Pediatric radial head dislocation can be part of a syndrome or isolated. management depend mainly on the etiology

2. PEDIATRIC RADIAL HEAD
DISLOCATION
By

3. Objectives
 Radiological Anatomy of the elbow
 Differentiate congenital vs traumatic (proper diagnosis)
 If traumatic isolated or Monteggia
 Debate in management

4. Is this congenital or traumatic ?

5. • Assessment of these radiographs depends on evaluating the
anatomic relationships of the ossification centers of the
elbow including
The position of the radial head relative to the capitellum
Anterior humeral line relative to the capitellum
Baumann’s angle
Interpretation of pediatric elbow radiographs is complicated by
the cartilaginous components of the elbow that are radiolucent.

6. Radio-capitullar line
(AP)
Anterior humeral &
Radio-capitullar lines
(Lat)

8. Relation bet. Humeral shaft & capitellum
• The capitellum is angulated
anteriorly about 30 degrees.
• The appearance of the distal
humerus is similar to
a hockey stick.

9. Radial head stabilizers

11. Causes
Congenital
• Rare but it is the
most common cong.
anomaly of elbow
• Isolated or syndromic
in more than of 50%
Traumatic
Mostly as a part of monteggia
Rarely as isolated
Developmental
Inadequate length of the
radius & multiple hereditary
osteochondromatosis (MHE)

12. Congenital VS traumatic
 Bilateral involvement in 60%
 Hypoplastic capitellum
 Lack of history of trauma
 Dome shaped radial head
 Other congenital anomalies
 Posterior is the most common

13. Radiographic diagnostic criteria as described
by McFarland
 Shortening of the ulna or overlength of
the radius
 Hypoplasia of the capitellum
 Grooving of the distal radius
 Prominent ulnar epicondyle
 Partially defective trochlea
 Dome-shaped radial head with a long
narrow neck

14. Additional criteria that favour a congenital dislocation are
described by Mardam-Bey & Ger (1979)
 Bilateral involvement
 Other congenital anomalies
 Familial occurrence
 Dislocation seen at birth
 No history of trauma
 Ulnar bowing

15. Presentation
 Congenital radial head dislocation is not
manifest at birth because the condition is
difficult to detect clinically.
 Usually diagnosed years after birth
No associated history of trauma.
 limitation of forearm motion especially supination.
 Mechanical block of elbow flexion occurs with anterior radial head dislocation.
 Posterior dislocation presents with bony prominence of the radial head in the postro-lateral aspect
 Painful elbow snapping as a result of annular ligament interposition during flexion and extension

16. Isolated congenital vs syndromic
• 60% of all cases, seen in conjunction
with various syndromes e.g
Nail patella syndrome
Silver’s syndrome
Ehlers-Danlos syndrome
congenital radioulnar synostosis
mental retardation
Other associated anomalies include
 Skeletal dysplasia
 Craniosynostosis
 Synostosis of the tibia and fibula
 Scoliosis.

17. Nursemaid's elbow (Pulled elbow)
• Untreated traumatic dislocation of the radial head during childhood
may present with radiographic and clinical manifestations that are
similar to those of congenital radial head dislocation.
• The differentiation can be difficult.
Radiographic criteria that may support its congenital nature include:
 Short radius relative to the ulna
 Bilateral involvement
 The presence of other musculoskeletal anomalies

18. Let‘s to answer this ?
Is this congenital or traumatic ?

19. Isolated VS Monteggia
• Isolated traumatic radial head
dislocation is exceptional
• When you find a case of traumatic
radial head dislocation is considered
Monteggia till proved otherwise
• Diagnosis of isolated radial head
dislocation is the diagnosis of
exclusion
Isolated traumatic dislocation of the
radial head is controversial

21. Isolated traumatic dislocation
• The mechanism is not well known
 Two opposing theories are described.
Forced hyper-pronation forearm on
elbow in extension with or without
varus has been described
The other is hyperforced elbow extension
on full supination of the forearm with or
without tear of the biceps

22. Treatment of congenital radial head dislocation
SURGERY
• Various surgical treatment possibilities
have been discussed in literature:
 Resection
 Rotation & shortening osteotomy
 Reconstruction of the annular ligament
 Ulnar osteotomy ± annular reco.
 Ilizarov assisted reduction
Conservative
The elbow is not so forgiving when
operated upon
DO NOT TOUCH ASYMPTOMATIC PATIENT

24. Indications of surgery
• Symptomatic patient :
 Pain
 Painful snapping
 Functional impairment (ROM)
 Cosmetic reasons.

25. Treatment of traumatic radial head dislocation
Conservative
DO NOT TOUCH ASYMPTOMATIC PATIENT
Acute
Closed reduction ± pinning
If failed
Open reduction with annular repair or
reco. ± pinning
Chronic
Surgery
Open reduction +
Annular lig. Reco.
Ulnar osteotomy

26. Annular ligament reconstruction
Using
 Central or lateral slip of
triceps fascia
 Forearm fascia
 Fascia lata
 Palmaris longus tendon.
Theoretically this fascial slip acts both as a dynamic
and static stabilizer and prevents radial head
subluxation.
Modified Bell Tawse technique

27. Actually reconstruction alone is insufficient to maintain the reduction.
Possible complications
 Osteolytic changes
 Avascular necrosis
Narrowing and growth disturbance of the radial neck
 Heterotopic ossification
 Radio-ulnar synostosis
 Restricted pronation and supination

28. Missed Monteggia fracture in children:
Is annular ligament reconstruction always required?
• CONCLUSION:
Distraction-angulation osteotomy of the ulna suffices in
most cases of missed monteggia fracture and the need
for annular ligament reconstruction is based on
intraoperative findings of radial head instability
Indian journal of orthopedic IJO 2009

30. Ulnar osteotomy with or without ligament
reconstruction
 Floating osteotomy without fixation or stabilized by graft
 Corrective diaphyseal osteotomy
 Proximal bending osteotomy
 Angulation and elongation osteotomy ( most popular nowadays)
 Gradual lengthening and angulation of the ulna using an external fixator.

31. Angulation elongation osteotomy

32. Angulation-Elongation
osteotomy
What a result

37. They concluded their work into this table

38. What about trans-capitullar K- wire
(much debate)
Old thinking
In procedures involving reconstruction around the radial head, it is mandatory to
stabilize the radial head by a trans-capitellar K wire to prevent redislocation

39. What about
Ilizarov

41. How to plan your frame

42. What a result ?!

43. Take home message
Identify radial head dislocation
Differentiate congenital from traumatic
Differentiate isolated traumatic from monteggia
Specify treatment method of each case individually