CASE REPORT

Transbrachialis Buttonholing of the Radial Head as a Cause for Irreducible Radiocapitellar Dislocation: A Case Report Christopher L. Camp, MD and Shawn W. O’Driscoll, MD, PhD Background: Isolated dislocation of the radial head is an uncommon injury among pediatric patients. Although closed reduction may be successful, some patients require open reduction with or without soft-tissue repair or reconstruction. If the radiocapitellar joint is not properly reduced, the long-term complications of pain, stiffness, neuropathy, and dysplasia can result from chronic radial head dislocation. Methods: While performing a cartwheel, a 13-year-old gymnast sustained a radiocapitellar dislocation that was unable to be reduced by closed means and failed 2 attempts at open reduction. Ultimately, the radial head was determined to have translated anterior to the brachialis muscle during the dislocation and subsequently buttonholed through the muscle as the elbow was flexed and rotated. It remained suspended by the brachialis tendon, preventing anatomic reduction. Once the radial head was delivered from this tendinous sling, anatomic restoration of the radiocapitellar joint was obtained. Results: Ultimately, the patient was able to return to full, unrestricted activity. At 9 months following surgery, she denied pain, and the elbow was stable upon examination. Elbow range of motion was 5 to 130 degrees with 80 and 90 degrees of pronation and supination respectively. Conclusions: This represents the first reported case of suspension transbrachialis buttonholing of the radial head in the brachialis tendon as a cause of initially irreducible radiocapitellar dislocation. When evaluating patients with persistent anterior subluxation or dislocation of the radial head, this etiology should be considered. Level of Evidence: Level IV—case report. Key Words: radiocapitellar dislocation, pulled elbow, nursemaid elbow, brachialis, radial head

head subluxation (“pulled elbow” or “nursemaid elbow”) which is one of the more commonly encountered traumatic conditions in pediatric patients.1 Anterior radiocapitellar dislocations may occur as the result of combined axial, torsional, and/or extension forces, and associated injury such as fracture, ulnohumeral dislocation, and ligamentous disruption can occur. Closed reduction is not always successful for radiocapitellar dislocations, which often require open reduction.2–9 Reduction is critically important to prevent progressive pain, stiffness, neuropathy, and proximal radioulnar dysplasia; all of which are documented sequelae of chronic radial head dislocation.10–13 For cases requiring open operative intervention, the most commonly noted block to anatomic reduction is interposed annular ligament.3,4,14 In these cases, the annular ligament may be damaged necessitating repair or reconstruction to maintain stable joint congruency following reduction. On rare occasions, even open surgery may not permit successful radiocapitellar reduction at first attempt. In such situations, additional investigations into the cause of irreducibility are merited. Possible causes may be the result of radioulnar or distal humeral dysplasia (especially in cases of chronic radial head dislocation) or soft-tissue restraint or interposition other than that of the annular ligament. Currently, there are a few case reports of the biceps tendon serving as a block to reduction of the anteriorly dislocated radial head9,15–18; however, in this report, we detail the presentation, treatment, and outcome of a patient with an initially irreducible radial head dislocation due to transbrachialis buttonholing of the radial head.

(J Pediatr Orthop 2015;35:e67–e71)

T

rue radiocapitellar dislocation is a relatively uncommon injury in children. This is in contrast to radial

From the Department of Orthopedic Surgery and the Sports Medicine Center, Mayo Clinic and Mayo Foundation, Rochester, MN. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Shawn W. O’Driscoll, MD, PhD, Department of Orthopedic Surgery and the Sports Medicine Center, Mayo Clinic and Mayo Foundation, Rochester, 200 First Street, SW, Rochester, MN 55905. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Pediatr Orthop



CASE REPORT A 13-year-old female gymnast and cheerleader noted the sudden onset of severe elbow pain and visible deformity after performing a 1-handed cartwheel. She was diagnosed with an isolated radiocapitellar dislocation at her local emergency department where closed reduction was unsuccessful (Fig. 1). She was taken to the operating room and open reduction was attempted under a general anesthetic. This was unsuccessful and she was subsequently transferred to a tertiary-care center where a repeated attempt at open reduction was also unsuccessful. The radial head was able to be reduced with the elbow fully flexed and supinated; however, it quickly dislocated anteriorly when the elbow was in any other position. There was no detectable interposition of the annular ligament or evidence of any other intra-articular bony or soft-tissue block to reduction.

