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TRAUMATIC
J. J. WILEY,*
Traumatic
the
Other
the
DePalma
The
JOHN
and
J. P. HORWICH,*
PEGINGTON,t
of Orthopaedic
1970,
purpose
Smith
of this
paper
Scant
an
knowledge
unusual
is to
ten
OTTAWA,
as an
of
of
CANADA
of Ottawa
isolated
lesion
particularly
the
is considered
clinical
the possible
mechanism
1956, TraVaglini
1962,
is available
cases
ELBOW
THE
University
condition,
displacement
report
AT
and Anatomy,
elbow
the
as to the nature
the
this
radius
(Spinner
injury,
with
a
features
of injury
and
Vesely
1967,
of the pathological
Kaplan
1970).
and
a study
of
the
relevant
features.
MECHANISM
From
elbow
RADIUS
types of dislocation,
Stelling
and
Cote
1929,
1972).
such
at the
described
of the
permits
Surgery
radius
have
(Thomas
which
anatomical
of the
authors
classification
management
lesion
THE
dislocation
injury.
including
OF
the Departments
From
rare
DISLOCATION
the
history
at the time
pronated
(Vesely
it is impossible
ofinjury.
1967).
OF
to be certain
It is probable
Further
violence
DETAILS
Sex
of two
forearm,
ways
: 1) with
producing
the
exact
position
TEN
Direction
affected
dislocation
Female
8
Left
Anterior
2
Male
7
Left
Lateral
3
Male
10
Right
Anterior
4
Female
5
Right
Lateral
5
Male
48
Left
Lateral
6
Female
5
Left
Lateral
7
Male
9
Left
Lateral
8
Male
32
Right
Lateral
9
Male
7
Left
Anterior
10
Male
5
held
behind
the
(Corbett
and
of
I
arm
forearm
and the forearm
in at least one
PATIENTS
Side
I
(years)
‘
hyperpronation
of the
I
OF
Age
number
of the
that the elbow is partly
outstretched
is applied
to the pronated
forearm
TABLE
RELEVANT
Case
INJURY
,
Left
I
back,
Anterior
‘
the
193 1); 2) with
patient
the
then
affected
falls
arm
backwards
fixed
on the
on his
ground
in a one-hand
handstand)
the patient’s
body pivots
around
this extremity
(Vesely
1967).
In either
case the added
body
weight
increases
the pronation
and applies
a varus
strain
to
the elbow.
Eventually
the annular
ligament
ruptures
laterally
or antero-laterally
and the
radial
head
escapes
from
the joint.
The dislocated
proximal
radius
may eventually
assume
(as
a position
probably
lateral,
depends
anterior,
on
*
the
Department
t Department
56B,
VOL.
6
NO.
3,
AUGUST
or even
postero-lateral
positioning
of Orthopaedics,
of Anatomy,
1974
of
to the elbow
the extremity
after
Ottawa
Hospital.
Faculty
General
of Medicine,
the
University
joint
injury
proper.
has
Its final
location
occurred.
of Ottawa.
501
502
J.
J.
WILEY,
J.
PEGINGTON
AND
CLINICAL
The
patient,
movement.
commonly
Little
in flexion
and
upon
position
the
be missed
the elbow.
drawn
the
capitulum
three
elbow,
long
axis
of the
is accomplished
and,
if necessary,
reduction
to
weeks
direct
and
the
radial
then
thumb
was
managed
head.
The
gently
aged
ten
from
five
years
lateral
the
details
The
four
anterior.
extent
of
Reduction
the
was
Nine
unaware
right
in all
only
was
were
closed
available
limitation
for
months
patients.
were
There
seven
1-A
girl aged
eight
years
a fall (Fig.
1).
