Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Radius, Proximal


Related Terms

  • Broken Elbow
  • Essex-Lopresti Fracture
  • Forearm Fracture
  • Fractured Elbow
  • Radial Head Fracture
  • Radial Neck Fracture

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Neurologist
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

Duration depends on the severity of the injury, whether the dominant or nondominant arm is involved, the type of treatment (surgical, nonsurgical), the surgical result, the presence of underlying conditions (e.g., osteoporosis, osteoarthritis, rheumatoid arthritis), and any complications.

Medical Codes

ICD-9-CM:
813.00 - Closed Fracture of Radius and Ulna, Upper End of Forearm, Unspecified
813.05 - Closed Fracture of Head of Radius
813.06 - Closed Fracture of Neck of Radius
813.07 - Closed Fracture of Other and Unspecified Fractures of Proximal End of Radius (Alone); Multiple Fractures of Radius, Upper End
813.08 - Closed Fracture of Radius with Ulna, Upper End (Any Part)
813.10 - Open Fracture of Upper End of Forearm, Unspecified
813.15 - Open Fracture of Head of Radius
813.16 - Open Fracture of Neck of Radius
813.17 - Open Fracture of Other and Unspecified Fractures of Proximal End of Radius (Alone)
813.20 - Closed Fracture of Shaft of Radius or Ulna, Unspecified
813.21 - Closed Fracture of Shaft of Radius (Alone)
813.30 - Open Fracture of Shaft of Radius or Ulna, Unspecified
813.31 - Open Fracture of Radius (Alone)
813.81 - Closed Fracture of Radius (Alone), Unspecified Part
813.83 - Closed Fracture of Radius with Ulna, Unspecified Part
813.91 - Open Fracture of Radius (Alone), Unspecified Part
813.93 - Open Fracture of Radius with Ulna, Unspecified Part

Overview

A fracture of the proximal radius (radial head and / or neck) can occur with direct injury to the elbow or indirect injury through the forearm and / or wrist. The elbow joint is very complex but is often described as a hinge joint composed of three bones: two from the forearm (radius and ulna) and one in the upper arm (humerus). These bones work together to allow movement and dexterity of the elbow, forearm, and wrist. The radius moves around the ulna and—with articulation at the distal end of the ulna (radioulnar joint)—allows forearm rotation (supination / pronation or palm up and down). The radius articulates with the humerus (radiocapitellar joint) to allow both forearm rotation and elbow flexion and extension. The ulna is linked to the distal end of the humerus by ligaments and allows for flexion and extension (bending the elbow up and down). The elbow joint is stabilized by ligaments and is in close proximity to the brachial artery and the median, radial, and ulnar nerves.

A fracture of the proximal radius usually occurs as the result of a fall onto an outstretched hand or a direct blow to the lateral elbow. Damage to the other bones of the elbow joint (humerus or ulna fractures and dislocations) or to the soft tissues surrounding the fracture site (tendon, ligament, nerve, and blood vessel injury) may occur simultaneously. One study used x-rays and MRI to look at the association between fracture and ligamentous injury in 24 individuals with a radial head fracture but no tenderness at the elbow joint. It found that 54% of the subjects had medial collateral ligament damage, 80% had lateral ulnar collateral ligament damage, and 50% sustained injury to both the medial and lateral ligaments. Although this is a small study, it does point to a significant association between radial head fracture and ligamentous injury (Itamura).

Proximal radius fractures may be nondisplaced (no misalignment of bones) or displaced (bones not aligned). The Mason classification system is used for both treatment and prognosis. Type I proximal radius fractures involve no displacement and minimal joint (articular) involvement and may be difficult to identify with diagnostic imaging. Type II fractures are those in which the bone fragments have separated by at least 2 mm (displaced); the fragments may be rotated or bent (angulated). Type III fractures (of which are three subclasses) are those in which the head of the radius has broken into many separate fragments (comminuted fracture). A Type IV fracture is a comminuted fracture with elbow dislocation (Morgan).

