Radial Head Fracture
Most common elbow fracture in adults (33%), occurring after a fall on an outstretched hand. Forearm rotation recovery is the main rehabilitation challenge. Mason-Johnston classification with 4 types.
Characteristics
Radial head fractures account for approximately 33% of all elbow fractures and 1.5 to 4% of all fractures in adults [1]. The typical mechanism is a fall on an outstretched hand (FOOSH – Fall On Outstretched Hand), transmitting an axial force along the radius to the radial head which impacts against the humeral capitellum. The radial head plays a fundamental biomechanical role: secondary valgus stabilizer of the elbow, longitudinal stabilizer of the forearm via the interosseous membrane, and pivot of forearm rotation [2]. Its preservation is therefore essential.
Annual incidence is estimated at 2-3 per 10,000 inhabitants, peaking between ages 30 and 60 with no marked sex predominance. Clinical examination reveals exquisite tenderness over the radial head (lateral aspect of the elbow), hemarthrosis limiting full extension, and painful forearm rotation. Aspiration of the hemarthrosis under local anesthesia provides immediate relief and allows assessment of residual mobility and detection of mechanical blockage indicating a free intra-articular fragment.
Associated injuries are frequent and must be systematically sought: medial collateral ligament rupture, coronoid process fracture, interosseous membrane injury (Essex-Lopresti syndrome) [3].
- The radial head is a concave disc covered with articular cartilage over 280° of its circumference, articulating with the capitellum (humeroradial) and the radial notch of the ulna (proximal radioulnar). It pivots during forearm rotation and transmits 60% of axial compression forces at the elbow.
- Main mechanism: fall on outstretched hand with the elbow in slight flexion and forearm in pronation. Axial force compresses the radial head against the capitellum. A forced valgus mechanism may associate a medial collateral ligament injury.
- Risk factors: contact sports, activities with fall risk (cycling, skiing, horseback riding), osteoporosis, ligamentous hyperlaxity. Peak incidence between 30 and 60 years. Slight female predominance in recent series.
- Complications and associated injuries: forearm rotation stiffness (most frequent sequel), residual elbow instability, Essex-Lopresti syndrome (interosseous membrane rupture with proximal radius migration), humeroradial arthritis, proximal radioulnar synostosis.
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- Type I – Non-displaced
Non-displaced fracture or displacement less than 2 mm, without mechanical blockage. Marginal fracture line visible on standard radiographs or CT scan. Functional treatment with early mobilization. Healing in 4-6 weeks. Excellent prognosis.
- Type II – Displaced, marginal fragment
Fracture displaced more than 2 mm with a single marginal fragment involving a portion of the radial head. Possible mechanical blockage in forearm rotation. Surgical treatment by internal fixation (screws, mini-plate) if significant displacement or mechanical limitation. Good prognosis after anatomical reduction.
- Type III – Comminuted
Comminuted fracture of the entire radial head, not reconstructable surgically. Multiple displaced articular fragments. Indication for metallic radial head prosthesis if associated instability. Simple excision only in the absence of ligamentous or interosseous membrane injury.
- Type IV – Fracture-dislocation
Radial head fracture (any type) associated with elbow dislocation. Added by Johnston to Mason's original classification. Severe injury combining joint instability and fracture. Systematic surgical treatment: dislocation reduction, radial head reconstruction or prosthesis, ligament repair. Guarded prognosis.
Medical and Surgical Management
- Mason I: functional treatment with analgesic sling for 48-72 hours then early active mobilization. No cast. Aspiration of hemarthrosis if significant tension. Excellent prognosis with restitutio ad integrum.
- Mason II: internal fixation with Herbert screws or mini-plates if displacement > 2 mm, mechanical blockage, or fragment involving more than one-third of the articular surface. Anatomical reduction and stable fixation allowing early mobilization.
- Mason III-IV: metallic radial head prosthesis (modular implant) if reconstruction is impossible. Simple excision contraindicated if associated instability or interosseous membrane injury. Concomitant ligament reconstruction frequently necessary.
Physiotherapy treatment
- Mason I: early active mobilization once pain subsides (day 3-7). Active forearm rotation as priority with dowel rod rotation exercises. Complete extension must be recovered early to avoid residual deficit.
- Terminal extension recovery: gentle sustained stretching in extension by gravity (arm resting on table, wrist hanging off edge). Extension deficit is the most frequent and disabling functional sequel.
- Forearm rotation: key rehabilitation exercise. The radial head pivots on the capitellum during these movements. Progressive active rotations, dowel rod exercises, functional activities (turning a handle, screwing/unscrewing).
- Progressive forearm muscle strengthening: pronators (pronator teres, pronator quadratus), supinators (supinator, biceps), wrist flexors and extensors. Functional reintegration and progressive return to sports from week 8-12.
After the session
You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.
Questions About Elbow Rehabilitation
When should I start physiotherapy after elbow surgery?
Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.
What are the goals of elbow rehabilitation?
Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.
Is elbow rehabilitation painful?
The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.
Scientific sources
Average duration
6 to 12 weeks depending on Mason type, up to 4-6 months for Mason III-IV with prosthesis