures in older adults)
7. Risk Factors
- Demographics: Women more frequently affected than men; 85% occur between the 3rd and 6th decades of life [1]
- Osteoporosis/osteopenia: Increases fracture risk and comminution with lower-energy mechanisms
- Sports/activities: Contact sports, cycling, skating, equestrian activities
- Falls risk: Elderly patients, balance disorders, polypharmacy, alcohol use
- Prior elbow injury: Increases susceptibility to re-injury and complicates management
8. Differential Diagnosis
- Occult radial head fracture (radiograph-negative with positive fat pad sign) [3][9]
- Radial neck fracture — similar mechanism, more distal location
- Capitellum fracture — lateral elbow pain, may coexist
- Coronoid process fracture — medial elbow pain, associated with dislocation [7]
- Olecranon fracture — posterior elbow pain, inability to extend against gravity
- Elbow dislocation — obvious deformity, global instability
- Lateral epicondylitis — chronic overuse, no acute trauma (mimic in subacute presentations)
- Monteggia fracture-dislocation — proximal ulna fracture with radial head dislocation [10]
9. Past Medical History
- Prior elbow fractures, dislocations, or surgeries
- Osteoporosis or osteopenia
- Inflammatory arthritis (rheumatoid — may affect bone quality)
- Anticoagulant use (larger hemarthrosis)
- Chronic steroid use (bone quality)
- Diabetes (healing implications)
10. Physical Exam
- Inspection: Swelling and ecchymosis over lateral elbow
- Palpation: Point tenderness over the radial head (palpated in the "soft spot" triangle between olecranon, lateral epicondyle, and radial head); palpate the DRUJ and dorsal forearm for Essex-Lopresti [3-4]
- ROM: Limited extension and supination are the most sensitive findings; assess for mechanical block vs. pain-limited motion [3]
- Elbow extension test: Inability to fully extend the elbow has moderate sensitivity for fracture [11]
- Forearm rotation: Pain with pronation/supination is characteristic [1]
- Stability testing: Varus and valgus stress testing for collateral ligament integrity [3]
- Neurovascular exam: Radial, ulnar, and median nerve function; distal pulses and capillary refill
11. Lab Studies
- Routine labs are not indicated for isolated radial head fractures
- If surgical intervention is anticipated: CBC, BMP, coagulation studies per institutional protocol
- Consider bone density evaluation (DEXA) in older patients with low-energy mechanism if osteoporosis is suspected
12. Imaging
- First-line: Elbow radiographs (AP, lateral, and oblique views) — the oblique view improves fracture detection [3]
- Key radiographic findings:
- Posterior fat pad sign (always abnormal) and anterior fat pad elevation (sail sign) — indicate joint effusion/hemarthrosis and imply occult fracture even if fracture line is not visible [3][12]
- Fracture line at the radial head, displacement, comminution
- Occult fracture: If radiographs are negative but clinical suspicion remains, apply a posterior splint and obtain repeat radiographs in 7–14 days [3]
- Point-of-care ultrasound: Sensitivity 97%, specificity 95% for forearm fractures; can detect effusion and cortical disruption [3][9]
- CT scan: For further fracture characterization — comminution, displacement, impaction, articular involvement — especially when surgical planning is needed [3][13]
- MRI: Consider if ligamentous injury (Essex-Lopresti, collateral ligaments) is suspected [14]
- Wrist radiographs: Obtain if DRUJ tenderness is present to evaluate for Essex-Lopresti injury [5]
13. Special Tests
Mason Classification (Modified by Johnston): [1][3]
- Hemarthrosis aspiration: Performed via the lateral "soft spot" approach with elbow flexed ~80°; aspirate hemarthrosis, then inject local anesthetic (bupivacaine) to allow pain-free ROM assessment — critical for determining mechanical block [1]
- Fluoroscopy: May be used intraoperatively or in clinic for dynamic assessment of stability
14. ECG
- Not routinely indicated
- Consider in elderly patients if the fall was precipitated by syncope, arrhythmia, or cardiac event
15. Assessment
Severity stratification by Mason type drives management