Type I and many Type II fractures are less severe and may heal well without surgical intervention, but fractures with significant displacement (Types III and IV) will require open reduction-internal fixation (ORIF) to realign the separated fracture fragments. If the proximal radius has become severely displaced or fragmented, excision of the radial head and / or replacement of the proximal radius (radial head arthroplasty) may be necessary.

At the time of injury, proximal radius fractures may become dislocated (fracture-dislocation), with the radial head migrating toward the elbow joint. An Essex-Lopresti fracture is a radial head or neck fracture with dislocation of the distal radioulnar joint (DRUJ) at the wrist and associated rupture of the membrane between the radius and ulna (interosseous membrane).

Incidence and Prevalence: Elbow fractures are fairly common, and 33% include fracture of the radial head or radial neck (Rabin). In adults, olecranon fractures account for 20% of all elbow injuries, and coronoid process fractures occur in 10% to 15% of elbow dislocations (Riego de Dios). Fractures of the proximal radius occur in up to one-third of elbow fractures and dislocations, with radial head fractures the most common type of elbow fracture in adults (Rabin).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals with osteoporosis, those with limited elbow range of motion secondary to osteoarthritis, and postmenopausal women have an increased risk of fracturing the proximal radius during a fall. Individuals who fall from a height have increased risk of sustaining an Essex-Lopresti fracture.

Source: Medical Disability Advisor



Diagnosis

History: Most individuals with elbow injury recount a recent history of a fall onto an outstretched hand or direct elbow trauma and may complain of elbow pain, swelling, and limited range of motion. A complete medical history may be obtained to determine the presence of underlying conditions (e.g., osteoporosis, osteoarthritis) that may increase the risk of fracture.

Physical exam: On physical exam, the individual will be unable to fully extend the elbow and will complain of pain with rotation (pronation and supination) of the forearm. Clicking (crepitus) may be observed with attempts to actively rotate the forearm. Palpation of the lateral elbow may reveal specific tenderness at the radial head. Swelling (joint effusion), bruising (ecchymosis), and deformity of the lateral elbow may be evident. Numbness or weakness of the forearm, wrist, thumb, and fingers may be present if nerve injury has occurred. The physician will assess the function of all nerves of the forearm and hand, examine the arteries, and look for other injuries.

Tests: Plain x-rays of the elbow (anteroposterior, lateral, oblique, and radial head-capitellar views) usually establish the diagnosis of proximal radius fracture and determine if there is concurrent dislocation or partial dislocation (subluxation) of the radial head. Hidden (occult) elbow fractures are common and are suspected when a radiographic "fat pad sign" is seen. A positive fat pad sign occurs when injury results in bleeding into the joint (hemarthrosis), displacing the fat pad. Either posterior fat pad displacement or anterior fat pad displacement (sail sign) indicates acute fluid accumulation (usually blood) in the elbow joint, suggesting a possible radial head fracture. If x-rays are inconclusive, elbow joint fluid may be aspirated and analyzed for the presence of fat and blood, which would be present if an occult fracture has occurred. MRI may be performed to assess the ligaments, tendons, cartilage, neurovascular structures, and interosseous membrane (between the radius and ulna). Complicated fractures with possible neurovascular injury may require MRI, CT scans, nerve conduction studies, or vascular studies to determine the extent of damage.

Source: Medical Disability Advisor



Treatment

Treatment of a proximal radius fracture is determined by the degree of displacement of the fracture fragments and by whether the fracture involves the elbow joint (intra-articular). For a nondisplaced proximal radius fracture (Type I), partial immobilization in an arm sling may be all that is required until the fracture begins to heal within several days. Nondisplaced fractures with involvement of more than one-third of the joint surface and with evidence of elbow ligament injury should be immobilized for at least 2 weeks as a result of the risk of subsequent dislocation of the elbow with movement. The physician may aspirate joint fluid to decrease pressure. The individual may be placed in a posterior long arm splint for a few days with the elbow joint in 90° of flexion and the forearm supinated to encourage healing. Once the fracture is stabilized, early movement of the elbow is essential to reduce the risk of stiffness and joint contracture.

