Radial Head Replacement PDF Evidence¶
A protected recovery plan after replacement of the radial head at the elbow with a metal implant, built around early protected elbow and forearm movement to prevent stiffness, with the forearm positioned to protect any repaired ligaments and the elbow rested in a simple sling for comfort.
This protocol guides your recovery after radial head replacement at the elbow — where a shattered radial head is replaced with a small metal implant — with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist — bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses and on exactly what was repaired during your operation.
If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review.
What to expect¶
The radial head is the round top of one of the two forearm bones, where it meets the elbow. When it is broken into too many pieces to fix, it is replaced with a small metal implant that restores a stable, congruent elbow and a smooth forearm rotation axis. This is often done as part of repairing a more complex injury — a fracture-dislocation sometimes called a "terrible triad", where the radial head, a piece of the coronoid, and the ligaments on the side of the elbow are all injured together.
Because the implant restores stability, the priority of your rehabilitation is early protected movement to prevent stiffness — elbows are very prone to going stiff after this kind of injury, and the best protection against that is to start moving early. Your elbow is rested in a simple sling for comfort between exercises — not a hinged brace — and the sling comes off for your exercises and for washing.
Two things shape how soon and how far you move:
- Any ligaments that were repaired need protecting. If the ligament on the outside of the elbow (the lateral collateral ligament) was repaired, the forearm is held and exercised turned palm-down (pronated) early on; if the ligament on the inside (the medial collateral ligament) was repaired, it is held palm-up (supinated); if both, in a neutral mid-position. Your therapist will tell you which applies to you.
- The elbow must be protected from sideways (varus) stress and, early on, from full straightening if the elbow was unstable. This is why movement is opened up in stages rather than all at once.
Movement is progressed steadily, with strengthening usually beginning from about six weeks and a return to full activity around three months. The implant and the healing keep settling for several months, which is why heavier loading is built back gradually.
Precautions and limitations¶
- Wear your simple sling for comfort as directed — this is not a hinged brace, and it comes off for exercises and washing.
- Keep the forearm in the position your therapist gives you during early exercises (palm-down if the outside ligament was repaired, palm-up if the inside one was, neutral if both) — this protects the repair.
- Do NOT put sideways (varus) stress through the elbow — avoid leaning on the elbow or letting the arm hang unsupported across your body early on.
- Do NOT force full straightening early if you have been told the elbow was unstable — straighten only within your allowed range.
- Do NOT lift, push, pull or bear weight through the operated arm until cleared (commonly around six weeks) — keep early hand use light.
- Keep your shoulder, wrist and fingers moving from the start, and do NOT drive while your arm is in the sling or cannot safely control the wheel.
For wound, swelling and scar management, see the practice's wound care guidance.
Your exercises¶
Kieran Hirpara 4.0
Elbow bends and straightening (active-assisted)
Out of the sling, gently bend and straighten the operated elbow within the range you have been given, using your other hand to help guide it so the arm does not have to work hard. Early motion is the most important thing here — the metal implant has restored a stable elbow so it is safe to move, and moving early is what keeps the elbow from going stiff. Stay within any limit on full straightening if you have been given one.
10 times, 3–4 times a day, within your allowed range
Kieran Hirpara 4.0
Forearm rotation (palm up / palm down)
With your elbow tucked at your side and bent to a right angle, gently turn your palm up towards the ceiling, then down towards the floor. Keep the elbow still and let only the forearm rotate. Early on you may be asked to favour one direction (palm down, or palm up) to protect a repaired ligament — follow the direction your therapist gives you. This keeps the forearm supple, which is one of the first movements to stiffen after this injury.
10 times each allowed direction, 3–4 times a day
Shoulder and hand movement
Keep your shoulder, wrist and fingers moving freely from day one so they do not stiffen while the elbow recovers. Make a full fist and stretch the fingers out, circle the wrist, and move the shoulder gently. Use the hand for light everyday tasks within comfort. None of this loads the elbow repair.
10 times each, several times a day
Scar care
Once the wound is fully healed and the surgeon or therapist has cleared it, massage the scar with a little moisturiser using small circles for a few minutes. This keeps the scar supple and less sensitive. Do not start until the wound is completely closed.
