Radial Head Dislocation Research Articles

An Analysis of Associated Conditions and the Relationship Between the Severity of Hand Manifestations With That of the Forearm in Ulnar Longitudinal Deficiency

A deeper investigation of medical and musculoskeletal conditions in patients with ulnar longitudinal deficiency (ULD) is needed. The association between the severity of the manifestations of ULD in the hands and forearms has not been firmly established. The purpose of this study was to describe the medical and musculoskeletal conditions associated with ULD and examine the relationship between hand and forearm anomalies. The Congenital Upper Limb Differences registry was queried for all patients with a diagnosis of ULD, as defined by the Oberg-Manske-Tonkin classification system, between 2014 and 2020. The patients' demographic information, medical and musculoskeletal comorbidities, radiographs, and clinical images were reviewed. The participants were classified using the Bayne, Cole and Manske, and Ogino classification systems. Of 2,821 patients from the Congenital Upper Limb Differences registry, 75 patients (2.7%) with ULD (14 bilateral), with 89 affected extremities, were included. Hand anomalies were present in 93% of the patients. Approximately 19% of the patients had an associated medical comorbidity, and 20% of the patients had an associated musculoskeletal condition. Cardiac anomalies were present in 8.0% of the patients, and 12% of the patients had a lower extremity abnormality. Radial head dislocation was observed in 13 of 18 patients with Bayne type II or III ULD compared with 8 of 43 patients with other types of unilateral ULD. There was a significant positive association among the Bayne and Ogino, Bayne and Cole/Manske, and Ogino and Cole/Manske classification systems in patients with unilateral ULD. Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. There is a significant positive association between the severity of forearm anomalies and that of hand anomalies in patients with unilateral ULD. All patients with ULD should undergo a thorough cardiac evaluation by their pediatrician or a pediatric cardiologist. Symptom prevalence study III.

Neglected Monteggia Fractures in Children—A Retrospective Study

(1) Background: A Monteggia fracture is an infrequent injury in children. It can be missed during an initial consultation in 20–50% of patients. Chronic radial head dislocation may lead to several complications. Thus, surgical reconstruction of chronic Monteggia injuries is justified. The aim of this study is to analyze the single tertiary center experience in the treatment of neglected Monteggia fractures. (2) Methods: A retrospective study of patients treated for missed Monteggia fractures was conducted. Hospital records, operative charts, follow-up records and a set of X-rays were analyzed for each patient. Radiographic results were graded as good, moderate or poor. The functional status of elbows was estimated using the Mayo Elbow Performance Index. (3) Results: A total of 13 patients (8 boys and 5 girls) aged 4–12 years (mean 7.15) were treated during the study period. An angulation osteotomy of the ulna was performed in ten patients and a radial shortening osteotomy in three patients. A Bell–Tawse annular ligament reconstruction was performed in five patients, and a direct repair was performed in two patients. Eight patients had radiocapitellar trans-fixation. There were nine good radiographic results, three moderate and one poor. The functional result was excellent in nine patients, good in three and poor in one. (4) Conclusions: Our work has many limitations (only 13 patients and different types of operations), and conclusions should be drawn very carefully from such a small and diverse group. The surgical reconstruction of neglected Monteggia fractures in children should be attempted in all patients. Angulation and elongation osteotomies of the ulna are suitable for most patients. If there is a marked overgrowth of the radius, gradual ulnar lengthening and radial head reduction using the Ilizarov method may be a better option. Annular ligament reconstruction is not mandatory.

Successful Management of Congenital Radial Head Subluxation in a Juvenile Dog Using Ultra-High Molecular Weight Polyethylene Suture Toggle

AbstractCongenital humeroradial subluxation was diagnosed by clinical examination and radiography in a 16-week-old female dog that presented for left forelimb lameness. This was treated surgically by open reduction followed by placement of an ultra-high molecular weight polyethylene suture from the craniolateral aspect of the proximal radius to the caudomedial aspect of the ulna, secured with a toggle and suture button. Postoperative findings were consistent with clinical improvement and radiographs were compatible with resolution of elbow subluxation. To our knowledge, this is the first case report of congenital humeroradial subluxation to be managed with an ultra-high molecular weight polyethylene suture toggle.

