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Isolated dislocation of the radial head: a report of two cases
Case reports
125
involvement, is Letterer-Siwe disease. This is usually a rapidly fatal malady of infancy. Treatment is the subject of debate. Radiotherapy may predispose to late malignant change in bone. Cytotoxic therapy is used in the more severe cases with systemic involvement. Steroid injections into the bony lesions or curettage and bone grafting may increase the speed but not the rate of healing (Navert et al., 1983; Enneking, 1983). A search of the literature reveals a solitary report of pathological long bone fractures in this condition. In 1956, Mercer and Duthie described a 31-year-old woman with Hand-SchiiHer-Christian disease who sustained bilateral fractures through deposits in the trochanteric regions of both femurs. The femurs failed to unite over the next 4 years, following initial treatment in a spica and subsequent deep X-ray therapy.
CASE REPORT A 6-year-old boy presented to the paediatric casualty department in December 1985 having fallen and sustained a pathological fracture in the mid-shaft region of the right femur (Fig. la, b). He had histologically proven Hand-Schiiller-Christian disease for 4 years prior to this, and the fracture had occurred through a known lesion. He had received cytotoxic therapy to control pulmonary involvement but had not been on medication for 18 months prior to presentation.
&pests
for reprints should be addressed to: Miss H. G. Prince
FKCS,
He was treated conservatively, initially by 2 weeks of balanced traction in a Thomas splint, followed by HamiltonRussell skin traction. Radiographs at 12 days showed early callus formation. By 4 weeks there was bridging callus present and he was mobilized at 5 weeks, ‘touch’ weight bearing on crutches. Full weight bearing was allowed at 9 weeks when radiographs showed sound union. At 12 months union remained sound, but the pre-existing lesion was still present (Fig. 2a, b). It is felt that this case is worth reporting as it shows that in a child with histiocytosis X, a pathological long bone fracture can heal successfully without surgical intervention, though the underlying lesion may persist.
Acknowledgement We are most grateful to Mr C. L. Colton for allowing us to report his patient, and would like to thank Mrs S. Blythe for secretarial assistance.
REFERENCES Enneking W. F. (1983) Musculo-Skeletal Tumour Surgery. Vol. 2. London, Churchill Livingstone, 1331. Mercer Sir W. and Duthie R. B. (1956) Histiocytic granulomatosis. J. Bone Joint Surg. 38B, 279. Navert C., Zornoza J., Ayala A. et al. (1983) Eosinophilic granuloma of bone. Diagnosis and management. Skeletal Radiol. 10,227. Paper accepted 24 September 1987.
Orthopaedic
Department,
University
Hospital,
Nottingham.
Isolated dislocation of the radial head: a report of two cases Gavin R. Tait and S. K. Sulairnan Division
of Orthopaedic
Surgery,
Victoria Infirmary,
Summary Two cases of isolated dislocation of the radial head in children are presented. The clinical presentation, radiographic appearances, management and prognosis are discussed, and a brief literature review is presented.
INTRODUCTION ISOLATED dislocation of the radial head without an associated fracture of the ulna is a rare childhood injury. McFarland (1936) described congenital dislocation of the radial head, but Lloyd-Roberts (1977) believed such an entity doubtful, and probably an undiagnosed traumatic dislocation. Radial head dislocation is more commonly seen in the Monteggiatype fracture, in association with a fracture of the midshaft of the ulna. Anterior and lateral dislocations occur in 85-90 per cent and posterior dislocations in 10-15 per cent of such fractures (Wilson, 1976). Evans (1949) demonstrated experimentally that isolated radial head dislocation is caused by extreme pronation, the proximal radius acting as a lever arm on the
Glasgow
fulcrum of the fractured ulna, which results in the radial head being levered and ‘screwed out’ of the annular ligament. However, it has been generally accepted that flexibility of children’s bones allows the ulna to bend without being fractured (Hume, 1957). It has been suggested that if one examined the ulna carefully an occult fracture of the ulna would be evident (Vesley, 1967; Mercer Rang, 1983) and if not then during the healing phase, a radial bowing of the ulna would become apparent (Bucknill, 1977). In both our cases, at the time of the initial roentgenographic examination and at subsequent follow-up to 6 months this did not happen. The clinical picture is of a fall onto the outstretched hand, presenting with a painful elbow. A fullness on the lateral aspect of the elbow may indicate the abnormal position of the radial head. Elbow movements are restricted by pain, and the arm is held in pronation. The radiographs are of crucial importance, as the diagnosis may be missed clinically. Anteroposterior and lateral views will demonstrate the dislocation of the radial head: the longitudinal axis of the radius will not pass through the capitulum in either view. 0 1988Butterworth & Co (Publishers) 0020-1383/X8/020 12542 $0340
Ltd
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 2
126
Fig. 2. Case 2, a,
A-P and b, lateral radiographs.
