SCIENTIFIC/CLINICAL ARTICLES
JHT READ FOR CREDIT #022
Radial Head Fractures—Advanced Techniques
in Surgical Management and Rehabilitation
Kraig Y. Bano, MPT, CHT
y tures in the elbow, and the treatment of nondisplaced fractures is
Hand & Upper Extremity Center
PRO Physical Therapy
Newark, Delaware
Main Line Hand Center
Exton, Pennsylvania
Randeep S. Kahlon, MD, FACS
Orthopaedic Trauma Service
ChristianaCare
Wilmington, Delaware
School of Physical Therapy
University of Delaware
Newark, Delaware
First State Orthopaedics
Wilmington, Delaware
Radial head fractures are the most common fractures
in the elbow.1 Treatment of nondisplaced fractures can
often be straightforward, but the associated injuries
seen in both nondisplaced and displaced radial head
fractures greatly influence decision making about ap-
propriate and reasonable intervention choiczes.
Major progress in the management of these fractures
has been in part attributed to information gained
from long-term follow-up studies on radial head exci-
sions, new biomechanical research studies on elbow
stability, and improved surgical techniques. As the sur-
gical management of radial head fractures has evolved,
treatment interventions for therapy have similarly
been modified and improved. This article summarizes
current advanced techniques in the surgical manage-
ment and rehaabilitation of radial head fractures.
HISTORICAL BACKGROUND
A comprehensive summary of the literature by
Schwartz and Young documented the first description
y
Affiliation at the time manuscript was created.
Correspondence and reprint requests to Kraig Y. Bano, MPT, CHT,
Main Line Hand Center, 495 Thomas Jones Way, Suite 204, Exton,
PA 19341; e-mail: <kbano25@hotmail.com>.
doi:10.1197/j.jht.2006.02.011
114 JOURNAL OF HAND THERAPY
ABSTRACT: Radial head fractures are the most common frac-
often straightforward. However, radial head fractures with concur-
rent injury to the elbow stabilizers may require complex treatment
and therapy that are targeted at specifically restoring elbow stabil-
ity. This treatment of complex radial head fractures has recently
improved because of long-term follow-up studies, increased bio-
mechanical research on elbow stability, and improved surgical
techniques. With an open line of communication between the sur-
geon and the therapist, an appropriate therapy plan can be initi-
ated to protect both simple and complex injuries. The therapist
should have knowledge of specific tissue healing and treatment
techniques, and the patient must be educated in possible out-
comes, safe arcs of motions, positioning, and proper splint use.
This article summarizes current advanced techniques in the surgi-
cal management and rehabilitation of radial head fractures. Com-
prehensive protocols for decision making and treatment are
introduced for both simple and complex radial head fractures.
J HAND THER. 2006;19:114–36.
of radial head fractures to be that of Paul of Aegina
(AD 625–690) in his description of fractures of the
lower arm.2 In 1897, Helserich was the first to rec-
ommend radial head resection for late deformity.
Hammond in 1910 recognized the role of radiology
in the diagnostic workup and also recommended
excision of the radial head or displaced fragments.3
Watson-Jones, in 1930, noted only 50% good results
for displaced fractures and also noted that radial
head excision leads to radial shortening and/or ulnar
dislocation.4 During this time, many authors advo-
cated a range of treatments involving nonoperative
treatment, fragment excision, head excision, manipu-
lation, and tendon reconstruction for angulation.
In 1954, Mason put forth a classification system
based on his review of 100 patients5 (Figure 1). Type I
fractures were nondisplaced and did well with non-
operative treatment. Type II fractures, which he
called ‘‘marginal sector fractures,’’ were displaced
and had varying results. If the fragment was less
than 25% of the articular surface, he recommended
nonoperative treatment. Fragment excision was re-
served for larger fragments, and head excision was
reserved for head tilting or fracture comminution.
Type III fractures were comminuted and he advised
early excision. (Note that none of his patients under-
went open reduction internal fixation [ORIF].)

FIGURE 1. Mason classification of radial head fractures.
(Reprinted with permission from Green’s Operative Hand
Surgery, 5th ed. Philadelphia, PA: Elsevier, 2005)
Subsequently, as attempts at ORIF increased and
improved, many Mason II fractures were reclassified
intraoperatively into Mason III because the severity
of radial head fracture comminution is usually un-
derappreciated on the preoperative films. Johnston
added a type IV fracture category in 1962, described
as radial head fracture with elbow dislocation, and
noted that primary radial head excision was not a be-
nign procedure.6 Since that time, increasing research
into elbow anatomy and biomechanics, in addition to
advances in ORIF techniques and instruments, has
greatly advanced operative techniques. Hotchkiss,
in 1997, modified the Mason classification by adding
specific displacement guidelines and classifying type
II fractures as those that are repairable and type III
fractures as those that are not repairable7 (Figure 2).
Morrey advocated an additional level of classification
(termed the Mayo classification) in which isolated ra-
dial head fractures were ‘‘simple or uncomplicated,’’
whereas radial head fractures associated with an-
other elbow fracture or ligament injury were termed
‘‘complex or complicated.’’8 This allowed for treat-
ment of simple fractures based on the Mason classifi-
cation and allowed for treatment of the complex
injuries based on the associated injury. As the Mayo
classification is the most current and inclusive classi-
fication, it will be used in this article.
An important distinction should be noted regard-
ing the terminology of ‘‘simple’’ or ‘‘complex.’’ This
article focuses on radial head fractures, but simple or
complex are also often used in classification of elbow
dislocations. When used in reference to radial head
fractures, the two terms denote an associated injury
with the radial head fracture. However, when used
in reference to elbow dislocations (without radial
head fracture) the two terms denote whether the
dislocation is reducible and whether the dislocation
can be maintained without surgery.
In 1941, Speed was the first to consider prosthetic
replacement (metal) in lieu of excision for commi-
nuted fractures.9 Silicone replacement was champ-
ioned by Swanson and others at a later date. The
Swanson silicone radial head implant went on to be-
come the most-used implant worldwide for these
fractures.10 Long-term follow-up studies of patients
with silicone arthroplasty, however, have revealed
problems with implant wear, implant failure, and sil-
icone synovitis.11,12 Other materials used for arthro-
plasty have included acrylic, ultra-high molecular
weight polyethylene, ceramics, and various metals.
Arthroplasty with metallic implants is the current
state of the art, and recent advances have been cen-
tered on bipolar designs and modular designs.13
ANATOMY AND BIOMECHANICS
A complete discussion of elbow biomechanics (see
the article in this issue by Lockard) is beyond the

HOTCHKISS CLASSIFICATION OF PROXIMAL RADIAL FRACTURES*

Type I
• Nondisplaced or minimally displaced fracture of head or neck
• No mechanical block to rotation
• Displacement less than 2 mm or a marginal lip fracture
Type II
• Displaced (usually > 2 mm) fracture of head or neck (angulated)
• May have mechanical block to motion or be incongruous
• Without severe comminution (technically possible to repair by open reduction and
internal fixation)
• More than a marginal lip fracture of the radial head
Type III
• Severely comminuted fracture of the radial head or neck
• Judged not reconstructable on basis of radiographic or intraoperative appearance
• Usually requires excision for movement
*All of these fractures may have associated injuries such as a coronoid fracture, elbow dislocation, or medial collateral or
interosseus ligament tears. From Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision. J Am
Acad Orthop Surg 5:1-10, 1997.

FIGURE 2. Hotchkiss classification of radial head fracture.

