Ulnar lengthening for children with forearm deformity from hereditary multiple exostoses: a retrospective study from a tertiary medical center.

BACKGROUND: Patients with hereditary multiple exostosis (HME) usually present with forearm deformity with or without radial head dislocation. Ulna lengthening has been proposed to address this condition. Exostosis resection plus ulna lengthening has been adopted in our hospital since 2008, and patients with this condition were retrospectively reviewed. Herein, we aimed to investigate the optimal timing and clinical outcomes of this surgical approach. METHODS: In all, thirty-five patients (40 forearms), including 22 boys and 13 girls, were enrolled in our study from July 2014 to September 2020. We divided the patients into 4 groups based on the age when they received surgery and the status of the radial head. Pronation and supination of the forearm, flexion and extension of the elbow, wrist ulnar deviation and wrist radial deviation, and radiological parameters including ulnar length (UL), ulnar variance (UV), the percentage of radial bowing (RB/RL), radio articular angle (RAA) and carpal slip (CS), were assessed and recorded. RESULTS: The mean UL was significantly improved after surgery in four Groups (P<0.05). In patients with radial head dislocation, we found significant improvement in forearm, wrist function and elbow flexion (p < 0.05). For the patients with radial head dislocation, the juniors demonstrated better improvement in % RB and RAA (p<0.05, p = 0.003 and 0.031). CONCLUSION: Exostosis resection and ulna lengthening with unilateral external fixation can effectively improve the function and radiological parameters of forearm deformity in HME children. For patients with radial head dislocation, early surgery can achieve better results. For patients not associated with radial head dislocation, we recommend regular follow-up and surgical treatment after 10 years of age.

Predictors of Radial Head Dislocation in Patients with Multiple Hereditary Exostoses.

Background: Radial head dislocation in patients with multiple hereditary exostoses (MHE) is associated with loss of function and cosmetic problems. The treatment of the deformity with radial head dislocation is difficult and the timing of surgical intervention is important. The aim of this study was to evaluate the factors predictive of radial head dislocation in patients with MHE. Methods: Patients diagnosed with forearm deformity due to MHE between 1995 and 2021 were retrospectively evaluated. Radiographic parameters including radial bow (RB), ulnar bow (UB), total radial bow (TRB), total ulnar bow (TUB), percent ulnar length (PUL), ulnar shortening (US), radial articular angle (RAA), modified Masada classification and irregularity of proximal radioulnar joint (PRUJ) of the dislocated group (group D), that is subluxation or dislocation of the radial head, and the located group (group L) were compared. Results: A total of 18 patients and 25 limbs (5 girls and 13 boys) with a mean age of 10.5 years were included. There were significant differences in TUB (22.8° ± 5.6° vs. 10.7° ± 6.5°), PUL (97.5% ± 5.5% vs. 108.2% ± 7.7%) between group D and group L (p < 0.05). Moreover, irregularity of PRUJ on radiographs was more in group D (p < 0.05). Conclusions: It is possible that appropriate radiographic assessment in relation to radial head dislocation may prevent delayed surgical treatment of forearm deformities in MHE. Level of Evidence: Level IV (Diagnostic).

Anterior Congenital Radial Head Dislocation in an Adult with Associated Posterior Interosseous Nerve Palsy.

Introduction: Anterior congenital radial head dislocation (CRHD) is a rare abnormality that is less commonly seen in the adult population. Most of the time, adult-onset symptoms are due to the prolonged dislocation of the radiocapitellar joint that has been present since birth. One of the possible complications of having a prolonged radial head dislocation is the presence of neuropathies such as posterior interosseous nerve (PIN) palsy. There has been, however, no literature published regarding the relationship of CRHD with PIN palsy. Case Report: We here report a 66-year-old male incidentally diagnosed with anterior CRHD with concomitant PIN palsy after acquiring a fracture of the lateral humeral condyle. Open reduction internal fixation of the lateral condyle was done along with decompression of the said nerve. PIN palsy was completely recovered 2 months after surgery. Conclusion: Surgeons must be aware that PIN palsies can occur in the presence of a chronic radial head dislocation, even if asymptomatic. Prompt nerve decompression as well as removal of the mechanical block is pertinent to avoid the perilous effects of an irreversible PIN palsy.

Isolated lateral radial head dislocation in a child: A case report and literature review.

