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An isolated posterior dislocation of radial head in adults – A rare injury: A case report
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
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ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
An isolated posterior dislocation of radial head in adults e A rare injury: A case report A.P. Singh a,f, V. Garg b,*,f, R. Vaishya c,f, A.P. Singh d,f, R. Raman e,f a Consultant Orthopaedic Surgeon, Punjab Civil Medical Services-1, Mukerian, Punjab 144211, India b Fellow Arthroscopy, ISKSAA, Dept of Orthopedics, Delhi 110034, India c Professor Orthopedics, Indraprastha Apollo Hospitals, New Delhi 110076, India d Consultant Orthopedics, Kanwar Hospital and Research Centre, Hajipur, Hoshiarpur, Punjab 144211, India e Consultant Orthopedic, Vardhman Govt. Medical College, West Bengal 713144, India
article info
abstract
Article history:
An isolated posterior dislocation of radial head in adults is a rare injury. We report a 32-
Received 2 April 2014
year-old male patient with posterior dislocation of radial head associated with articular
Accepted 7 May 2014
fracture fragment of the radial head. Open reduction and internal fixation with a minis-
Available online xxx
crew was done and patient had excellent outcome at a follow up of 2 years. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Radial head fracture Post dislocation elbow Monteggia fracture Radial head fixation
1.
Introduction
Isolated posterior dislocation of radial head is a rare injury especially in skeletally mature individuals.1 Usually posterior dislocation of radial head is common in children and is considered under the monteggia variant. Earlier reports of cases of acute radial head dislocation in adults have been associated with either ulna fracture or elbow dislocations.2
2.
Case report
A 32-year-old male presented with painful left elbow held in slightly flexed and supinated position in the emergency room. He had a history of fall on his non-dominant left hand. Swelling was obvious on lateral and posterior aspect of elbow. On examination all rotatory movements were restricted and painful. There was no tenderness on medial side of elbow,
* Corresponding author. E-mail address: [email protected] (V. Garg). f Source e Kanwar Hospital and Research Centre, Hajipur, Hoshiarpur, Punjab, India. http://dx.doi.org/10.1016/j.apme.2014.05.011 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011
2
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Fig. 1 e AP radiograph pre-operative.
forearm or distal radioulnar joint. Neurovascular examination was within normal limits. Radiographs of elbow showed posterior radial head dislocation with intra-articular fracture fragment of radial head displaced superiorly (Figs. 1 and 2). There was no other associated bony injury.
3.
Fig. 3 e AP radiograph post-op.
Surgical technique
Patient was taken for open reduction and exploration of the joint. Kocher approach with proximal extension was used with careful dissection to preserve the soft tissue attachment of the fractured fragment. Annular ligament was torn. Radial head was lifted anteriorly by pressure of small Hohmann retractors placed subperiosteally. Radial head articulation with capitellum was confirmed. A 1.5 mm Kirschner wire (K-wire) was used to temporarily fix the articular fragment. A 2.7 mm miniscrew (Max ortho, Bombay, India) was used to fix the fractured fragment and articular congruity and stability was confirmed. Thorough joint lavage was done. Annular ligament was reconstructed. A 2 mm K-wire was used to fix the radiocapitellar joint in neutral position of forearm. The K-wire was removed at 2 weeks and flexion extension movements of the elbow were initiated. Rotatory movements were started at 3 weeks. At 8 weeks light weight lifting was allowed. After a
Fig. 2 e Lateral radiograph pre-operative.
follow up of 2 years the patient had 0e110 of movement with full pronation and supination (Figs. 3 and 4).
4.
