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Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures — a rare combination
Injury, Int. J. Care Injured (2004) 35, 90—92
Case report
Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures –— a rare combination F.J. Fleming*, R. Flavin, A.R. Poynton, T. Glynn Department of Orthopaedics, Waterford Regional Hospital, Waterford, Ireland
Case report An 8-year-old Caucasian male was referred to our unit with a left upper limb injury sustained during a fall from a playground slide. The exact mechanism of injury is unknown but it was reported that the patient’s full body weight was transmitted through the left arm on impact. Examination revealed a markedly swollen left elbow and left forearm deformity with two 1 cm lacerations on the volar aspect of the forearm approximately 4 cm from the wrist joint. Neurovascular examination was normal and there were no other injuries noted. Radiographic examination revealed a posterior dislocation of the left elbow associated with grossly displaced distal third fractures of the radius and ulna (Fig. 1). Elbow reduction and wound toilet were performed under sedation in the emergency room. A stable arc of motion was elicited at the elbow post reduction. Intravenous antibiotics (cefotaxime 750 mg) and tetanus toxoid were administered. The patient was transferred to the operating room and a thorough wound debridement was performed through a z-shaped volar incision incorporating the lacerations. Both lacerations communicated with the respective fracture sites. Severe soft tissue damage was noted with considerable local damage to the bellies of the flexor muscles. The radial fracture was reduced and stabilized with two crossed 1.6 mm Kirschner wires. The ulna was approached through a separate ulnar incision, reduced and stabilized with a single cross 1.6 mm Kirschner wire. Postoperative films demonstrated satisfactory reduction and alignment of the radius and ulna (Fig. 2). On the morning of the first postoperative *Corresponding author.
day the patient was found to have symptoms and signs suggestive of a flexor compartment syndrome. The volar compartments were immediately decompressed with a complete volar fasciotomy. All flexor muscles, both superficial and deep, were viable. The wound was inspected 48 h later and partial skin closure obtained. Complete wound closure was not subsequently obtained due to residual swelling and a split thickness skin graft was performed. The patient made an uneventful postoperative recovery. The skin graft took fully. A long arm cast was employed until the Kirschner wires were removed at 6 weeks. Both fractures went on to solid union (Fig. 3). Left elbow and wrist range of motion returned to normal over the following 6 months.
Discussion This is the first reported case of a posterior elbow dislocation associated with ipsilateral open fractures of the radial and ulnar diaphyses. In this age group, fractures associated with elbow dislocation commonly occur around the elbow and include those of the epicondyles, radial head and coronoid process.1 Ulnar diaphyseal fractures are frequently associated with radial head dislocation, i.e. Monteggia fracture dislocation of the forearm. The combination of posterior elbow dislocation and ipsilateral open diaphyseal fractures of the radius and ulna has not been described before. The force required to produce the injury reported in this case is considerable and likely to be far greater than that required for a simple elbow dislocation. Complications due to neurovascular injury and severe soft tissue swelling are, therefore, more likely. This was illustrated in the present case by the marked
0020–1383/$ — see front matter ß 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00143-2
Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures –— a rare combination
91
Figure 1 A posterior dislocation of the left elbow associated with grossly displaced distal third fractures of the radius and ulna.
Figure 2
AP view demonstrating reduction and alignment of radius and ulna on the first day postoperatively.
local soft tissue damage and the onset of compartment syndrome. Fortunately, this was recognized early and dealt with appropriately. The question arises if a single volar incision was adequate for decompression in this case. Clinically, only the
flexor compartments were involved. There was no pain on passive stretch of the extensor muscles and the dorsal compartments were soft. It was, therefore, felt that an additional dorsal incision was not required. As to the technique of volar
Figure 3 Six month postoperative AP radiograph.
92
decompression, Gelberman et al. have established that the Henry and volar ulnar approach are equally effective in decompressing the flexor compartments of the forearm.2 The important point here is to ensure that both the superficial and deep flexor compartments are decompressed.
Conclusion Elbow dislocation with ipsilateral radial and ulnar shaft fractures is rare.
F.J. Fleming et al.
Considerable force is required to produce this pattern of injury and the clinician must have a high suspicion for associated complications.
References 1. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations–—simple and complex. Orthop Clin North Am 1999;30(1):63—79. 2. Gelberman RH, Zakaib GS, Mubarak SJ. Decompression of forearm compartment syndromes. Clin Orthop 1978;134: 225—9.