INTRODUCTION: Radial head dislocations in children can result from congenital anomalies, traumatic events, or as part of more complex injuries like Monteggia fractures. These dislocations are rare and may be overlooked unless considered in differential diagnoses. CASE PRESENTATION: We describe a unique instance of a post-traumatic isolated lateral radial head dislocation in a 5-year-old boy with no previous medical concerns. The child presented with persistent pain and limited mobility in the left elbow following an unwitnessed fall at home. Diagnosis was confirmed via radiographs showing the dislocation without associated fractures. Closed reduction under anesthesia was successfully performed. CLINICAL DISCUSSION: This case underscores the importance of a high index of suspicion and thorough imaging in diagnosing pediatric radial head dislocations. Our discussion includes a review of the literature and the clinical approach for managing such injuries, highlighting the specifics of the closed reduction technique used. CONCLUSION: Isolated lateral radial head dislocations, although rare, can occur and are amenable to closed reduction. This case contributes to the limited reports of such dislocations in pediatric patients, emphasizing the need for awareness and precise management strategies to prevent long-term complications.

Missed Monteggia Injuries in Children and Adolescents: A Treatment Algorithm.

Monteggia injuries are rare childhood injuries. In 25-50% of cases, however, they continue to be overlooked, leading to a chronic Monteggia injury. Initially, the chronic Monteggia injury is only characterized by a moderate motion deficit, which is often masked by compensatory movements. Later, however, there is a progressive valgus deformity, neuropathy of the ulnar nerve and a progressive deformity of the radial head ("mushroom deformity") with ultimately painful radiocapitellar arthrosis. In the early stages, when the radial head is not yet deformed and there is no osteoarthritis in the humeroradial joint, these injuries can be treated with reconstruction procedures. This can be achieved either by an osteotomy of the proximal ulna with or without gradual lengthening. If there is already a severe deformity of the radial head and painful osteoarthritis, only rescue procedures such as functional radial head resection or radial head resection with or without hemi-interposition arthroplasty can be used to improve mobility and, above all, to eliminate pain. In this review article, we provide an overview of the current treatment options of chronic Monteggia injury in children and adolescents and present a structured treatment algorithm depending on the chronicity and dysplastic changes.

A Novel Operation Technique for Forearm Deformities in Patients with Brachial Plexus Birth Injury: Retrospective Analysis of 14 Patients.

Background: We aimed to evaluate the effectiveness of our novel operation technique that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon in patients with chronic radial head dislocation secondary to brachial plexus birth injury (BPBI). Methods: Fourteen patients with chronic radial head dislocation resulting from BPBI were included in this study, with a minimum 1-year postoperative follow-up period. All patients underwent the same surgical procedure. The range of motion of affected elbow was measured with a standard goniometer. The Mayo Elbow Performance Score (MEPS) was used to measure for evaluation of functional result of these patients. The affected elbow radiograph also obtained in the last visit for evaluation of compatibility of the radiocapitellar joint. Results: Fourteen patients (10 males and 4 females) were included in the study. The average age at the time of surgery was 7.2 (5-8) years and average follow-up was 73.2 ± 19 (36-131) months. Although the forearm active-passive pronation decreased, active-passive supination significantly improved postoperatively (p < 0.001). Ten patients had excellent MEPS results (90 and above), two patients with good results (75 and 80), one patient with fair (65) and one patient with poor result (55). Radiocapitellar reduction was achieved in 78.5% (11/14) of the patients. Conclusions: The novel surgical techniques that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon improved the functional outcomes of patients with chronic radial head dislocation secondary to BPBI. Level of Evidence: Level IV (Therapeutic).

Radial head volume measurements using quantitative three-dimensional computed tomography images for radial head deformation following missed Monteggia lesions.

Background: In chronic radial head dislocation cases, the radial head may enlarge and become dome-shaped. To date, there is no validated tool to quantify radial head deformation and predict its influence on surgical outcomes. This study assesses the potential value of volume and surface calculations obtained by quantitative three-dimensional computed tomography scanning (Q3DCT) in the workup for a corrective surgery in pediatric patients with missed Monteggia lesions. Material and methods: Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and articular surface size of the radial head were calculated using Q3DCT, and a three-dimensional reconstruction of the articular surface relief was depicted in a heat map. The head-neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age-/sex-matched controls. Results: The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age-/sex-matched controls (volume 1487 mm3 vs. 1163 mm3, P = .32; articular surface size 282 mm3 vs. 236 mm3, P = .33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps. A higher head-neck ratio correlated to a larger radial head volume (Pearson r = 0.73; P = .2). Discussion and conclusion: Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential.

Irreducible isolated anteromedial radial head dislocation due to ruptured anterior capsule and annular ligament interposition: A case report.

