Injury, Int. J. Care Injured (2005) 36, 324—329

www.elsevier.com/locate/injury

Distal radioulnar joint dislocation in associationwith elbow injuries

A.K. Malika,*, P. Pettitb, J. Compsonc

aNorth East Thames Rotation, 3 Kirklee Road, Kelvinside, Glasgow G12 0RL, UKbSouth East Thames Rotation, UKcKing’s College Hospital, London, UK

Accepted 18 February 2004

KEYWORDSEssex-Lopresti;Distal radioulnar joint;Dislocation;Elbow;Wrist

* Corresponding author. Tel.: +44 7E-mail address: akmalik100@hot

0020–1383/$ — see front matter # 2doi:10.1016/j.injury.2004.02.018

Summary Traumatic distal radioulnar joint (DRUJ) dislocation with or without anassociated fracture is a rare injury. When coupled with a radial head fracture this iscommonly known as the Essex-Lopresti injury. We report two cases of elbow disloca-tion with ipsilateral radial neck fractures and associated true DRUJ dislocations. Thishas not been previously described in the literature.In elbow injuries with wrist involvement, symptoms in the latter may be subtle. Due

to inadequate examination of the affected joint, poor initial radiographic views, andgeneral rarity of this injury, distal radioulnar joint dislocations are frequently missed.We hope our experience illustrates the need to examine thoroughly the joint aboveand below the injured site, and to be aware of the potential for DRUJ instability in allpatients with elbow injuries.# 2004 Elsevier Ltd. All rights reserved.

Introduction

Traumatic distal radioulnar joint (DRUJ) disloca-tion with or without an associated fracture is a rareinjury. When coupled with a radial head fracturethis is commonly known as the Essex-Loprestiinjury, named after the author who describedtwo such cases in 1951.8 The dislocation asdescribed by Essex-Lopresti was a longitudinaldisplacement that could either be acute or ofdelayed onset. The Essex-Lopresti injury in asso-

947 273 934.mail.com (A.K. Malik).

004 Elsevier Ltd. All rights rese

ciation with a fracture dislocation of the elbow hasonly once been reported in the literature.1 Wereport two cases of elbow dislocation with ipsilat-eral radial neck fractures and associated true DRUJdislocations, one dorsal and the other palmar. Tothe best of our knowledge this has not been pre-viously described in the literature. The Essex-Lopresti is a rare injury, and while attention isdrawn to the elbow injury the associated distalradioulnar joint dislocation is all too commonlyoverlooked. We hope that our experience will high-light the need to examine the wrist in every elbowinjury and to be aware of the possibility of DRUJdislocation.

rved.

Distal radioulnar joint dislocation 325

Figure 1

Figure 2

326 A.K. Malik et al.

Figure 3

Case one

A 33-year-old male riding his bicycle was hit by a carand fell on to the point of his left elbow. Clinicallythe most obvious deformity was in the left elbow.Radiographs revealed a posterior dislocation of theelbow associated with an ipsilateral displaced radialneck fracture (Fig. 1). The elbow was reduced undersedation in the A&E department. Check radiographsconfirmed reduction and the radial head appearedto be in an acceptable position. An above elbow castwas applied. On referral to our clinic 3 weeks later itwas noted that he had a prominent distal ulna withlack of forearm rotation. Radiographs revealed adorsal dislocation of the radioulnar joint (Fig. 2).

Figure

Under general anaesthesia the following day thepatient underwent closed reduction of the disloca-tion. This was maintained with Kirschner wires withthe forearm in a position of supination. Wires wereremoved 2 weeks later. Gradual forearm rotationwas commenced in conjunction with an elbow brace(Fig. 3).

Case two

A 34-year-old solicitor fell off his bicycle. Initialradiographs showed an elbow dislocation with aradial neck fracture that was reduced under seda-tion. Check radiographs showed that the radial neck

4

Distal radioulnar joint dislocation 327

Figure 5

fracture was minimally displaced with no loss oflength (Fig. 4). An above elbow cylinder plasterwas applied for 3 weeks. Four weeks following theinjury it was found that the patient had a palmardislocation of the distal radioulnar joint (Fig. 5a andb). The following day the patient underwent openreduction and repair of the triangular fibrocartilagecomplex. The distal radioulnar joint was held inreduction using Kirschner wires (Fig. 6). The elbowwas immobilized in a hinged brace for 3 weeks. At 3months the patient had almost full range of move-ment at the elbow. The patient had no supination of

the forearm but was able to pronate from neutralto 708.