Knowledge and awareness level about radial head subluxation mechanism among Saudi population living in western region of Saudi Arabia

Background: There is a scarcity of published studies on the Saudi population’s knowledge of radial head subluxation. The purpose of this study was to determine the level of Saudi community awareness regarding pulled elbow. Methods: A cross -sectional study was done on 396 Saudi residents. An online questionnaire was used to collect data about participants’ demographic characteristics and their knowledge about radial head subluxation, mechanism of injury, and how to deal with it. Results: 47% of the participants had heard of radial head subluxation, 32.7% studied it, and 32.2% heard about it through friends or family members. Only 23.1% heard about it via doctors. Males and 1-5 year-old children are the most commonly affected, according to 21.2% and 63.1% of participants , respectively. The majority of participants (68.9%) properly identified the case presentation as pain at the injury site, 61.6% identified the case as being diagnosed by clinical examination. Of them, 50.8% correctly identified the cause as children being heldby their hand or forearm and 19.4% have had to deal with an elbow subluxation. Only 44.7% identified the hospital management as the professional management of this situation and 15.4% of the participants had a good level of knowledge regarding radial head subluxation. Participants who were medical practitioners or studying medical sciences, and who had already heard about elbow subluxation or dealt with a case of elbow subluxation, had a significantly higher percentage of having good knowledge. Conclusion: There is a need to raise Saudi community awareness regarding elbow subluxation through community-wide health education campaigns. Keywords: knowledge, radial, head, subluxation, Saudi, western

Pediatric Monteggia Fracture Outcome Assessment - Preliminary Report.

The term Monteggia fracture refers to a class of injuries encompassing the fracture ofthe proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed. 15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient. Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one ofthepatients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function. 1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

Elbow Injuries in Children

Elbow Injuries in Children

Neglected Monteggia fracture: a review.

Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture.If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. When the radial head is not reduced, several deformities develop at the humeroradial joint, including cubitus valgus and osteoarthritis.Adequate radiographs are crucial when the surgeons deal with forearm injuries.At present, proximal ulnar osteotomy and open reduction of chronic radial head dislocation provides satisfactory functional outcomes because of anatomic alignment reconstruction.Supplementary procedures, including transcapitellar pinning and repair or reconstruction of the annular ligament, which are performed in order to enhance stability of the humeroradial joint, should be thoroughly assessed based on joint rotational stability after reduction and on potential complications.

Hinge positioning method of Ilizarov apparatus in correcting radial head luxation caused by multiple hereditary exostoses.

Objectives In this study, we present a specified hinge positioning method to achieve satisfying and steerable lengthening and angulation to correct forearm multiple hereditary exostoses (MHE) combined with severe radiocapitellar joint dislocation using Ilizarov ring fixators.Patients and methods Between January 2014 and December 2018, a total of 30 forearms of 23 patients (11 males, 12 females; mean age: 18.3±6.8 years; range, 8 to 35 years) who suffered from type IIa (n=2) or IIb (n=28) MHE with severe radiocapitellar joint luxation were retrospectively analyzed. All patients were treated with Ilizarov external fixators with our specified hinge positioning method. Range of motion of the elbow, forearm and wrist and Visual Analog Scale (VAS), as well as Disabilities of Arm, Shoulder, and Hand (DASH) score, and radiological parameters, including radial articular angle (RAA), ulnar variance (UV) and carpi slip (CS), were recorded preoperatively and at final follow-up and were compared.Results Clinical and radiological outcomes were evaluated. Range of motion of the elbow, forearm and wrist, VAS, DASH and radiological features, including RAA, CS, and UV were significantly improved, except for range of motion of the forearm supination. Temporary nail track infection was seen in two of the forearms and was controlled with oral antibiotics. None of the patients developed radial head dislocation again.Conclusion Clinical and radiological outcomes of this novel hinge positioning method are satisfactory in treating MHE with severe radial head dislocation, and this method can be an alternative treatment for MHE by setting a milestone for accurate radiocapitellar joint reduction.

Outcomes of radial head implants in total elbow arthroplasty.