Reduction
was
years later showed
full restoration
1-Anterior
Case 2-A
boy
The
was
injury
under
general
immobilisation
of extension,
aged
easily
across
the
extension
one
of
joint
plaster
our
from
splint
for
in only
three
instances.
there
was
so
All
nine
On examination,
no instance
The
free
to
to nerves
aged
from
from
were
examine
or vessels.
accident
symptoms
six patients
had
and supination
of the
were
were
opportunity
interval
were
patients
children
Six dislocations
related
however,
pronation
Full
of recurrence
CASE
no
the
examination,
I.
of the
to
and
restriction
had been
dislocation.
REPORTS
sustained
an anterior
performed
of elbow
under
general
anaesthesia.
Follow-up
examination
two
movement.
There
were no symptoms
related
to the elbow.
dislocation
of radius
at elbow,
dislocation
of the left radius
at the elbow
in
1
with
normal
elbow
for comparison
(right).
a tree sustaining
a lateral
dislocation
of the left radius
(Fig. 2).
as a total dislocation
of the elbow.
Reduction
was performed
anaesthesia,
the radius
reducing
as the forearm
was supinated.
After three weeks
of
he was allowed
full use of the elbow.
Five years later the elbow still lacked 10 degrees
although
he had no symptoms.
initially
seven
In
in Table
All
years.
FIG.
Case
shown
adults.
5 to 20 degrees.
from
was
are
no complications
ILLUSTRATIVE
Case
with
head.
in a posterior
were
follow-up
to
of movement.
ranging
two
injuries,
There
in all cases.
seven
series
involved
injury.
were
wire
may
dislocation
of
elbow
a line
MATERIAL
in the
but
elbow
All
or extension
restored
patients
years
soft-tissue
from
of any
of flexion
ten
accomplished
patients
ranging
the
to forty-eight
or less.
and
review
of
Depending
radius
combined
radial
a Kirschner
is immobilised
supination.
as a total
of the normal
the
any
free
mobilised.
CLINICAL
Relevant
over
against
be surprisingly
of the
of the
driving
elbow
end
capitulum.
forearm
the
pressure
by
and
proximal
over-diagnosed
radiograph
supination
guarded
may
to pronation
bisects
gentle
elbow,
movement
of the
or even
a lateral
radius
by
HORWICH
a painful
Passive
resistance
1967),
that on
unstable
an
is marked
the radiograph
(Wang
It is well to remember
elbow
cases
there
dislocation
the
with
is apparent.
the
through
the
but
P.
FEATURES
presents
distortion
of the
Reduction
of
if any
extension,
on
a child,
J.
fell from
described
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
TRAUMATIC
DISLOCATION
OF THE
RADIUS
AT
THE
503
ELBOW
Case 3-A
boy aged ten sustained an anterior dislocation of the proximal
right
radius
when
he fell
from a slide (Fig. 3).
The dislocation
was reduced
under
general
anaesthesia.
The elbow
was
immobilised
in a posterior
plaster
splint
for three
weeks
and then mobilised.
Seven
years
later there
were no symptoms
from the elbow;
the patient
was unaware
of any limitation
of movement
although
the elbow
lacked
10 degrees
of extension.
FIG.
Case
2-Lateral
FIG.
Case
2
dislocation.
3
3-Anterior
dislocation.
PATHOLOGICAL
Lateral
stripping
and
incision,
its
dislocation
the
of the
position
with
forced
included
membrane.
radius
enclosing
annular
ligament,
and
extended
to include
dislocation
osseous
muscles
the
The
repeatedly
lateral
aspect
of the
of
the
humero-ulnar
forearm
quadrate
joint
With
the radial
head
dislocated
laterally,
radial
head
to its normal
position
or directed
posteriorly.
Although
in none of our patients
been
VOL.
described.
56 B,
NO.
3,
AUGUST
1974
reproduced
of the
applying
certain
forces
the annular
ligament,
pronation
rupture
was
ANATOMY
in the
elbow,
to the forearm.
the radial
head
and
ligament,
remained
varus
but
elbows
accurately
strain
no
apparently
of corpses
incising
the
by
capsule
With
a lateral
capsular
could
be dislocated
from
at the
elbow
apparent
injury
(Fig.
to
4).
the
This
inter-
undisturbed.
supination
of the forearm
the head
to a seemingly
was dislocation
posterior,
either
reduced
the
irreducible
position
such dislocation
has
504
J.
