The elbow joint is a complex joint, in which superior radioulnar joint plays a key role in the pronation and supination of the forearm. The radial head may be fractured when it collides with the capitulum. This can occur with a pure axial load (e.g., Essex-Lopresti injury), a valgus load, posterolateral rotatory type of load, or as the radial head dislocates posteriorly as part of a posterior Monteggia fracture or posterior olecranon fracture-dislocation ^[1]. It accounts for about 2% of all fractures around the elbow, but bilateral radial head fractures are very rare. Few studies are available in literature documenting these type of injuries. Hence, we are reporting this unique and rare presentation of bilateral radial head fracture in a patient which was conservatively managed with full functional recovery.

A 20-year-old male presented to the emergency department with complaints of pain and swelling in bilateral elbow joints following a roadside accident involving a bike skid. The patient had a fall backward with both arms in outstretched position. At the time of fall, there was extension at shoulder and elbow; supination at forearm; and dorsiflexion at wrist. On clinical examination, swelling 2 × 1 cm was noted on posterolateral aspect of elbow over radial head. Deep tenderness over radial head was present bilaterally. Pronosupination and flexion-extension movements at elbow were painful and restricted. No varus or valgus instability was noted in both elbows. On radiography, type I radial head fracture (Mason’s Classification) was noted bilaterally (Fig. 1 and 2). The patient was managed conservatively with above elbow slab ×2 weeks and NSAIDs. Following slab removal after 2 weeks, physiotherapy both elbows was initiated. The patient had pain free and full range of motion at 6 weeks follow-up (Fig. 3, 4, 5).

Mason classification is commonly used for classification of radial head fractures with Mason type 1: undisplaced marginal fractures; type 2: displaced marginal fractures; and type 3 as comminuted fractures ^[2]. Morrey has further refined this classification by adding variables of displacement, articular surface and fracture dislocation – (a) fractures of radial neck, (b) including a quantitative definition of displacement (a fragment involving 30% or more of articular surface that is displaced more than 2 mm), and (c) incorporated fracture-dislocations of the elbow ^[3]. Mason type 1 is the injuries frequently reported, while some studies have reported, Mason type 2 and Mason type 3 injuries as a bilateral fracture head radius presentation [4, 5, 6, 7, 8] (Table 1). Radiography (AP and Lateral View) elbow is an important tool, being essential for diagnosis of radial head fractures. Inclusion of a joint above and below elbow is essential to avoid missing fracture combinations like Essex-Lopresti fractures ^[9]. Some additional views, for example, Green Span view may be required for better visualization of radial head fracture. MRI is helpful in 76–90% of patients with radial head fractures for detection of soft tissue and cartilaginous injuries ^[10]. Clinically, relevant associated injuries, for example, coronoid fractures and elbow dislocations were found in 39% of patients with radial head fractures in some studies with likelihood of associated injury strongly correlated to the severity of the radial head fracture ^[11]. Treatment of radial head fractures ranges from conservative management in Mason type 1 fractures, for example, immobilization to operative modalities such as ORIF with Herbert Screws/1.5–2 mm cancellous screws, arthroscopic excision, and radial head arthroplasty in Mason type 2 and 3 fractures ^[1]. Conservative treatment, for example, above elbow slab/pressure bandage or cuff and collar sling for support followed by active mobilization as early as possible is the method of choice for Mason type I fractures ^[8]. The shortest the period of immobilization, the best are patient-reported outcome measure scores (PROMs) at follow-up ^[12]. These fracture types are prone to overtreatment in the form of radiographic follow-up without modifying treatment, leading to unnecessary patient visits, radiation exposure, and increased costs ^[13]. Introduction of new techniques and implants for the fixation of small articular fracture fragments in type 2 fractures has improved their surgical outcome ^[14]. In some studies with comparative evaluation of surgical and conservative modalities of treatment in Mason type 2 fractures, no clear cut advantage of one technique over the other has been reported ^[10]. Isolated comminuted radial head fractures, without associated instability of the elbow, are managed by resection of the radial head with satisfactory outcome ^[15]. Replacement of comminuted radial head by silicone implants restores elbow stability, but several implant-related problems and complications have been reported ^[16]. On the other hand, ORIF is another option for Mason type III fractures, but ORIF in more than 3 fracture fragments has resulted in unsatisfactory outcome due to difficult reduction, hardware failure, and non-union ^[17]. Only one randomized study comparing ORIF versus radial head arthroplasty for comminuted unstable radial head fractures has reported significantly better PROMs in arthroplasty group ^[18]. However, it is currently unknown whether one fixation technique has superior outcomes over the others. The present patient was having bilateral radial head fractures (Mason Type 1) and, hence, was managed by bilateral above elbow immobilization for 10 days followed by active elbow exercises, following which he had full range of motion.

Bilateral radial head fractures in a patient are a discreet clinical entity. A high index of suspicion, meticulous history, clinical examination, and appropriate imaging is essential in patients with history of falls on outstretched hands to avoid missing diagnosis. Early diagnosis, proper management, and appropriate physical rehabilitation lead to complete functional recovery.

Bilateral radial head fractures are an injury pattern, both rare and unique. Meticulous history, clinical examination, and radiography help identifying fracture geometry and providing appropriate treatment to the patient, leading thereby to improved functional outcome.