- Mason I (most common): Excellent prognosis — 95% good/excellent outcomes with conservative treatment at 2 years [1]
- Mason II: Good prognosis — both operative and nonoperative treatment yield comparable functional outcomes at 1 year (DASH scores: 0.0 vs. 1.7, p = 0.076); the key decision point is presence of mechanical block [15-16]
- Mason III: Higher complication rates; ORIF-related complications are the most common cause of revision [17]
- Mason IV / Terrible triad: Complex injury requiring surgical management; stiffness and instability are the primary long-term concerns [7][17]
Stiffness is the most common long-term complication across all types (67.4% of revision cases), followed by instability (36.5%) and painful osteoarthritis (29.2%). [17]
16. Treatment Plan
Mason Type I (Nondisplaced)
- Sling for comfort for 48 hours, then begin early active ROM [8][11]
- 90% of surgeons favor immediate mobilization over immobilization [18]
- Avoid prolonged cast immobilization — increases stiffness risk [11]
- NSAIDs/acetaminophen for pain [8]
Mason Type II (Displaced, noncomminuted)
- Without mechanical block: Nonoperative management is reasonable — outcomes are comparable to ORIF [15-16]
- With mechanical block or ≥2 mm displacement with ≥30% head involvement: ORIF with screws is recommended [4][19]
- Aspiration + local anesthetic injection to assess for mechanical block is a key step [1][4]
Mason Type III (Comminuted)
- ≤3 fragments: ORIF may be attempted if anatomic reduction is achievable [19-20]
- >3 fragments: Radial head arthroplasty (replacement) is preferred [19][21]
- Radial head excision is rarely performed now; replacement is preferred when collateral ligaments are compromised [22]
Mason Type IV (with dislocation)
- Urgent reduction of dislocation
- Surgical repair of radial head (ORIF or replacement) + ligament repair ± coronoid fixation [7]
- Lateral collateral ligament complex repair is typically required [7]
Aspiration technique (for all types with tense effusion): Lateral approach through the soft spot triangle, elbow flexed 80°, aseptic technique [1]
17. Disposition
- Discharge from ED: Mason Type I and most isolated Mason Type II fractures without mechanical block — sling, analgesia, orthopedic follow-up within 5–7 days [3][23]
- Orthopedic consultation in ED: Mason III, Mason IV, terrible triad, open fractures, neurovascular compromise, suspected Essex-Lopresti injury [7][19]
- Admission: Elbow dislocations requiring reduction under sedation/anesthesia, polytrauma, vascular injury, or need for urgent surgical intervention
- Virtual/telephone follow-up: For suspected Mason I fractures, structured advice with no face-to-face review has shown 96% patient satisfaction and only 1% late surgical intervention rate [23]
18. Follow Up / Return Precautions
Follow-up timing
- Mason I: Orthopedic or primary care follow-up in 1–2 weeks; repeat radiographs if initial films were negative [3][11]
- Mason II: Orthopedic follow-up within 5–7 days for reassessment of ROM and consideration of surgical intervention
- Mason III/IV: Per orthopedic surgeon, typically within days of injury
Return precautions — advise patients to return immediately for:
- Increasing pain, swelling, or inability to move the elbow
- Numbness, tingling, or weakness in the hand or fingers
- Color change (pallor, cyanosis) or coolness of the hand
- Fever or signs of infection (if aspiration was performed)
- Mechanical locking or catching of the elbow
Patient counseling
- Early gentle ROM exercises (pendulum, gentle flexion/extension) are critical to prevent stiffness — the most common complication [17]
- Avoid heavy lifting or forceful gripping for 4–6 weeks
- Ice and elevation for swelling in the first 48–72 hours
- Expected recovery: Most Mason I fractures achieve full function by 6–12 weeks; Mason II may take 3–6 months; complex fractures may have prolonged recovery [1][24]
References
1. Aspiration of the Elbow Joint for Treating Radial Head Fractures. — Foocharoen T, Foocharoen C, Laopaiboon M, Tiamklang T. The Cochrane Database of Systematic Reviews. 2014.
2. Surgical Interventions for Treating Radial Head Fractures in Adults. — Gao Y, Zhang W, Duan X, et al. The Cochrane Database of Systematic Reviews. 2013.
