Isolated palmar dislocation of the distal radioulnar joint in a football player

Palmar dislocation of the distal radioulnar joint without concomitant fracture of the radius or ulna is an uncommon injury. We report one case in a college football player. This case was unusual in that open reduction was required 2 days after the injury because of an unsuccessful closed reduction. Received: 22 February 1999     

青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗

目的 探讨青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗方法.方法 采用短缩尺骨、重建下尺桡关节法,对7例桡骨陈旧性骨折、短缩,下尺桡关节重度脱位患者进行治疗.术后对患者腕关节外形、功能进行随访.结果 所有患者外形恢复良好,功能评价优6例,良1例.结论 短缩尺骨、重建下尺桡关节法是治疗桡骨陈旧性骨折、短缩,下尺桡重度脱位的有效方法.     

不固定下尺桡关节治疗桡骨远端骨折合并下尺桡关节不稳定的病例对照研究

目的：探讨桡骨远端骨折合并下尺桡关节不稳的治疗方式。方法：2007年6月至2009年12月,采取切开复位内固定治疗不稳定型桡骨远端骨折264例,其中42例术中发现合并下尺桡关节不稳,20例采取克氏针固定下尺桡关节或旋后位石膏外固定治疗（固定组）,22例未行固定（非固定组）。术后对握力和腕关节活动范围进行观察;采用Sarmiento改良的Gaaland-WeAey评分系统（GW评分）对腕部功能进行评估,并测试下尺桡关节稳定性。结果：41例患者均获得1年以上随访,所有患者桡骨远端骨折均在术后3个月内获得愈合,下尺桡关节均对合良好,没有出现明显半脱位或脱位。两组患者的握力、腕关节活动范围及GW评分差异无统计学意义（P〉0．05）。l例发生远期下尺桡关节不稳。结论：对桡骨远端骨折合并下尺桡关节不稳定采用锁定钢板固定系统治疗桡骨远端骨折的同时,固定与不固定下尺桡关节临床效果无差异,因此对于合并下尺桡关节不稳的桡骨远端骨折,若桡骨远端骨折能获得满意的解剖复位,不推荐l期固定下尺桡关节。     

Galeazzi fracture-dislocation: a new treatment-oriented classification

Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.     

Radioulnargelenkverletzungen

The proximal and distal radioulnar joints are both responsible for free rotation of the forearm and thus functionally interconnected. The Monteggia injury (ulna fracture + radial head luxation) and the Galeazzi injury (diaphyseal radial fracture + dislocation of the radioulnar joint) have a better prognosis than radioulnar joint injuries in conjunction with distal radius fractures. The latter lead to injury of the ulnocarpal complex and more frequently to malalignment of the distal radioulnar joint, which in turn leads to arthrosis. This is characterized by early occurrence of pain, loss of strength in the hand, and limited rotation of the forearm. Thus, surgical management should be especially directed at restoration of the articular surface, correct length adjustment, and reconstruction of the anatomic angle. The choice of surgical procedure depends on the extent of destruction of the distal radial articular surface, the degree of dislocation, and the presence of soft tissue damage.     

Complex dislocations of the distal radioulnar joint. Recognition and management.

Contrary to most reported series, it has been the authors' experience that dislocations of the distal radioulnar joint (DRUJ) associated with fractures of the forearm are frequently irreducible. This report reviews the authors' experience with these injuries, focusing on the recognition and management of what the authors call "complex" DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or "mushy" reduction caused by soft tissue or bone interposition. From 1984 until 1989, at the authors' institution, 11 patients were treated for fractures of the radius associated with dislocations of the DRUJ. Eight of these patients had a classic Galeazzi fracture dislocation. Two patients had severe open radius and ulnar fractures. One had an unstable comminuted intraarticular fracture of the distal radius. Of these 11 patients, four had "complex" dislocations of the DRUJ. In two cases, the extensor carpi ulnaris was displaced volar to the distal ulna, necessitating open reduction. A third case involved delayed recognition of multiple wrist and forearm joint dislocations associated with a severe open fracture of both bones of the forearm and required late exploration, reduction, and temporary internal fixation. A fourth case involved recurrent dorsal subluxation of the distal ulna after open reduction and internal fixation of a comminuted intraarticular distal radius fracture. It is clear that complex dislocations of the DRUJ occur more frequently than previously noted. Careful attention to these injuries during initial reduction attempts will reveal "mushy" or unobtainable reductions, an important indication for exploration for entrapped tendon, bone, or soft tissue.     

Surgical correction of recurrent volar dislocation of the distal radioulnar joint. A case report

Recurrent volar dislocation of the distal ulna is an unusual injury. The role of various anatomic structures in providing stability of the distal radioulnar joint is controversial. Surgical reconstruction of the distal radioulnar joint was performed in a 25-year-old woman. A sling procedure was performed along with reconstruction of the fibrous osseous canal of the extensor carpi ulnaris (ECU). The ECU appears to play a role in stabilizing the distal radioulnar joint. When dislocation of the ECU tendon is noted intraoperatively, reconstruction of the fibrous osseous canal should be done.     

