This is a relatively common injury. Immediate is needed to prevent persistent disability of the elbow joint.
MECAHNISM OF INJURY
This is due to indirect violence following a fall on an outstretched hand. The valgus force impinges on the extended elbow.
NATURE OF INJURY
Several types of fracture of the head and neck of radius can be produced. Recognition of these various types is essential for proper treatment. There may be undisplaced spiral fracture, vertical split fracture without displacement, vertical split fracture with separation of fragment, comminuted fracture of the head and fracture neck of radius.
ASSOCIATED INJURY ALONG WITH FRACTURE OF RADIUS
There can be associated injury along with the fracture of the head and neck of radius.
- Fracture of the capitellum: The capitellum may be fractured with flakes of cartilage floating inside the joint cavity.
- Medial ligament rupture: Rupture of the medial ligament due to severe valgus injury produces momentary dislocation of the elbow. The patient may have residual tenderness on the medial side of the joint even after successful treatment for the fracture neck of radius.
- Haemo–arthrosis: patient experiences intense pain when haemo-arthrosis is present.
- Extensor muscle rupture: Rupture or stripping of the extensor muscle following pressure by the head of the radius may produce restricted extension of the elbow-joint even after excision of the head of radius is done.
Most fractures can be easily diagnosed by x-ray. In cases of undisplaced crack fracture, several x-rays may be required to detect the fracture. X-ray can be misleading as the fracture is usually more serious than the radiological evidence.
All fractures of the head of radius are not treated by excision. The dictum of “open, see and remove” must be discouraged.
Indication of conservative treatment: Undisplaced fracture without any loss of congruity of the articular surface should be treated by conservative means.
Indication of surgery: Displaced fracture, loss of congruity of the articular surface and comminuted fracture should be treated by excision of the head of radius. The surgery is performed with the help of orthopedic devices and medical implants. These are available from the top orthopedic implant companies in India as fracture of head and neck are a part of orthopedics.
- Immobilization: Immobilization in simple cuff and collar sling or by application of a triangular sling for a period of 3 weeks is sufficient. Exercise is advocated but the joint movement returns only slowly.
- Aspiration: In some cases haemo-arthritis can develop, producing intense pain. Aspiration of the tensed-up haemo-arthritis relieves the pain.
Immediate operation is not required but this should not be delayed too long. Late management by excision of the head of radius after the onset of arthritis following fracture may relieve the pain, but this may not prove to be a complete success.
Technique of Operation: During the operation for excision of head of radius, a search is made for fracture of the capitellum, and for any loose bony fragment inside the joint- cavity. There is no need to cover the stump of radius by the periosteum.
Post- Operative Management: Once the wound has healed, the patient is advised to exercise the elbow. It takes some time before the movement is full. In many cases there may be permanent restriction of terminal extension. Pronation and supination movements remain full.
FRACTURE NECK OF RADIUS IN ADULTS
The same type of violence which produces fracture of the head of radius can also produce fracture of the neck.
NATURE OF INJURY
There may be fracture with or without displacement. Angulation at the fracture site can at times be present.
- Undisplaced fracture: Immobilization by applying a dorsal slab extending from below the axilla to the metacarpal heads for a period of 3 weeks is all that is required.
- Reduction of fracture: Reduction is done in cases where the fracture is displaced. The surgeon applies pressure with the aid of the thumb over the site of fracture and helps to put it into the normal position. The elbow-joint is immobilized in a 90⁰ flexed position by applying a dorsal slab. This is usually maintained for a period of 3-4 weeks. Active exercise is performed at the end of immobilization.
FRACTURE NECK OF RADIUS (CHILDREN)
Fracture of the head of the radius is rarely seen in children. Lesion involving the proximal radial epiphysis in the form of fracture of the neck is produced by a fall on an extended and pronated arm. The valgus strain besides producing fracture of the neck can also produce avulsion of the medial ligament of the elbow-joint.
TYPES OF FRACTURE
The fracture may be undisplaced, displaced, angulated or completely displaced. In rare cases the radial epiphysis after sustaining fracture can be displaced inside the muscle or under the skin. It is important to judge the degree of angulation being produced following fracture. This deformity up to the angle of 30⁰ does not require manipulation as remodeling during the process of union will correct the abnormality.
Resection of the head of the radius during the growing age period must never be done. This results in growth disparity between the ulna and radius and produces radial deviation of the hand.
- Undispalced fracture: Simple immobilization is done by plaster cast for a period of 3-4 weeks.
- Displaced fracture and fracture with angulation: Closed reduction is successful in most cases. Pressure is applied with the aid of the thumb or tip of the finger to place the head of radius in position. The manoeuvre is carried out under general anaesthesia.
Immobilization: A dorsal plaster cast is applied with the elbow flexed at 90⁰. Check x-ray is done and correction of displacement and angulatory deformity are carefully performed.
Operation is performed in the case of failure to correct the angulation to less than 30⁰ or to bring the displaced fracture into position. The radial head is approached from the posterior aspect. The head is placed in the normal position and the elbow is flexed at 90⁰. Usually the head is maintained in a position of alignment by this method. Immobilization is done by a long dorsal cast for 4 weeks with the elbow flexed at 90⁰.