Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

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Technical note

Chronic isolated radial head dislocation in adults: Technical note and

literature review
Alice Bordet a , Oregan Le Mentec a , Marc Arcens b , Pierre Trouilloud a,c ,
Emmanuel Baulot a,c , Pierre Martz a,c,∗
a
Département d’orthopédie et traumatologie, CHU de Dijon, 21000 Dijon, France
b
Hôpitaux universitaires de Genève, avenue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
c
INSERM UMR1093-CAPS, université Bourgogne–Franche-Comté, 21000 Dijon, France

a r t i c l e i n f o a b s t r a c t

Article history: Isolated traumatic radial head dislocation is exceedingly rare in adults, usually diagnosed on an emer-
Received 5 June 2020 gency basis, and reduced by external manoeuvres. If the diagnosis is not made immediately, external
Accepted 14 September 2020 reduction is no longer feasible. Various options have been described for treating these chronic forms,
including therapeutic abstention, radial head resection and annular ligamentoplasty combined, if appro-
Keywords: priate, with osteotomy of the ulna. In patients with incapacitating symptoms, proposing a surgical option
Radial head dislocation makes sense. Here, we describe the technique developed by PM Grammont, which combines ligamen-
Chronic elbow dislocation
toplasty and an oblique flat osteotomy of the ulna. We used this technique in a 31-year-old male with
Elbow ligamentoplasty
Osteotomy of the ulna
isolated anterior dislocation of the radial head of 3 months’ duration. One year after surgery, he had
fully recovered range of motion in all planes. He returned to work 5 months after surgery. The promising
clinical and radiological outcomes in our patient support the use of this technique in adults with chronic
isolated radial head dislocation.
Level of evidence: IV.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction annular ligamentoplasty. We describe the use of this technique and

its one-year outcome in a young, physically active male who had
Isolated traumatic radial head dislocation is common in chil- chronic anterior radial head luxation.
dren but rarely seen in adults, with fewer than 40 reported cases
[1–5], in contrast with Monteggia lesions, whose frequency is con- 2. Operative technique
siderably greater. Because the range of flexion–extension of the
elbow is preserved, the radial head dislocation can be missed ini- The technique was first described by PM Grammont in 1979. A
tially, notably in multiply injured patients. At the acute phase, posterior approach to the elbow with ulnar nerve release is used.
reduction by external manoeuvres is recommended. After 3 weeks, Dissection is performed to expose the triceps brachii, the anconeus
external reduction is no longer feasible due to local tissue retrac- muscle, and the flexor carpi ulnaris muscle. These muscles are
tion, sometimes with tissue interposition [3]. In the few reported detached subperiosteally (Fig. 1) to expose the annular ligament,
cases of chronic radial head dislocation, the management strategy which is very frequently torn, and the dislocated proximal radio-
ranged from therapeutic abstention [4], to radial head resection ulnar joint. A strip of tricipital tendon measuring about 1 cm in
[1–7] or annular ligamentoplasty combined in some cases with an width and pedicled on the olecranon is taken from the middle third
osteotomy of the ulna, depending on the functional demands of the of the tendon and used to strengthen the annular ligament (Fig. 2).
patient [8,9]. A posterior-to-anterior bone tunnel is drilled with a bit measur-
Here, we report a surgical technique that stabilises the radial ing 4.5 mm in diameter (Figs. 2 and 3), at the level of the annular
head by combining an oblique flat osteotomy of the ulna with ligament.
If the dislocation is anterior, an oblique flat osteotomy of the
ulna is performed using an oscillating saw. The osteotomy starts
∗ Corresponding author at: Service d’orthopédie–traumatologie, CHU de Dijon, proximally at the lateral edge of the ulna and ends distally at its
14, rue Paul-Gaffarel, 21079 Dijon cedex, France. medial edge (Figs. 2 and 3). This osteotomy thus preserves the
E-mail address: [email protected] (P. Martz). insertion of the inter-osseous membrane (IOM) that participates

https://doi.org/10.1016/j.otsr.2021.102829
1877-0568/© 2021 Elsevier Masson SAS. All rights reserved.
A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 1. Posterior approach to the elbow with ulnar nerve (U) release and exposure of the triceps brachii (T), anconeus muscle (A), and flexor ulnaris carpi (FUC) – from
drawings by PM Grammont.