Initially, many Type II and Type III proximal radius fractures may also be treated conservatively if fracture fragments do not block elbow joint range of motion; however, significant displacement or unstable bone fragments will require surgery. The fracture fragments are realigned and stabilized with a combination of plates and screws (open reduction–internal fixation [ORIF]), while the patient receives general or regional anesthesia. Any fracture fragments that cannot be stabilized are removed, and torn ligaments are repaired. Essex-Lopresti fractures and severely comminuted fractures may require excision of the radial head and replacement with a prosthesis (arthroplasty) to maintain joint integrity and function. After surgery, the elbow is flexed to 90° and a long arm splint cast is applied. After 2 weeks, the cast may be changed to a hinged brace (depending on stability) to allow some elbow movement during the next 4 weeks of healing.

Type IV proximal radius fracture-dislocations are treated by first reducing the dislocation and then by stabilizing the fracture conservatively or operatively according to the degree of displacement.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Non-displaced Radial Head Fracture
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

The long-term outcome after proximal radius fracture depends on the Mason classification of the fracture and early rehabilitation to preserve range of motion in the elbow. With Type II and Type III proximal radius fractures, good to excellent results are obtained with ORIF in 90% to 100% of individuals. For Type III fractures receiving radial head arthroplasty, good to excellent results are achieved in 70% to 100% of individuals, although implant failure rates may be as high as 42% (Rabin 2006).

With radial head excision following a displaced proximal radius fracture, fair to good results are achieved in up to 90% of individuals, although prolonged postoperative elbow pain and instability may occur (Herbertsson).

Regardless of treatment approach, early mobilization of the elbow joint is critical if fracture stability will allow.

Source: Medical Disability Advisor



Rehabilitation

The purpose of rehabilitation following a proximal radius fracture is to reduce pain and to restore full function to the elbow joint. The goals are to minimize deconditioning, prevent muscle contractures, and restore full range of motion and strength.

Protocols for rehabilitation are based upon the stability of the healing fracture, whether the fracture is displaced or nondisplaced, and whether there is associated neurovascular injury. If the fracture was managed surgically, the surgeon may recommend specific rehabilitation guidelines.

Initially, application of cold packs or ice may help to decrease swelling and pain. Unless contraindicated, passive range of motion exercises (flexion/extension, supination/pronation of the elbow) often begin 2 to 7 days post fracture for simple, nondisplaced fractures. Therapists instruct the individual to perform early range of motion exercises for the shoulder, wrist, and hand, progressing to strengthening exercises as tolerated. As the healing process progresses (3 to 6 weeks postfracture), the therapist increases active range of motion activities for the injured elbow and forearm and adds gripping and isometric exercises. The therapist will then progressively increase the individual's flexibility, strength, coordination, and endurance with an emphasis on function and independence in activities of daily living. Individuals who have undergone surgery follow a similar program of progressive increase in graded activity but at a slower pace.

Bone healing may occur within 6 to 12 weeks, but the return of full bone strength may take longer. The treating physician will guide the individual about appropriate resumption.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Radius, Proximal
Occupational / Hand / Physical TherapistUp to 16 visits within 8 weeks
Surgical
SpecialistFracture, Radius, Proximal
Occupational / Hand / Physical TherapistUp to 20 visits within 8 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.

Source: Medical Disability Advisor



Complications

Complications include nonunion or malunion of bony fragments, avascular necrosis, forearm compartment syndrome, post-traumatic osteoarthritis, neurovascular injury, infection, an unstable joint, deformity, or permanent stiffness and lack of mobility.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Following a proximal radius fracture, ice packs, rest, and arm elevation may be required, with frequent work breaks every 2 hours or as pain and swelling dictate. The physician may advise temporary lifting or carrying restrictions for the injured arm.

Individuals with fractures of the nondominant arm that did not require surgery can return to work (modified duty) in 1 to 2 weeks. Individuals with more severe fractures requiring surgery and / or fractures involving the dominant arm may require longer periods of work restrictions. If the use of pain medication is allowed while working, modification of any drug testing policies may be necessary, and the operation of heavy equipment may need to be avoided.

