Case Report

Surgical Management of an Unusual Elbow dislocation with radial shaft fracture and annular ligament disruption: A Case Report

by Giovanni Vicenti*, Massimiliano Carrozzo, Claudio Buono, Walter Ginestra, Giulia Colasuonno, Guglielmo Ottaviani, Biagio Moretti

Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Policlinico Consorziale, Bari, Italy; Orthopaedic and Trauma Unit, Bari, Italy

*Corresponding author: Giovanni Vicenti, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale, Bari, Italy; Orthopaedic and Trauma Unit, Bari, Italy

Received Date: 02 July 2023

Accepted Date: 07 July 2023

Published Date: 10 July 2023

Citation: Vicenti G, Carrozzo M, Buono C, Ginestra W, Colasuonno G, et al (2023) Surgical Management of an Unusual Elbow dislocation with radial shaft fracture and annular ligament disruption: A Case Report. Ann Case Report. 8: 1364. https://doi.org/10.29011/25747754.101364

Abstract

Study design: A report of a rare case of transverse dislocation of the elbow (both ulna and radius) associated with fracture of the shaft of the ipsilateral radius and description of annular ligament plasty performed.

Objective: Describe and identify a rare pattern of elbow dislocation associated with radial shaft fracture using an alphanumeric code, which avoid confusion in forearm fracture–dislocations nomenclature and help surgeons with detection of lesions and guiding surgical treatment.

Introduction: Transverse dislocation of the elbow is a rare injury and most of the cases have been described in paediatric patients. Association of this injury with fracture of forearm bones is rare and has been also unknown since the new lockerclassification system of forearm fracture-dislocation has been presented in 2020.According to this classification is possible to distinguish between simple dislocations and complex dislocations (fracture–dislocations) of the forearm joint and furthermore to identify every pattern possibility of fracture-dislocations. In this case, report a complex dislocation of the forearm and its surgical management is described.

Presentation of case: A 36-year-old male patient sustained trauma to his left upper limb during sport activity. Radiographic evaluation revealed transverse dislocation of the elbow and fracture of the shaft of the ipsilateral radius. Open fixation of the fracture with closed reduction of the elbow was carried out followed by annular ligament plasty with triceps tendon to treat the residual radial head dislocation.

Conclusion: The aim of this case report is to illustrate an alternative technique, not well described in literature to treat cases of severe elbow instability, because of elbow fractures. The use of a lateral string of triceps tendon for annular ligament reconstruction avoids triceps tendon weakening and provides a better clinical outcome. It is also important, as described in literature; the use of the appropriate classification system to avoids misdiagnosis and heal delay because of a complex forearm injury.

Keywords: Elbow dislocation; Fracture; Annular ligament plasty; Trauma

Introduction

The forearm has to be considered as a single functional unit [1,2] made of radius and ulna, distal radioulnar joint (DRUJ), middle radioulnar joint (MRUJ) and proximal radioulnar joint (PRUJ), respectively stabilized by the triangular fibrocartilage complex, the interosseus membrane (IOM) and the annular ligament [3] . The three joints of the forearm are classified in two groups: anatomical joints and functional joints. The anatomical ones are the distal radioulnar joint (DRUJ) and proximal radioulnar joint (PRUJ), the functional one is the middle radioulnar joint (MRUJ) made of forearm bones and IOM [1,4]. These structures are also known as forearm “lockers” that allow the forearm stability. According to Elzinga K. et al the forearm unit acts like a ring distributing the mechanical stress along the arc [3,5]. If one component of the forearm ring results, injured, other associated lesions need to be excluded in order to avoid a destabilization of the forearm. The IOM itself is formed by distal membranous portion, central band (which is the most functionally important component), dorsal oblique accessory cord and finally proximal oblique cord [6,7]. The use of new classification systems allows identifying different patterns of fracture-dislocation avoiding the misdiagnosis of a forearm injury. Herein we present a case of forearm fracturedislocation misdiagnosis treated by a two-step approach.

