Neurobionplus
Home About Journal AHEAD OF PRINT Current Issue Back Issues Instructions Submission Search Subscribe Blog    
Login 

Users Online: 264 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
 


 
CASE REPORT Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 1  |  Page : 50-51
Ipsilateral posterior dislocations of the elbow and superior radio-ulnar joint associated with a comminuted radial shaft fracture - A case report


Department of Orthopaedics, Kasturba Medical College Hospital, Manipal, India

Click here for correspondence address and email
 

How to cite this article:
Vidyadhara S, Rao SK. Ipsilateral posterior dislocations of the elbow and superior radio-ulnar joint associated with a comminuted radial shaft fracture - A case report. Indian J Orthop 2006;40:50-1

How to cite this URL:
Vidyadhara S, Rao SK. Ipsilateral posterior dislocations of the elbow and superior radio-ulnar joint associated with a comminuted radial shaft fracture - A case report. Indian J Orthop [serial online] 2006 [cited 2020 Feb 17];40:50-1. Available from: http://www.ijoonline.com/text.asp?2006/40/1/50/34433

   Introduction Top


Superior radio-ulnar dislocation is commonly associated with fracture of the proximal third of the ulnar diaphysis. This is eponymically known as a Monteggia fracture-dislocation. Dislocation of the superior radio-ulnar joint occurring with a concomitant comminuted radial diaphyseal fracture is extremely rare. We have encountered a variant of this unclassifiable injury with an associated posterior elbow dislocation and present it as a more severe form of a similar injury.


   Case Report Top


A 36-year old woman fell onto a stone from a height of 4 feet while she was walking on a wooden bridge that collapsed. She fell with her left forearm pronated and elbow flexed underneath her body. Immediately following the fall, she was unable to move the left upper limb. She did not have any neurovascular deficits. The radiographs showed a posterior dislocation of the elbow with posterior dislocation of superior radio-ulnar joint and comminuted fracture of the radial shaft at the junction of proximal and middle thirds [Figure - 1]a. There was no associated coronoid fracture. Patient underwent a manual closed reduction of the dislocations under general anaesthesia prior to fixation of shaft fracture. The post­reduction X-rays showed reduced dislocations of the elbow and the radial head with unreduced fracture shaft of radius [Figure - 1]b.

The patient underwent closed retrograde square nailing of the radius after anatomical reduction of shaft fracture. After the introduction of the square nail of appropriate size and length into the radius from just lateral to Lister's tubercle, the intra-operative fluoroscopic images revealed non­concentricity in the reduction of radial head. When another attempt was made to reduce by closed manipulation, the elbow dislocated posterior irreducibly. Therefore, an open reduction of the radial head dislocation was done through Kocher's approach. The annular ligament was found interposed between the articulating surfaces preventing concentric reduction of the radial head. Once the radial head was repositioned, the elbow dislocation was reduced easily and was stable all through range of motion of the elbow. Post-operatively the limb was immobilized in a splint with 90°elbow flexion and forearm in mid-prone position for 3 weeks to allow for soft tissue healing [Figure - 1]c.

At 3 weeks post-op, elbow and forearm mobilisation were begun. At three months post surgery, the patient had 45° - 90° elbow flexion with a 45° fixed flexion deformity. She could supinate only 30° while the pronation was full. Roentgenograms showed a satisfactory evidence of union of the fracture. She was fitted with an external distraction device to regain extension of the elbow. She was last followed up one-year post surgery and her movements improved to 5°- 120° of elbow flexion and supination of 45°.


   Discussion Top


This case report describes a rare injury combination in the upper limb trauma, posterior dislocations of elbow and superior radio-ulnar joints along with ipsilateral comminuted fracture shaft of the radius. The mechanism of injury was hyperpronation trauma of the forearm with hyperflexion of the elbow and a direct impact on the forearm.

