Radial head fractureMANAGEMENT

MUSCULOSKELETAL AND RHEUMATOLOGIC PRESENTATIONS · 12 SECTIONS

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419 items

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01Approach to the Critical Patient/attcp61

Immediate priorities

›Stabilization and escalation

›Airway compromise unlikely

›Hypotension evaluation if high energy trauma

›Analgesia early

›If severe pain, IV opioid titration with monitoring

›Limb threat screen

›Open fracture concern

›Neurovascular compromise

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive finger and wrist extension

›Associated injury screen

›Elbow dislocation concern

›Forearm instability concern

›Essex-Lopresti pattern concern

›Wrist pain with radial head fracture

›Early consultation triggers

›If open fracture, immediate orthopedics

›If elbow dislocation, orthopedics

›If mechanical block to motion, orthopedics

›If suspected terrible triad, orthopedics

Neurovascular and function checkpoints

›Documented baseline

›Radial pulse

›Capillary refill

›Median nerve motor

›Thumb opposition

›OK sign

›Ulnar nerve motor

›Finger abduction

›Radial nerve motor

›Wrist extension

›Finger extension

›Sensory distribution

›Median

›Ulnar

›Radial

›Active finger and wrist range

›Pain limited motion vs true weakness

Immobilization and pain control

›Initial immobilization

›Posterior long arm splint

›Elbow 90 degrees flexion if tolerated

›Forearm neutral or position of comfort

›Sling for comfort

›Pain control ladder

›Acetaminophen

›Adult 1000 mg PO q6 to 8 hours

›Maximum 4000 mg per 24 hours

›Ibuprofen

›Adult 400 mg PO q6 to 8 hours

›Maximum 2400 mg per 24 hours

›Naproxen

›Adult 500 mg PO once then 250 mg PO q6 to 8 hours

›Maximum 1250 mg per 24 hours

›If inadequate pain control, oral opioid short course

›Oxycodone 5 mg PO q6 hours as needed

›Constipation risk counseling

›If severe pain or reduction needed, IV options

›Morphine 0.05 mg per kg IV

›Repeat every 10 to 15 minutes to effect

›Fentanyl 1 mcg per kg IV

›Repeat 0.5 mcg per kg every 5 to 10 minutes to effect

02History/hx32

Key history elements

›Injury context

›Mechanism

›Fall on outstretched hand

›Direct lateral elbow impact

›Axial load through wrist

›Time since injury

›Dominant arm

›Symptoms and function

›Lateral elbow pain

›Mechanical block to motion

›Inability to fully pronate or supinate

›Wrist pain

›Essex-Lopresti concern

›Hand numbness or weakness

›Red flags and complexity

›Prior elbow injury or surgery

›Anticoagulant or antiplatelet use

›Immunosuppression

›Diabetes

›Risk modifiers

›Osteoporosis risk

›High energy trauma

›Polytrauma screen

Classic and atypical presentations

›Typical presentation

›Lateral elbow pain after FOOSH

›Pain with forearm rotation

›Tenderness over radial head

›Pitfalls

›Minimal pain with occult fracture

›Isolated effusion with posterior fat pad on x-ray

›Focus on elbow only

›Missed wrist and DRUJ injury

03Physical Exam/exam36

Focused elbow and forearm exam

›Inspection and palpation

›Swelling and effusion

›Lateral ecchymosis

›Skin breaks

›Open fracture concern

›Point tenderness radial head and neck

›Medial tenderness

›MCL injury concern

›Range of motion

›Flexion extension

›Pronation supination

›Mechanical block assessment

›Pain pattern

›Pain with rotation suggests radial head involvement

›Stability screen

›Gross dislocation deformity

›Varus and valgus pain with gentle stress

›Distal exam for associated injuries

›DRUJ tenderness

›Ulnar variance change concern

›Wrist range of motion limitation

›Interosseous membrane pain

›Neurovascular

›Radial pulse and perfusion

›Median ulnar radial nerve motor and sensory

PITFALLS

›Missed unstable injury patterns

›Terrible triad pattern

›Radial head fracture

›Coronoid fracture

›Elbow dislocation

›Essex-Lopresti pattern

›Radial head fracture

›Interosseous membrane disruption

›DRUJ instability

›Inadequate documentation

›Pre and post immobilization neurovascular exam

04Differential Diagnosis/ddx22

Traumatic elbow pain and effusion

›Bony injury

›Radial head fracture ICD-10 S52.12

›Radial neck fracture ICD-10 S52.13

›Coronoid process fracture ICD-10 S52.04

›Olecranon fracture ICD-10 S52.02

›Distal humerus fracture ICD-10 S42.4

›Joint injury

›Elbow dislocation ICD-10 S53.10

›DRUJ injury ICD-10 S63.01

›Soft tissue injury

›LCL complex injury

›MCL injury

›Triceps tendon injury

›Mimics

›Lateral epicondylitis

›Septic arthritis

›Fever and severe pain with minimal motion

›Hemarthrosis on anticoagulation

SNOMED CT aligned terms

›Radial head fracture SNOMED CT concept

›Intra articular fracture of proximal radius

›Elbow joint effusion SNOMED CT concept

›Traumatic hemarthrosis consideration