actively in reducing the dislocation (Fig. 4). The oblique flat design are used to re-attach the annular ligament, in the anatomical posi-
of the osteotomy permits external rotation (in supination) of the tion, to the posterior aspect of the proximal ulnar fragment under
distal fragment to create an angulation, and therefore a relative the internal fixation plate (Fig. 5). At the end of the procedure, the
lengthening of the ulna (Fig. 4). Thus, reduction is produced by the ulnar nerve is left in its anatomical position.
traction forces applied to the IOM. Stability of the construct is evaluated at the end of the procedure
Obviously, the orientation of the osteotomy cut and the by obtaining static and dynamic image-intensified fluoroscopy
amount of rotation applied depend on the type of disloca- views. Flexion–extension and pronation–supination movements
tion. The technique described here is appropriate for anterior are applied to ensure that the construct is strong and to confirm
radial head dislocation with a completely or partially intact the radial head reduction in all planes by appropriate fluoroscopy
IOM. views.
The osteotomy is fixed by a rigid construct. Here, a 3.5 plate with
three bicortical screws was placed on either side of the osteotomy
3. Clinical case
(Figs. 4 and 5).
The tricipital transplant is threaded through the tunnel previ-
We used the above-described technique in a 31-year-old male
ously drilled in the ulna, then wrapped around the neck of the
who was a manual labourer and had a chronic isolated anterior dis-
radius, and finally sutured to itself (Fig. 5). Trans-osseous sutures
location of the left radial head. The dislocation occurred when he

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 2. Preparation of the pedicled strip of tricipital tendon (1), opening of the annular ligament of the radial head (2), and drilling of the bony tunnel (3). The dotted line
shows the placement of the oblique flat osteotomy of the ulna – from drawings by PM Grammont.

fell from his bicycle more than 3 months earlier (Fig. 6). He had no persisted at the limits of the motion range. The PREE score was
history of bone or joint disease and his medical history was unre- 66/100 and the MEPS 60/100. The osteotomy site was painless to
markable. His main complaint was loss of strength that prevented palpation. A follow-up radiograph showed no secondary displace-
him from working. ment of the material and visualised signs of bone healing.
Clinically, loss of strength and persistent pain over the medial Six months after surgery, the patient was pain free (PREE score,
epicondyle were noted. Range of motion was moderately decreased 3/100 and MEPS, 100/100) and had recovered full range of motion
(arc of motion, 20◦ –120◦ ), but there was no perceptible instabil- (flexion–extension arc, 0◦ –160◦ and full painless pronation and
ity. The patient related elbow evaluation (PREE) score [10] was supination). Strength was comparable to the opposite side (Fig. 7).
61/100 and the Mayo elbow performance score (MEPS) [11] was He was able to return to work 5 months after surgery. After one year,
65/100. the ulnar osteotomy was healed, with no secondary displacement,
Surgery was performed 4 months after the initial injury. The and the radial head was reduced (Fig. 8).
osteotomy was fixed by a right 3.5 locking compression plate
from Synthes® (West Chester, PA, USA). A posterior plaster splint 4. Discussion
with the elbow flexed at 90◦ and the arm in neutral rotation
was used for 2 weeks, after which a rehabilitation protocol This surgical technique is a conservative option that provides
was initiated. Passive flexion–extension and pronation–supination satisfactory functional outcomes in the short term to patients with
movements under the pain threshold were performed first. After chronic isolated radial head dislocation. It is reasonable to expect
6 weeks, the patient was able to start active rehabilitation with no that it will avoid the long term complications reported with the
restrictions. other techniques described in the literature (Table 1), namely,
At 6 weeks, the range of passive and active motion remained abstention, radial head resection [7,12–15], and annular ligamen-
limited, with a 30◦ –100◦ arc of motion in flexion–extension, a 40◦ toplasty alone [8,14]. These approaches often result over time in
deficit in pronation, and a 30◦ deficit in supination. Some pain radio-humeral instability or ulnar impaction syndrome.

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 3. Osteotomy of the ulna: lateral view with representation of the bony tunnel–from original drawings by PM Grammont.

Table 1
Surgical techniques reported in the literature for radial head dislocation.

Indication/Characteristics Osteotomy Ligamentoplasty Complications

Therapeutic abstention [4] If no functional No None Pain

disorders Instability
Stiffness
Immobilisation in Distal radio-ulnar
supination injury
Osteoarthritis of the
elbow
Radial head resection [7,12–15] All dislocations No None Early humero-ulnar
osteoarthritis
Ulnar impaction
syndrome
Loss of strength
Cubitus valgus
Isolated plasty of the annular ligament [8,14] Recent injury++ No Suture of the annular Recurrence +++ (50% if
ligament or use of a insufficiently tight)
transplant (palmaris Blockage of
longus, triceps) pronation–supination
Radial head necrosis
Hiramaya [14,16,17] Neglected Monteggia Yes ulna Palmaris longus tendon Humero-radial
injury osteoarthritis
Pain
Humero-radial Stiffness
arthroereisis pin Recurrence
Bouyala [14,17,18] Neglected Monteggia Yes ulna ± Non-union
injury in children Not suitable for adults
Bell Tawse [17,19,20] Anterior dislocation No Tricipital strip Residual instability
Our technique (PM Grammont) All dislocations Yes ulna Tricipital strip

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 4. Left: posterior view of the ulnar osteotomy. Right: posterior view of the reduction in external rotation (red arrow) with plate fixation; note the effect of placing the
interosseous membrane under tension (blue arrow) – from drawings by PM Grammont.