The injury complex in this report, i.e. posterior dislocations of the elbow and the superior radio-ulnar joint, and fracture shaft of radius has been described previously by Shukur et al [1] and Wong et al [2] . Their patients had an injury different from that of ours only with respect to the comminution of the radial shaft fracture. They also advised open reduction of only the fracture when there is associated radio-ulnar joint dislocation. In contrast to our report, the dislocations were concentrically reduced after anatomical reduction of the radial shaft fracture.

Soon et al described a young patient who had a traumatic elbow dislocation with an ipsilateral proximal radial shaft fracture, which, after reduction of the elbow and internal fixation of the radial shaft fracture elsewhere, showed a persistent radial head subluxation on follow-up [3] . This was found to be a result of non-anatomical fixation of the radial shaft, which when they re-reduced and fixed, resulted in the radial head being concentrically reduced. Hence anatomical reduction of the radial shaft fracture is the corner stone in these high-energy injuries. The radio-ulnar relationship is usually preserved in anterior but disrupted in posterior fracture dislocations [4] . Hence the radio-ulnar relation through out the range of motion of the elbow has to be watched for carefully after reduction.

Beach and Hewson had described an almost similar injury [5] . Treatment of their case consisted of a closed manipulation of the elbow, which resulted in a concentric reduction of both the radio-humeral and humero-ulnar joints with an acceptable alignment of the radial shaft. Their patient did not have a disruption of the superior radio-ulnar joint. In our case, the superior radio-ulnar joint was not concentrically reduced even when the radial shaft was anatomically reduced.

Evans has described a Galleazi fracture-dislocation associated with radial head dislocation [6] . He found that accurate anatomic reduction and fixation of the radial shaft results in an immediate stable radial head relocation. Contrary to this, the authors found in our case that the elbow and radial head dislocated after or during the anatomic reduction and internal fixation of the radial shaft fracture. This could possibly be due to an associated interosseous membrane tear.

This report is also aimed at increasing the awareness of the occurrence of a double injury of the forearm. The practical application of this concept is that the forearm is vulnerable to injury at two anatomical sites. Goldberg and Young have reviewed a wider spectrum of this double injury of the forearm [7] .

In conclusion, the reported case herein is the result of continued high-energy force on the elbow and forearm and that anatomical fixation of the shaft fracture and open reduction of the radial head if required is the viable treatment option.

 
   References Top

1.Shukur MH, Noor MA, Moses T. Ipsilateral fracture dislocation of the radial shaft head associated with elbow dislocation: Case report. J Trauma 1995; 38: 944-946.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Wong CJ, Jahromi I, Aradi AJ. Fracture of the upper radius with ipsilateral dislocations of the elbow and superior radio-ulnar joints. A case report. Int Orthop 1998; 22(1): 62-64.  Back to cited text no. 2    
3.Soon JCC, Kumar VP, Satkunanartham K. Elbow dislocation with ipsilateral radial shaft fracture - An unusual outcome. Clin Orthop 1996; 329: 212-215.  Back to cited text no. 3    
4.O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instructional course lectures 2003; 52: 113-134.  Back to cited text no. 4  [PUBMED]  
5.Beach PM, Hewson JS. Elbow dislocation with comminuted fracture of the proximal radial shaft. Thoughts on the mechanism. Am J Surg 1966; 112: 941-942.  Back to cited text no. 5    
6.Evans ME. Pronation injuries of the forearm with special reference to the anterior Monteggia fracture. J Bone Joint Surg 1949; 31B: 578-588.  Back to cited text no. 6    
7.Goldberg HD, Young JWR, Reiner BI, et al. Double injuries of the forearm: A common occurrence. Radiology 1992; 185: 223-227.  Back to cited text no. 7    

Top
Correspondence Address:
S Vidyadhara
Dept. of Orthopaedics, KMC Manipal, Karnataka 576 104
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34433

Rights and Permissions


    Figures

  [Figure - 1]



 

Top
 
 
  Search
 
   
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

 Article Access Statistics
    Viewed2795    
    Printed78    
    Emailed0    
    PDF Downloaded166    
    Comments [Add]    

Recommend this journal