Traumatic radial head dislocation without a bone-associated lesion is uncommon, and irreducible cases are rare. We herein present a case of isolated irreducible anteromedial radial head dislocation due to anterior capsule and annular ligament interposition in a 16-year-old female patient. The patient was injured when she was thrown by an opponent during a judo match, and her right elbow was outstretched, combined with forearm pronation. Open reduction was required because of soft tissue interposition into the radiocapitellar joint. The ruptured anterior capsule and annular ligament were repaired using the overlapping suture technique; hence, the radial head was stabilized. At 3.5 years follow-up, the patient had satisfactory elbow function, and redislocation did not occur; however, mild degenerative changes were observed on radiographs. We discussed the injury mechanism using anatomical features in this case and previous literature.

Bilateral anterior congenital radial head dislocation in adults: a case report and literature review.

Objective: Congenital dislocation of the radial head (CRHD) is a rare condition, with bilateral anterior cases being even less common worldwide. Only a few cases had residual pain after adulthood, even when left untreated. Herein, we describe an adult case of bilateral anterior CRHD with significant pain and snapping during motion. The aim of this study was to report the physical and radiological findings, treatment methods, and short-term outcomes of our case and to review adult CRHD cases in the literature. Patient: A 21-year-old male patient presented to our hospital with chief complaints of snapping and exacerbated pain during motion in his left elbow. Diagnoses and interventions: Detailed medical history and physical examination results were recorded. Radiographic examinations were performed on the bilateral elbow, and the diagnosis of bilateral anterior congenital radial head dislocation was confirmed. To relieve the pain and snapping in the left elbow, we performed open reduction and fixation of the radial head with annular ligament reconstruction and ulnar osteotomy. Postoperatively, the elbow rested at 90° flexion with a cast for 16 weeks, and the K-wire was removed on the 10th week; afterward, active functional exercises were performed. Outcomes: The patient was followed-up for 1 year. The pain in his left elbow was relieved with a reduction in the visual analog scale score from 7 to 3. The range of motion of the left elbow was changed from 0° to 135° (preoperative) to -5° to 120° (postoperative) (extension-flexion) without any snapping. However, restrictions in external rotation have not yet been fully resolved. Further physical rehabilitation is required. Conclusion: When managing patients with congenital radial head dislocation, the contralateral elbow should be evaluated to identify potential bilateral cases. Surgical options should be discussed with adult patients only for the strong need for functional improvement, although the outcomes may not be fully satisfactory.

Perched Anteromedial Radial Head Dislocation.

Perched anteromedial radial head dislocation is a rare injury pattern that is yet to be reported in the literature. This article describes a case report of an isolated radial head dislocation that was perched on the coronoid process. The images in this study show this rare injury pattern, which did not include a fracture of the coronoid or true elbow dislocation. The patient was successfully treated with a closed reduction. The patient regained full ROM and function. Previously described literature has failed to report this injury pattern or successful closed treatment. The success of this case demonstrates the difficulty of closed reductions even under proper anesthesia and the importance of performing them in the setting where the surgeon has the option to convert to open reduction in unsuccessful cases.

Radiographic evaluation of ulnar deformity in patients with hereditary multiple osteochondroma and its relationship with radial head dislocation.

INTRODUCTION: In patients who have hereditary multiple osteochondroma (HMO), progressive deformity of the forearm skeleton may lead to radial head dislocation. The latter is permanent, painful and causes weakness. HYPOTHESIS: There is a relationship between the amount of ulnar deformity and the presence of radial head dislocation in patients with HMO. MATERIALS AND METHODS: This was a cross-sectional radiographic study comprising an analysis of anterior-posterior (AP) and lateral x-rays of 110 forearms in children having a mean age of 8 years and 4 months who were followed for HMO between 1961 and 2014. Four factors reflecting on the ulnar deformity in the coronal plane were investigated on the AP view and three factors in the sagittal plane were investigated on the lateral view to identify any relationship between ulnar deformity and radial head dislocation. The forearms were separated into two groups: with radial head dislocation (26 cases) and without radial head dislocation (84 cases). RESULTS: Ulnar bowing, intramedullary angle of ulnar bowing, tangent ulnar angle and overall ulnar angle were significantly higher in the group of children who had a radial head dislocation (0.05 vs 0.03, p<.001; 161 vs 167, p<001; 156 vs 162, p<001; 50 vs 30, p<.001) in univariate and multivariate analyses. DISCUSSION: Ulnar deformity, evaluated using the method described here, is more often associated with radial head dislocation than other previously published radiological parameters. This provides new insight on this phenomenon and may help to determine which factors are associated with radial head dislocation and how to prevent it. CONCLUSION: Ulnar bowing in the context of HMO, especially when evaluated on AP radiographs, is significantly associated with radial head dislocation. LEVEL OF EVIDENCE: III; case-control study.