Anterior
in
dislocation
cadaveric
anterior
posterior
tendon
could
with
proximal
the
and annular
of the radial
produce
dislocation
considerable
J. PEGINGTON
WILEY,
of the
specimens
capsule
aspect
J.
such
an
end
of the
in
extreme
forearm
ligament,
head.
and
It did
injury.
could
not be reproduced
force,
in some cases
AND
In
J.
P.
radius
HORWICH
be reproduced
could
supination,
by
with
completely
difficulty
severing
the
applying
force
in an anterior
direction
not appear
that simple
over-pull
of the
a number
of
specimens
tested
this
type
without
extensive
disruption
of the annular
tearing
the upper
portion
of the interosseous
of
to the
biceps
anterior
ligament
membrane.
and
FIG. 4
Cadaveric
specimen-the
supinator
muscle
has
been severed
and retracted.
There
is lateral
dislocation
of the radial head.
Note the tear of the
lateral joint capsule
and annular
ligament.
Normal
head
anatomy-During
within
structures
include
The capsule
which
encircles
and posterior
of the radius
(Fig.
5).
The
the
fibres
pronation
of the
the
joint
capsule,
of the elbow
the head
and
margins
so that
joint
neck
of the
it does
strengthened
part
sweep
epicondyle
around
of the ulna.
The quadrate
proximal
radio-ulnar
and
in front
certain
on
is also
thickened
of the
several
structures
maintain
the proximal
radio-ulnar
ligaments
distally
radius.
and
the
lateral
the
interosseous
the
joint.
aspect
annular
annular
ligament
to the anterior
as
far
to the neck
radial
head
of the joint
by the
in shape,
its apex
being
attached
anterior
and
posterior
ligament.
joint
radial
These
membrane.
the strbng
is attached
fibres gain loose attachment
rotatory
movements
of the
is triangular
to the
behind
the
to blend
with
The ligament
Its lowest
with the
capsule
its base
of and
supination
thus stabilising
extends
of the
notch.
interfere
This
lateral
and
ulna,
ulnar
not
capsule
ligament.
to
notch
the radial
as
The
the
borders
radial
of the
collateral
radial
notch
supports
the synovial
membrane
at the inferior
limit
of the
This small
ligament
extends
between
the radial
neck
and the
inferior
border
of the radial
notch
(Fig.
6).
The
interosseous
membrane
is a strong
fibrous
sheet
which
stretches
between
the
interosseous
borders
of the radius
and ulna.
It has a free upper edge.
Its fibres course
obliquely
downwards
proximally
ligament
joint.
from
radius
to
into the extremity
ulna,
so allowing
(Fig. 5).
for
the
transmission
THE
JOURNAL
of forces
OF
BONE
from
AND
JOINT
the
hand
SURGERY
Above
from
the
TRAUMATIC
DISLOCATION
border
of the interosseous
the upper
tuberosity
of
the
ulna
to
the
OF THE
RADIUS
membrane
radius
just
AT
THE
is a variable
below
its
505
ELBOW
fibrous
band
tuberosity.
This
is called
the oblique
cord.
Its obliquity
is in the opposite
direction
to the
interosseous
membrane
and it probably
represents
a portion
of the fascia
which
found
on the deep surface
of the supinator
muscle
(Martin
1958) (Fig. 5).
stretching
structure
fibres
of the
is sometimes
OBLIQUE
CORD
5
FIG.
The
stabilising
structures
which
joint.
maintain
the radio-humeral
QUADRATE
ANNULAR
FIG.
6
The quadrate
ligament.