Discussion

Isolated traumatic dislocations or subluxations ofthe distal radioulnar joint are rare. The firstreported case was described by Cotton and Brickleyin 1912, although in their paper they claim that itwas described by Desault in 1777.5 Due to inade-quate examination of the affected joint, poor initial

328 A.K. Malik et al.

Figure 6

radiographic views, and general rarity of this injury,distal radioulnar joint dislocations are frequentlymissed.4

Dislocations and instability of the DRUJ in asso-ciation with fractures are well documented.Between them, Lidstrom and Frykman reviewed945 patients with Colles’ fractures and found anincidence of DRUJ disturbance in 15 and 18.6%respectively.9,11 DRUJ dislocation has been reportedin association with Colles, Smith’s and Galeazzifractures.2,3,10 The first description of a radial headinjury in association with DRUJ dislocation wasdescribed by Curr and Coe in 1946.6 Peter Essex-Lopresti described two such cases in 1951, and thisinjury pattern is now commonly named after him.8

Traditionally distal radioulnar joint dislocationsare termed dorsal or palmar ulnar despite the factthat it is recognized that it is the distal radius alongwith the carpal bones that undergoes the abnormaldisplacement.4 Dorsal dislocation of the DRUJ ismore common than the palmar variety. The originalEssex-Lopresti injury involves neither type of dis-location contrary to popular thinking. The mechan-ism of injury is usually a longitudinal force resultingin impaction of the radial head. With excision or as aresult of gross impaction of the radial head, there isloss of radial length. The dislocation is longitudinaland can be seen to be a translation injury.4 It isprimarily due to changes in the relative lengths ofthe radius and ulna as a result of proximal migration

of the radius, resulting in a positive ulnar variancewith or without soft tissue injury to the distal radio-ulnar joint.7,8

It is recognized that elbow injuries can also resultin injuries to the wrist. The Essex-Lopresti is onesuch injury. True dislocation at the DRUJ is extre-mely rare. Such an injury in conjunction with aradial neck and not a radial head fracture has notbeen described before in the literature. In both ourcases unlike the original Essex-Lopresti injury, thefracture was through the radial neck. The resultingdeformity was therefore mainly angulation withsome rotation and translation of the radius proxi-mally, rather than translation on its own. Thisexplains why the DRUJ dislocation was not a long-itudinal one, but instead palmar or dorsal.

In elbow injuries with wrist involvement, symp-toms in the latter may be very subtle and frequentlyas Essex-Lopresti stated, ‘‘no pain in the wrist orswelling of the forearm was noted’’.8 We recom-mend careful examination of the wrist and in parti-cular the distal radioulnar joint in all elbow injuries.Tenderness and instability around the DRUJ, exces-sive prominence of the distal ulna (dorsal disloca-tion), lack of ulna prominence (palmar dislocation),limitation of ulnar deviation and pain in the wrist onpronation-supination of the forearm should makethe clinician suspect the diagnosis. A true lateralradiograph of the wrist will often show the com-monly associated dorsal subluxation of the distal

Distal radioulnar joint dislocation 329

ulna. Bock et al. recommended that all patientswith radial head fractures have radiographs takenof the wrist.1

The importance of early detection and diagnosisrelates to the eventual treatment and functionaloutcome for the patient. A review of 20 cases byTrousdale et al. in 1992 showed that those diagnosedwith Essex-Lopresti-type injuries fairedmuch betterthan the group that had their wrist injury missed.12

Treatment involved correction of radial lengtheither by stabilizing the radial head fracture or usinga radial head prosthesis. In the group with delayedpresentation additional ulnar shortening was alsoperformed. In both of our cases loss of radial lengthwas not the problem and this would not have helpedin the management. While dorsal dislocations canoften be treated by closed manipulation and Kirsch-ner wire stabilisation, the palmar variety often hasto be reduced by open reduction as the ulnar head islocked on the undersurface of the radius.4 Repair ofa torn triangular fibrocartilage complex may berequired.

We present two unusual cases of elbow disloca-tions associated with radial neck fractures and dis-locations of the distal radioulnar joint. While radialhead fractures have been documented in combina-tion with DRUJ dislocation, radial neck fractureshave not. One of the cases was of the rare palmardislocation. In both cases the wrist injury was initi-ally missed. We hope our experience illustrates theneed to examine thoroughly any joint above andbelow the injured site, and to be aware of the

potential for DRUJ instability in all patients withelbow injuries.

References

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2. Bowers WH. Instability of the distal radioulnar articulation.Hand Clin 1991;7:311—27.

3. Colles A. On the fracture of the carpal extremity of theradius. Edinburgh Med Surg J 1914;10:182—6.

4. CooneyWP, Linscheid RL, Dobyns JH. TheWrist: Diagnosis andOperative Treatment. St. Louis: Mosby; 1998.

5. Cotton FJ, Brickley WJ. Luxation of the ulna forward at thewrist (without fracture). Ann Surg 1912;55:368—73.

6. Curr JF, Coe WA. Dislocation of the inferior radioulnar joint.Br J Surg 1946;34:74.

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10. Khurana JS, Kattapuram SV, Becker S. Galeazzi injury with anassociated fracture of the radial head. Clin Orthop1988;234:70.

11. LidstromA. Fractures of the distal end of the radius. A clinicaland statistical study of end results. Acta Orthop Scand Suppl1959;41:1—95.

12. Trousdale RT, Amadio PC, Cooney WP, Morrey BF. Radioulnardissociation. J Bone Joint Surg 1992;74A:1486—97.