A few minutes, 2–3 times a day, once healed
Strengthening from 6 weeks
A LATER exercise — only once cleared, commonly from around six weeks. Begin gentle strengthening of the elbow, forearm and grip — for example squeezing a soft ball, then light resisted bending and straightening — and build the effort up gradually over the following weeks. Do not rush heavier loading; the elbow is still maturing for several months.
As guided by your hand therapist (from ~6 weeks only)
These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and forearm position you have been given. The early exercises keep the elbow and forearm moving to prevent stiffness without straining any repair — active-assisted elbow bending and straightening, gentle forearm rotation in your allowed direction, and keeping the shoulder and hand free. Strengthening and scar care belong to later phases and should not be started until you are specifically cleared. Stop anything that causes sharp pain or a feeling that the elbow is giving way.
Your clinical protocol¶
The rest of this page is the staged clinical protocol for rehabilitation after radial head replacement (radial head arthroplasty), most commonly performed for an unreconstructable comminuted radial head fracture, often as part of a terrible-triad fracture-dislocation. This section is to be provided to the hand therapist, and each phase opens with a plain-English explanation of what is happening. The implant restores a stable, congruent radiocapitellar articulation, so the guiding principle is early protected motion to prevent the stiffness these elbows are prone to — with the arc and forearm rotation gated by the integrity of any collateral-ligament and coronoid repairs.
Prior to treatment, check the patient's operation report and the examination-under-anaesthesia stability assessment, and liaise with the treating surgeon regarding: which collateral ligaments and/or coronoid were repaired, the stable arc demonstrated intra-operatively, and the protective forearm rotation. Dr Hirpara rests the elbow in a simple sling for comfort (no hinged brace) and favours an accelerated, early-motion approach where stability allows. Forearm-position rule: LCL repair → exercise/rest in pronation; MCL repair → supination; both → neutral mid-position; avoid varus stress and, where the elbow was unstable, terminal extension early.
Phase I — early protected motion (weeks 0 to 2)¶
The first two weeks start gentle protected motion as soon as wound stability allows — often within the first week — to get ahead of stiffness. The arm rests in a simple sling for comfort, off for exercises and hygiene. The elbow moves through its safe arc with the forearm held in the protective rotation for whichever ligament was repaired.
For your hand therapist:
Education and precautions - Immobilise in a simple sling for comfort (no hinged brace); off for exercises and washing - Begin active-assisted/active elbow flexion–extension within the intra-operatively demonstrated stable arc; avoid terminal extension if the elbow was unstable - Forearm rotation in the protective position: pronation if LCL repaired, supination if MCL repaired, neutral mid-range if both - No varus stress at any time; perform overhead exercises supine where unstable to neutralise varus and use gravity to coapt the joint - No weight-bearing or pushing through the operated arm
Management - Wound: surgical dressings as directed; confirm wound stability before commencing motion - Oedema: elevation, gentle hand pump, ice as needed - Exercises: AAROM/active elbow flexion–extension within the stable arc; forearm pro/sup in the protected direction with the elbow at 90°; full active shoulder, wrist, hand and grip ROM
Criteria to progress - Wound settling; comfortable controlled motion within the protected arc
Phase II — progressing the arc and forearm rotation (weeks 2 to 6)¶
From around two to six weeks the protected arc is gradually widened towards full extension and forearm rotation is opened up in both directions, with the aim of full pronation/supination by about eight weeks. Strengthening and loading are still withheld.
For your hand therapist:
Assessments - Active and passive elbow flexion–extension and forearm rotation; pain and swelling; wound/scar review; stability symptoms
Education and precautions - Progress towards full extension as stability allows (release any early extension block gradually) - Progress forearm rotation in both directions towards full, still mindful of the repaired ligament early in this phase - Continue to avoid varus stress and any loading through the arm
Management - Exercises: widen elbow flexion–extension arc to full; progress pro/sup towards full ROM (target full by ~8 weeks); commence scar management once the wound is healed; continue shoulder/wrist/hand ROM - An overhead (supine) motion programme remains useful where residual instability is a concern
Criteria to progress - Approaching full painless ROM; no instability symptoms; pain ≤3/10
Phase III — strengthening and return (weeks 6 to 12 and beyond)¶
Once movement is restored and the repairs are deemed secure (commonly around six weeks), strengthening begins and is built up gradually — grip, then resisted elbow and forearm work — progressing through the following weeks. Return to heavier activity is criterion-based, typically around three months.
