1 Orthopaedic Department, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

2 European University of Cyprus, School of Medicine, Nicosia, Cyprus

3 Department of Orthopaedics, ACPM Medical College, Dhule, Maharashtra, India

4 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

5 Department of Radiology, “Konstantopouleio” Hospital, Athens, Greece


Background: Some of the Mason type I fractures cannot be detected on early radiographic images. These occult
fractures are considered as a diagnostic challenge for physicians. Our aim was to determine the value of bedside
ultrasonography for the detection of Mason I radial head fractures that are non-visible in early X-ray’s.
Methods: A prospective blind single-center diagnostic study was conducted (from June 2012 till May 2013) concerning
23 patients who were clinically suspicious of having a radial head fracture. These patients were evaluated with a
bedside high frequency ultrasound in the Emergency Room (E.R.). The two sonographic criteria that were considered
to be diagnostic for fracture were: a. effusion besides the radial head-neck and b. cortical discontinuity of the radial
head or neck. All patients also underwent a Computed Tomography (CT) as the gold standard imaging modality for
diagnosis of occult radial head fractures.
Results: Fifteen out of 23 patients were diagnosed with radial head fracture using both ultrasound and CT. On the other
hand, there were three patients with negative ultrasound and positive CT, in addition two patients were found positive in
the ultrasonographic exam, while this result was not confirmed by the CT scan. In comparison with CT, ultrasound exam
appeared to have 83.3% sensitivity, 60% specificity, 88.2% positive prognostic value and 50% negative prognostic
value (when at least one diagnostic sonographic criterion was positive). The accuracy of the sonographic study for the
diagnosis of the aforementioned fractures was 78.2%. Effusion in contact with the radial neck was the most sensitive
sonographic sign (14/15 of the true positive radial head ultrasounds).
Conclusion: Bedside ultrasound in the E.R. was proven to be a sensitive tool for early (day-1) diagnosis of the occult
radial head fractures. It could be used as an adjacent imaging modality in patients suspicious for radial head fracture,
when the initial X-rays are negative.
Level of evidence: II


Main Subjects

1. Pappas N, Bernstein J. Fractures in brief: radial head
fractures. Clin Orthop Relat Res. 2010; 468(3):914-6.
2. Jarraya M, Hayashi D, Roemer FW, Crema MD, Diaz
L, Conlin J, et al. Radiographically occult and subtle
fractures: a pictorial review. Radiol Res Pract. 2013;
3. Duckworth AD, Clement ND, Jenkins PJ, Will EM,
Court-Brown CM, McQueen MM. Socioeconomics
deprivation predicts outcome following radial head
and neck fractures. Injury. 2012; 43(7):1102-6.
4. Kaas L, van Riet RP, Vroemen JP, Eygendaal D. The
epidemiology of radial head frac-tures. J Shoulder
Elbow Surg. 2010; 19(4):520-3.
5. Van Riet RP, Morrey BF, O’Driscoll SW, Van Glabbeek
F. Associated injuries compli-cating radial head
fractures: a demographic study. Clin Orthop Relat Res.
2005; 441(1):351-5.
6. Kodde IF, Kaas L, Flipsen M, van den Bekermon MP,
Eygendaal D. Current concepts in the management
of radial head fractures. World J Orthop. 2015;
7. Duckworth AD, Clement ND, Jenkins PJ, Aitken SA,
Court-Brown CM, McQueen MM. The epidemiology of
radial head and neck fractures. J Hand Surg Am. 2012;
8. Burkhard KJ, Wegmann K, Mueller LP, Gohlke FE.
Fractures of the radial head. Hand Clin. 2015;
9. Jones SG. Fractures of the head and neck of radiusseparation
of upper radial epiphysis. N Engl J Med.
1935; 212(20):914-7.
10. Morrey BF, An KN. Articular and ligamentous
contributions to the stability of the elbow joint. Am J
Sports Med. 1983; 11(5):315-9.
11. Morrey BF, Tanaka S, An KN. Valgus stability of
the elbow. A definition of primary and secondary
constraints. Clin Orthop Relat Res. 1991; 265(1):
12. Johnston GW. A follow-up of one hundred cases of
fracture of the head of the radius with a review of the
literature. Ulster Med J. 1962; 31(1):51-6.
13. Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch
T, Shean C. Radial head fractures: MRI evaluation of
associated injuries. J Shoulder Elbow Surg. 2005;
14. Kaas L, Turkenburg JL, van Riet RP, Vroemen JP,
Eygendaal D. Magnetic resonance im-aging findings in
46 elbows with a radial head fracture. Acta Orthop.
2010; 81(3):373-6.
15. Hausmann JT, Vekszler G, Breitenseher M,
Braunsteiner T, Vécsei V, Gäbler C. Mason type-I radial
head fractures and interosseous membrane lesions--a
prospective study. J Trauma. 2009; 66(2):457-61.
16. McGinley JC, Gold G, Cheung E, Yao J. MRI detection of
forearm soft tissue injuries with radial head fractures.
Hand (N Y). 2014; 9(1):87-92.