Autologous replacement of the head of the radius-proximal fibula versus second metatarsal base: an anatomic feasibility study.

INTRODUCTION: This study investigated the anatomic feasibility of a new surgical therapy option for radial head arthrosis using an autologous vascularized bone graft of the second metatarsal and proximal fibula to recreate the proximal radiohumeral joint. MATERIALS AND METHODS: Upper and lower extremities of eleven body donors were evaluated using CT prior to anatomic dissection. Several distinct anatomic parameters were measured on the ipsi- and contralateral radial and fibular head and the second metatarsal base: bone diameter, articular surface diameter, head height, metaphyseal (neck) diameter, articular surface radius, total articular surface area, and angulation of the articular surfaces (facet). Each dissection phase was photographed in a standardized fashion and all measurements were repeated by direct caliper-measurements. RESULTS: When comparing the proximal radius and fibula to search for anatomic similarities, similar values were found in the maximum articular surface diameter and minimum and maximum measures of the neck diameter. Comparing the proximal radius and the second metatarsal, statistically similar values were found in the maximum neck diameter performing direct measurements and CT evaluation, the maximum head diameter in CT evaluation and the articular facet angulation. CONCLUSIONS: Neither the proximal fibula nor the base of the second metatarsal are ideal bone grafts for replacement of the head of the radius. The base of the second metatarsal might be a bit more suitable as a potential donor since the angulation of the proximal articular facet is similar to that of the radius. LEVEL OF EVIDENCE: Level IV, anatomic study.

Forearm deformity in multiple hereditary exostosis. Radiologic predictors of radial head dislocation.

INTRODUCTION: Radial head dislocation in patients with multiple hereditary exostosis (MHE) can lead to functional deficit. We investigated whether the location of the exostosis and certain radiological criteria predict risk of radial head dislocation/subluxation. HYPOTHESIS: We hypothesized that the radiological criteria differentiate between patients who need closer follow-up of the forearm and others for whom multiple radiographs are superfluous. PATIENTS AND METHODS: We retrospectively reviewed the demographics of patients with MHE in our hospital, and radiographic measurements were made on forearm radiographs: radial length, ulnar length, ulnar variance, radial articular angle, and radial bowing. RESULTS: Forty-nine forearms were analyzed in 30 patients. Mean age was 9.5 years at first evaluation and 11.8 years at last evaluation. Radial head dislocation or subluxation was found in 6 forearms (12%). Risk factors comprised isolated exostosis in the distal portion of the ulna or exostosis in the distal part of both the ulna and radius, radial or ulnar shortening>4.6cm, radial bowing>8.1%, radial articular angle>35°, and≥3 exostoses in the forearm. DISCUSSION: In patients with MHE with risk factors for radial head dislocation, close follow- up with regular radiography is indicated and early surgery should be performed before the radial head dislocates. LEVEL OF EVIDENCE: IV; retrospective study.

Traumatic Irreducible Pediatric Radial Head Dislocations: A Unique Case and Review of the Literature.

Background: Irreducible radial head dislocations are uncommon injuries and blocks to reduction typically result from interposed soft tissue. We report the case of a pediatric patient who sustained an irreducible radial head dislocation with a concomitant posterior elbow dislocation and coronoid process fracture. To the author's knowledge, irreducible radial head dislocations presenting as part of a terrible triad like constellation of injuries have not been previously reported. A case-based review of the literature was also performed. Case Description: A 7-year-old male presents to our pediatric hospital as a transfer from an outside hospital after sustaining a posterolateral radial head and posterior elbow dislocation secondary to a fall. CT imaging and 3D reconstruction revealed a Type 1 coronoid process fracture. At our institution, closed attempts at reduction in the operating room under fluoroscopy with general anesthesia were also unsuccessful. Open reduction of the radial head and repair of the soft tissue structures was ultimately required to stabilize the patient's elbow injury. Conclusion: Irreducible pediatric radial head dislocations are rare and inherently unstable injuries. To the authors' knowledge, there are no prior reports of irreducible radial head dislocations that present in a terrible triad like fashion with a coronoid process fracture and posterior elbow dislocation. In the present report, successful treatment of this injury required open reduction and soft tissue repair. Level of Evidence: IV.

Clinical Presentation and Characteristics of the Upper Extremity in Patients with Musculocontractural Ehlers-Danlos Syndrome.