April–June 2006 115

scope of this article; however, some basics are rele-
vant. The proximal radio-ulnar joint (PRUJ) is highly
congruent and accounts for approximately 60–70° of
the articular surface of the radial head. The corre-
sponding safe zone is an arc of 110° where hardware
can be placed without impinging in the radial notch
during forearm rotation14,15 (Figure 3). Because of the
elliptical nature of the radial articular disk, there is a
slight radial/ulnar translation of the head and this is
accentuated in pronation.
The lateral collateral ligament (LCL) is an impor-
tant stabilizer against posterolateral (PL) instability.16
This is an important factor in assessing the soft tissue
component of the injury laterally, but it also dictates a
cautious surgical approach. The traditional Kocher
approach may actually violate the LCL; thus, a more
midaxial approach is recommended to avoid iatro-
genic LCL detachment and the sequelae of late failure
and residual pain. The surgical incision (in the deep
musculotendinous layer) should be limited to the
anterior one-half of the radiocapitellar joint (RCJ) in
order to spare the LCL and maintain PL stability.
The radial head is an important elbow stabilizer to
valgus stress.17 Lack of the lateral column support
(provided by the radial head) significantly increases
physiologic stress borne by the medial collateral liga-
ment (MCL). In one study, tension stress seen by the
MCL with an absent radial head reached as high as
33 the body weight.18 A concurrent MCL injury
with radial head comminution creates an instant val-
gus instability and predisposes to significant long-
term sequelae.
MECHANISM AND ASSOCIATED
INJURIES
A fall on an outstretched hand (FOOSH) with the
hand/forearm in pronation accounts for the large
majority of radial head fractures. The axial load upon
the elbow (with the hand pronated) stresses the
FIGURE 3. Proximal radio-ulnar joint rotation—note the
high congruency of the joint and the ‘‘safe zone’’ for fixa-
tion. (Reprinted with permission from Green’s Operative
Hand Surgery, 5th ed. Philadelphia, PA: Elsevier, 2005)
116 JOURNAL OF HAND THERAPY
anterolateral corner of the radial head articular disk
(Figure 4). This stress is followed in sequence by the
lateral and then the medial elbow ligament support-
ing structures, consistent with a PL rotation of the
joint. With this progression, dislocations of the elbow
occur in approximately 5–10% of radial fractures.1,6,19
Dislocations can often present with coronoid frac-
tures of varying severity. Thus, the ‘‘terrible triad’’
is a radial head fracture, a coronoid fracture, and dis-
location of the elbow (with the obligatory disruption
of at least one of the collateral ligaments).20
A concomitant LCL injury creates PL instability
and may indicate an occult elbow subluxation.
Commonly, the anterolateral wedge fracture off the
radial head is the result of a partial PL subluxation
and the LCL should be addressed concurrently if the
radial head is being treated operatively.1
Amis and Miller have shown that the radial head is
selectively fractured in increasing elbow flexion.21
The coronoid process is at highest risk between 0
and 35° of elbow flexion in FOOSH, whereas the ra-
dial head is at risk between 0 and 80° of flexion.
Depending on the size of the coronoid fracture, elbow
instability may be the actual major issue and the ra-
dial head fracture may just be a marker of this injury.
Additionally, in the lateral compartment, capitellum
fractures occur at a rate of 24% with displaced, oper-
ative radial head fractures.22
Medial collateral ligament injuries have been asso-
ciated with radial head fracture severity. Mason type
I fractures have associated MCL injuries less than 5%
of the time, whereas type II show an incidence of
approximately 50% and type III approximately
FIGURE 4. Anterolateral radial head at risk. (Illustration
by Elizabeth Roselius Ó 2005. Reprinted with permission
from Green’s Operative Hand Surgery, 5th ed. Philadel-
phia, PA: Elsevier, 2005)
87%.23 As previously mentioned, there is significant
increasing tensile stress for the MCL in the absence
of an intact radial column. MCL insufficiency can
present acutely in this circumstance but also can pre-
sent much later secondary to chronic MCL overload-
ing from the prolonged absence of radial column
support. This delayed or secondary presentation of
valgus instability often contributes to the develop-
ment of tardy ulnar nerve palsy.
The initial evaluation of any radial head fracture
should also include a wrist examination, particularly
the distal radio-ulnar joint (DRUJ), to rule out
an Essex-Lopresti injury. This entity occurs when
the radial head fracture has an associated tear of
the interosseous membrane (IOM) with possible tri-
angular fibrocartilage (TFCC) injury and possible
DRUJ instability. Axial forces in the forearm are
distributed 80% radius/20% ulna at the wrist but
change to 40% radius/60% ulna at the elbow.24 In or-
der to accomplish this transfer of load from the distal
radius to the proximal ulna, three structures are essen-
tial: the radial head, the IOM, and the DRUJ ligaments.
Thus, with radial head fractures, the IOM and DRUJ
become the remaining forearm axial stabilizers and
are at risk for rupture in the more severe radial head
injury patterns (Figure 5). In order to prevent radial
shortening of 5–10 mm and ulnocarpal impaction
syndrome, recognition of this injury requires repair
FIGURE 5. Essex-Lopresti injury—note the injury of the
interosseous membrane and distal radio-ulnar joint. (Illus-
tration by Elizabeth Roselius Ó 2005. Reprinted with per-
mission from Green’s Hand Surgery, 5th ed. Philadelphia,
PA: Elsevier, 2005)
of the radial column to maintain radial length, either
by ORIF or by radial head arthroplasty.25
Furthermore, the distal ulna should be closely ob-
served for dorsal instability and may require supina-
tion splinting to immobilize the DRUJ in a
concentrically reduced alignment. In reviewing the
Mayo experience, Trousdale et al. noted 80% satisfac-
tory results when the Essex-Lopresti injury was recog-
nized and treated appropriately versus only 14%
satisfactory results for late detection and subsequent
attempts at reconstruction.26
INTERVENTION OPTIONS
As with any fracture, management of radial head
fractures should be based on both patient factors and
injury-specific factors. Patient factors include age,
bone quality, (non-elbow) associated injuries, and
activity level. Injury-specific factors include fracture
size, displacement, rotation block, and associated
bony and ligament injuries (Table 1).
Initial management of a radial head fracture with
elbow dislocation involves a gentle reduction (under
conscious intravenous sedation) followed by repeat
radiographs to determine the success of the reduc-
tion. The initial radiographs, and any postreduction
radiographs, should be carefully assessed for associ-
ated fractures or displacement that may suggest a
complex injury or unstable elbow. Further evaluation
by computed tomography with three-dimensional
reconstructions can be helpful to evaluate associated
injuries, as plain radiographic studies (x-rays) do not
adequately reflect the amount of comminution
(Figure 6).
Nonoperative management with early active range
of motion is best used following type I and stable type
II fractures.7 This includes nondisplaced or mini-
mally displaced fractures without a rotation block
(Figures 7A and 7B). If a mechanical block to rotation
is noted, aspiration of the elbow hemarthrosis with
injection of local anesthetic is used to assess forearm
rotation. Morrey reports that nonsurgical treatment is
appropriate for type II fractures when 20–140° of flex-
ion and 70° of forearm rotation in each direction are
available under anesthetic block.27 Early motion pro-
tocols are successful in these cases, with careful clin-
ical follow-up to observe any subsequent or late
displacement of the fracture fragment(s). Larger frag-
ments (greater than one third of the articular surface)
require close observation for late displacement.
Open reduction internal fixation is recommended
for type II fractures with significant displacement
($2 mm), large fragment size ($33%), or mechanical
block to motion.28,29 Radial neck fractures with
greater than 20° of angulation impede forearm rota-
tion at the PRUJ, and surgery should be considered.30
In younger patients, we recommend ORIF for even
April–June 2006 117
 TABLE 1. Treatment of Radial Head Fractures
Simple (aka Mason I–III, Hotchkiss Complex (aka Johnston type IV or
I–III, or Morrey Simple) Morrey/Mayo Complex)
I Non-op Early range of motion (ROM) 1. Same radial head protocol as for simple
II Non-op Early ROM types I–III
II Operative 1. Open reduction internal fixation (ORIF) 2. Radial head excision (without
Indications: 2. Fragment excision (rare) arthroplasty) is contraindicated. Radial
1. Rotational block 3. Radial head excision (limited to older head reconstruction is essential to elbow
2. Displacement $2 mm population without complex injury) stability
3. Large fragment ($33%) All followed by early ROM 3. Fix associated injuries:
4. Neck $20% angulation a. Coronoid fracture
(Assumes repair is possible, b. Lateral collateral ligament (LCL)
otherwise reclassify as type III) rupture
III Operative 1. Metallic arthroplasty (especially if older) c. Medial collateral ligament rupture
Usually comminuted 2. ORIF (especially if younger) d. Essex-Lopresti lesion
Some are irreparable 3. Radial head excision (limited to older e. Olecranon fracture
Consider locking plate population without complex injury) f. Global instability may require
Metallic prosthesis over silicone All followed by early ROM external fixator (or use to protect
repair of an associated injury)
All followed by early ROM (protected with
safe arc, splints, or braces as needed)

comminuted fractures that are difficult to fix so as to
create an anatomic spacer (both to provide valgus sta-
bility and to minimize proximal radial migration)
(Figures 8A–8D). Fixation techniques have improved
tremendously over the last three decades and now in-
clude small subarticular compression screws, interos-
seous headless screws, plates, absorbable pins,
cannulated screws, threaded K-wires, and fixed
angle/locked plates. These improved fixation tech-
niques have extended the indications for ORIF. Any
surgical approach to the radial head must carefully
preserve the LCL attachment and may also involve
repair of the LCL attachment if avulsed from the lat-
eral epicondyle. Internal fixation should be limited to
the safe zone, as described above, to minimize rota-
tion block at the PRUJ.
Stable internal fixation of the radial head is of
significant value in complex fractures with associated
injuries, whether articular, ligamentous, or bony.
Stabilizing the proximal radius does provide signifi-
cant stability to the unstable elbow, but augmentation
with additional fixation for the associated injury may
still be needed. A congruous reduction and a stable
fixation are prerequisites to allow early motion tech-
niques (within days) and achieve successful results.
Failure to achieve rigid, congruous fixation leads to
persistent postoperative stiffness, pain, and, some-
times, ongoing articular damage on the corresponding
surfaces. Thus, if appropriate internal rigid fixation
cannot be attained, an alternative treatment should be
used. Ultimately, the decision to repair, excise, or
replace the head is an intraoperative decision.
Radial head excision following fracture has an
extensive but controversial history in the literature.
Currently, radial head excision has a limited role in
the acute management of these injuries. Specifically,

FIGURE 6. Radial head fracture comminution seen better on computed tomography (CT): A and B, injury films with 3-D
reconstructions. Note the radial head comminution, posterior displaced head fragment, and adjacent anterior coronoid
fracture.