For your hand therapist:
Assessments - Elbow and forearm strength versus the other side; pain/swelling response to loading; functional and work-/sport-specific testing as appropriate
Education and precautions - Begin gentle resisted strengthening (grip → resisted elbow flexion–extension and pro/sup) from around six weeks; build load gradually - Progress to functional and work-specific loading as tolerated; avoid sudden heavy or impact loading early
Management - Exercises: progressive resisted elbow/forearm strengthening (band → light weights); grip strengthening; graded functional loading; continue any residual mobility work - Watch for and report persistent or worsening pain, mechanical symptoms or loss of motion (possible implant overstuffing/loosening or capitellar wear), and refer back to the treating doctor if recovery plateaus or there is a poor outcome - Consider discharge once motion is functional and strength is near-symmetrical
Criteria for return to full activity - Functional pain-free ROM; near-symmetrical strength; confident, stable elbow under load
Getting back to work and activity¶
Light everyday hand use — eating, writing, light self-care — is encouraged from the start, within comfort, as long as it does not involve pushing, lifting or bearing weight through the elbow. Because you must not drive while the arm is in the sling or unable to safely control the wheel, plan for help with transport in the early weeks; driving resumes once you are out of the sling and can control the car, as confirmed at your review.
Strengthening usually begins from about six weeks and is built up gradually. Return to heavier work, lifting and sport is typically around three months, and is based on regaining full pain-free movement and adequate, symmetrical strength with a stable elbow — judged by Dr Hirpara and your hand therapist, not by the calendar alone. Heavier manual work and contact sport follow the same criterion-based progression.
After your protocol¶
This protocol works alongside the practice's general recovery advice — see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after radial head arthroplasty and terrible-triad reconstruction, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your elbow progresses and exactly what was repaired.
Evidence & references
Radial Head Replacement — Procedure Outcomes & Post-operative Rehabilitation (Radial Head Arthroplasty for Unreconstructable Fracture / Terrible Triad)¶
Topic scope: post-operative rehabilitation after radial head arthroplasty (RHA) — replacement of an unreconstructable comminuted radial head with a metallic implant — performed either in isolation or, more commonly, as one component of reconstructing a fracture-dislocation (the "terrible triad": radial head + coronoid + lateral collateral ligament ± medial collateral ligament). The radial head is a key secondary stabiliser of the elbow against valgus and axial (posterolateral rotatory) load, so the implant exists to restore a stable, congruent radiocapitellar articulation and forearm axis — not merely to fill a defect.
Defining principle of the rehab here: the implant restores stability, so the dominant clinical enemy is stiffness, to which these elbows are strongly predisposed. The rehab is therefore an early protected-motion pathway — start moving within days to a week — explicitly gated by the integrity of the collateral-ligament and coronoid repairs done at the same operation. The two deliberate restraints are (1) the forearm rotation position that offloads the repaired ligament (pronation protects a repaired LCL; supination protects a repaired MCL; neutral mid-range when both), and (2) avoidance of varus stress and, where the elbow was unstable, early terminal extension. A simple sling is worn for comfort — not a hinged brace. The single biggest branch point is how much residual instability was demonstrated on examination under anaesthesia, which determines how fast the arc and forearm rotation are released.
A. PROCEDURE OUTCOMES (radial head arthroplasty; repair-vs-replace context)¶
Metallic RHA is a reliable reconstruction for the unreconstructable radial head, and — critically for rehab — it restores enough stability to permit early motion even in the setting of associated dislocation, provided the ligaments and coronoid are addressed.