Isolated radial head dislocation is rare in adults. In children, in healing would increase the risk of non-union. Furthermore, in
contrast, they are a common result of neglected Monteggia injury adults, the ulna is not capable of plastic deformation. For biome-
with plastic deformity of the ulna. Although various techniques chanical reasons, it is therefore necessary to produce relative
have been described, most are not applicable to adults, whose lengthening of the ulna by an oblique plane osteotomy, which,
capacity for bone healing, bone remodelling, and motion range combined with the traction by the IOM, ensures reduction and
recovery are more limited. For instance, the modified Hirayama stability.
technique [14,16,17] combining temporary intra-articular pinning Adding ligamentoplasty to the suture of the annular ligament
with an osteotomy of the ulna and ligamentoplasty using a trans- also avoids the risk of multidirectional dislocation described by
plant of the palmaris longus requires prolonged immobilisation Hayami et al. The plasty used in our technique shares simi-
and may result in ankylosis. Similarly, the Bouyala technique larities with the technique described by Bell Tawse [17,19,20],
[14,17,18], which is indicated when the IOM is intact, consists in which consists in isolated ligamentoplasty of the annular liga-
a transverse osteotomy of the ulna with only precarious contact ment using a band of tricipital tendon, with no ulnar osteotomy.
of the bone fragments. This technique does not seem appro- In both children and adults, however, isolated ligamentoplasty is
priate for adults, in whom the more limited potential for bone not recommended due to the risk of specific complications, such

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 5. Posterior view of the final construct with plate fixation of the osteotomy and bone suturing of the pedicled transplant and annular ligament – from drawings by PM
Grammont.

as hourglass syndrome (constriction of the neck of the radius by However, to date, our patient has not experienced recur-
an excessively tight plasty that restricts mobility), ossifications rent dislocation, although anterior dislocations such as his are
within the ligaments, and residual instability. Ligamentoplasty known to cause major periarticular damage and multidirectional
remains useful when performed in combination with another instability [12]. Furthermore, as demonstrated by several cadaver
procedure to increase stability [3,8,14]. This has been demon- studies [12,22], the mechanisms of injury and the damaged
strated in both clinical [21] and biomechanical [8,12,22–24] studies structures vary with the direction of the dislocation. Thus,
demonstrating the crucial role for the IOM, notably its middle although this technique is effective in anterior dislocations,
third, in isolated radial head dislocation. Thus, for our technique, we cannot extrapolate to other forms of chronic radial head
the IOM must be competent for the osteotomy to be effec- dislocation.
tive.
One of the limitations of our technique may be the mechan- 5. Conclusion
ical quality of the IOM, as suggested by the above-mentioned
biomechanical studies [12,22]. We did not evaluate the IOM Thus, we believe that the technique combining an oblique flat
by performing magnetic resonance imaging before surgery, but osteotomy of the ulna with plasty of the annular ligament is indi-
such a precaution would seem recommendable. In patients with cated in patients with chronic anterior radial head dislocation
complete destruction of the IOM, reconstruction can be consid- due to a traumatic injury and causing symptoms in a physically
ered depending on the intraoperative results of the osteotomy. active patient. The medium-term outcomes are satisfactory and the

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 6. Preoperative radiographs of the left forearm: coronal view (on the left) and lateral view (on the right) showing isolated dislocation of the radial head.

complications associated with other surgical techniques are Funding

avoided. This technique deserves to be evaluated in a larger num-
ber of patients in order to assess its efficacy, reproducibility, and None.
limitations.

Contribution of authors

Disclosure of interest Alice Bordet, Pierre Martz, and Pierre Trouilloud contributed to
the conception and design of the study; the data collection was
Emmanuel Baulot is a consultant and designer for SERF and undertaken by Alice Bordet and Oregan Le Mentec; drafting and
ASTON. Pierre Martz is a consultant for SERF and XNov. The other revision of the article for important intellectual content by Alice
authors declare that they have no competing interest. Bordet and Pierre Martz; design of the figures by Marc Arcens; and

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A. Bordet, O. Le Mentec, M. Arcens et al. Orthopaedics & Traumatology: Surgery & Research 107 (2021) 102829

Fig. 7. Range of motion 6 months after surgery in flexion–extension (A and B) and in pronation–supination (C and D).

Fig. 8. Postoperative radiographs of the left forearm: coronal view (on the left) and lateral view (on the right) 6 months after surgery.

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