Symptoms of stiffness may require 12 months for improvement. It is important to understand that the duration guides address return to work but not resolution of symptoms. Depending on the facture and the healing, some individuals may have permanent symptoms. However, permanent symptoms do not mean individuals cannot work, only that they may have symptoms with or without activities.

Risk: Risk for re-injury is dependent on the fracture type and activities performed. Avoidance of loading the hand and arm is important. Type III and IV fractures will be unstable without surgery.

Capacity: Capacity is limited while the facture is healing. Stability of the fracture is key to current and future capacity. Modified use of the arm and hand may decrease swelling and improve mobility. Early return to modified work often results in a better outcome.

Tolerance: Activities will be limited by pain. Fracture pain and surgical pain will vary depending on the mechanism of injury, the type of surgery, and the individual’s ability to cope with pain.

Accommodations: Employers who can provide modified light work or one-hand work with the injured side as an assist-only hand can expect early return to work and better outcomes.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is typically achieved within 4 to 168 days of fracture distal radius and or ulna. Some additional improvement may occur up to 9 to 128 days after fracture.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual report fall onto an outstretched hand or direct trauma to the elbow?
  • Was there inability to fully extend the elbow? Inability to fully pronate and supinate the forearm?
  • Did individual complain of pain and swelling of the elbow or wrist? Limited elbow range of motion?
  • Were x-rays (including anteroposterior, lateral, oblique, and radial head-capitellar views) performed?
  • Was there a "fat pad sign" on x-ray?
  • Was diagnosis of proximal radius fracture confirmed?
  • Does individual have previously diagnosed osteoporosis or osteoarthritis?

Regarding treatment:

  • Was fracture nondisplaced or displaced?
  • If nondisplaced fracture, was individual placed in long arm splint and / or arm sling for at least several days?
  • If displaced fracture, was surgical realignment (open reduction, internal fixation [ORIF]) done? Radial head excision? Radial head arthroplasty?
  • Did postsurgical complications (infection, poor wound closure, joint contracture) occur?
  • Were rest, ice, and elevation recommended?
  • What type of medications (analgesics, NSAIDs, narcotics) were required for pain control?
  • Was individual compliant with treatment recommendations?
  • Was physical therapy recommended? Was individual compliant with rehabilitation?

Regarding prognosis:

  • Was fracture nondisplaced or displaced?
  • Did fracture involve the articular surface of the joint?
  • Was the dominant or nondominant arm affected?
  • Was there damage to surrounding nerves, blood vessels, or soft tissues?
  • Did an elbow joint contracture occur?
  • Was individual compliant with treatment recommendations and physical therapy? Was additional physical therapy required? Did individual have a home exercise program?
  • Were activities of daily living affected?
  • Did adequate time elapse for a full recovery?

Source: Medical Disability Advisor



References

Cited

Herbertsson, Pär, et al. "Fractures of the Radial Head and Neck Treated with Radial Head Excision." Journal of Bone and Joint Surgery 86-A 9 (2004): 1925-1930.

Itamura, John, et al. "Radial Head Fractures: MRI Evaluation of Associated Injuries." Journal of Shoulder and Elbow Surgery 14 4 (2005): 421-424.

Morgan, S. J. , et al. "Reliability evaluation of classifying radial head fractures by the system of Mason." Bulletin/Hospital for Joint Diseases 56 (2) (1997): 95-98.

Rabin, Steven, and Sandra L. Rabin. "Indications for Radial Head Replacement Following Elbow Trauma." Medscape. 19 Jan. 2006. WebMD, LLC. 21 Jan. 2013 <http://www.medscape.com/viewarticle/719214_1>.

Rabin, Steven, et al. "Radial Head Fractures." eMedicine. Ed. Harris Gellman. 14 Jun. 2011. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/1240337-overview>.

Riego de Dios, Ricardo , et al. "Imaging of Elbow Fractures and Dislocations in Adults ." Medscape General Medicine NA. eMedicine Specialties. 3 Aug. 2011. WebMD, LLC. 21 Jan. 2013 <http://emedicine.medscape.com/article/389069-overview>.

Source: Medical Disability Advisor






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