Volume 35, Number 7, October/November 2015

www.pedorthopaedics.com |

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

e67

J Pediatr Orthop

Camp and O’Driscoll



Volume 35, Number 7, October/November 2015

FIGURE 1. Initial anteroposterior and lateral view postreduction x-rays from outside hospital. She presented to our center in severe pain 10 days following her initial injury. Physical examination revealed mild swelling and deformity about the right elbow. Elbow range of motion (ROM) was not attempted secondary to pain. She remained neurovascularly intact and was able to fire all muscles of the wrist and hand. There was significant tenderness to palpation of the elbow. Repeat x-rays and a computed tomography (CT) scan confirmed persistent anterior dislocation of the radial head (Fig. 2). The CT was negative for any obvious mechanical blocks to reduction. It did reveal a minimally displaced marginal impaction fracture of the posterior radial head and 2 small avulsion-type fractures from the anterior radial neck. The following day (11 d postinjury) she was taken to the operating room for a third attempt at open reduction. Exami-

nation under anesthesia revealed elbow motion through an extension-flexion arc of 60 to 95 degrees. Forearm rotation was 10 degrees of pronation to 40 degrees of supination (the entire 30 degree arc of motion was from 10 to 40 degrees of supination). Fluoroscopic examination revealed no elbow instability to varus or valgus stresses. Her previous laterally based incision was opened and the joint was assessed through the Kaplan interval. The lateral soft tissues were severely disrupted and the annular ligament was not identifiable. The marginal impaction fracture was minimally displaced and did not require intervention. The radial head was able to be reduced with significant force; however, when the force was removed, the radial head immediately redislocated despite the fact that there were no apparent intra-articular impediments to reduction. It was then

FIGURE 2. Presenting computed tomography scan with 3-dimensional reconstruction (A and B) of the elbow highlighting the anterior radial neck capsular avulsion fracture, medial displacement of the radial head, and proper alignment of the ulna. These images also demonstrated the minimally displaced nature of the radial head marginal impaction fracture further supporting nonoperative treatment of this fracture.

e68 | www.pedorthopaedics.com

Copyright

r

2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Pediatr Orthop



Volume 35, Number 7, October/November 2015

Transbrachialis Irreducible Radial Head Dislocation

FIGURE 3. Intraoperative photographs demonstrating the radiocapitellar dislocation (A), radial head buttonholed through the brachialis preventing reduction (B) brachialis tendon was mobilized around the radial head (C) permitting anatomic reduction of the joint (D). Brach. T indicates brachialis tendon; Cap, capitellum; RH, radial head. reasoned that the block to reduction may be soft tissue wrapped around the radius distally. Therefore, the radius was explored distally to the level of the radial tuberosity. The anterior capsule and periosteum had completely avulsed from the anterior radial

neck, and this accounted for the small avulsion fractures noted on CT (Fig. 2). A tendinous structure was observed overlying the radius at the level of the radial neck (Fig. 3A). Additional inspection