Fig. 1. Case 1. a, A-P and b, lateral radiographs.
CASE REPORTS Two cases were seen: a boy aged 9 and a girl aged 4 years. Each patient had fallen onto their outstretched left hand, and had a painful elbow. Radiographs (Figs. 1 and 2) demonstrated an anterolateral dislocation of the radial head, with no injury to the ulna. Under general anaesthesia the dislocations were reduced by supinating the arm with local pressure over the radial head. The reductions were stable through full rotation of the forearm and extension of the elbow. The arms were then immobilized in full-arm plasters, at 90” of flexion and in full supination. The plasters were removed at 4 and 2 weeks respectively and mobilization begun. At review 6 months later elbow function, radiographs and growth were normal in both patients.
Acknowledgements We would like to thank
DISCUSSION
Hume A. C. (1957) Anterior dislocation of the radial head in children associated with undisplaced fracture of the ulna.
Five previous cases (Stelling et al., 1956; Hamilton and Parkes, 1973) of this condition recognized early and treated promptly by manipulation all had excellent results. Neviaser and LeFevre (1971) reported one case of failure of closed reduction due to the infolding of the proximal capsule of the radial head. Five cases of unreduced dislocations reported by Stelling et al. (1956) demonstrated loss of extension and supination of up to 40”, although with fair functional results and no growth retardation. Lloyd-Roberts and Bucknill (1977) reported two cases treated surgically at 19 and 36 months after injury, which also suffered marked loss of forearm rotation. Isolated dislocation of the radial head in children is rare and suspicion. treatment
the diagnosis depends on a high index of Diagnosis is confirmed by radiographs and in is by manipulation and immobilization
supination. A return to full function is to be expected, with no growth disturbance. Reyuesfs for
reprints
should be addressed fo: Gavin
Mr J. R. Loudon and Mr P. D. R. Scott for permission to report these cases.
REFERENCES Bucknill T. M. (1977) The elbow joint. Proc. R. Sot. Med. 70, 620. Evans E. M. (1949) Pronation injuries of the forearm. J. Bone Joint Surg. 31B, 578.
Hamilton W. and Parkes J. C. (1973) Isolated dislocation of the radial head without fracture of the ulna. Clin. Orthop. 97, 94.
J. Bone Joint Surg. 39B, 508.
Lloyd-Roberts G. C. and Bucknill T. M. (1977) Anterior dislocation of the radial head in children. J. Bone Joint Surg. 59B, 402.
McFarland B. (1936) Congenital dislocation of the head of the radius. Br. J. Surg. 24, 41. Mercer Rang (1983) Fractures in children and their treatment, 2nd ed. Baltimore and London, Williams and Wilkins, 192. Neviaser R. J. and LeFevre G. W. (1971) Irreducible isolated dislocation of the radial head. Clin. Orthop. 80, 72. Stelling F. H., Cote R. H. and Greenville S. C. (1956) Traumatic dislocation of head of radius in children. JAMA 160, 732.
Vesley D. G. (1967) Isolated traumatic dislocation of the radial head in children. Clin. Orthop. 50, 31. Wilson J. N. (ed.) (1976) Fractures and Joint Injuries: Watson-Jones, 5th ed, vol. 2. Edinburgh and London, Churchill Livingstone, 693.
Paper accepted 3 September
1987.
