Elbow Case Study 2 :

Fracture Of Right Radial Head

Susan Jones is a 35 year old taxi driver who sustained a fracture of the right radial
head following a fall onto her outstretched hand. The fracture was treated by open
reduction and internal fixation and back slab. She began active range of movement
exercises after 10 days and now requires further physiotherapy to gain range of
movement and strength. X-ray at 7 weeks has identified bony union at the fracture
site. Susan lives with her husband. She is normally fit and active with no health
problems. She usually attends the gym three times a week.

Anatomy & Pathology

Fractures of the radial head and neck commonly result from FOOSH as radial head
compresses against capitulum – modified masons classification :
Type 1 – non displaced.
Type 2 – radial head fractures > 2mm .
Type 3 – multiple separate fractures.

Subjective Examination
Where\What : Pain on lateral side of elbow

When: since break >10 days

How: FOOSH

0-10 rating: decreased since injury

24 hour cycle: ask

Better for: ask

Worse for: active movement

Type of pain: ask

Past Medical History/ General History: none

Red Flags and general concerns: malunion has been excluded as a problem – soft
tissue injury may be associated with original trauma
SH: lives with husband , drives a taxi

DH: none

Patients main outcome: she may say “return to taxi driving”

Objective Examination

Working Hypothesis: confirm diagnosis, beaware of possible soft tissue

injury

Advice & Consent: give and obtain

General Observations: are they using affected limb

Acute Observations:
Skin colour – discoloration
Swelling – at elbow joint
Posture – shoulder synergy ?
Muscle bulk – muscle wastage
Deformity – shape of joint – but remember malunion has been excluded

Active Tests: expect reduced ROM with stiffness, swelling ,pain and weakness

Flexion
Extension
Pronation
Supination – inability or difficulty in pronation and supination is originally a
diagnostic toold for radial head fractures

Passive Tests:may be reduced ROM with stiffness, swelling and pain – don’t
expect crepitus as malunion has been ruled out

Flexion
Extension – loss of motion common in last 10degree -> 15 degress is common
Pronation
Supination

Resisted Tests: possible weakness in affected arm - through lack of use

Flexion
Extension
Pronation
Supination

Special Tests:
Soft tissue test – larus and valgus stress test
Malunion and hence non-union has been ruled out so there is no need to percuss
radius head or translate radius – but do it anyway (double check)

Functional Tests:
Dexterity rests – picking up object
Strength test – pick up heavy object – be aware this may pain patient excessively
Endurance tests – pick up chair - be aware this may pain patient excessively

Palpation:
Expect point tenderness over radial head. Tenderness over wrist/forearm may indicate
a wider problem such as interosseous membraine injury or migration of radius.

Measurements:
Measure passive extension

Advice & Possible Treatment:

If no passive loss -> stretching and lifting routine
Loss of motion can occur – especially in extension – indedd post traumatic arthritis
may develop
Type 1 fractures – treated with sling
Type 2 fractures – treated with internal fixation
Type 3 fractures - excision