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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 55-57

Elbow dislocation with ipsilateral fracture of radius and ulna in a child – Case report and literature review


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission30-Sep-2019
Date of Decision07-Oct-2019
Date of Acceptance10-Oct-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_14_19

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  Abstract 


Fracture of diaphyseal forearm bones is common, while the elbow dislocation is a rare injury in the pediatric age group. Both injuries are widely reported in isolation or with various associated injuries. The concomitant association of both of these injuries even in adults is only described in the literature as sporadic case reports. The simultaneous presence of both of these injuries in children is even rarer. Here, we present a case of a 9-year-old child with posterior elbow dislocation and ipsilateral diaphyseal fracture of both bones of forearm that was appropriately managed with good outcome. Only one case has been reported younger than ours as per the literature search by authors regarding similar cases.

Keywords: Child, closed reduction, elbow, fixation, forearm, fracture, injury, radius, ulna


How to cite this article:
Dharmshaktu GS. Elbow dislocation with ipsilateral fracture of radius and ulna in a child – Case report and literature review. J Orthop Dis Traumatol 2019;2:55-7

How to cite this URL:
Dharmshaktu GS. Elbow dislocation with ipsilateral fracture of radius and ulna in a child – Case report and literature review. J Orthop Dis Traumatol [serial online] 2019 [cited 2020 Sep 22];2:55-7. Available from: http://www.jodt.org/text.asp?2019/2/3/55/273883




  Introduction Top


Diaphyseal forearm fractures are common pediatric injuries and also common reasons for operation.[1] Increasing age and male dominance have been well attributed to these injuries.[2] The junction of middle- and lower-third diaphysis region has been biomechanically evaluated to be vulnerable to fractures.[3] Most of these fractures occur in isolation, but injuries related to fractures around the wrist or elbow region may be associated at times. Pediatric elbow dislocation, on the other hand, is an uncommon entity with reported incidence of only 3% of all elbow injuries.[4] The fall on outstretched hand is a common mechanism for forearm injuries, whereas a valgus force at elbow and subsequent medial ligament complex disruption have been initiating factor in causing more common posterior or posterolateral elbow dislocation.[5] Elbow dislocation is a concomitant injury with both bone forearm fractures; however, it is a rare presentation with very few reports describing this pattern.[6],[7],[8],[9]


  Case Report Top


A 9-year-old male child was brought to us with a history of injury to his right upper extremity due to fall from height of approximately 5 ft and subsequent landing on his outstretched hand. There were pain, deformity, and disability to use the affected extremity, and dangling forearm was held by the support of opposite upper extremity by the child, as there were swelling and deformity at the elbow on the same side too. There was no open wound except a few abrasions over the dorsal aspect of forearm and legs. There was slow and painful restriction of active movement of fingers on affected side, and distal neurovascular status was intact. The deformity at the elbow was present with a depression above a prominent olecranon tip when compared with contralateral side. The clinical picture was suggestive of a posterior elbow dislocation with associated forearm fracture. The orthogonal radiographs confirmed the diagnosis of a posterior elbow dislocation with fractures of radius and ulna diaphysis [Figure 1] – wrong marker of left]. The child was planned for closed reduction of the dislocation along with operative fixation of forearm fractures with intramedullary nailing. Titanium elastic nailing system (TENS) was chosen as the method for forearm fracture fixation as the standard procedure.
Figure 1: Radiograph showing elbow dislocation with ipsilateral diaphyseal fracture of radius and ulna (The marker for the left side is erroneously printed)

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Following an informed consent for the surgery and data publication from the parents, the surgery was initiated under aseptic conditions and general anesthesia. The elbow was reduced by manual traction to forearm holding the upper-third region so not to disturb ipsilateral forearm fractures, whereas countertraction was provided through the child's flexed arm by an assistant. An uncomplicated reduction was achieved that was assessed clinically and confirmed on image intensifier for its adequacy and concentricity. The forearm fractures were then managed by introduction of TENS following prebending into radius from distal entry through Lister's tubercle and into the ulna through anconeus approach. The ulna nail was introduced closed, while the radius one required a mini-open incision over the fracture site. The fracture stability and maintenance of radial bowing were assessed on image intensifier. The adequate size of nail was ascertained under image guidance before cutting the nail ends and skin closure. A long plaster protection splint was given in view of the rest for elbow dislocation, whereas active finger and elbow movement encouraged throughout postoperative period.

Uneventful postoperative period with healing and removal of stitches was observed, whereas the plaster backslab was continued till 3 weeks. After 3 weeks, gentle physiotherapy and active range of motion exercises were initiated to a full preinjury level movement over a period of 6 weeks. Follow-up at 3, 6, and 12 weeks and then at 3 and 6 months were done with no fresh or remote complications noted. The fracture showed a gradual union [Figure 2]a and [Figure 2]b when viewed at 6 weeks. The implants were removed after 8 months. The patient was pain-free and actively involved in activities of daily living at follow-up of 9 months.
Figure 2: Postoperative radiograph (a) showing stable reduction and fixation of forearm fractures. The elbow is reduced and the radiograph at 12 weeks showing united forearm fractures (b)