Discussion
Isolated dislocation of the radial head without concomitant ulnar fracture or humeroulnar subluxation in adults is a rare injury.1,3e7 Most of the earlier reported cases were in children and were considered monteggia variants.2
Fig. 4 e Lateral radiograph post-op.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Heidt and Sterne, in 1982, were the first to describe this injury.1 Only 20 cases have been reported in adults in the literature,6 but we were not able to find any case in literature where posterior dislocation is associated with intra-articular fracture of radial head. The mechanism leading to an isolated radial dislocation has been variously described. Most authors describe an indirect mechanism. The proximal radioulnar joint is most stable in supination: in this position, the contact between radius and ulna is maximal and the interosseous membrane, the annular ligament, and the anterior fibres of the quadrate ligament are all taut, thus drawing the radial head snugly against its notch in the ulna. Cadaveric studies have shown that posterior dislocation of the radial head cannot occur without the rupture of the annular ligament; in addition, partial tear of the quadrate ligament and the proximal interosseous membrane takes place. We speculate the mechanism in our patient to be a hyperextension of the elbow with forearm in prone position leading to a posterior dislocation of the radial head. There are no guidelines for treatment. Most of these cases with isolated posterior radial head dislocation were treated conservatively except two cases.6,7 In one case open reduction was performed due to soft tissue interposition6 and in second one open reduction was done because of persistent instability of radial head and annular ligament reconstruction was done.7 In our case we reconstructed radial head and annular ligament and radio capitullar K-wire was applied for 2 weeks. Most of these reported cases showed excellent result following prompt diagnosis and reduction. Hence it is very necessary to identify these injuries as soon as possible and treat them promptly especially when associated with intraarticular fractures.
3
The recognition of such injuries is of paramount importance to prevent early degenerative arthritis of elbow. In our case we found that open reduction and internal fixation of posterior radial head dislocation with articular fracture yields excellent results.
Conflicts of interest All authors have none to declare.
references
1. Heidt Jr RS, Stern PJ. Isolated posterior dislocation of the radial head. A case report. Clin Orthop Relat Res. 1982;168: 136e138. 2. Bado JL. The monteggia lesion. Clin Orthop. 1967;50:71e78. 3. Negi AK, Pestonji MD, Iyer S. Isolated posterior dislocation of the radial head in an adult. J Postgrad Med. 1992;38:143. 4. Ibrahimi AE, Shimi M. Isolated, traumatic posterior dislocation of the radial head in an adult: a new case treated conservatively. J Emerg Trauma Shock. 2010 OcteDec;3(4):422e424. 5. Bonatus T, Chapman MW, Felix N. Traumatic anterior dislocation of the radial head in an adult. J Orthop Trauma. 1995;9:441e444. 6. Takami H, Takahashi S, Ando M. Irreducible isolated dislocation of the radial head. Clin Orthop Relat Res. 1997;345:168e170. 7. Dhawan A, Hospodar PP. Isolated posttraumatic posterior dislocation of the radial head in an adult. Am J Orthop. 2002;31:83e86.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
An isolated posterior dislocation of radial head in adults e A rare injury: A case report A.P. Singh a,f, V. Garg b,*,f, R. Vaishya c,f, A.P. Singh d,f, R. Raman e,f a Consultant Orthopaedic Surgeon, Punjab Civil Medical Services-1, Mukerian, Punjab 144211, India b Fellow Arthroscopy, ISKSAA, Dept of Orthopedics, Delhi 110034, India c Professor Orthopedics, Indraprastha Apollo Hospitals, New Delhi 110076, India d Consultant Orthopedics, Kanwar Hospital and Research Centre, Hajipur, Hoshiarpur, Punjab 144211, India e Consultant Orthopedic, Vardhman Govt. Medical College, West Bengal 713144, India
article info
abstract
Article history:
An isolated posterior dislocation of radial head in adults is a rare injury. We report a 32-
Received 2 April 2014
year-old male patient with posterior dislocation of radial head associated with articular
Accepted 7 May 2014
fracture fragment of the radial head. Open reduction and internal fixation with a minis-
Available online xxx
crew was done and patient had excellent outcome at a follow up of 2 years. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Radial head fracture Post dislocation elbow Monteggia fracture Radial head fixation
1.
Introduction
Isolated posterior dislocation of radial head is a rare injury especially in skeletally mature individuals.1 Usually posterior dislocation of radial head is common in children and is considered under the monteggia variant. Earlier reports of cases of acute radial head dislocation in adults have been associated with either ulna fracture or elbow dislocations.2
2.
Case report
A 32-year-old male presented with painful left elbow held in slightly flexed and supinated position in the emergency room. He had a history of fall on his non-dominant left hand. Swelling was obvious on lateral and posterior aspect of elbow. On examination all rotatory movements were restricted and painful. There was no tenderness on medial side of elbow,
* Corresponding author. E-mail address: [email protected] (V. Garg). f Source e Kanwar Hospital and Research Centre, Hajipur, Hoshiarpur, Punjab, India. http://dx.doi.org/10.1016/j.apme.2014.05.011 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011
2
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Fig. 1 e AP radiograph pre-operative.
forearm or distal radioulnar joint. Neurovascular examination was within normal limits. Radiographs of elbow showed posterior radial head dislocation with intra-articular fracture fragment of radial head displaced superiorly (Figs. 1 and 2). There was no other associated bony injury.
