Understanding Radial Head and Neck Fractures: What You Need to Know
⌚️ read time: 4 minutes
This week, let’s talk about one of the most common elbow injuries I see in my practice: radial head and neck fractures.
If you're reading this, chances are you or someone you know has fallen onto an outstretched hand and ended up with elbow pain. More often than not, that's how these fractures happen. Fortunately, they are usually a minor injury that heals up quickly. But as with anything, there are occasional bad actors and a few things to look out for.
Basic elbow anatomy
Just so we’re all on the same page, let’s look at some basic elbow anatomy. Just like any other joint, the elbow joint is where bones come together to allow movement. What’s interesting about the elbow joint though is that it’s actually the point of confluence between THREE bones, not just two.
The structural skeleton of our forearms is made up of two parallel bones that run down the forearm to the wrist: the radius and ulna (see image below). At the elbow, these both meet up with the humerus bone, the structural skeleton of our upper arm.
This convergence of three bones allows for two different types of motion. Flexion/extension (bending and straightening your elbow) and pronation/supination (rotating your palm up to palm down — did you know that motion was coming from your elbow??).
The top of the radius bone, just where it meets the elbow, is called the radial head. The head is the portion that is actually within the elbow joint itself. Naturally, the radial neck is just below the radial head.
How does this happen?
The vast majority of patients with this injury come to me after a slip and fall. That force from the fall travels up your arm like a shock wave, and your radial head (or neck) takes the brunt of the impact. While most of the time these fractures happen from simple falls, they can also result from higher-energy accidents that might cause additional damage to the surrounding tissues.
In fact, about 30% of the time, there's damage to other parts of the arm. Think of your forearm like a pretzel — it’s hard to break it only in one place. The ligaments on the outside of your elbow (we call them lateral collateral ligaments) are particularly vulnerable, getting injured in up to 80% of these fractures. Fortunately, the vast majority of these ligament injuries heal on their own.
Other associated injuries with radial head/neck fractures include ulna fractures, sprains of the ligament that connects the radius and ulna in the forearm, and even wrist fractures!
How to know if you have a radial head or neck fracture?
The most common symptoms I see in patients with a radial head or neck fracture are:
Pain on the outside of the elbow (that's where the radial head lives)
Swelling that makes the elbow look puffy
Pain with bending/straightening the elbow or rotating your forearm (going from palm up to palm down)
When you come to see me, I'll typically press around your elbow — there's usually tenderness right over the radial head/neck. I'll also check how well you can move your arm and make sure there's no nerve damage, especially if it was a harder fall.
As with any fracture, the only way to know for sure is with x-rays. And just like scaphoid fractures (link to my article here), this is a fracture that sometimes eludes detection on initial x-rays. If I don’t see an obvious fracture on your first visit, but I have a high suspicion, I’ll bring you back in two weeks for a new x-ray that will usually seal the deal.
Sometimes, if the fracture is more complicated (think multiple pieces of broken bone), we might need a CT scan to get a better look at your fracture pattern. Lots of shattered pieces within the joint could mean a need for surgery.
Treatment: From simple to surgical
Here's the good news: the vast majority of radial head and neck fractures don’t need surgery. In fact, they don’t need anything at all!
Wait, what did you just say?
I’d say 90% of these fractures I treat follow this pattern:
A patient comes in after a fall with REALLY bad elbow pain. The first few days of this injury feel extremely serious. These patients are convinced they need surgery.
I take x-rays and examine them. I then spend the rest of the visit convincing the patient that the ONLY thing they need to work on is getting that elbow moving as fast as possible.
By the time I check them back in a few weeks, patients who follow this instruction have minimal pain and often have their full elbow range of motion back — even before the fracture heals!
If the broken pieces are still lined up nicely (meaning the fracture is "nondisplaced"), this needs a few days (at most) in a sling. This is really just for comfort. No splint, no brace, no cast.
I can't stress enough how important early movement is — elbows get stiff really quickly.
This is a fracture that is almost always inherently stable. So the most common bad long-term outcome is permanent elbow stiffness, rather than the bones falling out of alignment or not healing.
This is contrary to our intuition for most other fractures in the human body. This is why I love seeing these patients a few days after the injury so I can reassure them and counsel them appropriately. The tough ones for me are the patients I see two weeks after their injury — when they’ve been in a splint or a sling the entire time. That’s when we get into trouble with prolonged or even permanent elbow stiffness.
Sometimes surgery is necessary
But sometimes surgery is necessary, especially if:
The bone pieces are significantly out of place
There are multiple fragments
Your elbow is unstable (due to ligament damage)
When we do need surgery, there are a couple of options. Again, this all depends on the ‘pattern’ of your injury. There are no hard and fast rules here.
If the fracture is relatively simple (fewer than three pieces), we can usually put it back together with some small screws or plates. In most of these cases, we can achieve primary bone healing (a reminder on how we do this here).
But if the bone is broken into too many pieces, we might need to replace the radial head with an artificial one, as seen in the x-ray below (not my x-ray, just one from the imaging service I work with). This is particularly true in cases where there's extensive damage to the elbow. Think of this like a partial joint replacement, more along the lines of a new hip or a new knee.
The recovery journey
Recovery from the standard non-displaced radial head or neck fracture is typically fairly straightforward.
Again, by far the biggest challenge I see is stiffness, especially when trying to rotate your forearm or get your elbow fully straight. That's why I'm such a stickler about starting gentle movement as soon as possible.
But with proper care and dedication to rehabilitation, most people get back to their normal activities in a few weeks without major limitations. As I said above, many return to see me feeling fully recovered, even before their bone is fully healed.
Takeaways:
Most radial head/neck fractures don’t need surgery - but proper diagnosis is crucial to make that call
Early movement (when appropriate) is your friend in preventing stiffness
Pay attention to your whole arm during recovery, not just the elbow, since these injuries can affect other structures as well
If you think you might have a radial head or neck fracture, don't try to tough it out. Getting evaluated early gives us the best chance at choosing the right treatment path and getting you back to your normal activities as smoothly as possible.