05Laboratory Tests/lt10

When labs add value

›Baseline and bleeding risk

›If anticoagulated, INR for warfarin effect

›If significant swelling or large hematoma, complete blood count

›Infection evaluation

›If septic arthritis concern, inflammatory markers

›C reactive protein

›Erythrocyte sedimentation rate

›If open fracture, baseline labs per local protocol

›Procedural sedation readiness

›If deep sedation planned, bedside glucose if altered mental status

06Diagnostic Tests/dt67

Scoring Systems

›Mason classification

›Type I

›Nondisplaced or minimally displaced

›No mechanical block

›Type II

›Displaced partial articular fracture

›Possible mechanical block

›Type III

›Comminuted and displaced

›Often unstable

›Type IV

›Radial head fracture with elbow dislocation

›Clinical application

›Type I

›Early motion focus

›Type II with block

›Operative evaluation

›Type III and IV

›Orthopedic management

›Limitations

›Plain film underestimates comminution

›Ligament injury not captured

MRI

›Indications

›Persistent pain with negative radiographs

›Suspected ligament injury with instability

›Suspected occult coronoid fracture

›Strengths

›LCL and MCL assessment

›Cartilage injury assessment

›Limitations

›Limited acute ED utility

›Access delays

›Indications

›Comminuted fracture on x-ray

›Surgical planning need

›Suspected terrible triad

›Coronoid fracture definition

›Protocol considerations

›Thin slice CT elbow

›3D reconstructions for operative planning

›Interpretation pearls

›Articular step off assessment

›Fragment count and location

›Coronoid involvement

Ultrasound

›Point of care applications

›Elbow effusion

›Posterior recess fluid

›Occult fracture support

›Effusion with focal cortical irregularity

›Limitations

›Not definitive for fracture classification

›Operator dependence

›Role in ED workflow

›Adjunct when radiographs equivocal

›Not a replacement for radiographs

Plain radiographs

›Standard views

›AP elbow

›Lateral elbow

›Oblique views

›Key findings

›Visible fracture line

›Joint effusion

›Posterior fat pad sign

›Radiocapitellar alignment

›Associated injury imaging

›If wrist pain, wrist and forearm radiographs

›If DRUJ concern, compare bilateral wrist if needed

07Disposition/dispo24

Admission and urgent management

›Admit or transfer criteria

›Open fracture

›Neurovascular compromise

›Compartment syndrome concern

›Unstable elbow after reduction attempt

›Polytrauma requiring inpatient care

›Urgent orthopedics

›Mechanical block to motion

›Mason Type II with significant displacement on imaging

›Mason Type III

›Mason Type IV

›Terrible triad concern

›Essex-Lopresti concern

Discharge criteria

›Safe discharge elements

›Pain controlled on oral regimen

›Intact neurovascular exam

›No open wound

›No instability concern requiring immediate intervention

›Clear follow up plan

›Follow up timing

›Type I and stable Type II

›Orthopedics or fracture clinic within 3 to 7 days

›Questionable stability

›Orthopedics within 24 to 72 hours

08Treatment/t74

Nonoperative management

›Immobilization strategy

›Type I

›Sling or posterior long arm splint for comfort

›Duration 2 to 5 days if pain allows

›Early range of motion thereafter

›Stable Type II without block

›Short immobilization

›Early supervised motion plan

›Activity guidance

›Avoid lifting and axial load until cleared

›Gentle flexion extension within pain limits after early period

›Pronation supination as tolerated once comfortable

Operative and specialist pathways

›Indications for operative evaluation

›Mechanical block

›Inability to rotate forearm due to bony impingement

›Comminution

›Instability patterns

›Terrible triad

›Essex-Lopresti

›Common orthopedic options

›ORIF

›Displaced Type II with block

›Radial head arthroplasty

›Nonreconstructable comminuted fractures

›Radial head excision

›Selected low demand patients without instability

›Evidence labeling for ED use

›Early mobilization for stable fractures improves motion outcomes

›ACEP Level C based on consensus and observational evidence

Reduction and procedural considerations

›If elbow dislocation present

›Closed reduction under analgesia or sedation

›Post reduction radiographs

›Post reduction stability check

›If splinting after reduction

›Posterior long arm splint

›Neutral rotation unless instability dictates otherwise

›Post procedure documentation

›Neurovascular exam repeated

›Pain reassessment

Medications

›Oral analgesics

›Acetaminophen dosing

›Adult 1000 mg PO q6 to 8 hours

›Maximum 4000 mg per 24 hours

›NSAID dosing

›Ibuprofen 400 mg PO q6 to 8 hours

›Maximum 2400 mg per 24 hours

›Naproxen 250 mg PO q6 to 8 hours

›Maximum 1250 mg per 24 hours

›Opioid short course

›Oxycodone 5 mg PO q6 hours as needed