118 JOURNAL OF HAND THERAPY

FIGURE 7. Type I radial head fracture (A and B, injury films).

it is reserved for the simple comminuted type III
fracture in the older population (Figures 9A–9F).
However, in complex acute injuries, there is signi-
ficant evidence to show that isolated excision
leads to failure and is difficult to reconstruct.26
Biomechanical studies have documented significant
pathologic alterations in elbow kinematics after acute
excision, and long-term studies show mixed clinical
results.31 Once the decision is made to excise the ra-
dial head, intraoperative stress examination of the
MCL, IOM, and DRUJ should be documented.
Excision thus should be reserved for those injuries
in which the above stress testing fails to document
any instability.32 Thus, we recommend early isolated
radial head excision only for the simple comminuted
fracture in the older population (with ligamentous
stability). For all other cases, radial head excision
should be performed sparingly. Specifically, for the ir-
reparable radial head fracture or complex radial head
fracture with ligamentous instability, we prefer metal-
lic arthroplasty replacement over excision. An early
active range of motion program is then implemented
with expectations of early return of motion.
Radial head arthroplasty (or replacement) is indi-
cated for all irreparable fractures with associated
injuries (all complex type III injuries) (Figures 10A–
10D). King et al. demonstrated that radial head re-
placement restores elbow kinematics and enhances
elbow stability akin to the native radial head.13 He
recommends radial head arthroplasty for all irrepara-
ble fractures regardless of other associated injuries to
minimize the incidence of missed associated complex

FIGURE 8. Type II displaced radial head fracture (A, B, injury films; C, D, post-op at three months).

April–June 2006 119

FIGURE 9. Type III radial head fracture in a 62-year-old female (A–C, injury films. Note the displaced posterior fragment
in C preventing extension. D–F, post-op at three months. Note that in addition to the radial head excision, the displaced
posterior fragment has been excised in F restoring extension).
injuries. Recent improvements in prosthesis design
allow for a more customized, modular fit and allow
for easier implantation.
The management of complex radial head fractures
is directed at the associated injury/instability (the
elbow dislocation) in addition to the radial head
fracture injury. Stabilization of the radial column (via
ORIF or replacement) is completed as indicated
above and then is augmented with additional repairs
as dictated by any persistent elbow instability. Large
coronoid fragments (especially the anteromedial
fragment, which is often missed) require stabilization
for early range of motion (ROM). LCL injuries are
repaired through the lateral approach as part of the
closure for the radial head treatment. If the repaired
elbow is not fully stabilized, the postoperative pro-
tocol is adjusted accordingly to minimize radial head
subluxation in the early phases of recovery.
120 JOURNAL OF HAND THERAPY
Intraoperative stress testing after radial head recon-
struction and LCL repair dictates the need for further
adjunctive stabilization (such as MCL repair or
external hinge fixation device). Because radial head
reconstruction with LCL repair alone often provides
a stable enough elbow for early range of motion,
additional stabilization is frequently not needed.
Essex-Lopresti lesions are best treated with radial
head reconstruction and stabilization of the DRUJ,
either by immobilization or by temporary DRUJ
pinning. In this instance, the mild loss of DRUJ
pronation (seen sometimes with supination pinning)
is much preferable to the risk of dorsal distal ulna
instability (seen with untreated DRUJ injuries).
Olecranon fractures are fixed with rigid internal
fixation (preferably using the newer anatomically
contoured olecranon plates rather than with the
traditional tension band technique) as this allows
FIGURE 10. Complex type III radial head fracture in a 51-year-old male (A, B, injury films. C, D, post-op at three months.
Note the lateral collateral ligament repair with suture anchor in the lateral epicondyle).
earlier full ROM in therapy. Occasionally, in the face
of gross instability despite the above repairs (or to
protect the above repairs), hinged elbow external
fixation is necessary to maintain a concentric elbow
reduction. If so, radial column fixation can be par-
tially ‘‘unloaded’’ by the lateral nature of the frame
but cautious observation of lateral column compres-
sive forces (that are often seen later upon frame
removal) is obligatory.
COMPLICATIONS
Complications are found in both nonoperative and
operative treatment outcomes. Nonunion can occur
with any radial fracture, including type I nondis-
placed fractures. Asymptomatic nonunion does not
require treatment, but symptomatic nonunion can be
addressed with either radial head excision or arthro-
plasty, depending on any residual associated injuries.
Late displacement is treated in a similar manner, but
close clinical observation is needed to prevent late
degenerative changes.
Additional complications include residual pain,
stiffness, failure of fixation, wrist pain, degenerative
arthritis, silicone synovitis, and heterotopic ossifica-
tion (HO). Residual pain is multifactorial including
articular malalignment or occult instability. Wrist
pain occurring early after injury may be the result
of a missed Essex-Lopresti lesion, whereas late pre-
sentation of this wrist pain is likely secondary to ul-
nar carpal arthrosis from proximal radial migration.
If this late ulnar carpal arthrosis (usually ulnar im-
paction syndrome) is allowed to progress, there will
be a significant wrist disability in all ROM. Studies
vary greatly as to the incidence of wrist pain
and the severity of wrist pain after radial head oper-
ative treatment with or without head excision.33,34
However, with the recent improvements in radial
head ORIF techniques and the increasing early recog-
nition of these associated injuries, the previous stud-
ies discussing the incidence of wrist pain may require
re-evaluation. Silicone synovitis and other failures of
silicone implants (axial failure, hardware breakage,
etc.) are presenting in increasing frequency in long-
term follow-up studies. Thus, currently, there are no
indications for silicone arthroplasty.
Heterotopic ossification occurs variably after radial
head excision, in delayed operative interventions,
and in head-injured patients.35 A patient with HO
who is asymptomatic is treated conservatively, and
excisional treatment is recommended for sympto-
matic patients willing to undergo extensive rehabili-
tation. With appropriate surgical, adjunctive, and
rehabilitation protocols, successful outcome in HO
cases can approach 75%.11 Surgical and rehabilitation
strategies are discussed in the Casavant and Hastings
article in this issue; adjunctive interventions include
April–June 2006 121
perioperative radiation therapy and high-dose post-
operative nonsteroidal anti-inflammatory drugs to
minimize HO recurrence.
With open and prompt communication between
the surgeon and the therapist, complications can be
addressed appropriately.
REHABILITATION
Initial Evaluation after Radial Head Fractures
When beginning therapy with the patient who has
sustained a radial head fracture, it is important to
obtain as much information about the injury and
interventions as possible. The therapist should be in
contact with the surgeon to obtain the following
information: date and mechanism of injury, type of
fracture, stability of fixation, type of intervention, any
concomitant injuries, and any limitations in ROM
due to joint instability. Knowledge of the intervention
and outcome rendered by the surgeon is important in
developing a therapeutic plan. The mechanism of
injury may reveal information regarding the intensity
of trauma and possibility of concomitant injuries to
not only the elbow but also other body parts. Injuries
in other areas in the upper extremity such as the
shoulder, wrist, hand, scapula, thorax, and lower
extremity alter the rehabilitation program. If there is
surgical intervention, information regarding the sta-
bility of the reduction, hardware type and location,
repair or reconstruction of concomitant injuries, and
quality of bone and ligaments involved is necessary
to develop an appropriate treatment plan for therapy.
Thus, the type of surgical intervention will dictate the
therapist’s plan of care and progression for treatment
(Tables 2 and 3).
Patient history includes the date and mechanism of
injury, hand dominance, any previous upper extrem-
ity injuries, and medical conditions that may affect
either healing or treatment. Activity of daily living
(ADL) limitations, work requirements, and hobbies
are also identified. Details regarding the patient’s
work status and timeline to return to work should be
obtained. A job task description is obtained from the
place of employment to assist with goal setting and
program development that may require intense work
conditioning. Opportunities for light or modified
duty are explored to allow the patient to transition
back to the work environment earlier. Hobbies such
as crafts, musical instruments, and sports are taken
into account, and the patient’s personal goals are
discussed and incorporated into treatment planning.
Pain is assessed for location, type, quality, intensity,
and behavior. A pain questionnaire, visual analog
scale, or verbal rating scale is useful. The same scale
as that administered for the initial rating is used for
the subsequent follow-up ratings to maintain consis-
tency. An outcome measure such as the Disability of
122 JOURNAL OF HAND THERAPY
the Arm, Shoulder, and Hand questionnaire or the
Patient-rated Elbow evaluation can help with goal
setting and to measure change in the patient over
time. Patients’ reports of specific ADL, work, and lei-
sure limitations are recorded. (These measures are
discussed further in the article by MacDermid and
Michlovitz in this issue.)
Objective physical measures are taken during the
initial examination. These include edema measure-
ments, wound assessment, ROM, and strength.
Edema is measured by girth at specific landmarks
or volumetry if the wounds are healed. When mea-
suring girth around the elbow, using the epicondyles
or joint line as landmarks gives more consistent re-
sults than using skin landmarks as bone position is
constant versus the mobility of skin. The ulnohum-
eral and radiohumeral joint lines are appreciated dis-
tal to the epicondyles. However, pain and edema may
prevent the palpation of these bony landmarks.
Circumferential tape measurement at the anterior el-
bow crease using the olecranon as a guide dorsally
may be substituted. The angle of the elbow during
girth measurement should also be noted to maintain
consistency for a measuring point during subsequent
measurements.
The wound should be thoroughly evaluated to
ensure that the sutures are intact and that there is no
evidence of infection. If a hinged external fixation
device is used, the pins should be assessed similarly.
Signs of infection include redness, edema, increased
skin temperature, discharge, odor, fever, and dehis-
cence of the wound. Pain with tapping of the pins
and loosening of the pins are possibly early indica-
tions of osteomyelitis. If these symptoms arise, it is
imperative to immediately contact the referring sur-
geon. The skin surrounding the wound should be
thoroughly inspected for abnormalities such as mac-
eration or blistering. The size of the wound, integrity
of closure, adherence, and blanching with motion are
noted. In general, there are rarely issues with the
incisions.
If instability of the elbow is present, the ROM limits
for the stable arc of motion should be obtained from
the surgeon before proceeding with the evaluation
and treatment. Forearm rotation motion is measured
with the elbow in 90° of flexion. Passive elbow ROM
measurements are deferred until appropriate to test.
ROM of uninvolved joints such as the shoulder and
wrist should be taken.
Strength testing is not appropriate before the frac-
ture has healed; therefore, it is assessed later. When
appropriate, testing is compared with the contralat-
eral side, if deemed normal, via manual muscle
testing, dynamometer measurement, isotonic/isoki-
netic testing, lift testing, or functional capacity
evaluation.
Sensory and motor function of the peripheral
nerves is also evaluated. The radial nerve is in close
 TABLE 2. Rehabilitation of Simple Radial Head Fractures
Weeks
Therapeutic
Intervention 0–2 2–4 4–6 6–8 8–12
Immobilization ,10 days
Splinting for Begins immediately
protection May continue until
three to six weeks
following injury or
surgery