The crisscross injury mechanism in forearm injuries

Introduction A new mechanism of injury of the forearm bones, crisscross injury, is described. It is more common than the Essex-Lopresti fracture dislocation. The old concept of isolated injury of one side of the radioulnar joint may be challenged. It often occurs in Mason type II fracture dislocation of the radial head or dislocation of radioulnar joints.Materials and methods The first part was a cadaveric study of the crisscross injury of forearms. The second part was a clinical study of the crisscross injury in some cases of Mason type II fracture radial head and double dislocation of the radioulnar joint.Results The cadaveric study confirmed a stable crisscross fracture dislocation injury with intact interosseous membrane. The clinical study echoed the presence of this injury by imaging techniques.Conclusion The crisscross injury mechanism explains the mirror pathogenesis of the traumatic fracture dislocation of the distal and proximal radioulnar joints with intact shaft of the radius and ulna. Co-existing subluxation or dislocation of the other radioulnar articulation must not be overlooked in cases of fracture dislocation of one radioulnar joint. Two types of crisscross injury of forearm bones are proposed.     

Simultaneous dislocations of the radiocapitellar and distal radioulnar joints

Posttraumatic instability of the distal radioulnar joint (DRUJ), occurring in isolation or in association with fractures of the radius, is well-documented. Few reports have identified simultaneous ipsilateral DRUJ instability and elbow dislocation. The authors of the present study describe a case of persistent radiocapitellar subluxation after closed reduction of an elbow dislocation, secondary to irreducible volar subluxation of the DRUJ.     

Gelenkflächenverhalten der Articulatio radioulnaris distalis bei fehlgestelltem distalem Radius

Pathological changes of wrist bones and ligaments after radial fracture loco typico induce permanent functional restriction and pain. In this paper the effects of malunion on the distal radioulnar joint are investigated and osteotomic therapy of Kinenböck's disease gets a new evaluation. By simulating radial malunions on anatomic forearm specimen the effects of these malunions on the contact area during supination, neutral position and pronation are measured. Isolated posttraumatic radial shortening as well as epiphyseal inclination and torsion cause a reduction of radioulnar contact. During supination and pronatijon the loss of radioulnar contact increases. Most significant reduction of contact takes place at a lower graduation of radial malunion. Pronatory torsion of distal radius compensates for a radioulnar contact reduction from combining dorsal inclination with radial shortening. One conclusion of this paper is an exact restitution of anatomical relations between ulnar head and radial notch after fracture of the distal radius.     

Irreducible dislocation of the distal radioulnar joint

Although dislocation of the distal radioulnar joint is commonplace in association with fractures of the radial shaft, irreducible dislocation has previously been considered to be rare. In the only three previously reported cases the tendon of the extensor carpi ulnaris blocked reduction of the distal radioulnar joint in Galeazzi injuries. The cases presented in this report show that other tendons may be involved, and that the injury may occur even when the ulna is broken. It is likely that the injury described is more common than is realized and is usually overlooked.     

Fractures and dislocations of the distal radioulnar joint

Fractures and dislocations of the distal radioulnar joint are frequently visualized as a secondary problem in comparison to the more apparent radius fractures. Frequently, in the long-term follow-up of patients with radius fractures, ulnar wrist pain secondary to distal radioulnar joint incongruity is the final outcome. Therefore, in the evaluation of the injured forearm the distal radioulnar joint must be assessed clinically and radiographically. In this assessment if distal radioulnar joint instability or incongruity is present then joint stabilization or reduction, respectively, must be attained.     

Transverse divergent dislocation of the elbow with ipsilateral distal radius fracture in a child

We report a rare case of an irreducible transverse divergent dislocation of the elbow with an ipsilateral distal radius torus fracture and a fracture of the coronoid process in a 9-year-old male. Closed reduction of the elbow was attempted, but the humeroulnar joint remained dislocated. At surgery, the avulsed anterior band of the medial collateral ligament complex of the elbow was found to be interposed between the medial condyle of the humerus and the olecranon. The dislocation was reduced after relieving the ligament entrapment, which was then repaired. The unstable proximal radioulnar joint was fixed with a Kirschner wire. Two years after surgery, the patient had a painless left elbow with full range of motion and no instability. He was able to use his upper extremity for all activities in his daily life and had returned to sports. No radiographic abnormalities were found at this follow-up, particularly premature epiphyseal closure of the radial head. Closed reduction has been successful in a majority of reported cases of transverse divergent dislocation of the elbow, yet the presence of an incomplete reduction of the ulnohumeral joint should alert the physician to the possible interposition of soft tissues or bony fragments necessitating an open reduction.     

Acute dislocations of the distal radioulnar joint and distal ulna fractures

This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.     

