Keywords
radial head dislocation - articular fracture - radius fracture - biceps tendon
Introduction
Elbow joint fractures are frequent injuries in the daily clinical practice. Occasionally,
these fractures are associated with a dislocation, usually with severe ligamentous
injuries to the surrounding structures.
Several publications[1] in the literature describe and classify the most frequent patterns of elbow fractures
and fracture-dislocations. One of the best-known injuries at this level are the Monteggia
and Galeazzi fracture-dislocations. In 1822, Cooper was the first author to describe
an isolated radial shaft fracture associated with a distal radioulnar joint dislocation.
However, this injury was called the Galeazzi fracture-dislocation, referring to Ricardo
Galeazzi, who described a series of 18 cases in 1934. In the Monteggia lesion, described
by Giovanni Battista Monteggia in 1814, a fracture of the proximal third of the ulna
occurs together with a dislocation of the proximal radioulnar joint. Years later,
in 1967, José Luís Bado described the most popular classification for this injury.
The Bado classification stratifies these fracture-dislocations into four types based
on the fracture site and the location of the radial head.
The present article describes the case of an adult patient with a radial shaft fracture
associated with a posterior elbow dislocation plus proximal radioulnar dislocation.
After closed reduction, an anteromedial dislocation of the radial head was evidenced;
although this injury resembles those described by Bado, it is not within any classification,
thus highlighting the importance of this case due to its rarity.
Clinical Case
A 70-year-old male patient presented to the Traumatology Emergency Service after a
casual fall from his own height with trauma to the right upper limb. A physical examination
revealed deformity and swelling of the forearm and elbow with disruption of the Nelaton
triangle, pain, and functional impairment. The patient had no distal neurovascular
abnormalities, and the distal radioulnar joint seemed stable. A radiological study
revealed a posterior elbow dislocation associated with a diaphyseal fracture of the
middle third of the radius and a proximal radioulnar dislocation. The posterior elbow
dislocation was reduced, followed by immobilization with a posterior brachiopalmar
splint. A control radiograph showed the reduction of the initial dislocation, in addition
to a secondary displacement of the radial shaft fracture and an anteromedial dislocation
of the radial head ([Figure 1]).
Fig. 1 Prereduction radiological images taken upon the arrival of the patient at the emergency
room.
In a delayed manner, the patient underwent surgery. Using an expanded Henry approach,
open reduction and internal fixation of the radius shaft fracture were performed with
a 7-hole, 3.5-mm locking compression plate (LCP, Synthes, Solothurn, Switzerland);
the anatomical reduction of the fracture was confirmed by arthroscopy. Next, repeated
maneuvers for closed reduction of the radial head were unsuccessful, leading to a
Kaplan approach to the radial head. Several attempts for open reduction of the radial
head were met with great resistance, with the radial head resuming its anteromedial
dislocation when the posterolateral traction required for reduction was suspended.
After carefully examining the field, we observed that the distal insertion of the
biceps tendon was surrounding the radial neck in 360°, preventing the reduction ([Figure 2]). Given these findings, the biceps tendon was reduced to its anatomical position,
followed by an immediate, spontaneous reduction of the radial head. The elbow was
explored, revealing stability at flexion-extension and pronation-supination. Finally,
the lateral collateral ligament was repaired using three 3.5-mm harpoons. The ruptured
capsule was also repaired, and correct joint congruence and elbow stability were verified
on arthroscopy.
Fig. 2 (A) Radiograph of the fracture at the emergency room with anteroposterior and lateral
cast.
The rehabilitation protocol with active mobilization started after a ten-day immobilization
period with a posterior brachiopalmar splint. Elbow movement was limited during the
first 3 weeks, with a ligament orthosis locked at -30° of extension and 100° of flexion.
Three months after the injury, the patient had an active joint balance of -5° to 120°
of flexion-extension and complete pronation-supination ([Figure 3]), in addition to radiological consolidation of the fracture ([Figures 4] and [5]).
Fig. 3 Patient mobility three months after the intervention.
Fig. 4 Dislocated radial head and biceps tendon interposed surrounding the radial head (grasped
with a mosquito forceps).
Fig. 5 Osteosynthesis of the radius shaft fracture with a 3.5-mm anteroposterior and lateral
locking compression plate.