Edema control Begins immediately

Continues
throughout
rehabilitation

Pain control Begins immediately

Continues throughout
rehabilitation

Scar management Begins three to four

weeks after
surgery, following
wound closure and
suture removal

Early active/active Begins as early as

assisted range of pain and edema
motion (ROM) allow
Usually less than
ten days
Stable ROM
Pain-free ROM
Also include
uninvolved joints

Passive range of Begins gentle,

motion avoiding soft
tissue injury
Stable range only

Joint mobs Begins three to four

weeks after injury
or surgery
Requires proper bone
healing
Needs to be stable

Splinting for motion Static, static

progressive,
or dynamic
splinting begins
Needs proper bone
healing

Strengthening Shoulder/scapular Isometric elbow PREs for all joints Strengthening Work conditioning
strengthening and exercises begin Pain-free ranges progressed as Include a total
isometric wrist at three to Needs proper bone tolerated body approach
exercises begin at four weeks healing
,2 weeks

proximity and can be damaged with radial head
fracture, dislocation, or surgical dissection. The ulnar
nerve in the cubital tunnel is susceptible to injury
with dislocation, medial epicondyle fracture, com-
pression from immobilization devices, or tardy palsy
from prolonged valgus instability. In the case of
severe edema with pain out of proportion at the
forearm, compartment syndrome should be consid-
ered and the patient should be referred for immediate
surgical evaluation.36
Once a thorough evaluation is completed, an edu-
cated assessment of the radial head fracture with

April–June 2006 123

 TABLE 3. Rehabilitation of Complex Radial Head Fractures
Weeks
Therapeutic
Intervention 0–2 2–4 4–6 6–8 8–12
Immobilization ,10 days
after surgery

Splinting for Thermoplastic splint

protection immediately after
surgery up to six
weeks post-op
Hinged elbow splint
Locked at 90 between
exercise sessions
Blocked motion in
stable range
If unstable, forearm
held in either pron/
sup/neutral forearm
rotation to increase
stability

Pain and edema Begins immediately

control post-op
Continues throughout
rehab

Wound care Immediately post-op

Prevent infection
With external fixator,
includes pin care

Scar management Begins three to

four weeks
after surgery,
following
wound closure
and suture
removal

Early active/active Begins as early as pain

assisted ROM and edema allow
Usually less than ten
days
Stable ROM in hinged
splint with blocked
motion
Pain-free ROM
Also include
uninvolved joints
Forearm rotated for
maximum stability
Forearm motion only to
neutral for four to six
weeks if using a
rotated position to
stabilize

Avoid stressing injured

ligaments

(Continued)

124 JOURNAL OF HAND THERAPY

 TABLE 3. Continued
Weeks
Therapeutic
Intervention 0–2 2–4 4–6 6–8 8–12
Passive range of Begins gentle,
motion avoiding soft
tissue injury
Stay in stable range
Avoid stretching/
stressing injured
structures or
increasing
instability

Joint mobs Begin joint mobs if

appropriate
Contraindicated
with instability,
especially with
excision,
arthroplasty,
and/or ligament
injury

Splinting for Static, static

motion progressive, and
dynamic splinting
may begin if
elbow is stable
Need proper bone
and ligament
healing
Avoid stressing
injured ligaments

Strengthening Shoulder/scapular Stable elbow Isometrics for the Wrist and elbow PREs begin if
strengthening and isometrics unstable elbow or PREs external fixator
isometric wrist begin at three to injured wrist In stable ROM involved
exercises begin at four weeks Pain-free ranges At 12–16 weeks,
,2 weeks Avoid causing begin work
damage conditioning as
appropriate
.12 weeks work
conditioning if
external fixator
involved

specific functional goals can be made. Then a treat-
ment plan is developed and modified as necessary
for the individual patient.
Goals for Rehabilitation
Goals for therapy are based on integration of the
history of the injury, concurrent patient medical
factors, and injury intervention with findings from
the initial examination, assessment, and function
necessary for ADL, work, and hobbies. Returning to
all functional activities, or at least maximizing func-
tion, is the main goal of therapy. Maximal motion for
the elbow and forearm should be achieved without
compromising stability or damaging repaired struc-
tures. Normal ROM at the elbow is 0° of extension
(up to 10° of hyperextension) and 140–150° of flexion,
with normal pronation and supination at 80–90°
each.37,38 Contralateral ROM measurements, pre-
suming that the elbow is not also injured, will define
the ideal goals, though functional and realistic goals
may vary from this based on the severity of the injury.
Morrey et al. demonstrated that most ADL, demon-
strated by 15 tasks, could be achieved with 100° of
elbow motion (from 30° to 130°) and 100° of forearm
rotation (from 50° pronation to 50° supination). They
also determined that all tasks were achieved in an arc
from 15° to 140° of elbow motion.39 Alternatively,
Vasen et al., in a study of 12 tasks, demonstrated
that elbow motion from 75° to 120° could enable the
performance of all tested tasks and motion from 90°
to 105° had minimal impairment.40 However, certain
job duties may require more or less motion than that
identified by these authors. In these instances, the