Case Report

A 36-year-old male was admitted to our Emergency Unit reporting accidental trauma to his left upper limb during sport activity complaining of forearm and elbow pain. The medical history was collected. No other comorbidities or previous surgeries were reported. At physical examination, there were swelling, and deformity of the elbow associated with tenderness over the radial shaft. Movements at the elbow were limited and painful. There were no associated injuries or distal neurovascular deficit. X-ray evaluation revealed dislocation of the radio-humeral, ulno-humeral and the proximal radioulnar joint with fracture of the radial shaft. The distal radioulnar joint (DRUJ) was not injured (Figure1). Closed reduction of the elbow dislocation was attempted without success in the emergency room. Immediately the patient underwent surgery to manage the radial shaft fracture and dislocation of the elbow. The reduction of the dislocation was carried out, and it was apparently found to be stable during the intraoperative X-ray control. Open reduction and internal fixation of the radial shaft fracture was performed using Synthes DCP plate and six screws .The standard Henry approach was used to expose the fracture preserving the interosseous nerve. Then, a long arm plaster valve was applied. On the first post-operative day the X-ray control showed a residual anterior radial head dislocation (Figure 2). A 3D TC of the left arm was performed in order to assess alterations in the synthesized radius of either shortening or lengthening which could lead to residual elbow dislocation (Figure 3). Considering the residual radial head dislocation, there was a clear injury of the forearm lockers (the annular ligament and the IOM). The fracture-dislocation has been classified as 1.2I according to the locker-based classification proposed by Artiaco [1]. Two days after surgery the patient was re-operated in order to reduce the dislocation by repairing the annular ligament. The Kocher approach was used to expose the radiohumeral articulation. A lesion of the Lateral Collateral Ligament and an unrepairable break of the annular ligament were observed. Furthermore the instability of the proximal radioulnar joint (PRUJ) was confirmed during pronosupination manouver. A strip from distal triceps tendon was isolated and used for the reconstruction of the annular ligament. It was detached from the lateral side (Figure 4), with care to preserve its attachment to the olecranon. The strip was transposed under the anconeus muscle and kept around the radial head. Pronosupination manouver, keeping a tension on triceps tendon strip loop was performed to assess the stability of the PRUJ (Figure 5). Then the loop was fixed by a corkscrew on the supinatory crest of the ulna. Then, the repair of the LCL by the fixation on the humeral epicondyle by one corkscrew was performed (Figure 6). At the end, a long arm plaster valve was applied and retained for two weeks, followed by a month of articulated brace with free flexion and extension.The post-operative x-ray control after one month showed PRUJ stability underlined by the evidence of an engrave under the radial head which represents the tensioning work done by the annular ligament (Figure 7). On clinical follow up one month and six months after surgery pronosupination, flexion and extension of the elbow were restored (Figure 9-10). No postoperative complications occurred and the fracture healing was assessed (Figure 8).

Pattern

1 (PRUJ)

2

(MRUJ)

3 (DRUJ)

Description

Two-locker injuries

1.2I

X

X

Isolated radial head fracture

1.2IU

X

X

X

Monteggia fracture-dislocation

1.2IR

X

X

X

1.2IRU

X

X

X

X

2I.3

X

X

Isolated dislocation of ulnar head

2IR.3

X

X

X

Galeazzi injury

2IU.3

X

X

X

Never described

2IRU.3

X

X

X

X

1.3

X

X

Leung crisscross injury

Three-lockers injuries

12I.3

X

X

X

Essex-Lopresti injury

1.2IRU.3

X

X

X

X

X

1.2IR.3

X

X

X

X

1.2IU.3

X

X

X

X

Table 1: Description of possible combinations of forearm fracture–dislocation patterns. Each lesion is described based on the anatomical structures involved in each type of forearm fracture–dislocation.

 

Figure 1: Left elbow, forearm and wrist X-rays.

 

Figure 2: Post-operative X-rays of the left forearm.

Figure 3: Post-operative CT of the left forearm.

Figure 4: Strip from the lateral side of distal triceps tendon was isolated and detached.