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AUTHOR AND EDITOR INFORMATION

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Author: Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Author and Editor Disclosure

Synonyms and related keywords: radial head dislocation, dislocation of the radial head, chronic radial dislocation, Monteggia fracture, Monteggia fracture dislocation, Monteggia injury, Monteggia complex, isolated radial head dislocation, forearm fractures, elbow dislocation, partial elbow dislocation, occult dislocation, Bado classification, Bado’s classification, radial head, ulna fracture, ulnar fracture, angulated forearm, shortened forearm, radiocapitellar line, anterior elbow dislocation, posterior elbow dislocation, lateral dislocation, capitellar dislocation, radial dislocation


OVERVIEW

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Dislocation of the radial head occurs most frequently in men who are subject to high-force injury.1 In children, the radial head is much more commonly subluxed than dislocated.

Isolated radial head dislocations are rare. Radial head dislocations are usually complicated by complete elbow dislocations or fractures, as in the Monteggia complex.

Monteggia described the combination of radial head dislocation and proximal ulnar fracture in 1814. More than a century later, Bado2, 3 further classified the Monteggia injury into 4 types based on the angulation of the fracture and direction of dislocation (see Table). The Bado classification is useful descriptively but not prognostically. (For more information on the anatomy and fracture patterns in elbow injuries, please see the Medscape article Restoring Elbow Stability After Fracture - Dislocation Part I: Elbow Anatomy and Patterns of Injury in Fracture-Dislocations.)

Radial head dislocation is often associated with significant trauma (eg, motor vehicle accidents, pedestrian–motor vehicle accidents, significant falls). The proposed mechanism is force directed onto an outstretched, pronated arm.4 A person with a radial head dislocation typically holds his or her elbow flexed at 90º and resists passive and active range of motion at the elbow, including pronation and supination. The elbow is often swollen and diffusely tender with increased point tenderness over the radial head. In the case of Monteggia fracture, crepitus may be present over the proximal ulna. The radial head may be palpable in an anterolateral or posterolateral location, and the forearm may appear shortened and angulated.



Swollen elbow from a radial head dislocation.

Radial head dislocations are easily missed on radiographs and, therefore, require a high index of suspicion.5, 6, 7 Undiagnosed chronic radial dislocations lead to poor outcome, limited function, and chronic pain.8 The therapeutic goals are to maximize patient comfort, to recognize and treat any coexisting injury, and to reduce the radial head dislocation within 6-8 hours of injury.9

Bado Classification of Monteggia Injuries

ClassificationIncidenceDescription
Type I60%Fracture of the proximal or middle third of the ulna with anterior angulation and anterior dislocation of the radial head
Type II15%Fracture of the proximal or middle third of the ulna with posterior angulation and posterior dislocation of the radial head
Type III20%Fracture of the ulnar metaphysis distal to the coronoid process with lateral dislocation of the radial head
Type IV5%Fracture of the proximal or middle third of the ulna and fracture of the proximal third of the radius with anterior dislocation of the radial head


INDICATIONS

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In patients with suspected injury, standard anteroposterior, lateral, and oblique radiographs should be taken of the elbow and forearm. For more information, see Elbow, Fractures and Dislocations - Adult. The radiocapitellar line can be used to evaluate for subluxations and dislocations of the radial head (see illustrations below).10 This line, drawn down the body of the radius, normally bisects the capitellum in any degree of flexion or extension. Deviation of this line suggests capitellar or radial dislocation. In a Monteggia fracture, the apex of the ulnar fracture points in the direction of the radial head dislocation.



Landmarks on lateral elbow radiograph: radial head (R), ulna (U), capitellum (C), and humerus (H).



Normal radiocapitellar line drawn from radius through the mid capitellum.



Abnormal radiocapitellar line due to dislocation of radial head. Line does not bisect capitellum. The apex of the ulnar fracture points in the direction of the radial head dislocation (anteriorly, in this case).


CONTRAINDICATIONS

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  • The management of a radial head dislocation is dictated by the presence or absence of an associated fracture. If an associated fracture is present, the forearm is not considered stable; in such a case, bedside reduction of a radial head dislocation is not appropriate.
  • Open and complex radial head dislocations as well as Monteggia fractures in adults require the consultation of an orthopedic or hand surgeon.11 Such injuries are usually reduced with fixation in the operating room.


ANESTHESIA

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Reduction is optimally performed on a relaxed and comfortable patient by using one of the following methods:


EQUIPMENT

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  • Splinting supplies are needed for postreduction.
  • If procedural sedation is used, the standard monitoring equipment is necessary.


POSITIONING

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  • For most reduction techniques, the patient may sit upright or lie supine.
  • Bado suggested that reduction be performed in the opposite direction of the external force at the time of injury and that the forearm be immobilized in this position.
  • Most injuries occur in a pronated position; therefore, after reduction, splint the forearm in the supine position with 90° elbow flexion.