April–June 2006 125

FIGURE 11. Examples of postinjury or postoperative splints to prevent forearm rotation. (A) A sugartong splint that limits
elbow extension and forearm rotation but allows elbow flexion. (B) A posterior long-arm splint including the elbow and
wrist that prevents both elbow and forearm motion. (C) A Muenster splint that limits elbow extension and forearm rotation
but allows elbow flexion. (A and C are courtesy of S. Blackmore MS, OTR/L, CHT).
functional goals are to gain motion for whatever tasks
are required by the patient.
Strength is maximized to allow for return to ADL,
hobbies, and work. However, the patient may return
to light or modified duty with less than maximal
strength while continuing therapy.
Attempting to meet the patient’s personal goals
and expectations for regaining motion and strength
are the guiding factors when developing therapeutic
goals. If the patient’s expectations are not realistic,
then the patient should be educated in the probable
outcomes based on the nature of their injuries.
Rehabilitation of Simple Fractures
Based on the Mayo classification, the term simple
or uncomplicated refers to isolated radial head frac-
tures.8 With this system, the Mason classification de-
notes the type of fracture involved. Generally, any
instability present is due to unstable fracture frag-
ments in type II and III and requires surgical inter-
vention to stabilize. For simple type I, II, and III,
early active/active assisted motion (A/AAROM)
programs have shown better outcomes versus pro-
longed immobilization1,8,11,27,42,44,56 (Table 2).
With simple type I and nonoperative simple type
II radial head fractures, a very short immobilization
period of up to a week is recommended. In general,
edema and pain dictate the time frame for immobi-
lizing the elbow. In most cases, sling immobilization
with a compression bandage is appropriate; however,
a more rigid support, such as a half cast or splint, may
be necessary (Figure 11B). Care is taken with fabricat-
ing the protective splint to avoid rubbing or increased
126 JOURNAL OF HAND THERAPY
pressure over the injured area. Flaring of the area and
use of foam can decrease discomfort and allow for
good support. The sling or splint may be used for sup-
port and protection after ROM begins, usually around
day three following injury.
In simple operative type II and III fractures, stabi-
lization in a long-arm cast or splint incorporating the
elbow, forearm, and wrist to prevent forearm rotation
is recommended (Figures 11A–11C). Stable reduction
and rigid fixation of the radial head are necessary for
early motion. These same splints are used for protec-
tion for up to three weeks with early active motion
beginning as early as day five postoperatively, but
no later than day ten, with stable fracture fixa-
tion.1,8,27,41–43 Limiting forearm rotation and elbow
extension to avoid unnecessary stresses to the healing
fracture is the primary goal of splinting. To accom-
plish this, Muenster and sugartong splints that allow
flexion but limit extension and forearm rotation are
used preferentially to long-arm splints, which com-
pletely immobilize the elbow. Normally, there are
no limits for elbow flexion following radial head frac-
tures; however, radiocapitellar contact increases as el-
bow flexion increases, so care should be taken if pain
increases with increasing flexion.
Rarely, total immobilization of the elbow is chosen
for intervention. One must critically consider the
detrimental effects of prolonged immobilization if
this type of intervention is used. Longer immob-
ilization causes increased joint stiffness due to adhe-
sion formation involving the joint capsule and
surrounding soft tissue. An immobilization period
of less than three to four weeks with early active
motion has been reported in the literature as having
better outcomes.8,11,42,44,45
 Edema and Pain Control
Regardless of the intervention chosen to initially
treat the fracture, edema and pain must be addressed
initially since both can limit gains in motion. In some
cases, the surgeon may elect to aspirate the elbow to
relieve both swelling and pain.1,27,43 Aspiration of the
joint allows surgical assessment for rotational block
and also improves early ROM significantly. It is our
experience that this improvement (while beneficial
for patient participation in initial therapy) is only
transient. Early edema control includes rest, ice, com-
pression, and elevation. Elevation incorporates the
use of gravity to decrease edema at the distal extrem-
ity, which helps minimize the progression to intersti-
tial fibrosis associated with chronic edema. This
effect is enhanced with the addition of gentle muscle
contractions of the upper arm, forearm, and intrinsic
muscles of the hand to mobilize the lymphatic and
venous systems. Ice and compression (in the form
of bandage wrapping or elastic sleeves) can also be
used between exercise sessions to minimize increases
in edema. Elevation coupled with retrograde mas-
sage is another effective method of reducing edema.
Pain control includes a variety of techniques and
modalities. Initially, medication from the surgeon is
helpful for reducing edema and pain. Cold applica-
tion is an easy and readily available method of
decreasing and limiting return of edema as well as
reducing pain symptoms. Electrical stimulation, us-
ing a variety of waveforms, has been shown to
decrease pain.46 High-volt pulsed stimulation and
modulated alternating current electrical stimulation
aid in pain reduction but have been noted as having
limited effects in reducing or inhibiting edema.46
Ultrasound has demonstrated potential to aid in
edema and pain control; however, its use is limited
to smaller surface areas, which makes it a poor choice
for larger area application.47 Once edema and pain
have been reduced, an early active motion program
may begin with fewer delays.
Wound Care and Scar Management
In simple type II and III fractures, following surgi-
cal intervention, wound care and scar management
are important parts of the rehabilitation process.
Rarely does wound care involve more than patient
education for maintaining a clean and dry incision
site to prevent infection and promote healing. Once
the sutures have been removed, scar management
begins. Initially, steri-strips may be applied to main-
tain wound closure and prevent dehiscence. At this
time, it is still important to monitor the area for
infection. Scar massage may begin at three to four
weeks following surgery to desensitize, add com-
pressive forces to decrease scar hypertrophy, and
add tensile stresses to aid with scar tissue
remodeling.44,48 We have found that compressive ap-
plications such as silicone gel sheets and elastomer
molds are excellent ways to minimize hypertrophic
scar formation. Either iontophoresis with iodine or
continuous wave ultrasound has been suggested to
help decrease scar formation and thickening.46,47
Early scar care limits the amount of scar tissue and
adhesions that can hinder return of motion.
Early Active/Active Assisted Motion
Early active/active assisted motion for simple
radial head fractures has been shown to lead to
improved outcomes.8,11,27,41,42–44,56 Early A/AAROM
helps to prevent stiffness, brawny edema, and adhe-
sion formation of the capsule and annular ligament
as well as promote healing and increase tensile
strength of the involved bony and soft tissue struc-
tures.1 In simple type I and II radial head fractures,
A/AAROM may be initiated as soon as edema and
pain will allow. For postoperative simple type II and
III fractures, A/AAROM usually begins as early as
day five and less than day ten. Splint use may be con-
tinued for protection from heavy activity for up to
three weeks following surgery. Full-time elbow immo-
bilization of three to four weeks may cause increased
adhesion formation and stiffness, which lead to in-
creased difficulty with regaining motion.8,11,42,45
Uninvolved joints in the upper extremity, such as
the scapulothoracic joint, shoulder, and wrist, are
addressed to ensure that motion has not been lost due
to concomitant injury or lack of use. Exercises for
these joints should be initiated at the beginning of
therapy, and the motion is monitored regularly. Pain
at the wrist, especially at the radial ulnar joint/
ulnocarpal area, should be evaluated for an undiag-
nosed Essex-Lopresti lesion. Symptoms of this in-
clude wrist pain with loss of motion (primarily
following radial head resection), a prominent dorsal
distal ulna, or severely limited DRUJ rotation. If these
findings are present but not previously documented,
further evaluation by the surgeon is warranted.
Elbow flexion and extension begin in a nonpainful
arc with the forearm in neutral rotation to decrease
radial head compression. However, positioning the
forearm in pronation with elbow extension decreases
the compressive force at the radial head by decreas-
ing the valgus moment associated with end-range
extension.49 Positioning the patient supine with the
shoulder at 90° of flexion is a practical way to use
gravity to assist elbow flexion and to increase active
contraction of the triceps for extension, as well as pro-
vide stabilization for the scapula. The patient seated
with the elbow and humerus supported on a table
and wedge uses gravity-assisted elbow extension
and increases active contraction of the biceps for flex-
ion. The patient should understand the necessity to
stabilize the scapula with elbow extension to
April–June 2006 127
eliminate protraction compensation. Generally,
greater effort is required to regain elbow extension
and forearm rotation. Elbow flexion usually returns
more readily.
Active/active assisted pronation and supination
may be initiated. Information from the surgeon will
determine if there is a specific limited safe arc of
motion or if motion may be increased as tolerated.
Initially, the elbow should be positioned in 90° of
flexion. Stabilizing the humerus on a plinth, between
the body and the plinth, or in a doorway for a home
program, decreases compensatory shoulder abduc-
tion and adduction with pronation and supination.
With the patient completing an early motion pro-
tocol, a home exercise program is initiated in a safe
arc of motion every hour or as edema and pain
permit. The home program should be modified as
necessary to safely regain maximal motion of the
elbow and forearm.
Passive Range of Motion
At four to six weeks from injury or surgery for
simple type I, II, and III, if there is appropriate
fracture stability, passive range of motion (PROM)
may begin. Valgus stress with extension should be
minimized to limit the compressive forces through
the radiocapitellar joint (RCJ). The goal of PROM is to
maximize motion at the joint without contributing to
increased fracture instability. Gentle, sustained
stretching should be used with prolonged holds at