17. Kodde IF, Kaas L, van Es N, Mulder PG, van Dijk CN,
Eygendaal D. The effect of trauma and patient related
factors on radial head fractures and associated
injuries in 440 patients. BMC Musculoskelet Disord.
2015; 16(1):135.
18. Smits AJ, Giannakopoulos GF, Zuidema WP. Long-term
results and treatment modalities of conservatively
treated Broberg-Morrey type 1 radial head fractures.
Injury. 2014; 45(10):1564-8.
19. Burkhart KJ, Franke S, Wegmann K, Ries C, Dehlinger
F, Müller LP, et al. Mason I frac-ture - a simple injury?
Unfallchirurg. 2015; 118(1):9-17.
20. Pavic R, Margetic P, Hnatesen D. Diagnosis of occult
radial head and neck fracture in adults. Injury. 2015;
46(Suppl 6):S119-24.
21. Yoon A, Athwal GS, Faber KJ, King GJ. Radial head
fractures. J Hand Surg Am. 2012; 37(12):2626-34.
22. Naredo E, Bijlsma JW, Conaghan PG, Acebes C, Balint
P, Berner-Hammer H, et al. Rec-ommendations for
the content and conduct of European League Against
Rheumatism (EULAR) musculoskeletal ultrasound
courses. Ann Rheum Dis. 2008; 67(7):1017-22.
23. Dębek A, Nowicki P, Czyrny Z. Ultrasonographic
diagnostics of pain in the lateral cubital compartment
and proximal forearm. J Ultrason. 2012; 12(49):
24. Eckert K, Ackermann O, Schweiger B, Radeloff E,
Liedgens P. Ultrasound evaluation of elbow fractures in
children. J Med Ultrason (2001). 2013; 40(4):443-51.
25. Cunningham PM. MR imaging of trauma: elbow and
wrist. Semin Musculoskelet Radiol. 2006; 10(4):
26. Gutierrez G. Management of radial head fracture. Am
Fam Physician. 1997; 55(6):2213-6.
27. Leschinger T, Müller LP, Hackl M, Wegmann K. The
cortical irregularity in the transition zone of the
radial head and neck: a reliable radiographic sign of
an occult radial head fracture. Arch Orthop Trauma
Surg. 2016; 136(8):1115-20.
28. O’Dwyer H, O’Sullivan P, Fitzgerald D, Lee MJ, McGrath
F, Logan PM. The fat pad sign following elbow trauma
in adults: its usefulness and reliability in suspecting
occult frac-ture. J Comput Assist Tomogr. 2004;
29. Bruinsma WE, Guitton T, Ring D, Science Variation
Group. Radiographic loss of contact between radial
head fracture fragments is moderately reliable. Clin
Orthop Relat Res. 2014; 472(7):2113-9.
30. Rineer CA, Guitton TG, Ring D. Radial head fractures:
loss of cortical contact is associ-ated with concomitant
fracture or dislocation. J Shoulder Elbow Surg. 2010;
31. Morewood DJ. Incidence of unsuspected fractures in
traumatic effusions of the elbow joint. Br Med J. 1987;
32. Burton KR, Mellema JJ, Menendez ME, Ring D,

Chen NC. The yield of subsequent radi-ographs
during nonoperative treatment of radial head
and neck fractures. J Shoulder El-bow Surg. 2016;
33. Acar K, Aksay E, Oray D, Imamoglu T, Gunay E. Utility
of computed tomography in el-bow trauma patients
with normal x-ray study and positive elbow extension
test. J Emerg Med. 2016; 50(3):444-8.
34. Sheps DM, Kiefer KR, Boorman RS, Donaghy J, Lalani
A, Walker R, et al. The interob-server reliability of
classification systems for radial head fractures: the
Hotchkiss modifi-cation of the Mason classification
and the AO classification systems. Can J Surg. 2009;
35. Kaas L, van Riet RP, Turkenburg JL, Vroemen JP, van
Dijk CN, Eygendaal D. Magnetic resonance imaging
in radial head fractures: most associated injuries are
not clinically rele-vant. J Shoulder Elbow Surg. 2011;
36. Platon A, Poletti PA, Van Aaken J, Fusetti C, Della Santa
D, Beaulieu JY, et al. Occult fractures of the scaphoid:
the role of ultrasonography in the emergency
department. Skel-etal Radiol. 2011; 40(7):869-75.
37. Yıldırım A, Unlüer EE, Vandenberk N, Karagöz A. The
role of bedside ultrasonography for occult scaphoid
fractures in the emergency department. Ulus Travma
Acil Cerrahi Derg. 2013; 19(3):241-5.
38. Hsu CY, Chiang YP, Liao CT, Hong YC. Sonographic
diagnosis of a medial talar avul-sion fracture. J Clin
Ultrasound. 2013; 41(9):570-3.
39. Warkentine FH, Horowitz R, Pierce MC. The use of
ultrasound to detect occult or unsus-pected fractures
in child abuse. Pediatr Emerg Care. 2014; 30(1):43-6.
40. Najaf-Zadeh A, Nectoux E, Dubos F, Happiette L,
Demondion X, Gnansounou M, et al. Prevalence and
clinical significance of occult fractures in children
with radiograph-negative acute ankle injury. A metaanalysis.
Acta Orthop. 2014; 85(5):518-24.
41. Hoffman DF, Adams E, Bianchi S. Ultrasonography of
fractures in sports medicine. Br J Sports Med. 2015;
42. van Leeuwen DH, Guitton TG, Lambers K, Ring D.
Quantitative measurement of radial head fracture
location. J Shoulder Elbow Surg. 2012; 21(8):1013-7.
43. Waterbrook AL, Adhikari S, Stolz U, Adrion C. The
accuracy of point-of-care ultrasound to diagnose
long bone fractures in the ED. Am J Emerg Med. 2013;