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  Discussion Top


The association of diaphyseal forearm bone fractures along with elbow dislocation has been reported on rare instances and is considered severe injury than simple elbow dislocation, as continued axial force has been postulated as the underlying mechanism.[9] Careful assessment of underlying soft-tissue and neurovascular injury, apart from the exclusion of impending compartment syndrome, is warranted in this regard. The sequence of injury is described as dislocation first following a fall on outstretched hand with full extended elbow and pronated forearm, whereas the wrist is radially deviated. Fracture of the forearm bones first nullifies the force enough to cause dislocation further strengthening the theory.[6],[10] Not all reported cases have diaphysis fractures of forearm bones involved, and many describe adult patients, thus occurrence of this pattern in a child of <10 years of age is a rare presentation. Madhar et al. in a small but probably the largest series describing such cases reported six cases with a mean age of 31 years.[7] Kose et al. and Rijal et al. described the injury in an 80-year-old female and 16-year-old male patient, respectively.[6],[8] Fleming et al. have reported the youngest child of 8 years in recent reports with similar injury patterns.[9] Goni et al. described the additional lateral condyle fracture to the aforementioned injury in a 44-year-old female.[10] Another report describes the floating dislocated elbow injury pattern in the past.[11] Mathur et al. described similar fractures with divergent elbow dislocation in a 12-year-old female child.[12] Many workers relate this injury pattern to a Monteggia equivalent injury.[13],[14] One previous report tries to clarify whether it should be called a Monteggia equivalent type 1 or 2 injuries.[15] Overall, a complex injury in pediatric age is uncommon entity but leads to a good functional outcome if managed appropriately.[16],[17] The relevant findings of reported cases within the last 15 years are described in the literature [Table 1]. The current report describes a child with rare injury pattern that is rarely described in the English language literature and highlights the importance of sticking to standard approaches to manage these complex injuries.
Table 1: A brief description of recent reported cases of elbow dislocation with ipsilateral both bone forearm fractures (reported in or after 2004)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999;19:344-50.  Back to cited text no. 1
    
2.
Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B 1997;6:79-83.  Back to cited text no. 2
    
3.
Hsu ES, Patwardhan AG, Meade KP, Light TR, Martin WR. Cross-sectional geometrical properties and bone mineral contents of the human radius and ulna. J Biomech 1993;26:1307-18.  Back to cited text no. 3
    
4.
Henrikson B. Supracondylar fracture of the humerus in children. A late review of end-results with special reference to the cause of deformity, disability and complications. Acta Chir Scand Suppl 1966;369:1-72.  Back to cited text no. 4
    
5.
Rhyou IH, Kim YS. New mechanism of the posterior elbow dislocation. Knee Surg Sports Traumatol Arthrosc 2012;20:2535-41.  Back to cited text no. 5
    
6.
Kose O, Durakbasa MO, Islam NC. Posterolateral elbow dislocation with ipsilateral radial and ulnar diaphyseal fractures: A case report. J Orthop Surg (Hong Kong) 2008;16:122-3.  Back to cited text no. 6
    
7.
Madhar M, Saidi H, Fikry T, Cermak K, Moungondo F, Schuind F, et al. Dislocation of the elbow with ipsilateral forearm fracture. Six particular cases. Chir Main 2013;32:299-304.  Back to cited text no. 7
    
8.
Rijal L, Kc KM, Sagar G. Elbow dislocation with ipsilateral radius and ulna fracture: Is it so common? Nepal Med Coll J 2012;14:163-4.  Back to cited text no. 8
    
9.
Fleming FJ, Flavin R, Poynton AR, Glynn T. Elbow dislocation with ipsilateral open radial and ulnar diaphyseal fractures – A rare combination. Injury 2004;35:90-2.  Back to cited text no. 9
    
10.
Goni V, Behera P, Meena UK, Gopinathan NR, Akkina N, Arjun RH. Elbow dislocation with ipsilateral diaphyseal forearm bone fracture: A rare injury report with literature review. Chin J Traumatol 2015;18:113-5.  Back to cited text no. 10
    
11.
Viegas SF, Gogan W, Riley S. Floating dislocated elbow: Case report and review of the literature. J Trauma 1989;29:886-8.  Back to cited text no. 11
    
12.
Mathur K, Nazir AA, Patil S, Lin K. Divergent dislocation of elbow with ipsilateral fracture in both forearm bones in a child. Eur J Orthop Surg Traumatol 2006;16:36-7.  Back to cited text no. 12
    
13.
Frazier JL, Buschmann WR, Insler HP. Monteggia type I equivalent lesion: Diaphyseal ulna and proximal radius fracture with a posterior elbow dislocation in a child. J Orthop Trauma 1991;5:373-5.  Back to cited text no. 13
    
14.
Hung SC, Huang CK, Chiang CC, Chen TH, Chen WM, Lo WH. Monteggia type I equivalent lesion: Diaphyseal ulna and radius fractures with a posterior elbow dislocation in an adult. Arch Orthop Trauma Surg 2003;123:311-3.  Back to cited text no. 14
    
15.
Modi P, Dhammi IK, Rustagi A, Jain AK. Elbow dislocation with ipsilateral diaphyseal fractures of radius and ulna in an adult-is it type 1 or type 2 Monteggia equivalent lesion? Chin J Traumatol 2012;15:303-5.  Back to cited text no. 15
    
16.
Ramesh S, Lim YJ. Complex elbow dislocation associated with radial and ulnar diaphyseal fractures: A rare combination. Strategies Trauma Limb Reconstr 2011;6:97-101.  Back to cited text no. 16
    
17.
Kumar P, Manjhi LB, Rajak RL. Open segmental fracture of both bone forearm and dislocation of ipsilateral elbow with extruded middle segment radius. Indian J Orthop 2013;47:307-9.  Back to cited text no. 17
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