Keywords
dislocations - elbow joint - fractures - bone - radial fractures
Palabras clave
dislocaciones - articulación del codo - fracturas - hueso - fracturas radiales
Introduction
Posterior dislocation of the elbow associated to a radial shaft fracture is a rare
lesion, found in only three records in the literature.[1]
[2]
[3] It can be diagnosed by loss of forearm rotation, wrist and elbow instability and,
sometimes, can be associated with pain and nerve injuries.
In the present case, we performed immediately after the trauma (urgent care) an open
reduction internal fixation (ORIF) surgery of the radial fracture by means of a locking
plate, associated to closed elbow reduction and stabilization with dynamic bracing.
Case Report
A 26-year-old woman was seen in our service with a traumatic deformity of her right,
dominant forearm and elbow after a fall from a balance board. The range of motion
(ROM) of the elbow was overall limited. Forearm swelling and deformity were present.
Neurovascular testing showed abnormal radial nerve sensitivity at the forearm zone,
but upper limb perfusion was deemed as normal ([Fig. 1E] and [F]).
Fig. 1 Preoperative aspects.
Elbow, forearm and wrist radiographs ([Fig. 1A] to [D]), and associated elbow 3D computed tomography (CT) reconstructed images ([Fig. 2]) showed a radial shaft fracture and posterior dislocation of the elbow. There were
no other injuries in the wrist or in the elbow.
Fig. 2 Preoperative aspects.
The initial treatment was performed in the emergency room; however, the dislocation
of the elbow could not be reduced, and, at that moment, the medical team decided to
perform surgical treatment. The patient was positioned in the supine position, and
the upper limb was supported on a specific hand table; brachial plexus anesthesia
and sedation were employed.
A Henry approach was used to reach the radial shaft fracture, which was reduced and
fixated with a 3.5-mm locked plate, and six Synthes locking screws (Depuy Synthes,
Raynham, MA, USA). During the radial fracture reduction maneuver, the dislocation
of the elbow was spontaneously reduced. Due to the anatomic reduction, sufficient
stabilization, and vascular bone fragment status, the medical team decided not to
use bone grafting ([Fig. 3A] and [B]).
Fig. 3 Postoperative aspects.
After the surgery, cast mobilization for the right upper limb was employed, and the
patient remained in hospital for 2 days. The first dressing change occurred 7 days
postoperatively, and by that time the patient had already shown partial improvement
of the radial nerve paresthesia, along with good active and passive ROM of the elbow
and of the forearm. On the same day, the patient was referred to the rehabilitation
sector, and dynamic elbow bracing was placed, thus allowing complete elbow flexion
with a restriction of the last 30° of extension ([Fig. 3C]). The patient continuously wore this bracing for 3 weeks, removing only for hygiene
and physical therapy sessions. Daily sessions of rehabilitation lasted for 3 months,
and then the patient could be allowed to start physical activities.
At 1 year postoperatively, the patient showed good wrist, forearm, and elbow ROM,
attaining 70° of flexion, 60° of extension, 20° of radial deviation, 30° of ulnar
deviation, 60° of pronation, 90° of supination, 120° of elbow flexion, and total elbow
extension ([Fig. 4]). The motion of all fingers was normal. A disabilities of the arm, shoulder and
hand (DASH) score of 5, visual analogue scale (VAS) of 0, and grip strength of 92%,
as compared with the nonaffected side, were obtained. Radiographs indicated healing
of the radial fracture, with adequate elbow congruity, and satisfactory radiographic
parameters.
Fig. 4 Clinical results.
Discussion
The treatment of dislocation of the elbow associated to ipsilateral forearm fractures
is difficult and complicated, and the indications, surgical options, and timing of
surgery may vary. Closed reduction of dislocation of the elbow and perfect, anatomical
reduction of the radial shaft fracture prevent further deformity, stiffness, and loss
of motion.[1]
[2]
[3]
Ring et al[4] pointed out that isolated fractures of the radial shaft are more common than the
true Galeazzi fractures, and surgeons should not overlook the injury to the distal
or proximal radioulnar joint in association to isolated diaphyseal fractures of the
radius (clinical and radiographs examinations of the forearm must always include the
elbow and the wrist). Nonetheless, these lesions can be treated without a specific
approach of the distal radioulnar joint (DRUJ) with immediate mobilization. In the
present case, after stabilization of the radial shaft fracture, the dislocation of
the elbow was spontaneously reduced, and stability was attained.
We agree that the dislocation of the elbow has a different trauma mechanism from the
transverse, radial shaft fractures, and our search did not produce any link for the
single trauma. Therefore, we consider that the best answer consists of two trauma
mechanisms, with treatment ensued at the same time.
Beach et al,[1] in 1966, suggested nonoperative treatment. However, nowadays, surgical treatment
is preferred. In the present case, we chose anatomical reduction, sufficient stabilization,
and early mobilization, with complete healing. In the present case, successful clinical
results with no complications were seen at 12 months.
Soon et al[2] reported complications in a 25-year-old man with a similar injury (dislocation of
the elbow and radial shaft fracture associated with lesion of the ligament in the
proximal radioulnar joint). In the first procedure, after the radial fixation, the
olecranon reduced, but the radial head kept dislocating. The problem was solved after
a further procedure, with the correction of the rotation of the radial fracture and
the reconstruction of the ring ligament.
Nowadays, case reports of concomitant, ipsilateral multiple injuries that uncommonly
occur together in a single traumatic episode are very rare. The awareness of this
association for early recognition is of paramount significance for ideal clinical
results.[5] In the present case report, after 1 year, the patient had no pain, and had attained
the same ROM as compared with the nonaffected side. Radiographs showed full healing
of the fracture with adequate DRUJ and elbow joint congruity.