3.
Fig. 3 e AP radiograph post-op.
Surgical technique
Patient was taken for open reduction and exploration of the joint. Kocher approach with proximal extension was used with careful dissection to preserve the soft tissue attachment of the fractured fragment. Annular ligament was torn. Radial head was lifted anteriorly by pressure of small Hohmann retractors placed subperiosteally. Radial head articulation with capitellum was confirmed. A 1.5 mm Kirschner wire (K-wire) was used to temporarily fix the articular fragment. A 2.7 mm miniscrew (Max ortho, Bombay, India) was used to fix the fractured fragment and articular congruity and stability was confirmed. Thorough joint lavage was done. Annular ligament was reconstructed. A 2 mm K-wire was used to fix the radiocapitellar joint in neutral position of forearm. The K-wire was removed at 2 weeks and flexion extension movements of the elbow were initiated. Rotatory movements were started at 3 weeks. At 8 weeks light weight lifting was allowed. After a
Fig. 2 e Lateral radiograph pre-operative.
follow up of 2 years the patient had 0e110 of movement with full pronation and supination (Figs. 3 and 4).
4.
Discussion
Isolated dislocation of the radial head without concomitant ulnar fracture or humeroulnar subluxation in adults is a rare injury.1,3e7 Most of the earlier reported cases were in children and were considered monteggia variants.2
Fig. 4 e Lateral radiograph post-op.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Heidt and Sterne, in 1982, were the first to describe this injury.1 Only 20 cases have been reported in adults in the literature,6 but we were not able to find any case in literature where posterior dislocation is associated with intra-articular fracture of radial head. The mechanism leading to an isolated radial dislocation has been variously described. Most authors describe an indirect mechanism. The proximal radioulnar joint is most stable in supination: in this position, the contact between radius and ulna is maximal and the interosseous membrane, the annular ligament, and the anterior fibres of the quadrate ligament are all taut, thus drawing the radial head snugly against its notch in the ulna. Cadaveric studies have shown that posterior dislocation of the radial head cannot occur without the rupture of the annular ligament; in addition, partial tear of the quadrate ligament and the proximal interosseous membrane takes place. We speculate the mechanism in our patient to be a hyperextension of the elbow with forearm in prone position leading to a posterior dislocation of the radial head. There are no guidelines for treatment. Most of these cases with isolated posterior radial head dislocation were treated conservatively except two cases.6,7 In one case open reduction was performed due to soft tissue interposition6 and in second one open reduction was done because of persistent instability of radial head and annular ligament reconstruction was done.7 In our case we reconstructed radial head and annular ligament and radio capitullar K-wire was applied for 2 weeks. Most of these reported cases showed excellent result following prompt diagnosis and reduction. Hence it is very necessary to identify these injuries as soon as possible and treat them promptly especially when associated with intraarticular fractures.
3
The recognition of such injuries is of paramount importance to prevent early degenerative arthritis of elbow. In our case we found that open reduction and internal fixation of posterior radial head dislocation with articular fracture yields excellent results.
Conflicts of interest All authors have none to declare.
references
1. Heidt Jr RS, Stern PJ. Isolated posterior dislocation of the radial head. A case report. Clin Orthop Relat Res. 1982;168: 136e138. 2. Bado JL. The monteggia lesion. Clin Orthop. 1967;50:71e78. 3. Negi AK, Pestonji MD, Iyer S. Isolated posterior dislocation of the radial head in an adult. J Postgrad Med. 1992;38:143. 4. Ibrahimi AE, Shimi M. Isolated, traumatic posterior dislocation of the radial head in an adult: a new case treated conservatively. J Emerg Trauma Shock. 2010 OcteDec;3(4):422e424. 5. Bonatus T, Chapman MW, Felix N. Traumatic anterior dislocation of the radial head in an adult. J Orthop Trauma. 1995;9:441e444. 6. Takami H, Takahashi S, Ando M. Irreducible isolated dislocation of the radial head. Clin Orthop Relat Res. 1997;345:168e170. 7. Dhawan A, Hospodar PP. Isolated posttraumatic posterior dislocation of the radial head in an adult. Am J Orthop. 2002;31:83e86.
Please cite this article in press as: Singh AP, et al., An isolated posterior dislocation of radial head in adults e A rare injury: A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.011