Discussion
Posterior elbow dislocation is usually associated with an ulnar fracture with radial
head dislocation, the so-called Monteggia fracture-dislocation. The association with
a diaphyseal radius fracture is very infrequent, with few cases described in the literature.
The first clinical case was published in 1929 by Valende; a second, very similar case
was reported 30 years later by Beach and Hewson.[1] Both cases were resolved with closed reduction of the elbow dislocation along with
open reduction and osteosynthesis of the radius fracture. In addition, we found several
case descriptions[1]
[2] of patients with radial shaft fractures associated with radial head fractures, but
with no elbow dislocation. There is no current validated classification that typifies
the association of diaphyseal radial fracture and posterior dislocation of the elbow.
Wong-Chung et al.[3] published a clinical case of a patient with a distal radial fracture and posterior
elbow dislocation, proposing it as a type-V injury per the Bado classification system.
However, other authors do not agree with including this type of fracture among the
Monteggia-like injuries due to the lack of ulnar shaft fracture.
Referring to the injuries described in our case, Domingo et al.[4] reported the clinical case of a patient in which the ruptured radial collateral
ligament prevented the correct closed reduction of the radial head. However, we did
not find in the literature any association like the one depicted here.
The literature does not describe a clear mechanism for this injury. Some authors,
such as Osborne and Cotterill,[5] advocate that this mechanism consists of a compressive axial force with the elbow
slightly flexed, while others, such as Soon et al.,[6] defend that this injury results from a fall with a hyperextended arm, radial deviated
wrist, and hyperpronated forearm. Therefore, after the present review, we assume that,
in our case, what happened was a low-energy trauma to the hand, with radial deviation
and a partially extended elbow; this resulted in a combined lesion mechanism of valgus,
supination and axial compression, leading to the rupture of the lateral structures
of the elbow and posterior olecranon translation, followed by pronation and consequent
interposition of the distal biceps tendon. Distally-transmitted forces resulted in
a diaphyseal radial fracture, as opposed to stage-3 complete elbow dislocations, in
which forces spread to the medial and anterior structures, injuring the joint capsule
and the medial collateral ligament.
Most authors[4]
[7] recommend closed reduction of the elbow with open reduction and internal fixation
of the radial shaft fracture to treat these injuries. Few publications address the
conservative treatment of these conditions, including a report from Beach and Hewson,[1] who, in 1966, described the case of an 87-year-old patient who was managed conservatively,
probably due to comorbidities.
Focusing on the surgical treatment of similar injuries, Domingo et al.[4] and Soon et al.[6] presented several cases with persistence of radial head dislocation after osteosynthesis
of the radius fracture, requiring a lateral approach and lateral collateral ligament
repair to regain congruence. However, none of them presented an interposed biceps
tendon. When discussing the need for repair of the radial collateral ligament, some
authors, such as Ramesh et al.[7] and Jeong et al.,[8] propose an initial surgical repair to avoid prolonged immobilization and early rehabilitation.
Like us, other authors[9] believe that, if a stable reduction of the elbow is achieved after reduction of
the radial head, there is no clear indication for surgical repair of the radial collateral
ligament. In our case, closed reduction of the radial head was not possible due to
the interposition of the long head of the biceps around the neck of the radius, a
fact never discussed in adults so far in literature.
Most cases described[9]
[10] in the literature with an irreducible dislocation of the radial head affect children
and result from the interposition of soft tissues, such as a groove at the joint capsule
level or even a ruptured annular ligament.
The production mechanism, described by Sasaki et al.,[11] consists of a fall with the hand in hyperextension and supination that causes dislocation
of the radial head followed by forearm hyperpronation, which accounts for the interposition
of the biceps tendon around the radial neck, preventing its correct reduction. Early
diagnosis is critical for the good evolution of these injuries; otherwise, more aggressive
surgeries, including tenotomies, reclamping and shortening osteotomies, are required.[10]
The diaphyseal radial fracture associated with a posterior elbow dislocation and an
anteromedial dislocation of the radial head due to interposition of the biceps tendon
is extremely rare. No other cases in adult patients were found in the literature.
Therefore, we consider the case herein reported interesting, so that our colleagues
may consider this possibility in the event of irreducible radial head dislocations.