TECHNIQUE

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  • Assess and document the neurologic and vascular status of the arm.
  • Further evaluate the arm based on the type of injury described below.
    • Monteggia injuries were once treated nonoperatively in adults. However, surgical treatment of these injuries results in decreased pain, less restricted motion, decreased valgus, and less late neuropathy.12, 13, 14, 15, 16 Once the ulna is fixed, often by operative compression plating,17, 18 the radial head often self-reduces. If orthopedic or surgical care is not immediately available, the physician who provides initial treatment may splint the fracture and perform reduction as instructed below for children, with prompt referral to a specialist.
    • Although operative repair is recommended in adults, a conservative approach is often used in children with Monteggia injuries.19, 20, 21 Children may be treated by closed reduction of both bones and long-arm–cast immobilization.22 The key to reduction in children is to obtain normal length and alignment of the ulna, after which the radial head falls into place. When necessary, open reduction and internal fixation are performed.23 Some advocate primary operative care in complete ulnar fractures because of the shortening and angulation that may occur without fixation. In general, surgical repair of ulnar fractures in children may involve relatively smaller plates and screws than those used in adults because of rapid osseous repair. In transverse and short oblique fractures, an intramedullary wire may be used.
  • Type I Monteggia injury (anterior dislocation)
    • Closed reduction: Treatment is usually nonsurgical in children. The key to success is the proper reduction of the ulnar fracture. Reestablish the proper length of the ulna and correct any angulation. Once the ulna is reduced, the radial head is easily replaced. With the elbow flexed 115° to relax the biceps, provide longitudinal traction and fully supinate the arm while providing posterior manual pressure on the proximal radius anteriorly. Splint the arm in 90° flexion and supination, using 3-point molding to counteract the forearm musculature. Repeat radiographs in one week to assess continued proper reduction. A long-arm cast may be used for 3 weeks, followed by 3 weeks in a short-arm cast.
    • Open reduction: Indications for open reduction are failure to maintain ulnar or radial anatomic position.
  • Type II Monteggia injury (posterior dislocation)
    • Closed reduction: Reduction is accomplished with longitudinal traction with the elbow extended because the ulna is most stable with the arm extended. The radial head is reduced with pressure directed anteriorly onto the radial head. Once reduced, 3-point cast molding is placed with the elbow in extension and pronation (70° of flexion). This metaphyseal fracture heals quickly and the cast can usually be removed in 3 weeks. However, immobilization must continue until union of the ulna occurs, which may take up to 10 weeks in older patients. Flexion may return slowly.
    • Open reduction: Operative indications are the same as in type I Monteggia injuries.
  • Type III Monteggia injury (lateral dislocation)
    • Closed reduction: The incidence of posterior interosseous nerve injury is high with this lesion; however, this resolves spontaneously and rapidly. Reduction is accomplished by hyperextension and stabilization of the olecranon followed by a valgus force to the olecranon. This force corrects the greenstick fracture, and the radial head often spontaneously reduces. If necessary, direct medial pressure to the radial head facilitates reduction. Controversy exists concerning the best type of immobilization for a type III injury. Some advocate splinting, as in type I Monteggia injuries (115° of flexion), and some recommend immobilization in a long-arm cast in extension with valgus stress applied to the ulna.24 The cast should be maintained for 4-6 weeks.
    • Open reduction: This type of injury is most commonly irreducible because of annular ligament interposition.
  • Type IV Monteggia injury (fracture of both forearm bones)
    • Closed reduction: Nonoperative methods for this unstable fracture are difficult and often unsuccessful.
    • Open reduction: Unlike the other 3 types of Monteggia injury, type IV lesions usually require initial surgical stabilization of the radius and ulna fractures. The elbow is immobilized in supination and hyperflexion (115°) in a long-arm cast for 3 weeks. A short-arm cast is applied for an additional 3–4 weeks.
  • Reduction of the isolated dislocated radial head25, 26, 27, 28, 29, 30
    • Anterior: Supinate the arm and flex the elbow to 115° to relax the biceps. An assistant holds the humerus distally for stabilization while the physician applies distal traction to the wrist and direct posterior pressure to the radial head.

      Technique for reduction of an anterior radial head dislocation.
    • Posterior:31 The arm is held supinated in extension at the patient’s side and the humerus is stabilized distally. With care not to hyperextend the arm, distal traction is placed at the wrist and anterior pressure is applied to the radial head.

      Technique for reduction of posterior radial head dislocation.
    • Lateral: Similar to the technique used in a posterior reduction, provide stabilization to the distal humerus and distal traction at the wrist while applying medial pressure to the radial head.