Case report
Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures –— a rare combination F.J. Fleming*, R. Flavin, A.R. Poynton, T. Glynn Department of Orthopaedics, Waterford Regional Hospital, Waterford, Ireland
Case report An 8-year-old Caucasian male was referred to our unit with a left upper limb injury sustained during a fall from a playground slide. The exact mechanism of injury is unknown but it was reported that the patient’s full body weight was transmitted through the left arm on impact. Examination revealed a markedly swollen left elbow and left forearm deformity with two 1 cm lacerations on the volar aspect of the forearm approximately 4 cm from the wrist joint. Neurovascular examination was normal and there were no other injuries noted. Radiographic examination revealed a posterior dislocation of the left elbow associated with grossly displaced distal third fractures of the radius and ulna (Fig. 1). Elbow reduction and wound toilet were performed under sedation in the emergency room. A stable arc of motion was elicited at the elbow post reduction. Intravenous antibiotics (cefotaxime 750 mg) and tetanus toxoid were administered. The patient was transferred to the operating room and a thorough wound debridement was performed through a z-shaped volar incision incorporating the lacerations. Both lacerations communicated with the respective fracture sites. Severe soft tissue damage was noted with considerable local damage to the bellies of the flexor muscles. The radial fracture was reduced and stabilized with two crossed 1.6 mm Kirschner wires. The ulna was approached through a separate ulnar incision, reduced and stabilized with a single cross 1.6 mm Kirschner wire. Postoperative films demonstrated satisfactory reduction and alignment of the radius and ulna (Fig. 2). On the morning of the first postoperative *Corresponding author.
day the patient was found to have symptoms and signs suggestive of a flexor compartment syndrome. The volar compartments were immediately decompressed with a complete volar fasciotomy. All flexor muscles, both superficial and deep, were viable. The wound was inspected 48 h later and partial skin closure obtained. Complete wound closure was not subsequently obtained due to residual swelling and a split thickness skin graft was performed. The patient made an uneventful postoperative recovery. The skin graft took fully. A long arm cast was employed until the Kirschner wires were removed at 6 weeks. Both fractures went on to solid union (Fig. 3). Left elbow and wrist range of motion returned to normal over the following 6 months.
Discussion This is the first reported case of a posterior elbow dislocation associated with ipsilateral open fractures of the radial and ulnar diaphyses. In this age group, fractures associated with elbow dislocation commonly occur around the elbow and include those of the epicondyles, radial head and coronoid process.1 Ulnar diaphyseal fractures are frequently associated with radial head dislocation, i.e. Monteggia fracture dislocation of the forearm. The combination of posterior elbow dislocation and ipsilateral open diaphyseal fractures of the radius and ulna has not been described before. The force required to produce the injury reported in this case is considerable and likely to be far greater than that required for a simple elbow dislocation. Complications due to neurovascular injury and severe soft tissue swelling are, therefore, more likely. This was illustrated in the present case by the marked
0020–1383/$ — see front matter ß 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00143-2
Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures –— a rare combination
91
Figure 1 A posterior dislocation of the left elbow associated with grossly displaced distal third fractures of the radius and ulna.
Figure 2
AP view demonstrating reduction and alignment of radius and ulna on the first day postoperatively.
local soft tissue damage and the onset of compartment syndrome. Fortunately, this was recognized early and dealt with appropriately. The question arises if a single volar incision was adequate for decompression in this case. Clinically, only the
flexor compartments were involved. There was no pain on passive stretch of the extensor muscles and the dorsal compartments were soft. It was, therefore, felt that an additional dorsal incision was not required. As to the technique of volar
Figure 3 Six month postoperative AP radiograph.
92
decompression, Gelberman et al. have established that the Henry and volar ulnar approach are equally effective in decompressing the flexor compartments of the forearm.2 The important point here is to ensure that both the superficial and deep flexor compartments are decompressed.
Conclusion Elbow dislocation with ipsilateral radial and ulnar shaft fractures is rare.
F.J. Fleming et al.
Considerable force is required to produce this pattern of injury and the clinician must have a high suspicion for associated complications.
References 1. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations–—simple and complex. Orthop Clin North Am 1999;30(1):63—79. 2. Gelberman RH, Zakaib GS, Mubarak SJ. Decompression of forearm compartment syndromes. Clin Orthop 1978;134: 225—9.