The annular
ligament
has been
Radio-ulnar laxity is noted with neutral
forearm
ulna
The supinator
and sweeps
preserves
The
The role
muscle
around
provided
information
of the radial
head
VOL.
56 B,
arises
behind
the elbow
from the
the annular
ligament
and radius
to some extent
the integrity
of the region.
stability
of the upper
end of the radius
was
of individual
stabilising
structures-Selective
NO.
3,
on the role played
during
supination
and
AUGUST
1974
by each
pronation.
LIGAMENT
LIGAMENT
incised laterally.
rotation.
lateral
to its
epicondyle
and
radial
insertion.
studied
on dissected
removal
of the
of them
in maintaining
cadaveric
stabilising
the
normal
from the
It also
specimens.
structures
position
506
J. J. WILEY,
Firstly,
a series
supinator
been
with
removed.
the
was
to the
specimens
Thus
annular
ulna
of
its oblique
the
J. PEGINGTON
was
prepared
cord,
the
only
structure
ligament,
AND
in each
quadrate
the
of which
interosseous
membrane,
ligament
and the lateral
elbow
ligament
had all
intact
to stabilise
the upper
end of the radius
the radial
head in its normal
snug relationship
left
which
maintained
of the
forearm-pronation,
Secondly,
in all positions
J. P. HORWICH
neutral
and supination.
specimens
were prepared
interosseous
membrane,
oblique
cord,
and
had been removed.
completely
ture
into
became
radial
so that
the
only
the radial
the posterior
taut,
notch
notch
fibres
(Fig.
ofthe
the
with
its
of the elbow
was divided
stabilising
was the quadrate
ligament.
of the forearm
the radial
position
loosely
pronation
muscle
the lateral
ligament
The annular
ligament
laterally
intact
in which
supinator
struc-
In the neutral
head
fitted
only
6). However,
with
quadrate
ligament
rigidly
of the
holding
the radial
head
ulna.
Similarly,
supination
vided
good
stabilisation
as the anterior
fibres
ligament
tightened
(Kaplan
1964).
Although
in the
proof this
this
ligament
of the
readily
normal
undoubtedly
reinforces
proximal
radio-ulnarjoint,
the stability
disruption
occurs
if the
of
limits
of
rotation
the
forearm
are
exceeded.
Thirdly,
tures
and
7
FIG.
Figure
7-The
interosseous
membrane
and
the annular
ligament
are intact.
In pronation the membrane
is lax. Figure 8-After
lateral
incision
of the annular
ligament
the
lax interosseous membrane
allows dislocation of the head of the radius as the forearm
is pronated
further.
supinated
(Fig.
The
1).
With
extreme
ligament
the forearm
was
pronated
to be dislocated
laterally
degree
annular
of
slipping
lateral
one
Finally,
produced
effect
two
occurs
It should
from
again
the
were
small
cord
emphasised
In
pronation
there
membrane
because
interosseous
of radius
was
quite
in this
and
some
degree
ulna
possible
it would
be only
thus
oblique
the
cord
supination
remarkable
laxity
position
the interosseous
are
more
closely
is folded
is moderately
taut when
slackening
of
approxi-
between
them
taut in the
the forearm
is
reappears.
completely
incised
membrane
allowed
off the capitulum
laterally.
When
the radial
head
(Fig. 8). Such a
it into
full
with
brought
and
in the membrane.
oblique
supination,
with a good
all strucmembrane
the head
only being
capable
of
capitulum.
cord.
Pronation
of the forearm
in
articulating
found
of
with
Pronation
oftension
mated
and the membrane
(Fig.
7).
The membrane
neutral
position
and quite
still
that
prepared
the
degrees
the
supination
but
were
ligament.
varying
borders
not
but
band,
this
be
was
specimens
of
annular
supination
millimetres,
several
laxity
except
of these
specimens
was then
the laxity
of the interosseous
to such an extent
that it slipped
movement
or
the
produced
8
FIG.
specimens
removed
the
tension.