FIGURE 4. Illustrations outlining the presumed injury mechanism. During hyperextension of the elbow, the radial head dislocated anterior to the brachialis tendon (A). As the elbow was flexed and rotated, the radial head buttonholed through the brachialis (B) and became suspended by the lateral portion of the tendon, preventing reduction (C). By permission of Mayo Foundation for Medical Education and Research. All rights reserved. Copyright

r

2015 Wolters Kluwer Health, Inc. All rights reserved.

www.pedorthopaedics.com |

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

e69

J Pediatr Orthop

Camp and O’Driscoll



Volume 35, Number 7, October/November 2015

FIGURE 5. Postoperative lateral radiographs of the elbow reveal an anatomically reduced radial head with significant heterotopic ossification at 2 months (A) that improved at 9 months (B). revealed that this was the lateral aspect of the brachialis tendon. It appeared that the radial head had dislocated anteriorly in extension and traveled anteromedial to the lateral border of the brachialis tendon. As the elbow flexed, the radial head buttonholed through the brachialis. When the force was removed, the radial head remained suspended in the dislocated position with the lateral portion of the brachialis tendon acting as a sling preventing reduction (Figs. 3B, 4). Once this tendinous sling was delivered from around the radial head (Fig. 3C), the radial head reduced spontaneously (Fig. 3D). At that point, the annular ligament was visualized for the first time and was noted to have scarred onto the anterior aspect of the radial neck where the capsular avulsion had occurred. This scarring was freed and the annular ligament was repaired with suture anchors anteriorly and posteriorly. After wound closure the elbow extended to 35 degrees and flexed to 120 degrees with gravity. With minimal force (approximately 500 g), the elbow flexed from 15 to 135 degrees. It pronated to 50 degrees and supinated to 70 degrees. The elbow was stable throughout this ROM. She was placed in a long arm splint with the arm in approximately 30 degrees of flexion and neutral rotation. On postoperative day 4, her splint and dressing were removed, and a removable posterior-based splint was fabricated. This splint was removed once every hour to begin light ROM exercises. She returned for clinical evaluation 2 weeks after surgery (25 d from injury) at which time her elbow was stable. Her elbow ROM was 45 to 70 degrees with 20 degrees of pronation and 30 degrees of supination. At this point, she had already begun to form heterotopic ossification in the anterior elbow (Fig. 5A). Formal physical therapy focusing on active ROM exercises was initiated at this time. Two months postinjury, her elbow ROM was 50 to 115 degrees with 20 degrees of pronation and 80 degrees of supination. By 9 months, elbow ROM was 5 to 130 degrees with 80 and 90 degrees of pronation and supination, respectively. At this time, she rated her elbow as “almost normal” and gave it a score of 9 of 10 on the summary outcome determination scale.19 Her elbow remained stable both subjectively and on thorough examination. She denied any pain or limitations to her activities and some of the heterotopic ossification had largely resorbed (Fig. 5B). She was able to return

e70 | www.pedorthopaedics.com

to cheerleading and could perform backhand springs and somersaults without limitation.

DISCUSSION Radiocapitellar dislocations are uncommon, and may require open intervention.2–8,14 On occasion, reduction may not be readily achieved even with an open surgical approach. In those instances, additional investigation should be performed to identify the block to reduction. Most commonly, the causative structure is interposed annular ligament3,4,14; however, this is not always the case. Associated ulnar fractures, commonly occurring as a Monteggia injury, should also be ruled out because the radial head is not likely to reduce when malalignment of the ulna persists. There was no clinical or radiographic evidence of ulna injury or deformity in this case, and this is further supported by the fact that the radial head easily reduced once the brachialis tendon was freed. To our knowledge, the patient presented in this case represents the first report of an initially irreducible radial head dislocation due to suspension of the proximal radius in the brachialis tendon. After failing closed reduction and 2 separate attempts at open reduction, the radiocapitellar articulation was able to be anatomically reduced once it was delivered from the lateral portion the brachialis tendon which was acting as a suspensory sling. Although preoperative magnetic resonance imaging was not obtained on this patient, it may have proven helpful in better understanding this mechanism causing persistent dislocation. In patients with irreducible radiocapitellar dislocations, this etiology should be considered. The key findings leading one to suspect suspension buttonholing of the radial head in the brachialis as a cause for irreducible dislocation include an anterior and medially dislocated radial head with no readily identifiable intraarticular block to reduction. Copyright

