The Most Common Elbow Fracture, and the One Where Resting It Is ALWAYS the Mistake
Maybe you fell on an outstretched hand. The outer side of your elbow hurts, and the thing that really hurts is turning your palm up.
You can probably still bend the elbow, and that seemed “not too bad”, which is why people wait-and-see.
The radial head is the top of your forearm bone where it meets the elbow, and it is the most commonly fractured bone in the adult elbow. Most of these are small, undisplaced cracks that heal without surgery.
And most of the bad outcomes come not from the fracture but from the six weeks of not moving it afterwards. I know I sound like a broken record: our elbows stiffens faster than any other joint in the arm.
That is the whole story of this injury.
Why the X-ray might look normal
Radial head fractures can be hairline and hard to see.
What gives them away is indirect: blood filling the joint pushes small pads of fat away from the bone, and those displaced pads show up on a side-view X-ray as dark triangles that shouldn’t be there.
Radiologists call the front one the sail sign: A visible posterior fat pad is abnormal in any adult elbow.
The practical meaning: if you fell, your elbow is swollen and sore, and the report mentions fat pads or an effusion but no clear fracture, you should be managed as though you have one, with repeat imaging or a scan if things don’t settle.
The question that decides treatment
Not how big the fracture is. It’s whether the fragment is physically blocking rotation.
The radial head has to spin smoothly every time you turn your palm over. A displaced piece of it can jam that rotation mechanically, and no amount of therapy moves a bone that’s in the way.
The complication is that a freshly injured elbow full of blood hurts too much to test properly. So a common and genuinely useful step is draining the joint and putting local anaesthetic in, then asking you to rotate.
- Rotation is full once the pain is gone: no mechanical block, treat without surgery.
- It stops dead at a certain point even pain-free: something is jamming, and it needs fixing or removing.
Broadly: undisplaced fractures are managed with early movement, and are straightforwardly easy-ish to treat and manage with a compliant patient.
Displaced ones with a block on the other hand…always need to get fixed with small screws or a plate.
Badly shattered ones may need the radial head replaced with a metal one, which sounds drastic and works well.
The pattern that changes everything
A radial head fracture combined with a fracture of the coronoid, plus a dislocated elbow, is called the terrible triad.
The name is not an exaggeration. That combination leaves the elbow genuinely unstable and it needs surgery, usually urgently, with a much longer and more careful recovery.
If your elbow came out of joint as well as breaking, you’re reading the wrong article. Start with elbow dislocation and the stiff elbow after.
Recovery, and why the sling comes off early
This is where I spend most of my time with these patients, and where the advice most often contradicts what feels natural.
A broken elbow that isn’t moved for three weeks doesn’t heal quietly. It heals into a MUCH smaller, tighter, stiffer elbow.
For an undisplaced fracture:
- Days 0 to 5: sling for comfort and only for comfort. Out of it several times a day. Ice, elevation. Gentle bending and straightening starting almost immediately, within pain limits.
- Week 1 to 3: sling gone entirely. Range of motion work several times daily, especially turning the palm up and down. Using the arm for light everyday tasks.
- Weeks 3 to 6: pushing towards full range. This is the window where stiffness is either beaten or becomes permanent.
- Weeks 6 to 12: strengthening, load, return to most activity.
- Months 3 to 6: the finished result, heavier sport and manual work.
After surgery the same principles apply, on a timeline your surgeon sets, and full recovery runs closer to 6 months.
Honest expectation-setting: losing the last 10 to 20 degrees of full straightening is common after any significant elbow injury, and it’s frequently permanent. Most people never notice functionally, because the arm works fine through that range. Worth knowing in advance so it doesn’t feel like failure at week eight.
When to go back
- Rotation that isn’t improving at all between weeks 2 and 6, or that stops abruptly at a hard endpoint rather than a painful one.
- New locking, catching or grinding, which can mean a loose fragment in the joint.
- Numbness or tingling in the hand that appeared after the injury.
- An elbow that gets more swollen and more painful rather than less over the first fortnight.
The short version
Fall, outer elbow pain, worst turning the palm over: assume radial head until imaged, and don’t accept a normal-looking X-ray if there’s an effusion on it.
Then move it. The instinct to protect a broken elbow is exactly the instinct that costs people range, and range in this joint is not easy to win back.
Written by Nigel Chua, hand occupational therapist in practice since 2005. Tens of thousands of hands, wrists and elbows assessed and treated. My credentials are here. This article explains; it doesn’t examine. Follow your own surgeon’s protocol where it differs from anything here.