3. Common Fractures of the Radius and Ulna. — Patel DS, Statuta SM, Ahmed N. American Family Physician. 2021.
4. Decision-Making in the Treatment of Radial Head Fractures: Delphi Methodology. — Surucu S, Torres KA, Mitchell G, et al. Journal of Shoulder and Elbow Surgery. 2023.
5. Essex-Lopresti Lesions and Longitudinal Radioulnar Instability: A Narrative Review. — Sheth M, Mitchell S, Bell B, Wu C. JBJS Reviews. 2022.
6. The Essex-Lopresti Injury. — Heifner JJ, Gray RRL. Journal of Orthopaedic Trauma. 2024.
7. Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update. — Fahs A, Waldron J, Afsari A, Best B. The Journal of the American Academy of Orthopaedic Surgeons. 2024.
8. ACOEM Practice Guidelines: Elbow Disorders. — Hegmann KT, Hoffman HE, Belcourt RM, et al. Journal of Occupational and Environmental Medicine. 2013.
9. Diagnosis of Occult Radial Head and Neck Fracture in Adults. — Pavić R, Margetić P, Hnatešen D. Injury. 2015.
10. The Radiological Findings in Complex Elbow Fracture-Dislocation Injuries. — Al-Ani Z, Tham JL, Ooi MWX, et al. Skeletal Radiology. 2022.
11. Mason Type I Fractures of the Radial Head. — de Muinck Keizer RJ, Walenkamp MM, Goslings JC, Schep NW. Orthopedics. 2015.
12. ACR Appropriateness Criteria® Acute Elbow and Forearm Pain. — Chen KC, Ha AS, Bartolotta RJ, et al. Journal of the American College of Radiology : JACR. 2024.
13. Interobserver Reliability of Radial Head Fracture Classification: Two-Dimensional Compared With Three-Dimensional CT. — Guitton TG, Ring D. The Journal of Bone and Joint Surgery. American Volume. 2011.
14. The Treatment of the Acute Essex-Lopresti Injury. — Grassmann JP, Hakimi M, Gehrmann SV, et al. The Bone & Joint Journal. 2014.
15. Operative vs. Nonoperative Treatment for Mason Type 2 Radial Head Fractures: A Randomized Controlled Trial. — Mulders MAM, Schep NWL, de Muinck Keizer RO, et al. Journal of Shoulder and Elbow Surgery. 2021.
16. The Treatment of Isolated Mason Type II Radial Head Fractures: A Systematic Review. — Lanzerath F, Hackl M, Wegmann K, Müller LP, Leschinger T. Journal of Shoulder and Elbow Surgery. 2021.
17. Surgical Revision of Radial Head Fractures: A Multicenter Retrospective Analysis of 466 Cases. — Hackl M, Wegmann K, Hollinger B, et al. Journal of Shoulder and Elbow Surgery. 2019.
18. Current Concepts in the Management of Radial Head Fractures: A National Survey and Review of the Literature. — Barakat A, Mcdonald C, Singh H. Annals of the Royal College of Surgeons of England. 2023.
19. Radial Head Fractures--an Update. — Pike JM, Athwal GS, Faber KJ, King GJ. The Journal of Hand Surgery. 2009.
20. Fractures of the Radial Head and Neck. — Ruchelsman DE, Christoforou D, Jupiter JB. The Journal of Bone and Joint Surgery. American Volume. 2013.
21. Indications and Clinical Results of Radial Head Replacement: Has Anything Changed?. — Eyberg BA, McKee MD. Journal of Orthopaedic Trauma. 2019.
22. Fractures of the Radial Head. — Duckworth AD, McQueen MM, Ring D. The Bone & Joint Journal. 2013.
23. A New "Virtual" Patient Pathway for the Management of Radial Head and Neck Fractures. — Jayaram PR, Bhattacharyya R, Jenkins PJ, Anthony I, Rymaszewski LA. Journal of Shoulder and Elbow Surgery. 2014.
24. Early Controlled Mobilisation Improves Functional Outcomes in Nonoperatively Treated Radial Head Fractures: A Multicenter Retrospective Cohort Study. — Altuntas Y, Ipek E, Bozca MA, Tuter I, Eren OT. Clinical Rehabilitation. 2026.