r

2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Pediatr Orthop



Volume 35, Number 7, October/November 2015

REFERENCES 1. Brown D. Emergency Department visits for nursemaid’s elbow in the United States, 2005-2006. Orthop Nurs. 2009;28:161–162. 2. Belangero WD, Livani B, Zogaib RK. Treatment of chronic radial head dislocations in children. Int Orthop. 2007;31:151–154. 3. Choung W, Heinrich SD. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid’s elbow). J Pediatr Orthop. 1995;15:454–456. 4. Corella F, Horna L, Villa A, et al. Irreducible ‘ulled elbow’ report of two cases and review of the literature. J Pediatr Orthop Part B. 2010;19:304–306. 5. De Boeck H. Treatment of chronic isolated radial head dislocation in children. Clin Orthop Relat Res. 2000;380:215–219. 6. Horii E, Nakamura R, Koh S, et al. Surgical treatment for chronic radial head dislocation. J Bone Joint Surg Am. 2002;84A: 1183–1188. 7. Kim HT, Park BG, Suh JT, et al. Chronic radial head dislocation in children, part 2: results of open treatment and factors affecting final outcome. J Orthop. 2002;22:591–597. 8. Krul M, van der Wouden JC, van Suijlekom-Smit LWA, et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012;1:1–22. 9. Bonatus T, Chapman MW, Felix N. Traumatic anterior dislocation of the radial head in an adult. J Orthop Trauma. 1995;9:441–444. 10. Kim HT, Conjares JN, Suh JT, et al. Chronic radial head dislocation in children, part 1: pathologic changes preventing stable

Copyright

r

2015 Wolters Kluwer Health, Inc. All rights reserved.

11. 12. 13. 14. 15. 16. 17. 18. 19.

Transbrachialis Irreducible Radial Head Dislocation

reduction and surgical correction. J Pediatr Orthop. 2002;22: 583–590. Oka K, Murase T, Moritomo H, et al. Morphologic evaluation of chronic radial head dislocation: three-dimensional and quantitative analyses. Clin Orthop Relat Res. 2010;468:2410–2418. Oner FC, Diepstraten AF. Treatment of chronic post-traumatic dislocation of the radial head in children. J Bone Joint Surg Br. 1993;75:577–581. Holstnielsen F, Jensen V. Tardy posterior interosseous nerve plasy as a result of an unreduced radial head dislocation in monteggia fractures—a report of 2 cases. J Hand Surg Am. 1984;9A:572–575. Triantafyllou SJ, Wilson SC, Rychak JS. Irreducible “pulled elbow” in a child. A case report. Clin Orthop Relat Rep. 1992;284:153–155. Veenstra KM, van der Eyken JW. Irreducible antero-medial dislocation of the radius. A case of biceps tendon interposition. Acta Orthop Scand. 1993;64:224–225. Yoshihara Y, Shiraishi K, Imamura K. Irreducible anteromedial dislocation of the radial head caused by biceps tendon clinging around the radial neck. J Trauma. 2002;53:984–986. Upasani VV, Hentzen ER, Meunier MJ, et al. Anteromedial radial head fracture-dislocation associated with a transposed biceps tendon: a case report. J Shoulder Elbow Surg. 2011;20:E14–E18. Armstrong RD, McLaren AC. Biceps tendon blocks reduction of isolated radial head dislocation. Orthop Rev. 1987;16:104–108. Blonna D, Lee GC, O’Driscoll SW. Arthroscopic restoration of terminal elbow extension in high-level athletes. Am J Sports Med. 2010;38:2509–2515.

www.pedorthopaedics.com |

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

e71

Transbrachialis Buttonholing of the Radial Head as a Cause for Irreducible Radiocapitellar Dislocation: A Case Report.

Isolated dislocation of the radial head is an uncommon injury among pediatric patients. Although closed reduction may be successful, some patients req...
1MB Sizes 0 Downloads 11 Views