- RHA restores elbow stability and kinematics when the native head is unreconstructable, but ligament repair is required to fully restore stability. Cadaveric work shows radial head excision alters kinematics and stability, arthroplasty restores them in the ligament-intact elbow, and in the ligament-disrupted elbow arthroplasty plus LCL repair is needed to correct varus–valgus laxity [Beingessner et al., J Bone Joint Surg Am 2004, DOI 10.2106/00004623-200408000-00018]. Strong (mechanistic/biomechanical).
- RHA gives functional, durable ROM in unstable elbow injuries equivalent to stable injuries. A 15-year single-surgeon series (68 patients) found patients with unstable radial head fractures plus dislocation achieved flexion and rotational arcs similar to stable injuries, with no difference in complication rate or implant survivorship — though supination loss was ~10° greater in the unstable group [Lott et al., J Shoulder Elbow Surg 2018, DOI 10.1016/j.jse.2017.10.011]. Moderate (Level II cohort).
- Long-term monopolar implant survival is good, with stiffness/sizing the main failure modes. A 15-year follow-up of the Acumed anatomical (press-fit, monopolar) implant for Mason III–IV fractures confirms durable function and survival, with the principal complications being joint stiffness, malpositioning and improper sizing [Tarallo et al., J Shoulder Elbow Surg 2026, DOI 10.1016/j.jse.2025.05.038]. Moderate (long-term cohort).
- Implant failure/revision risk is real, especially with associated instability. In a young active (military) cohort, RHA carried higher implant-failure rates than ORIF (20% vs 2.9%), and dislocation, coronoid fracture and concomitant ligament repair each predicted complications — underscoring that the injury complex, not just the implant, drives outcome [Kusnezov et al., HAND 2017, DOI 10.1177/1558944717715136]. Moderate.
- Terrible-triad reconstruction aims explicitly to restore stability sufficient for early motion. Comprehensive reviews frame the entire surgical sequence (LCL repair, radial head fix/replace, ± coronoid, ± MCL/fixator) as a means to permit early ROM and pre-empt stiffness, posttraumatic arthrosis and instability [Fahs et al., J Am Acad Orthop Surg 2024, DOI 10.5435/jaaos-d-24-00310]. Moderate–strong (narrative review).
B. REHABILITATION / THERAPY EVIDENCE¶
The rehab evidence base is built on biomechanics + surgical-series protocols rather than RCTs: there is strong agreement on early protected motion and on forearm-position-based ligament protection, but the exact arc and timing are individualised to intra-operative stability.
- Early motion is the consensus priority to prevent stiffness. Across operative series and textbook protocols, formal active and active-assisted ROM is begun within the first week once wound stability is confirmed, with splinting between sessions usually discontinued by 2–3 weeks and strengthening from ~6 weeks [Monica & Mudgal, Hand Clin 2010, DOI 10.1016/j.hcl.2010.04.008; Duckworth et al., Clin Orthop Relat Res 2014, DOI 10.1007/s11999-014-3516-y]. Moderate (consensus/series).
- Motion is gated by stability, with varus stress avoided at all times. Where instability is a concern, an overhead (supine) rehabilitation protocol begun ~10–14 days post-op achieves early motion while gravity coapts the joint and neutralises varus; "a stiff stable elbow is preferred over a loose incongruous one" [Rockwood and Green's Fractures in Adults, 2019]. Moderate (textbook consensus).
- Forearm rotation is positioned to protect the repaired ligament. Published RHA protocols position and exercise the forearm in pronation when the LCL was repaired, supination when the MCL was repaired, and neutral mid-range when both were repaired, progressing to full rotation as the repair consolidates [single-centre RHA protocol & narrative review, ResearchGate 2018; UVA / Christ Hospital RHA PT protocols — see URLs]. Weak–moderate (protocol consensus).
- A coronoid fracture treated without fixation does not preclude early motion in selected triads. Where the LCL and radial head are addressed and intra-operative fluoroscopic stability is confirmed, type I–II coronoid fractures can be left unfixed and still rehabilitated with early motion to good ROM and DASH scores [Papatheodorou et al., Clin Orthop Relat Res 2014, DOI 10.1007/s11999-014-3471-7]. Moderate (Level IV series).