Radiocarpal fracture-dislocations

Radiocarpal fracture-dislocations most often are caused by high-energy trauma. These difficult, uncommon injuries involve significant soft-tissue and osseous trauma, requiring meticulous reduction and fixation. The mechanism of injury is generally a severe shear or rotational insult. Anatomically, the dislocation results in disruption of the radiocarpal ligaments and, usually, both the radial and the ulnar styloid. Understanding the anatomy of the radiocarpal joint is central to understanding the osseous and soft-tissue constraints that are disrupted with a radiocarpal dislocation. Diagnosis can be reliably made on physical examination and radiographic evaluation. Radiocarpal fracture-dislocation injuries must be differentiated from Barton fractures. Associated injuries such as open fractures, neurovascular involvement, and distal radioulnar dislocations also must be taken into account. Closed reduction can be obtained relatively easily, but open reduction and internal fixation is typically necessary to ensure accurate anatomic restoration of injured bone and ligaments.     

Bilateral Galeazzi fracture-dislocations

We present the case of a patient with bilateral Galeazzi fracture-dislocations with an irreducible distal radioulnar joint (DRUJ) on one side. Current treatments, such as anatomic reduction and stable internal fixation of the radius and anatomic and stable reduction of the DRUJ followed by plaster immobilization in supination, have produced results much better than those associated with historical conservative treatments. The most important part of successful treatment is maintaining intraoperative control of reduction quality, DRUJ stability, and, if necessary, open reduction of the DRUJ. Here we describe the surgical technique and present the rare case of a DRUJ being irreducible because of interposition of the extensor carpi ulnaris tendon.     

Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited

Seven adults with displaced radial head fractures had concurrent dislocation of the distal radioulnar joint. Because support of the radius was lost at both the elbow and wrist, proximal migration of the radius from 5 to 10 mm occurred. Different types of fractures were classified to designate the best method of restoring radial length to prevent chronic wrist pain and stiffness. Type I fractures had large displaced radial head fragments with minimal or no comminution and amenable to interfragmentary fixation. Type II fractures had severe comminution requiring radial head excision and prosthetic replacement. Type III were old injuries with irreducible proximal migration of the radius managed by ulnar shortening and radial head prosthetic replacement. There were three Type I, two Type II, and two Type III fractures. Results of treatment were graded as 3, excellent; 2, good; 1, fair; and 1, poor. The three excellent results were in patients in which restoration of radial length was achieved within one week of injury. Suboptimal results occurred in the remaining four patients when definitive surgery was delayed four to ten weeks. The poor result was in a patient treated only by radial head excision and who refused further surgery. Recommendations include meticulous clinical and roentgenographic examination of the distal radioulnar joint in all patients with displaced radial head fractures. Preservation of the radial head with anatomic reduction and rigid internal fixation is preferred, but radial head replacement may be necessary in cases with extensive comminution. Radial head excision alone, though contraindicated, may be restructured by ulnar shortening and radial head prosthetic replacement.     

Luxationsfrakturen des Unterarms

Combined forearm fractures are identified according to their location as Galeazzi, Monteggia, or Essex-Lopresti injuries. The feature common to these three forms is the combination of a forearm fracture with instability of the distal or proximal radioulnar joint. Appropriate management of the injury at an early stage is indispensable to achieve good functional results. Galeazzi fractures should initially be treated by open reduction and correct anatomy restored by plate osteosynthesis. Fixation of the distal radioulnar joint with Kirschner wires should be performed in cases of persistent dislocation or instability and limited to 6 weeks. Monteggia fractures should be surgically approached, taking care not to overlook possible additional injuries (radial head, coronoid process). Essex-Lopresti injuries are treated by surgical reconstruction of the radial head, and in cases of comminuted fractures by implanting a radial head prosthesis. Subsequent treatment entails at least 14 days immobilization in a supinated position using an upper arm cast. Early functional therapy should follow when all three forms of injuries have been treated.     

Corrective osteotomy for volar instability of the distal radioulnar Joint associated with radial shaft malunion

Volar instability of the distal radioulnar joint is an uncommon wrist disorder. We report three cases of recurrent volar instability of the distal radioulnar joint secondary to fracture of the radial shaft. In all cases, X-rays showed a volar apex deformity of the radial shaft. Opening wedge osteotomy and iliac bone grafting was performed on the distal diaphysis of the radius instead of on the radial shaft, in order to adjust the distal radioulnar joint more easily. Pre-operative dislocations and painful clunks disappeared in all three patients. However, slight instability of the distal radioulnar joint remained in all cases. Osteoarthritis of the distal radioulnar joint was noted in one patient 31 months after the operation. All of the patients were satisfied with the results and did not desire further operations.     

Pediatric complex divergent elbow dislocation

A divergent dislocation of the elbow is a very rare injury, and only a few cases have been described in the literature. It is characterized as a dorsal dislocation of the ulnohumeral joint combined with a lateral dislocation of the proximal radius. All three articulations of the elbow joint are involved. Like in our case, it can be accompanied by an avulsion fracture of the coronoid and a distal radius fracture. For correct understanding of the injury, proper radiographic studies are imperative. In contrast to some earlier reports that advise a conservative approach, we performed a very aggressive operative treatment. To ensure anatomic reconstruction of the elbow, surgical exposure of the various injuries was performed first. After gross reduction of the joint dislocation, definitive osteosynthesis of the distal radius fracture was performed. Subsequently, the coronoid process and lateral collateral ligament could be repaired anatomically, improving the stability of the elbow. An uneventful recovery with excellent elbow motion and stability was achieved.