There is no consensus on the management of the radial head in total elbow arthroplasty (TEA). In 3-part TEA designs, options include radial head retention, excision, or arthroplasty. Biomechanical studies suggest improved varus-valgus stability with radial head implants in unlinked total elbows. Unfortunately, complications with radial head implants have been common with historical designs. The aim of this study was to evaluate the clinical and radiographic outcomes of radial head implants in a current 3-part TEA and identify risk factors for mechanical failure. We performed a retrospective review of radial head implants with a 3-part convertible TEA from 2001 to 2016. Clinical outcomes, functional scores, and radiographic outcomes were recorded. The preoperative radiocapitellar alignment was measured using the radiocapitellar ratio (RCR). Statistics include descriptive statistics, t tests, logistic regression, and Kaplan-Meier survival curves. We identified 44 TEAs in 40 patients, with a mean follow-up period of 7.2 years. The average age at surgery was 58 ± 11 years; 80% of the TEAs were performed in women. The indication for surgery was rheumatoid arthritis in 86%; of the implants, 61% were unlinked. The average preoperative RCR was 10.7 ± 17.9. Postoperatively, 2 radial head implants (5%) were subluxated, 6 (14%) were dissociated, and 2 (5%) were dissociated with implant dislocation on radiographic review. The revision rate for radial head subluxation, dissociation, or dislocation was 7% (n = 3). Univariate logistic regression showed that male sex (P = .002), abnormal preoperative RCR (P = .02), linked implant (P = .03), and older age (P = .04) were risk factors for radial head subluxation, dissociation, or implant dislocation. A multivariate model with all 4 variables did not demonstrate statistical significance. The incidence of radial head arthroplasty subluxation, dissociation, or implant dislocation was high (23%). In a univariate logistic regression model, male sex, abnormal preoperative RCR, and linked implants were all statistically significant risk factors for mechanical failure of the radial head implant. Our multivariate model did not show any statistically significant independent risk factors. Polyethylene wear or loosening of the radial head implants was not observed in this study; failure of the bipolar linkage was the principal mode of failure. Although further study is required, caution should be used when considering inserting a radial head implant in male patients with significant preoperative radiocapitellar malalignment. Radial head subluxation or dissociation is not an absolute indication for revision in an asymptomatic patient. Improvements in radial head implant designs in TEA are needed.

Does the Skeletal Phenotype of Osteogenesis Imperfecta Differ for Patients With Non-COL1A1/2 Mutations? A Retrospective Study in 113 Patients.

Osteogenesis imperfecta (OI) is a heritable disease characterized by bone fragility and other extra skeletal manifestations. Most patients with OI have mutations in the COL1A1 or COL1A2 genes. However, a significant minority of patients with clinical OI have non-COL1A1/2 mutations, which have become easier to detect with the use of genetic panels. Traditional understanding of OI pathogenesis was expanded because of these new mutations, and their phenotypic-genotypic relationship is largely unknown. We hypothesized that patients with non-COL1A1/2 mutations have different skeletal clinical presentations from those with OI caused by COL1A1/2 mutations. Patients were categorized into 4 groups according to our modified functional classification, namely, quantitative COL1A1/2 haploinsufficiency (group 1), qualitative COL1A1/2 dominant negative mutations (group 2), mutations indirectly affecting type I collagen synthesis, processing and posttranslational modification (group 3) and mutations altering osteoblast differentiation and function (group 4). Both group 3 and 4 were classified as non-COL1A1/2 mutation group. Of 113 OI patients included, 51 had COL1A1/2 quantitative haploinsufficiency mutations (group 1), 39 had COL1A1/2 qualitative dominant negative mutations (group 2), and 23 patients had OI caused by mutations in 1 of 9 other noncollagen genes (groups 3/4). Patients with non-COL1A1/2 mutations (groups 3 and 4) have severe skeletal presentations. Specifically, OI patients with non-COL1A1/2 mutations experienced more perinatal fractures, vertebral compression fractures and had more long bone deformities. Although the occurrence of scoliosis was similar, the cobb angle was larger in the non-COL1A1/2 mutation group. Radial head dislocations, ossification of interosseous membrane, extraskeletal ossification, cervical kyphosis, and champagne glass deformity of the pelvis were more frequent in this group. The clinical phenotype of OI in patients with non-COL1A1/2 is severe and has unique features. This information is useful for clinical diagnosis and prognosis. Level III.