›Avoid concurrent sedatives

›No driving while using

›Procedural sedation options

›Ketamine IV

›1 mg per kg IV

›Additional 0.5 mg per kg IV as needed

›Propofol IV

›0.5 mg per kg IV bolus

›Repeat 0.25 to 0.5 mg per kg every 1 to 3 minutes to effect

›Antibiotics for open fracture

›Cefazolin IV

›2 g IV

›If weight 120 kg or more, 3 g IV

›If severe penicillin allergy, clindamycin IV

›900 mg IV

Monitoring and complications

›Complication surveillance

›Stiffness risk

›Prolonged immobilization increases stiffness

›Heterotopic ossification risk

›Higher risk with severe trauma and surgery

›Chronic instability risk

›Missed ligament injury

›DRUJ pain developing after discharge

›Essex-Lopresti late recognition

09Special Populations/sp35

Pregnancy

›Imaging considerations

›Radiographs acceptable when clinically indicated

›Abdomen shielding when feasible

›CT only if benefits outweigh risks

›Shared decision documentation

›Medication considerations

›Acetaminophen preferred

›NSAID avoidance in third trimester

›Opioid short course if needed

›Lowest effective dose

›Follow up

›Obstetric communication if trauma significant

Geriatric

›Higher fracture risk

›Low energy FOOSH common

›Osteoporosis screening referral

›Treatment nuances

›Lower tolerance for prolonged immobilization

›Stiffness and loss of independence risk

›Fall risk evaluation

›Medication risk

›NSAID renal and GI risk

›Opioid delirium and fall risk

›Lower starting doses

Pediatrics

›Injury pattern differences

›Radial neck fractures more common than true radial head fractures

›Physeal injury consideration

›Exam and imaging pearls

›Fat pad sign important for occult injury

›Comparison views rarely needed

›Management

›Early ortho involvement for angulated neck fractures

›Immobilization often shorter

›Red flags

›Monteggia lesion concern with forearm deformity

›Ulna fracture with radial head dislocation

10Background/b24

Epidemiology

›Frequency and context

›Common adult elbow fracture pattern

›Mechanism often FOOSH with valgus and axial load

›Associated injuries

›Ligament injury common with displaced fractures

›Terrible triad association with dislocation

Pathophysiology

›Anatomy and function

›Radial head as secondary stabilizer to valgus stress

›Radiocapitellar joint load transmission

›Injury mechanics

›Axial load through radius

›Valgus moment causing impaction and shear

›Instability mechanisms

›LCL disruption leads to posterolateral rotatory instability

›Interosseous membrane disruption leads to forearm longitudinal instability

Therapeutic Considerations

›Early motion principle

›Goal to prevent stiffness

›Short immobilization for stable injuries

›Stability first principle

›Instability patterns need specialist management

›Radial head preservation supports elbow stability

›Evidence labeling

›Early mobilization in stable fractures associated with better range of motion

›ACEP Level C consensus statement framing

11Patient Discharge Instructions/pdi22

Copy discharge instructions

›Radial head fracture home care

›Sling or splint use as directed

›Hand and finger motion several times daily

›Elevation to reduce swelling

›Pain control

›Acetaminophen use within maximum daily dose

›Ibuprofen or naproxen if safe for you

›Opioid only if prescribed and only as needed

›Activity restrictions

›No lifting with injured arm until cleared

›Avoid pushing up from chair with injured arm

›Follow up

›Orthopedics or fracture clinic appointment within advised timeframe

›Repeat imaging may be needed

›Return to ER now if

›New numbness or weakness in hand

›Fingers turning blue or very cold

›Severe increasing pain not controlled with medication

›Worsening swelling with tightness in forearm

›Fever with worsening redness or drainage

›New wrist pain or inability to rotate forearm

›Splint too tight with worsening pain or tingling

12References/r12

Guidelines and reviews

›Mason classification original description and subsequent orthopedic reviews

›Standard classification referenced in orthopedic trauma texts

›Orthopedic trauma society guidance on radial head fracture management

›Early mobilization for stable fractures

›Emergency medicine fracture care references

›Splinting techniques and neurovascular documentation standards

Decision support and key concepts

›Terrible triad injury pattern descriptions

›Radial head fracture plus coronoid fracture plus elbow dislocation

›Essex-Lopresti injury descriptions

›Longitudinal forearm instability with DRUJ involvement

›Procedural sedation safety standards in emergency care

›Continuous monitoring and resuscitation readiness

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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