J. of Korean Orthop. Assoc. 2004; 39: 582-5 Proximal Radio-Ulnar Translocation Associated with Elbow Dislocationon -Case Report- Bong-Jin Lee, M.D., Sung-Rak Lee, M.D., and Dong-Hwan Shin, M.D. Department of Orthopaedic Surgery, Halla General Hospital, Jeju, Korea A translocation of the proximal radius and ulna combined with a posterior dislocation of the elbow is quite rare. To the best of our knowledge, the only case with this condition, who had been treated using a closed method was reported by MacSween in 1978. This paper reports a ten-year-old girl who fell from a desk onto her outstretched left hand. The initial radiographs showed a simple posterior dislocation of the elbow. However, the radiographs taken after the closed reduction revealed a translocation of both forearm bones. It was possible to relocate both bones using a closed method, and the patient recovered from the associated ulnar nerve palsy at five weeks post-trauma. At the follow-up examination three months post-trauma, the nerve was found to be fully regenerated using electromyography and a nerve conduction study, and the patient regained the full range of elbow motion without pain. When a posteri- or dislocation of the elbow occurs, close attention is needed in order to detect the combined transloca- tion of the proximal radio-ulnar joint. If treated early, a closed reduction leads to a good result. However, a careful physical examination and a thorough investigation of the radiographs are necessary. Key Words: Proximal radio-ulnar joint, Translocation, Closed reduction The elbow is the most commonly dislocated joint in chil- in her left hand was normal, but the sensation in the two dren. However, a simultaneous dislocation of the elbow and ulnar digits and the strength of abduction and adduction a translocation of the proximal radio-ulnar joint is a rare of the finger was decreased. The anteroposterior and lateral injury. To the best of the our knowledge, there has only been radiographs indicated a simple posterior dislocation of the one such case treated with a closed method5). elbow (Fig. 1). Therefore, traction was applied to the elbow We experienced a case of proximal radio-ulnar transloca- under intravenous sedation and the elbow appeared to be tion combined with a posterior elbow dislocation, which reduced with a clunk. However, the flexion and extension was treated with a closed reduction. This case stresses the were slightly restricted, and the forearm was fixed in pro- importance of considering this type of injury using a care- nation. The radiographs taken after the closed reduction ful investigation of radiographs and the earliest reduction revealed a translocation of both forearm bones, such that the using a closed method. ulna articulated with the capitellum and the radial head articulated with the trochlea (Fig. 2). A second closed reduc- CASE REPORT tion was performed under fluoroscopic control. It was pos- A ten-year-old girl fell from a desk onto her outstretched sible to relocate both bones by supination of the wrist and left hand. She complained of severe pain in her left elbow, direct pressure over the medial side of the radial head and which was swollen, bruised and deformed. The circulation the lateral side of the olecranon (Fig. 3). Full flexion and extension were then possible and the normal range of rota- Address reprint requests to tion was restored. Initially, the elbow was immobilized for Dong-Hwan Shin, M.D. Department of Orthopaedic Surgery, Halla General Hospital, one week in a long arm splint at 90 degrees flexion and full 1963-2 Yeon-dong, Jeju 690-170, Korea supination, due to swelling, and was then immobilized in Tel: +82.64-740-5111, Fax: +82.64-743-3110 E-mail: [email protected] a long arm cast in the same position for an additional three 582 Proximal Radio-Ulnar Translocation Associated with Elbow Dislocationon 583 L Fig. 1. Initial radiographs were read as a posterior dislocation Fig. 3. Radiographs taken after the second closed reduction of the elbow. show an anatomical reduction of the elbow. The arrows indicate the reduced radiocapitellar joint and the arrowheads indicate the ulnohumeral joint. L Fig. 2. Radiographs taken after the first closed reduction reveal a Fig. 4. At 3 months post-trauma, the patient regained her full translocation of both forearm bones. The arrows show the radi- range of supination and pronation. al head and capitellum and the arrowheads show the proximal ulna and trochlea. the elbow in a child. His patient was treated using closed weeks. At the time of cast removal, the patient was instruct- method, but he reported a 10 degree loss of pronation at ed to perform an active range of motion exercise of the elbow. one year after the injury. At five weeks post-trauma, the patient appeared to have A