Musculocontractural Ehlers-Danlos syndrome (mcEDS) is a subtype of EDS caused by defective dermatan sulfate biosynthesis, characterized by multiple malformations (craniofacial features, ocular and visceral malformations) and progressive cutaneous, skeletal, vascular, and visceral fragility-related manifestations. Repeated dislocations and deformities of the joints due to joint relaxation are observed, causing serious damage to the musculoskeletal system of the whole body; however, the motor function of the upper limbs and the morphology of the bone joints have not been systematically investigated. In this study, we present a detailed and comprehensive report on upper limb lesions of 13 patients with a mean age at the first visit of 21 years. Twelve patients (92.3%) had a history of dislocation. Eleven patients (84.6%) had shoulder dislocations, and two patients (15.4%) had elbow dislocations. Four patients (30.8%) had elbow osteoarthritis, and three patients (23.1%) had distal radioulnar joint (DRUJ) osteoarthritis. The phalanges and metacarpals are thin, and the ratio of medullary cavity of the metacarpal bone decreases with age. As bone and joint deformity progresses, patients with mcEDS should be recommended to receive regular follow-up, including radiology. The present findings suggest an important role for dermatan sulfate in the maintenance of the skeletal system.

Distraction osteogenesis at the proximal third of the ulna for the treatment of Masada type I/IIb deformities in children with hereditary multiple exostoses: a retrospective review of twenty cases.

BACKGROUND: Ulna distraction by monolateral external fixator (MEFix) is a good option for the treatment of Masada type I and IIb deformities in children with hereditary multiple exostoses (HMEs). However, there is no consensus regarding where to perform ulnar osteotomy. Our hypothesis is that osteotomy at the proximal third of the ulna and progressive distraction with MEFix can simultaneously correct elbow and wrist deformities in patients with HME. METHODS: We retrospectively reviewed patients with HME who underwent ulna distraction osteogenesis from June 2014 to March 2019. The carrying angle (CA), radial articular angle (RAA), ulnar variance (UV), radial variance (RV) and range of motion (ROM) of the affected forearm and elbow were clinically assessed before lengthening and at the last follow-up visit. The total ulna lengthening distance (LD) and radiographic outcome were also recorded. RESULTS: Nineteen patients (20 forearms) with HME aged 9.1 ± 2.4 years at the time of surgery were retrospectively reviewed. The mean follow-up period was 26.1 ± 5.6 months. There were 11 patients (12 forearms) with Masada type I deformities and eight patients (8 forearms) with Masada type IIb deformities. Patients with type IIb deformity had higher RV, lower CA values, less elbow flexion and forearm pronosupination than those with type I deformity (p < 0.05); RV was an independent risk factor for radial head dislocation, with the cut off at RV > 15.5 mm. The mean LDs in patients with type I and type IIb deformities were 33.6 ± 6.6 mm and 41.4 ± 5.4 mm, respectively. The mean CA, UV, RV, forearm pronation and ulna deviation at the wrist improved significantly following surgery in all patients. In particular, five of eight patients (62.5%) with type IIb deformities had concentric reduction of the radiocapitellar joint, while no radial head subluxation was detected in patients with type I deformities at the last follow-up. Three complications were recorded: two pin-track infections and one delayed union. CONCLUSIONS: Distraction osteogenesis at the proximal third of the ulna provides satisfactory clinical and radiological outcomes in patients with Masada type I and IIb deformities. Early treatment of Masada type I deformities is indicated before progression to more complex type IIb deformities.

Delayed radial head dislocation after radial shaft fracture fixation: a case report and review of the literature.

BACKGROUND: Ipsilateral fracture of the radial shaft with dislocation of the radial head was a rare injury, but a delayed radial head dislocation after radial shaft fracture fixation was more extremely rare. CASE PRESENTATION: A 39-year-old man fell from the height on his outstretched hand and injured his left, non-dominant forearm. Preoperative radiographs demonstrated a comminuted fracture of the proximal third of the radius but with no apparent dislocation of the distal or proximal radioulnar joints or the elbow. Seven days after the injury, the radius was fixed with a reconstruction locking plate, and the immediate postoperative radiograph revealed a satisfactory reduction. However, a radiograph done at the 4th week postoperatively showed that the radial head dislocated. Manual reduction under anesthesia was tried but failed and the patient refused to take another open surgery. The patient had an acceptable range of motion 12 months after the surgery: elbow flexion 120°, full elbow extension, forearm pronation 80°, forearm supination 80°, but he complained the pain around the elbow. CONCLUSION: In the case of radial shaft fracture especially the when occurs at the proximal third of the radial shaft, even if the radiograph does not show the injury of the proximal radioulnar joint, we should also make a thorough examination of the proximal radioulnar joint. If the radial head dislocation is not initially diagnosed or treated late, a delayed dislocation would be very difficult to manage with a poor expected outcome.