end ranges of flexion and extension. This follows the
guide that a low-load, prolonged stress will cause
greater plastic changes in tissues than a high-load,
short-duration stress.50,51 Overzealous stretching
may lead to increased edema, guarding, and spasm,
which will limit progression of motion. Elbow flexion
and extension PROM begins with the humerus and
scapula in a stable position to avoid compensatory
movements. The patient positioned supine, with the
FIGURE 12. (A) Passive range of motion (PROM) for supination by a therapist with the humerus fixed on a foam wedge
and the elbow in 90° flexion. (B) An example of self-PROM into supination with the humerus fixed between the patient’s
body and a plinth. Note that the force for rotation is directed through the distal radius and not at the hand in both examples.
128 JOURNAL OF HAND THERAPY
humerus supported on the plinth or wedge, is an ex-
cellent position. The forearm is positioned in either
neutral or pronation to decrease the valgus forces
with elbow extension.
Pronation and supination PROM is performed with
the elbow at 90° with the humerus stabilized. This can
be accomplished with the elbow at the side and using
a plinth to prevent shoulder abduction and adduction
or with the humerus fixed on the plinth in supine or
sitting (Figures 12A–12B). Rotational force should be
directed through the distal radius and ulna, and not
the hand, to avoid stressing the ligaments in the wrist.
Forceful pronation is avoided initially due to the in-
creased contact between the healing radial head and
capitellum with increasing pronation.
Motion deficits should be differentiated among
capsular joint stiffness or a ‘‘two joint muscle’’ length
restriction, such as the biceps, triceps, or forearm
muscles. For instance, if passive elbow extension is
limited, the biceps is evaluated in both lengthened
(shoulder extension and forearm pronation) and
slacked (shoulder flexion and forearm supination)
positions while passively extending the elbow. If it is
determined that muscular tightness or guarding is
limiting motion, then specific muscle stretching and
muscle energy techniques are incorporated. If, how-
ever, the motion limitation is unchanged, then the
limitation is due to joint tightness. The wrist flexor and
extensor muscles may also require testing. If the
restrictions are due to the joint capsule and surround-
ing ligaments, the use of hot packs or continuous wave
ultrasound to the capsule with a sustained stretch can
be helpful with increasing motion.47 Further interven-
tions such as joint mobilization and splinting may be
incorporated as adjuncts for increasing joint motion.
Joint Mobilization
At three to four weeks from injury or surgery for
simple type I, II, and III, if the elbow ROM is limited by
RCJ, humero-ulnar joint (HUJ), PRUJ, or DRUJ tight-
ness, then joint mobilization may begin. It is important
to understand that both good fracture and joint stabil-
ity must be present in order to begin mobilization.
Accessory joint motion of the involved and uninvolved
elbows (assuming that the uninvolved joint is normal)
should be compared to assess for any limitation that is
hindering motion. Grade I and II mobilizations for the
RCJ, PRUJ, and DRUJ can be used to decrease pain and
edema. Grade III and IV mobilizations for the RCJ,
PRUJ, and DRUJ are used to increase capsule mobility
and elbow motion. For the HUJ, Grade I and II joint
distraction can decrease pain and edema and Grade III
and IV distractions can increase capsular mobility and
elbow ROM.
Limited pronation and supination may be due to
tightness at either PRUJ or the DRUJ or both. During
supination, the radial head rotates and translates
anteriorly to stretch the anterior capsule and sur-
rounding soft tissue at the PRUJ as the distal radius
rotates posteriorly around the ulnar head at the
DRUJ. In pronation, the radius acts in the opposite
manner, with the head rotating and translating
posteriorly to stretch the posterior capsule and
surrounding soft tissue as the radius rotates volarly
around the ulna. Therefore, if forearm supination
rotation is limited by the PRUJ, anterior mobilization
of the radial head at the PRUJ is appropriate, whereas
if there is limitation at the DRUJ, posterior mobiliza-
tion of the radius on the ulna is appropriate. For
pronation, these would be reversed.
With simple type II and III fractures treated with
surgery, the fracture stability should be verified
prior to initiating mobilization to the PRUJ and
FIGURE 13. (A) A serial static volar long-arm belly gutter splint used for contractures of 30° or less. (B) A static-progress-
ive turnbuckle extension splint used for contractures of greater than 30°. (C) A dynamic supination/pronation splint.
(Photos courtesy of S. Blackmore, MS, OTR/L, CHT).
RCJ. With full radial head excision, mobilization at
the PRUJ is contraindicated. Whereas with partial
excision of the radial head, mobilization at the PRUJ
is contraindicated only if there is instability of the
lateral pillar.
Splinting for Motion
Splinting is another method used to increase ROM.
Splinting to improve ROM is based on the total end-
range time concept as described by Flowers and
LaStayo.51 A low-load, prolonged stress has been
shown to increase ROM more effectively than high-
load, short-duration stresses due to plastic changes
within the tissue.50,51
At four to six weeks after injury or surgery for
simple type I, II, and III fractures, splinting may be
initiated if the patient does not respond to ROM
exercises. Normally, elbow flexion does not require
more intervention than ROM exercises. Therefore,
most of the splinting for motion focuses on elbow
extension and forearm rotation. Serial static, night-
time elbow extension splinting is an excellent method
to increase motion using a low-load prolonged stress.
A volar long-arm serial static splint, such as a belly
gutter, may be used at bedtime for elbow flexion
contractures of 30° or less (Figures 13A–13C). Care
should be taken with serial static splinting to position
the joint in a tolerable end-range position, as stretch-
ing beyond tolerance can increase pain and decrease
splint compliance, which could potentially contribute
to increased edema and scarring. Static progressive
splints such as the turnbuckle and JAS elbow and
pronation/supination splints (Joint Active Systems,
April–June 2006 129
Inc., Effingham, IL) are used for flexion contractures
greater than 30° and forearm rotation. Custom ther-
moplastic dynamic splinting and the Dynasplint el-
bow and pronation/supination splint (Dynasplint
Systems, Inc., Severna Park, MD) may also be used
for flexion contractures greater than 30° and forearm
rotation. Static progressive and dynamic splinting
can be used intermittently during the day. (See
Davila and Johnston-Jones article in this issue for
more information on splinting used to regain motion.)
When fitting the patient with a splint to improve
motion, it is important to avoid unnecessary valgus
and varus stresses at the elbow. Valgus stress, espe-
cially with extension, can cause increased compres-
sion of the radial head. To avoid these stresses,
attention is directed to proper splint fitting and
patient education on proper splint use.
Strengthening and Conditioning
It is important to maintain the musculature of the
upper extremity as the fracture is healing. The ability of
the scapular musculature to form a stable base for the
upper extremity is of utmost importance in regaining
ROM and strength in the elbow, forearm, and wrist. For
that reason, proximal strengthening of the shoulder
girdle complex should be initiated if needed. Active
scapular exercises involving elevation/depression,
protraction/retraction, and combined motions are
started with initiation of therapy. Prone exercises for
scapular strengthening may be used without adding
stress to the healing radial head. However, prone
shoulder external rotation can stress the LCL and
should be avoided initially if there is pain. Exercises
for the deltoid may be added in either seated or
standing position. Resistance may be added via cuff
weights proximal to the elbow as the patient pro-
gresses. It may be necessary to wear the elbow splint to
protect the fracture with these exercises.
The early addition of isometric exercises and fine
motor activities may also aid with decreasing edema
distally. The submaximal isometrics are used to
maintain muscle quality and tone and avoid exces-
sive atrophy. Thus, the submaximal wrist isometric
exercises may be initiated early. Submaximal elbow
and forearm isometrics, however, should be initiated
later at three to four weeks following injury or
surgery of simple type I, II, and III fractures when
there is sufficient fracture stability to tolerate forces
across the radial head. There is evidence that the
flexor–pronator mass adds dynamic stabilization
against valgus stress, namely the flexor carpi ulnaris
and flexor digitorum superficialis.52 Strengthening
and fine motor activities for the intrinsic hand mus-
cles and digits are initiated if needed. Fine motor
and dexterity activities not only aid with digital
motion but also use combined motion of the upper
extremity, which promotes motion at all joints.
130 JOURNAL OF HAND THERAPY
Gradual progressive resisted exercises for the el-
bow, forearm, and wrist are initiated at four to six
weeks following injury or surgery of simple type I, II,
and III fractures. For elbow flexion and extension,
strengthening should begin in pain-free arcs of
motion with light resistance with hand or cuff
weights or resistive bands with progression as toler-
ated. Pronation and supination strengthening begins
with the elbow in 90° of flexion to minimize force at
the radial head and in a pain-free arc. The resistance
and ROM may be increased as tolerated. It is neces-
sary to have good wrist stability to maintain neutral
wrist posture with pronation/supination strengthen-
ing. A splint to support the wrist temporarily with
these exercises may be used so neutral wrist position
can be maintained for strengthening. At this time,
strengthening for the rotator cuff can be added using
weights or resisted bands if needed. Internal rotation
may be held, initially, if the valgus force causes dis-
comfort at the radial head.
Once good ROM and strength of the upper ex-
tremity are achieved, formal work and avocational
activity conditioning may begin as necessary. To
prepare patients who have been out of work for an
extended period for their return, specific condition-
ing is necessary. The program should incorporate
not only the upper extremity but also total body con-
ditioning to enable a safe transition to full work
duties. For manual laborers, activities that mimic
the patient’s daily activities such as box lifting and
carrying, pushing and pulling carts, and use of tools
such as screwdrivers and wrenches are excellent ad-