Delayed radial head dislocation after radial shaft fracture fixation: a case report and review of the literature

BackgroundIpsilateral fracture of the radial shaft with dislocation of the radial head was a rare injury, but a delayed radial head dislocation after radial shaft fracture fixation was more extremely rare.Case presentationA 39-year-old man fell from the height on his outstretched hand and injured his left, non-dominant forearm. Preoperative radiographs demonstrated a comminuted fracture of the proximal third of the radius but with no apparent dislocation of the distal or proximal radioulnar joints or the elbow. Seven days after the injury, the radius was fixed with a reconstruction locking plate, and the immediate postoperative radiograph revealed a satisfactory reduction. However, a radiograph done at the 4th week postoperatively showed that the radial head dislocated. Manual reduction under anesthesia was tried but failed and the patient refused to take another open surgery. The patient had an acceptable range of motion 12 months after the surgery: elbow flexion 120°, full elbow extension, forearm pronation 80°, forearm supination 80°, but he complained the pain around the elbow.ConclusionIn the case of radial shaft fracture especially the when occurs at the proximal third of the radial shaft, even if the radiograph does not show the injury of the proximal radioulnar joint, we should also make a thorough examination of the proximal radioulnar joint. If the radial head dislocation is not initially diagnosed or treated late, a delayed dislocation would be very difficult to manage with a poor expected outcome.

Pulled elbow? Here’s how to fix it easily. (Nursemaid's elbow)

Pulled elbow? Here’s how to fix it easily. (Nursemaid's elbow)

Surgical Management of Missed Pediatric Monteggia Fractures: A Systematic Review and Meta-Analysis.

To review surgical management and outcomes of missed pediatric Monteggia fractures. A systematic review was conducted using PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library from inception through March 2, 2020. The keywords were "Monteggia fracture," "missed Monteggia," "neglected Monteggia," "chronic Monteggia," and "chronic radial head dislocation." All original human studies on missed pediatric Monteggia fractures were included. Congenital Monteggia fractures and isolated radial head dislocations were excluded. The revised Methodological Index for Nonrandomised Studies tool was used to assess the quality of studies. Each patient's data were retrieved individually. The χ2 test and Fisher exact test were used to analyze the difference in outcomes for different surgical managements. Multivariate analysis was performed for variables that were significant on univariate analysis. Thirty studies with 600 patients were included. Proximal ulnar osteotomies (P = 0.016) and the absence of transcapitellar pinning (P = 0.001) were the most significant predictors for eventual reduction of radial head. Other surgical management variables were not significant predictors. These include open or closed reduction approach of radial head reduction; presence or absence of ulnar osteotomy; presence or absence of lengthening, angular correction, overcorrection, or bone grafting of ulnar osteotomy; type of fixation for ulnar osteotomy; presence or absence of radial osteotomy; presence or absence of annular ligament repair or reconstruction; and repair or reconstruction of annular ligament. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bony deformities in a child with untreated osteogenesis imperfecta type III

Osteogenesis Imperfecta (OI) is a skeletal dysplasia that affects the cross-linking of Type 1 collagen leading to a wide spectrum of manifestations including bony abnormalities, scleral abnormalities, dentinogenesis imperfecta, and hearing abnormalities [1]. Orthopedic manifestations of OI include basilar invagination, kyphoscoliosis, codfish vertebrae, bowing deformities of the long bones, coxa vara, protrusion acetabuli, pathologic fractures, and radial head dislocations [1]. The Sillence Classification, originally designed to describe Types I – IV, has been expanded upon to includes Type V, VI, VII, which do not have a Type I collagen mutation, and instead have other genetic explanations (CRTAP, LEPRE1 genes) for the abnormal bone seen on microscopy [1,2]. Type I, IV represent milder forms of disease, Type V-VII represent milder forms of disease, Type III is the most severe survivable form, and Type II is lethal at birth [1,2]. We present a case of Sillence Type III OI, diagnosed by genetic analysis at birth, with significant bony deformities. She did not have appropriate multidisciplinary medical management of her condition and presented to our clinic at age 14. Radiographs of the spine and extremities demonstrated kyphoscoliosis, bilateral protrusio acetabuli, multiapical bowing bony deformities of femora, tibia, humeri, forearm, radial head dislocations, and short stature. This case highlights the importance of multidisciplinary management for children with OI. This includes physical rehabilitation [3], bisphosphonates [3,4] and more recently gene therapies [3,4], and stem cell transplantation therapies [4]. Patients with Osteogenesis Imperfecta Type III have a limited lifespan [5] and it is important to maximize the advantage of medical therapies. In the absence of the appropriate medical care, osteogenesis imperfecta can develop progressive deformities in the long bones, a high risk of fragility fractures, and progressive kyphoscoliosis that can be difficult to manage surgically due to underlying osteopenia.