translocation of the both forearm bones might occur as recovered from the ulnar nerve palsy. At seven weeks post- a result of two mechanisms: The primary case occurs simul- trauma, full flexion was attained, but 30 degrees of exten- taneously with elbow dislocation, while the secondary case sion, 20 degrees of pronation and 30 degrees of supination develops after a closed reduction of the elbow dislocation. were lost. At the follow-up examination three months post- The latter case is referred to an iatrogenic translocation. trauma, the nerve was found to be fully regenerated using The possibility of an iatrogenic proximal radio-ulnar trans- electromyography and a nerve conduction study, and the location was first suggested by Harvey and Tchelebi4). They patient had regained pain-free full range of motion of the reported that in a pure lateral or posterolateral′′ dislocation elbow (Fig. 4). At the two years follow-up, the patient had of the elbow, which is diagnosed as a posterior dislocation, normal elbow function, and was able to play various sports. a reduction by traction and pronation might force the radi- al head to cross anteriorly over the ulna, resulting in a trans- DISCUSSION located position. In 1978, MacSween5) reported the first case of a transpo- Eklof. 3) suggested that a translocation of the proximal sition of the radius and ulna associated with dislocation of radioulnar joint combined with a dislocation of the elbow 584 Bong-Jin Lee∙Sung-Rak Lee∙Dong-Hwan Shin Table 1. Summary of the clinical data of previous case reports of a proximal radio-ulnar translocation combined with an elbow dislocation . MacSween (1978) Harvey (1979) Carey (1984) Eklof 1 (1990) Eklof 2 (1990) Eklof 3 (1990) Carl (1992) Age/Sex 6/M 7/F 12/M 8/F 8/F 10/M 10/F Injury Mechanism Fall Fall Fall Fall Associated Injury Fx. radial neck Ulnar nerve palsy Fx. coronoid Fx. Radial Fx. Radial Fx. Radial Fx. Coronoid process process neck head head Reduction Early, Closed Delayed Early, Open Delayed Early, Open Early, Open Early, Open (5 weeks), Open (5 weeks), Open Results (Last F/U) Pronation loss Ext/Flex 30/100 Ext & Sup Marked LOM Normal Normal Supination (1 Yr) Pron/Sup 30/10 loss (6 Mo) (2.5 Yr) (4 Mo) (3 Mo) loss (2 Yr) (3 Mo) Complication AVN of radial head M, Male; F, Female; Fx, Fracture; F/U, Follow-up; Yr, Year; Mo, Month; Ext, Extension; Flex, Flexion; Pron, Pronation; Sup, Supination; LOM, Limited range of motion; AVN, Avascular necrosis. might occur when the elbow is extended and pronated, as position of the bones of the proximal forearm. However, with the injury described in this report. During dislocation, this unexpected anatomical relationship is easily overlooked. the capsule and ligaments are disrupted to the point that Therefore, a careful physical examination and thorough in- the bones of the forearm cross each other and become vestigation of the radiographs are necessary to avoid serious locked in hyperpronation. complications. When a lateral or posterolateral dislocation In our case, during the first closed reduction, it was believed is recognized, traction and forced pronation should be avoid- there was a reduction and the characteristic ‘clunk’ was heard, ed in order to prevent an iatrogenic translocation of both but in fact only the posterior dislocation of the elbow was re- forearm bones. duced and the translocation of both forearm bones remained. It is believed that if detected early, a closed reduction, with Carey1) described this unsuccessful closed reduction as a careful pathoanatomical considerations would be successful ‘pseudoreduction’, in that the flexion and extension were in most cases of a proximal radio-ulnar translocation. improved, but the forearm remained fixed in almost com- plete pronation1). REFERENCES In all reports except for the one reported by MacSween5), 1. Carey RP: Simultaneous dislocation of the elbow and the proximal the closed reductions failed because the interposed soft tis- radio-ulnar joint. J Bone Joint Surg, 66-B: 254-256, 1984. sues prevented reductions3) and the radial head divot mechan- 2. Carl A, Prada S and Teixeira K: Proximal radioulnar transposi- ically locked onto the medial aspect of the proximal ulna2). tion in an elbow dislocation. J Orthop Trauma, 6: 106-109, 1992. The details of the previous reports are summarized in Table 3. Eklof O, Nybonde T and Karlsson G: Luxation of the elbow 1. The associated injuries are a radial head or neck fracture, complicated by proximal radio-ulnar translocation. Acta Radiol, 31: a coronoid process fracture, and a ulnar nerve palsy. The com- 145-146, 1990. plications are a limited range of motion and avascular necro- 4. Harvey S and Tchelebi′′ H: Proximal radio-ulnar translocation. sis of the radial head. A case report. J Bone Joint Surg, 61-A: 447-449, 1979.