If any
in the supinated
position
is not always
present.
reinforcing
(Martin
1958).
CONCLUSIONS
These
anatomical
observations
stabilises
positions.
The
if present,
confers
pronation
upper
of the
position
membrane
of
indicate
the
oblique
and
some
that
end
relationship
cord
and
stability
supination.
the
of the
only
the
when
supinated
practical
important
radius
quadrate
in the
For
most
is the
structure
the
forearm
ligament
offer
position,
purposes,
maintaining
the
normal
ligament.
The interosseous
is in the neutral
or supinated
only
limited
support.
The cord,
annular
and the ligament
in the extremes
however,
these
two structures
are
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
TRAUMATIC
considered
the radius
forearm
of insufficient
(Kaplan
1964).
for
lateral
DISCLOCATION
strength
From
dislocation
OF THE
RADIUS
to influence
significantly
these facts it is deduced
of the
radial
head
would
AT THE
the forces
the most
that
be one
507
ELBOW
required
to dislocate
likely
position
of the
of pronation.
SUMMARY
Isolated
I.
dislocation
associated
slight
with
primarily
occurs
reinforcing
into
of the radius
elbow
because
and
not
diagnosed,
belatedly
this
the
injury
be
a varus
occurs
strain.
most
commonly
Disruption
tearing
of the annular
joint.
The tensing
of the
manoeuvre
it may
diagnosed
and
consequently
recognised
supination
2. It is suggested
that
be
of
of this
structure
supination,
flexion
at the elbow
ligament,
interosseous
approximation
of
the
to reduce
such an injury.
may
be more common
than
over-diagnosed
as a congenital
as
dislocation
ofthe
total
which
is the
membrane
radius
radial
to
previously
dislocation
of the
as a pronation
radio-ulnar
of
most
important
through
neutral
ulna,
supports
appreciated.
the
injury,
articulation
elbow,
the
It may
or
it may
be
head.
REFERENCES
CORBETT,
19,
C. H. (1931):
155-157.
Anterior
dislocation
of the
radius
and
its recurrence.
British
Journal
of Surgery,
F. (1970):
The Management
ofFractures
and Dislocations-An
Atlas.
Second edition.
Volume
I,
Philadelphia,
London,
Toronto:
W. B. Saunders.
KAPLAN,
E. B. (1964):
The quadrate
ligament of the radio-ulnar
joint of the elbow.
Bulletin
ofthe
Hospital
for Joi,zt Diseases,
25, 126-130.
MARTIN,
B. F. (1958): The oblique cord of the forearm.
Journal
ofAnatomy,
92, 609-615.
SMITH,
F. M. (1972): Surgery
ofthe
Elbow.
Second
edition.
Philadelphia:
W. B. Saunders
Company.
SPINNER,
M., and KAPLAN,
E. B. (1970):
The quadrate
ligament
of the elbow-its
relationship
to the stability
of the proximal
radio-ulnar
joint.
Acta orthopaedica
Scandinavica,
41, 632-647.
STELLING,
F. H., and COTE,
R. H. (1956): Traumatic
dislocation
of head of radius
in children.
Journal
of
America,z
Medical
Association,
160, 732-736.
THOMAS,
T. T. (1929): A contribution
to the mechanism
of fractures
and dislocations
in the elbow region.
Annals of Surgery,
89, 108-121.
TRAVAGLINI,
F. (1962): La lussazione
traumatica
isolata del capitello
radiale.
Archivo
“Pi,tti”
di chirurgia
degli organi
di movimento,
16, 422-441.
VESELY,
D. G. (1967): Isolated traumatic
dislocations
of the radial
head
in children.
Clinical Orthopaedics
and
Related
Research,
50, 3 1-36.
WANG,
S. K. (1967): Roentgen diagnosis of radial head dislocation. Pacific Medicine
a,zd Surgery, 75, 22-25.
DEPALMA,
A.
p. 749.
VOL.
56B,
NO.
3,
AUGUST
1974