R. Tait FKCS,Division of Orthopaedic Surgery, Victoria Infirmary, Glasgow.
125
involvement, is Letterer-Siwe disease. This is usually a rapidly fatal malady of infancy. Treatment is the subject of debate. Radiotherapy may predispose to late malignant change in bone. Cytotoxic therapy is used in the more severe cases with systemic involvement. Steroid injections into the bony lesions or curettage and bone grafting may increase the speed but not the rate of healing (Navert et al., 1983; Enneking, 1983). A search of the literature reveals a solitary report of pathological long bone fractures in this condition. In 1956, Mercer and Duthie described a 31-year-old woman with Hand-SchiiHer-Christian disease who sustained bilateral fractures through deposits in the trochanteric regions of both femurs. The femurs failed to unite over the next 4 years, following initial treatment in a spica and subsequent deep X-ray therapy.
CASE REPORT A 6-year-old boy presented to the paediatric casualty department in December 1985 having fallen and sustained a pathological fracture in the mid-shaft region of the right femur (Fig. la, b). He had histologically proven Hand-Schiiller-Christian disease for 4 years prior to this, and the fracture had occurred through a known lesion. He had received cytotoxic therapy to control pulmonary involvement but had not been on medication for 18 months prior to presentation.
&pests
for reprints should be addressed to: Miss H. G. Prince
FKCS,
He was treated conservatively, initially by 2 weeks of balanced traction in a Thomas splint, followed by HamiltonRussell skin traction. Radiographs at 12 days showed early callus formation. By 4 weeks there was bridging callus present and he was mobilized at 5 weeks, ‘touch’ weight bearing on crutches. Full weight bearing was allowed at 9 weeks when radiographs showed sound union. At 12 months union remained sound, but the pre-existing lesion was still present (Fig. 2a, b). It is felt that this case is worth reporting as it shows that in a child with histiocytosis X, a pathological long bone fracture can heal successfully without surgical intervention, though the underlying lesion may persist.
Acknowledgement We are most grateful to Mr C. L. Colton for allowing us to report his patient, and would like to thank Mrs S. Blythe for secretarial assistance.
REFERENCES Enneking W. F. (1983) Musculo-Skeletal Tumour Surgery. Vol. 2. London, Churchill Livingstone, 1331. Mercer Sir W. and Duthie R. B. (1956) Histiocytic granulomatosis. J. Bone Joint Surg. 38B, 279. Navert C., Zornoza J., Ayala A. et al. (1983) Eosinophilic granuloma of bone. Diagnosis and management. Skeletal Radiol. 10,227. Paper accepted 24 September 1987.
Orthopaedic
Department,
University
Hospital,
Nottingham.
Isolated dislocation of the radial head: a report of two cases Gavin R. Tait and S. K. Sulairnan Division
of Orthopaedic
Surgery,
Victoria Infirmary,
Summary Two cases of isolated dislocation of the radial head in children are presented. The clinical presentation, radiographic appearances, management and prognosis are discussed, and a brief literature review is presented.
INTRODUCTION ISOLATED dislocation of the radial head without an associated fracture of the ulna is a rare childhood injury. McFarland (1936) described congenital dislocation of the radial head, but Lloyd-Roberts (1977) believed such an entity doubtful, and probably an undiagnosed traumatic dislocation. Radial head dislocation is more commonly seen in the Monteggiatype fracture, in association with a fracture of the midshaft of the ulna. Anterior and lateral dislocations occur in 85-90 per cent and posterior dislocations in 10-15 per cent of such fractures (Wilson, 1976). Evans (1949) demonstrated experimentally that isolated radial head dislocation is caused by extreme pronation, the proximal radius acting as a lever arm on the
Glasgow
fulcrum of the fractured ulna, which results in the radial head being levered and ‘screwed out’ of the annular ligament. However, it has been generally accepted that flexibility of children’s bones allows the ulna to bend without being fractured (Hume, 1957). It has been suggested that if one examined the ulna carefully an occult fracture of the ulna would be evident (Vesley, 1967; Mercer Rang, 1983) and if not then during the healing phase, a radial bowing of the ulna would become apparent (Bucknill, 1977). In both our cases, at the time of the initial roentgenographic examination and at subsequent follow-up to 6 months this did not happen. The clinical picture is of a fall onto the outstretched hand, presenting with a painful elbow. A fullness on the lateral aspect of the elbow may indicate the abnormal position of the radial head. Elbow movements are restricted by pain, and the arm is held in pronation. The radiographs are of crucial importance, as the diagnosis may be missed clinically. Anteroposterior and lateral views will demonstrate the dislocation of the radial head: the longitudinal axis of the radius will not pass through the capitulum in either view. 0 1988Butterworth & Co (Publishers) 0020-1383/X8/020 12542 $0340
Ltd
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 2
126
Fig. 2. Case 2, a,
A-P and b, lateral radiographs.