- Restoring radiocapitellar contact (by replacement) is what permits the early-motion pathway in the unstable elbow; conservative or excision pathways are reserved for stable patterns and depend on the same early-mobilisation principle [Charalambous et al., J Shoulder Elbow Surg 2011, DOI 10.1016/j.jse.2011.02.013]. Moderate.
Recovery trajectory (expected, evidence-anchored)¶
| Phase | Window | Restraint | Therapy focus | Strength / load | Notes |
|---|---|---|---|---|---|
| I — Early protected motion | Week 0–2 (often start <1 wk) | Simple sling for comfort (no hinged brace); stable-arc only; forearm in ligament-protective rotation; no varus stress | Active/active-assisted elbow flexion–extension within the intra-operative stable arc; forearm pro/sup in the protected direction; full shoulder/wrist/hand ROM; supine overhead programme if unstable | None | Wound stability confirmed before motion; "stiff-stable > loose-incongruous" |
| II — Arc & rotation progression | Week 2–6 | Release extension block / forearm rotation gradually as stability allows | Progress elbow arc to full extension; open forearm rotation both directions; scar management once healed | None | Aim full pronation/supination by ~8 weeks; supination is the slowest to recover (~10° residual loss common) |
| III — Strengthening & return | Week 6–12+ | Restrictions lifted as repairs consolidate | Grip → resisted elbow/forearm strengthening; graded functional and work-specific loading | Begin ~6 wk, build gradually | Return to heavier work/sport criterion-based ~3 months; watch for overstuffing/loosening/capitellar wear |
(Phase windows mirror the precautions in the patient protocol; they are typical, stability-gated guides, not trial-derived deadlines.)
C. KEY CONTROVERSIES / EVIDENCE QUALITY¶
- Repair (ORIF) vs replace (RHA) the radial head. For reconstructable heads, ORIF is generally preferred and no prosthesis equals the native head biomechanically; for unreconstructable comminution (Mason III–IV) or in the unstable/dislocated elbow, RHA is the more reliable option because fixation constructs fail under the higher stresses [Kusnezov et al. 2017; Charalambous et al. 2011; Leigh & Ball, J Shoulder Elbow Surg 2012, DOI 10.1016/j.jse.2012.03.005]. Moderate; selection-dependent.
- Terrible-triad early motion vs protected immobilisation. Modern practice favours restoring enough stability (LCL ± radial head ± coronoid ± MCL/fixator) to permit early motion and avoid stiffness; the supine/overhead protocol exists precisely to reconcile early motion with residual instability. The trade-off ("stiff-stable preferred over loose-incongruous") is consensus, not RCT-settled [Rockwood and Green 2019; Fahs et al. 2024]. Moderate (consensus).
- Monopolar vs bipolar implants. Both are used; bipolar designs were intended to self-align and tolerate sizing imperfection, while monopolar anatomical implants show good long-term survival. No clear superiority is established, and overstuffing/sizing error harms either design more than the bearing type does [Tarallo et al. 2026; Doornberg et al., J Bone Joint Surg 2007, DOI 10.2106/jbjs.e.01340]. Weak (no head-to-head superiority).
- Implant-related complications. Overstuffing the radiocapitellar joint, malsizing and stem loosening cause capitellar erosion/osteopenia, pain and stiffness; capitellar erosion is reported from metal-on-cartilage articulation, and accurate head height/diameter is the key technical guard [Van Riet et al., J Bone Joint Surg 2004, DOI 10.2106/00004623-200405000-00028; Monica & Mudgal 2010]. Rehab cannot fix a malsized implant — persistent loading pain/stiffness warrants surgical review. Moderate.
- Supination is the laggard. Across series, forearm supination is the motion most likely to remain mildly deficient (≈10° loss), partly from scarring and partly from MCL-protective early positioning; patients should be counselled accordingly [Lott et al. 2018]. Moderate natural-history.
D. EVIDENCE STRENGTH FLAGS (summary)¶
- STRONG (biomechanical / mechanistic): RHA restores elbow stability and kinematics only in concert with collateral-ligament repair (varus–valgus laxity corrected by RHA + LCL repair, not RHA alone).