ditions to the conditioning program. Equipment with
isotonic and isometric instrumented dynamometers
is available for exercise including those by
Baltimore Therapeutic Equipment (Hanover, MD)
and Biodex (Shirley, NY), which can be used to
strengthen as well as simulate work activities in var-
ious positions. In some cases, a modified or short-
ened workday coupled with work conditioning
enables the patient to make a smooth transition
back to the workplace.
Patients may be returning to avocational activities
such as hobbies or sports that require specific condi-
tioning. For instance, baseball and softball players
use throwing programs that are position specific to
return to their sports. It is important to know the level
of function that is necessary for each patient to safely
and confidently return to his or her pre-injury level of
activity and design a conditioning program appro-
priate to reach that level.
Complications
Elbow and wrist pain, stiffness, and radiocapitellar
arthritis can occur. Symptomatic fracture nonunion
can limit motion and function. Contractures limiting
extension may develop due to adhesions of the
anterior capsule. A residual flexion contracture of 10–
15° is not infrequent in the more severe injuries.
Adhesions involving the radial neck and annular
ligament may limit rotation of the forearm. Muscle
guarding or spasm, most notably by the biceps
brachii, can limit elbow motion.53 Development of
HO or myositis ossificans can also prevent elbow mo-
tion. Wrist pain and loss of motion may be indicative
of an Essex-Lopresti lesion, which may not have been
initially diagnosed.
Rehabilitation of Complex Fractures
Complex or complicated radial head fractures also
involve concomitant elbow fractures or ligament
injury.8 These fractures are designated type I–III corre-
sponding to the Mason classification. Complex frac-
tures differ from simple ones because of the addition
of instability of the elbow due to factors beyond the ra-
dial head fracture fragment alone. Rehabilitation of
these injuries depends on the level of involvement of
concomitant factors and the intervention chosen by
the surgeon (Table 3).
The approach used by the surgeon and therapist
for complex type I and type II fractures involving lig-
amentous or other osseous structures with resultant
instability will be different from that used for simple
type I and II fractures. Complex type I fractures are
rare and require focusing on the concomitant injuries
since the radial head fracture is stable. Treatment in-
volves splinting coupled with an early ROM pro-
gram. Splinting stabilizes against varus/valgus
stresses and limits elbow extension within a stable
range (see later in this article). Splint use may con-
tinue for protection for three to four weeks following
injury. Complex type II can be treated nonsurgically
or surgically. Nonsurgical type II treatment denotes
a stable radial head fracture fragment without dis-
placement or rotational block. Initial treatment is
the same as that for complex type I. Surgical type II
requires addressing both the fracture intervention
and intervention for concomitant injury. The elbow
and forearm are immobilized in a long-arm splint
or locked hinged splint for a period of less than ten
days followed by an early motion program. A hinged
splint is then used to allow elbow motion within safe
limits and prevent varus/valgus stresses (see below).
The splint is worn for up to six weeks for protection.
Muenster and sugartong splints are inappropriate
due to their inability to provide the accurate limita-
tion of extension necessary for the unstable elbow.
For complex type III and Johnston type IV frac-
tures, both the surgical repair of the radial head and
the repair of the associated injuries dictate rehabili-
tation. Initial management is the same as that for
complex type II fractures. However, a hinged external
fixation device may be necessary to maintain elbow
reduction stability.
Postoperative care for complex type II and III
fractures depends on the surgeon’s intervention. As
with simple type II and III fractures, stable reduction
and rigid fixation of the radial head are necessary for
early motion. However, intervention regarding asso-
ciated injuries will modify the rehabilitation pro-
gram. For example, when a coronoid fracture has
undergone surgical fixation, elbow extension is lim-
ited to prevent stress to the repair and redislocation.
LCL injuries are not always surgically reconstructed,
depending on elbow stability following the radial
head repair. With nonsurgical and surgically treated
LCL injuries, varus stress with positioning and mo-
tion is avoided. The forearm is positioned in prona-
tion within a splint to increase stability (see later in
this paper). MCL reconstruction is not frequently per-
formed since repair of the radial head and LCL gen-
erally provides adequate stability for early motion.
With both LCL and MCL injuries, a hinged elbow
splint may be necessary for increased stability.
Studies have shown that in cases with a compro-
mised or absent MCL, the radiocapitellar complex
acts to assist against cubitus valgus and thus becomes
an important stabilizer to valgus stress.1,8,17,54 In this
new role (as the sole remaining valgus stabilizer), the
radial column sees increased compressive joint
forces, which may stress the radial head repair or
the nondisplaced fracture. However, if there is an
MCL injury, splinting with the forearm in supination
aids in stability with motion and valgus stress is
avoided. A hinged elbow splint will increase stability
and decrease valgus stresses. An associated Essex-
Lopresti lesion may require splinting in supination
to reduce the dorsal ulnar head instability. Surgery
may be required to stabilize the DRUJ. Olecranon
fractures require limitation of extension and full flex-
ion. Because the triceps inserts onto the olecranon,
early active extension and full passive flexion are
contraindicated. With more global instability, hinged
external fixation may be necessary to provide stabil-
ity and allow for a limited arc of early motion.
Splinting
Splinting for elbow stabilization with an extension
block is common with complex fracture rehabilita-
tion. Splinting can be either custom thermoplastic or
prefabricated in nature. With instability due to liga-
mentous or concomitant fractures, a hinged elbow
splint can be used to provide initial immobilization
and later unlocked to allow for protected motion.8,42
The splint is worn for three to six weeks following
surgery and will require modification as edema
decreases. The patient is provided with information
regarding proper care, use, and skin monitoring.
The typical forearm position when managing el-
bow instability is pronation. In our opinion, forearm
rotation needs to be modified according to elbow
April–June 2006 131
stability. An unstable fracture fragment at the more
common anterolateral aspect of the radial head
causes posteromedial instability. Positioning the fore-
arm in pronation allows the larger, stable portion of
the radial head to contact the capitellum, which aids
with stabilizing the joint. However, an unstable frac-
ture fragment at the PL aspect of the radial head leads
to anteromedial instability, which is more effectively
stabilized with the forearm in supination. If the MCL
is injured, the forearm is positioned in supination,
which tightens the lateral ligaments and flexor/pro-
nator origin while providing lateral column support
against valgus stress. For LCL injuries, the forearm
is pronated, which tightens the medial ligaments
and extensor/supinator origin.11,48 For injuries to
both the LCL and MCL, the forearm is positioned in
neutral or, in some cases, an examination under anes-
thesia by the surgeon is required to determine the
safe arc or safe position. In a study by Pomianowski
et al., varus and valgus laxity was examined under
a variety of surgical and nonsurgical conditions and
flexion angles.55 They found that laxity was signifi-
cantly affected by forearm rotation position. It was
determined that elbow laxity for both varus and val-
gus loads was greatest in pronation and 20° of elbow
flexion. For complex fractures with joint instability,
the position of the forearm for both immobilization
and ROM must be discussed with the surgeon to
plan for greatest stability and least stress to the in-
jured structures.
Pain and Edema Control and Wound Care
As with rehabilitation with simple fractures,
edema, pain, wound care, and scar management
must be addressed early. The same methods as those
described previously for simple fractures apply to
complex fracture care. If a hinged external fixation
device is used, additional patient education regard-
ing the device is necessary. The pin sites are avenues
from the outside environment directly to the bone so
prevention of infection is of utmost importance. Once
these factors are addressed, an early motion protocol
may begin with fewer hindrances.
Early Active/Active Assisted Motion
Early motion following complex fractures is simi-
lar to that following simple fractures. The concept of
using motion early in the healing process to prevent
stiffness, adhesion formation of the radial head and
neck with the annular ligament and brawny edema
formation, as well as promote healing, increase mo-
tion, and increase tensile strength of the involved
tissue is the same.1,8,11,27,42,43,56 Motion of nonaffected
joints such as the scapulothoracic joint, shoulder,
wrist, and hand should begin immediately.
132 JOURNAL OF HAND THERAPY
For complex type I and nonsurgical type II, A/
AAROM begins after less than ten days of immobi-
lization as immobilization periods of three weeks or
more have demonstrated less favorable results.8,42,44
Care is taken to avoid stresses to associated injuries.
For instance, with MCL and LCL injuries, valgus
and varus stresses should be minimized. Motion is
limited to the stable arc indicated by the surgeon.
In complex surgical type II and III fractures with
either ligamentous or concurrent bony injuries, mo-
tion begins within ten days of surgery in protected
forearm rotation (described previously) and limited
arc of motion. Knowledge of the injured ligaments and
bony structures and an understanding of the elbow
and forearm kinematics are essential for proper treat-
ment. For instance, if the LCL was reflected or
reconstructed during the procedure, then varus
stresses are minimized and a pronated forearm posi-
tion is maintained with elbow motion to increase
stability. The range through which motion is safe is
indicated by the surgeon. The use of the hinged elbow
splint increases stability with early motion while
protecting against valgus and varus moments that
would normally stress the MCL and radial head and
LCL. The splint is locked in 90° flexion between
exercise sessions, with forearm rotation dictated by