Diagnosis and treatment of focal fibrocartilaginous dysplasia of the distal ulna.

Focal fibrocartilaginous dysplasia (FFCD) of the distal ulna is a rare benign lesion resulting in progressive radiocapitellar dislocation, limb deformity and limitation in function. This study reported our experience with 10 cases and it aimed to determine a reasonable strategy for diagnosis and treatment. Ten cases treated from 2010 to 2018 in our department were retrospectively reviewed. The diagnosis was based on imaging features. All patients underwent lesion excision in the early stage and five patients required ulna lengthening in the second stage. The radiographic and functional outcomes were analyzed and reported. The median age at diagnosis was 32 months (range, 6-36 months). The median age at the time of surgery was 34 months (range, 10-40 months). The median clinical and radiographic follow-up period was 37 months (range, 24-50 months). The ulna was shortened by an average of 31 mm (range, 27-35 mm). There was no new radial head dislocation after lesion excision. For five cases of radial head dislocation, the median elbow varus angle before ulnar lengthening was 20° and it decreased to 5° after ulnar lengthening. Supination and pronation of the elbow increased from 50°-10° to 70°-30°. We believe that early excision of the lesion can prevent radiocapitellar joint dislocation in patients with FFCD of the ulna. Ulna lengthening can correct limb deformity and improve the range of motion.

A case of pseudoarthrosis of the ulna and radial head dislocation since birth associated with neurofibromatosis

A case of pseudoarthrosis of the ulna and radial head dislocation since birth associated with neurofibromatosis

A case of ulnar head dislocation with radial head dislocation

A case of ulnar head dislocation with radial head dislocation

Upper Extremities Injuries in Children Attending Pediatric Emergency Department-SFH, Riyadh-Saudi

Trauma is a physical injury caused by violence or other forces; in serious trauma, the patient will be at risk of death or loss of function. Trauma is a leading cause of morbidity and mortality among all age groups. Objective: To study the pattern and outcome of upper limbs trauma in children attending the pediatric emergency department. Methodology: This was a retrospective cross-sectional study conducted in the Department of Pediatrics at Security Forces Hospital-Al-Riyadh. Result: Total number of patients seen during the study period was 343 patients, their age range between 6 months and 13 years old with a mean age of 5.473 (±3.8572); also, results showed boys were 187 (54.5%) patients and girls were 156 (45.5%) patients. Based on the site of trauma in the upper limbs, lacerations were in 114 (33.2%), Hand and/or wrist fracture in 67 (19.5%), Nursemaid Elbow in 43 (12.5%), both Radius and Ulnar bones fracture in 33 (9.6%), Radius bone fracture in 29 (8.5%), supracondylar fracture in 22 (6.4%), Clavicle bone fracture in 20 (5.8%), Humorous bone fracture in 7 (2%), Condylar bone fracture 6 (1.7%), and there was 1 (0.3%) patient with Scapulae and Ulna fracture.

Monteggia Fracture-Dislocation.

A Monteggia fracture-dislocation involves a proximal one-third of the ulna fracture with a concomitant dislocation of the radial head proximally at the elbow. This fracture and dislocation often results from a fall on the outstretched hand (FOOSH) low-energy mechanism of injury. One must have a high index of suspicion with any ulnar fractures to look for a radial head dislocation so that the dislocation component is not missed. These injuries often require early orthopedic intervention. Any delays in treatment can lead to poor long-term outcomes including chronic valgus instability and radiocapitellar osteoarthrosis.

Diaphyseal Radius Fracture Associated with Irreducible Head Dislocation. Case Report

AbstractIrreducible dislocation of the radial head is an extremely rare lesion, especially in an adult patient. We present a case of diaphyseal radius fracture associated with a posterior elbow dislocation and an irreducible radial head dislocation. After closed reduction of the elbow, we performed open reduction and ostheosynthesis of the radius, and the radial head remained irreducible. We finally found, surrounding the radius, the interposition of the insertion of the biceps, and, after extracting it, we performed the correct reduction of the radial head. Six months after the surgery, the patient presented a full articular balance, with no pain. We have not found any similar case in the literature.