Fig. 1. Case 1. a, A-P and b, lateral radiographs.
CASE REPORTS Two cases were seen: a boy aged 9 and a girl aged 4 years. Each patient had fallen onto their outstretched left hand, and had a painful elbow. Radiographs (Figs. 1 and 2) demonstrated an anterolateral dislocation of the radial head, with no injury to the ulna. Under general anaesthesia the dislocations were reduced by supinating the arm with local pressure over the radial head. The reductions were stable through full rotation of the forearm and extension of the elbow. The arms were then immobilized in full-arm plasters, at 90” of flexion and in full supination. The plasters were removed at 4 and 2 weeks respectively and mobilization begun. At review 6 months later elbow function, radiographs and growth were normal in both patients.
Acknowledgements We would like to thank
DISCUSSION
Hume A. C. (1957) Anterior dislocation of the radial head in children associated with undisplaced fracture of the ulna.
Five previous cases (Stelling et al., 1956; Hamilton and Parkes, 1973) of this condition recognized early and treated promptly by manipulation all had excellent results. Neviaser and LeFevre (1971) reported one case of failure of closed reduction due to the infolding of the proximal capsule of the radial head. Five cases of unreduced dislocations reported by Stelling et al. (1956) demonstrated loss of extension and supination of up to 40”, although with fair functional results and no growth retardation. Lloyd-Roberts and Bucknill (1977) reported two cases treated surgically at 19 and 36 months after injury, which also suffered marked loss of forearm rotation. Isolated dislocation of the radial head in children is rare and suspicion. treatment
the diagnosis depends on a high index of Diagnosis is confirmed by radiographs and in is by manipulation and immobilization
supination. A return to full function is to be expected, with no growth disturbance. Reyuesfs for
reprints
should be addressed fo: Gavin
Mr J. R. Loudon and Mr P. D. R. Scott for permission to report these cases.
REFERENCES Bucknill T. M. (1977) The elbow joint. Proc. R. Sot. Med. 70, 620. Evans E. M. (1949) Pronation injuries of the forearm. J. Bone Joint Surg. 31B, 578.
Hamilton W. and Parkes J. C. (1973) Isolated dislocation of the radial head without fracture of the ulna. Clin. Orthop. 97, 94.
J. Bone Joint Surg. 39B, 508.
Lloyd-Roberts G. C. and Bucknill T. M. (1977) Anterior dislocation of the radial head in children. J. Bone Joint Surg. 59B, 402.
McFarland B. (1936) Congenital dislocation of the head of the radius. Br. J. Surg. 24, 41. Mercer Rang (1983) Fractures in children and their treatment, 2nd ed. Baltimore and London, Williams and Wilkins, 192. Neviaser R. J. and LeFevre G. W. (1971) Irreducible isolated dislocation of the radial head. Clin. Orthop. 80, 72. Stelling F. H., Cote R. H. and Greenville S. C. (1956) Traumatic dislocation of head of radius in children. JAMA 160, 732.
Vesley D. G. (1967) Isolated traumatic dislocation of the radial head in children. Clin. Orthop. 50, 31. Wilson J. N. (ed.) (1976) Fractures and Joint Injuries: Watson-Jones, 5th ed, vol. 2. Edinburgh and London, Churchill Livingstone, 693.
Paper accepted 3 September
1987.
R. Tait FKCS,Division of Orthopaedic Surgery, Victoria Infirmary, Glasgow.