the associated injury as described above. If a hinged
external fixation device is used, early motion is started
in a similar manner as with a hinged splint.
Active/active assisted motion should begin with
the humerus stabilized with proper forearm rotation
maintained. The specific degree for the stable arc of
motion, especially into extension, is obtained from
the surgeon. The patient begins with tolerable motion
within the stable arc in flexion and extension. At
home, this motion is performed by the patient in the
splint initially. The blocks set by the therapist or
surgeon on the hinged splint limit the patient’s
motion at home. In therapy, the splint may be
removed and A/AAROM in a safe arc of motion is
performed and carefully monitored. Elbow motion
performed with the patient in supine with the shoul-
der in flexion provides increased stability with elbow
flexion and extension. Gradually, the arc of motion is
increased at a rate of 5–10° of extension and 10° of
flexion per week as tolerated without compromising
healing structures or stability.
Pronation and supination active motion begins in
90° of elbow flexion.11,36 It is important to guard
against unnecessary varus or valgus stresses.
Stabilizing the humerus, as with simple fractures,
aids with decreasing compensatory motions that in-
crease valgus and varus moments at the elbow.
Again, forearm rotation may be limited initially due
to specific positioning for instability. For instance, if
the forearm is held in pronation to increase stability,
then forearm rotation should be limited to neutral
for four to six weeks, then gradually progressed
into supination.36 The opposite would be used for a
forearm being held in supination.
Passive Range of Motion
Passive range of motion begins at six to eight
weeks following surgery depending on fracture heal-
ing and joint stability. Information obtained from the
surgeon regarding healing status will determine if
PROM is appropriate. PROM guidelines were out-
lined previously with simple fractures. It is also im-
portant to be vigilant on avoiding stress to injured
ligaments or stretching into unstable ranges.
Maintaining proper forearm rotation as described
previously is important for elbow stability.
As with simple fractures, muscle tightness or
guarding may limit motion. Testing the triceps and
biceps in both lengthened and slacked positions will
determine if the motion deficit is due to the muscle or
from capsular or joint limitations. Forearm muscula-
ture should be assessed for shortening.
Joint Mobilization
Joint mobilizations with healing elbow instability
should be used by only therapists who are highly
competent and well experienced with manual tech-
niques. Joint mobilization is never used on the unsta-
ble elbow. Once appropriate fracture and soft tissue
healing has occurred and the joint is considered to be
stable, joint mobilization is used judiciously to gain
motion in complex type I and nonsurgical type II
fractures. At six to eight weeks following surgery or
injury, radiocapitellar mobilizations may be appro-
priate after sufficient healing has occurred. Grade I
and II mobilizations may be appropriate to decrease
pain and edema. However, Grade III and IV mobili-
zations are used judiciously and only with a stable
joint. As with simple fractures, accessory joint motion
should be assessed initially to determine if capsular
tightness is limiting motion. If a coronoid or olecranon
fracture is involved, ulnohumeral joint distraction is
contraindicated until full bony stability has occurred
and no other instability is present.
For complex type II and type III fractures treated by
excision or arthroplasty, RCJ mobilizations are con-
traindicated. When the radial head is excised, there is
already an inherent instability present. There is a risk
of loosening the prosthesis with mobilization that
would lead to complications such as pain, decreased
motion, and instability. PRUJ and DRUJ mobiliza-
tions are contraindicated with IOM, DRUJ, and PRUJ
injuries, radial head excision or arthroplasty, and
radial head instability.
Splinting for Motion
Splinting is an option to gain motion at four to
eight weeks following surgery or injury provided
there is good stability of the joint and all fractures are
healed. Splinting to regain motion has been described
earlier. Due to a history of joint instability, careful
assessment must be made of joint stresses applied by
any splint and patient pain associated with splint use.
Avoiding unnecessary stresses on healing structures
is important. Low-load prolonged stress not only
lengthens tight capsular structures, but also places a
stress on the remodeling ligaments. Understanding
the effects of splinting on all tissues involved is
important to maximize elbow motion while main-
taining stability.
Strengthening and Conditioning
Maintaining the musculature of uninvolved joints
is important as described for simple fractures.
Exercises for shoulder musculature including those
for scapular stabilization may be started in the first
week within tolerance. External rotation of the
shoulder with the patient prone-lying is avoided
initially due to increased stress on the LCL. The
splint should be used while performing these exer-
cises to protect the elbow from harmful stresses. If a
hinged external fixation device is being used, active
assisted motion may be necessary early due to the
added weight from the device. Fine motor/dexterity
exercises of the digits and intrinsic hand muscle
strengthening may begin as tolerated. Activities may
have to be modified due to protective splinting or
external fixation. Wrist submaximal isometrics may
begin early to assist with maintaining muscle tone
and decreasing edema unless there is a concomitant
wrist, IOM, or muscular injury. In these cases,
isometrics should be held until sufficient healing
has occurred. Isometric wrist exercises may contrib-
ute to soft tissue discomfort at pin sites if a hinged
external fixation device is used. Generally, strength-
ening can begin for the above motions at four to
eight weeks following injury or surgery depending
on the severity of the injuries. The same is true with
elbow isometric exercises. In stable elbow positions
and forearm rotation, submaximal elbow isometric
exercises may begin at three to four weeks postsur-
gery. When there is significant elbow or forearm
instability, strengthening may be delayed until six to
eight weeks. When a hinged external fixation device
is used, strengthening is generally deferred until
removal of the device and healing of bone and
tissues related to the pin sites.
For complex type II and III injuries, progression of
ROM activities of the elbow and forearm to strength-
ening may begin at six to eight weeks following sur-
gery. This time frame is based on the need for fracture
stability and adequate ligamentous stability. The sur-
geon is consulted to determine if it is appropriate to
progress the program to strengthening. When a
hinged external fixation device is used, this timeline
April–June 2006 133
may be eight to 12 weeks following surgery after re-
moval of the device. The progression for strengthen-
ing described for simple fractures can be applied to
complex fractures.
Based on the nature of the involved structures,
modification of the strengthening exercises may be
necessary. For the wrist, forearm, and elbow, resis-
tive exercises should begin in a stable, pain-free
range. It is important to stress correct form with
exercises to prevent stresses to healing ligaments or
fractures of the elbow. For instance, in attempting to
gain more supination, a patient may compensate
with shoulder adduction and external rotation,
which causes a valgus stress on the elbow.
Shoulder and scapular exercises can be progressed
as long as the injured structures are protected until
they are stable.
At 12–16 weeks postsurgery, the rehabilitation pro-
gram should be modified to include work condition-
ing or avocational needs as described previously. A
total body conditioning program based on the pa-
tient’s job-specific tasks begins. Modifications may
be made to accomplish job tasks in the case of motion
loss as long as safety is preserved. The patient may
work with a supportive brace in cases of prolonged
instabilities. Once again, returning to work in a
modified duty or partial day situation along with a
continued conditioning program is very beneficial
to the patient.
CONCLUSIONS AND PRACTICE
RECOMMENDATIONS
Accurate and complete diagnosis and early inter-
vention coupled with early motion protocols provide
the best outcomes for radial head fractures and
associated injuries.1,8,11,27,42,43,56 It is imperative that
the surgeon and therapist have early and continued
communication to effectively treat the patient. The
surgeon must provide information to the therapist re-
garding the injured structures, specifics about surgi-
cal intervention, stability of fracture fixation, and
joint stability. The therapist must understand tissue
healing, potential stresses to tissues, and treatment
techniques to protect the simple and complex in-
juries. The patient must be educated in possible out-
comes, safe arcs of motions, positioning, and proper
splint use. With the patient, doctor, and therapist
trio working together, maximal functional outcome
can be attained for simple and complex types of
radial head fractures.
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April–June 2006 135
 JHT Read for Credit
Quiz: Article #022
Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this
issue. There is only one best answer for each
question.
#1. Radial head resection following fracture may be
complicated by:
a. ulnar shortening and negative ulnar variance
b. radial lengthening and positive radial
variance
c. radial shortening and positive ulnar variance
d. ulnar lengthening and negative ulnar variance
#2. The shape of the radial articular dish is:
a. elliptical
b. spherical
c. irregular
d. flat
#3. The following combination leads to instant val-
gus instability with long-term sequelae:
a. comminuted radial head fracture 1 LCL
injury
b. comminuted radial head fracture 1 anterior
joint capsule injury
136 JOURNAL OF HAND THERAPY
c. nondisplaced radial head fracture 1 TFCC
tear
d. comminuted radial head fracture 1 MCL
injury
#4. The "terrible triad" is a combination of these
three:
a. radial head fracture, olecranon fracture, dislo-
cation of the elbow
b. radial head fracture, coronoid fracture, olecra-
non fracture
c. radial head fracture, coronoid fracture, dislo-
cation of the elbow
d. radial head fracture, TFCC tear, IOM tear
#5. The key to good management of most nondis-
placed radial head fractures is:
a. aggressive PROM
b. early ROM
c. the strict avoidance of any PROM
d. strengthening
When submitting to the HTCC for recertification,
please batch your JHT RFC certificates in groups
of three or more to get full credit.