- MODERATE: functional ROM after RHA in unstable injuries equivalent to stable injuries with good implant survivorship (Level II–IV cohorts); long-term monopolar implant survival with stiffness/sizing as main failure modes; early-motion-to-prevent-stiffness as the governing rehab principle; supine/overhead protocol for the unstable elbow; supination as the slowest-recovering arc.
- WEAK / CONSENSUS: the specific forearm-position-by-repaired-ligament rehab rule (pronation for LCL, supination for MCL, neutral for both) and the exact phase timings (protocol-derived, stability-gated, not RCT-validated); monopolar-vs-bipolar bearing choice (no proven superiority).
CITATIONS¶
RAG corpus (180,000+ Orthopaedic articles)¶
- The Effect of Radial Head Excision and Arthroplasty on Elbow Kinematics and Stability. J Bone Joint Surg Am. 2004. DOI: 10.2106/00004623-200408000-00018
- Radial Head Arthroplasty. Hand Clin. 2010. DOI: 10.1016/j.hcl.2010.04.008
- Results after radial head arthroplasty in unstable fractures. J Shoulder Elbow Surg. 2018. DOI: 10.1016/j.jse.2017.10.011
- Long-term survival of Acumed anatomical radial head implant for Mason type III-IV fractures: a 15-year follow-up. J Shoulder Elbow Surg. 2026. DOI: 10.1016/j.jse.2025.05.038
- Operative Management of Unstable Radial Head Fractures in a Young Active Population. HAND. 2017. DOI: 10.1177/1558944717715136
- Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update. J Am Acad Orthop Surg. 2024. DOI: 10.5435/jaaos-d-24-00310
- Terrible Triad Injuries of the Elbow: Does the Coronoid Always Need to Be Fixed? Clin Orthop Relat Res. 2014. DOI: 10.1007/s11999-014-3471-7
- Radial Head Replacement for Acute Complex Fractures: What Are the Rate and Risk Factors for Revision or Removal? Clin Orthop Relat Res. 2014. DOI: 10.1007/s11999-014-3516-y
- Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012. DOI: 10.1016/j.jse.2012.03.005
- Comminuted radial head fractures: aspects of current management. J Shoulder Elbow Surg. 2011. DOI: 10.1016/j.jse.2011.02.013
- Radial Head Arthroplasty with a Modular Metal Spacer to Treat Acute Traumatic Elbow Instability. J Bone Joint Surg Am. 2007. DOI: 10.2106/jbjs.e.01340
- Capitellar Erosion Caused by a Metal Radial Head Prosthesis. J Bone Joint Surg Am. 2004. DOI: 10.2106/00004623-200405000-00028
- Comparative study of radial head resection and prosthetic replacement in surgical release of stiff elbows. Int Orthop. 2014. DOI: 10.1007/s00264-014-2594-5
- Rockwood and Green's Fractures in Adults (terrible-triad surgical pitfalls; overhead/early-motion protocol; "stiff-stable preferred"). Wolters Kluwer, 2019.
Radial head replacement rehabilitation literature (URLs)¶
- Rehabilitation protocol after radial head arthroplasty — a single-centre experience and narrative review of the literature. ResearchGate (2018). https://www.researchgate.net/publication/326168570
- University of Virginia, Department of Orthopaedic Surgery — Radial Head Replacement Rehabilitation Guidelines (forearm-position-by-ligament; arc progression). https://med.virginia.edu/orthopaedic-surgery/wp-content/uploads/sites/242/2024/09/Radial-head-replacement.pdf
- The Christ Hospital — Radial Head Replacement Physical Therapy Protocol (Rao). https://www.thechristhospital.com/landingpages/Documents/Rao%20PT%20Protocols/Operative/Elbow/Rao%20Radial%20Head%20Replacement%20r1.pdf
- Cheshire Arm Clinic — Physiotherapy Protocol for Radial Head Replacement. https://cheshirearmclinic.co.uk/wp-content/uploads/2021/09/Radial-Head-Replacement.pdf
- Denver Shoulder — Rehabilitation Protocol: Radial Head Replacement. https://www.denvershouldersurgeon.com/pdf/radial-head-replacement-protocol.pdf