      Technique for reduction of lateral radial head dislocation.
    • Failure to reduce: In some instances, the elbow is not reducible using closed reduction techniques and operative repair is necessary. Reasons for this include delayed treatment,32 presence of interposed tissues that impede reduction, or an extremely unstable elbow. In rare cases, osteosynthesis or resection of the radial head may be necessary.
  • Postreduction care and rehabilitation
    • Once reduction is complete, reassess and document the neurologic and vascular status of the arm. Evaluate the elbow in its full range of motion (varus, valgus, pronation, supination) and check for soft tissue, bony blocks, or other instability. Apply a posterior splint in 90° flexion and supinate for isolated dislocations.
    • Obtain postreduction radiographs and reevaluate the radiocapitellar line. If reduction is performed in the operating room, stability of the radial head may be checked under fluoroscopy. Patients are generally admitted for 24 hours to observe for possible complications such as compartment syndrome.
    • The range of motion exercises can be initiated when pain and swelling permit. Frequent radiographs should be taken to confirm that the elbow remains reduced during early rehabilitation. In isolated radial head dislocations, range of motion is instituted within a few days and the splint is generally discontinued after 1-2 weeks if the elbow is deemed stable. Unstable elbows require longer immobilization.
    • After such an injury, a loss of 5-10° of extension compared with the contralateral elbow can be expected; however, uncomplicated radial head dislocations have a favorable prognosis.33
    • Follow-up with an orthopedist is mandatory.


PEARLS

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  • Be wary of other serious associated injuries, especially to the head and chest.
  • Carefully evaluate the bones and joints above and below the injury.
  • Always assess and document the neurologic and vascular status of the arm before and after reduction.
  • Before discharging a patient with a forearm or elbow injury, always use the radiocapitellar line to check any misalignment of the radial head.34 This is especially important in the case of an ulnar fracture.


COMPLICATIONS

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  • Osteomyelitis: Carefully evaluate for signs of an open fracture and treat appropriately to avoid serious infection.35
  • Compartment syndrome: Elevated compartment pressures are not uncommon after serious forearm injuries. For this reason, hospital admission for observation is advocated.
  • Neurologic injury: Although neurologic injury is uncommon, it may occur as a consequence of the injury or as a result of the reduction.36 The posterior interosseous nerve is the most commonly injured nerve; this injury results in weakness of finger or thumb extension.37, 38, 39, 40, 41 Sensory involvement is rare. Postreduction neurapraxia is often a temporary problem that resolves spontaneously.42 Paralysis that does not improve may require further surgery.
  • Chronic pain: Long-term disability and chronic pain can result from missed radial head dislocations, which occur in up to 50% of cases.
  • Redislocation: Immobilization does not guarantee the maintenance of reduction. Even if immobilized, the radial head may spontaneously dislocate. Repeat radiographs should be obtained at follow-up.
  • Loss of motion: Reduced ability to pronate and supinate or flex and extend the elbow is common immediately after cast removal. If loss of motion is promptly treated, function usually returns completely within 3 months.43 Stiffness may be avoided with early range of motion exercises or surgical capsulectomies.
  • Periarticular ossification: Periarticular ossification can occur in cases of chronic dislocations. Ossification tends to reabsorb postreduction. Heterotopic ossification should be excised more than 6 months after injury or treated with indomethacin or radiation.
  • Posttraumatic proximal radioulnar synostosis: This complication occurs in a minority of injuries and may be treated with anti-inflammatory medications, radiation, or surgery.44, 45
  • Nonunion of fracture


DELAYED TREATMENT

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  • As mentioned above, many radial head dislocations are missed on initial presentation and may be diagnosed years later.46
  • Previously undiagnosed radial head dislocations are fixed operatively in adults and are usually fixed operatively in children.47, 48
  • The triceps tendon can be used to reconstruct the annular ligament through techniques described by Bell Tawse,49, 50 Lloyd-Roberts, and Bucknill.51 DeBoeck describes a procedure without annular ligament reconstruction.52
  • At times, the nonreducible radial head may require excision.53 Seel, Peterson, and Papandera have also described alternative reduction techniques.


ACKNOWLEDGMENTS

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The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.


MULTIMEDIA

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Media file 1:  Landmarks on lateral elbow radiograph: radial head (R), ulna (U), capitellum (C), and humerus (H).
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Media type:  Illustration

Media file 2:  Normal radiocapitellar line drawn from radius through the mid capitellum.
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Media type:  Illustration

Media file 3:  Abnormal radiocapitellar line due to dislocation of radial head. Line does not bisect capitellum. The apex of the ulnar fracture points in the direction of the radial head dislocation (anteriorly, in this case).
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Media type:  Illustration

Media file 4:  Isolated posterior radial head dislocation.
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Media type:  X-RAY

Media file 5:  Reduced isolated posterior radial head dislocation.
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Media type:  X-RAY

Media file 6:  Technique for reduction of an anterior radial head dislocation.
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Media type:  Presentation

Media file 7:  Technique for reduction of posterior radial head dislocation.
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Media type:  Presentation

Media file 8:  Technique for reduction of lateral radial head dislocation.
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Media type:  Presentation

Media file 9:  Swollen elbow from a radial head dislocation.
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Media type:  Photo


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Joint Reduction, Radial Head Dislocation excerpt

Article Last Updated: Nov 19, 2007
Topic originally published: Jan 13, 2006