Thursday, September 26, 2013

Congenital Radial Head Dislocation

Congenital radial head dislocation is an unusual congenital anomaly of the elbow.  It is undoubtably present at birth but is rarely discovered until children get a bit older.  This is mainly because the limitations of radial head dislocation are not life- altering for most (including the motion limitations).  X- rays are usually the best way to discover a joint dislocation but may not be diagnostic in a young child.  Much of the elbow is cartilage in a young patient and the cartilaginous elbow is difficult to understand because cartilage is not visible on x- ray.  

So, congenital radial head dislocation often presents as children the reach an age of increased activities-   typically 4-8 years of age but often even older.  They usually complain of a lack of motion- specifically limited rotation of the forearm.  Rarely, elbow flexion or extension limitations may be noted.  Pain is rare in the younger patients but pain can be a problem in the teenager with a marked deformity .  When the dislocated radial head is bumped- it hurts.

Some basics.  First, children with congenital radial head dislocation have it for both elbows.  Second, it can be associated with syndromes- including nail- patella syndrome: http://ghr.nlm.nih.gov/condition/nail-patella-syndrome.  Others may include Klinefelters and Cornelia de Lange. Third, most dislocations are posterior or posterior- lateral but some may be anterior or truly lateral.  

One of the biggest issues with the diagnosis of congenital radial head dislocation is separating it from trauma causing a radial head dislocation.  It can be confusing.  There may be several tricks to separate the two. First, if both sides are involved, it is a birth (congenital) problem.  And second, the x- rays can help.  Typically the capitellum is rounded and the radial head is concave and round.  If these shapes are not present-  the radial head and capitellum have not developed normally because it is a problem present since birth (i.e., not a trauma).  Third, most radial head dislocations in kids are accompanied by an ulna fracture (Monteggia injury)- make sure ulna is ok!  And fourth, radial head dislocation may be a part of proximal radioulnar synostosis.  This is a different issue altogether.

In most cases, we do not surgically treat congenital radial head dislocations.  If discovered in a young child, there have been thoughts about putting it back in place but most believe this will not succeed.  In older kids, attempts to put radial head back in place are even less likely to succeed because the anatomy is altered.  So, given that most kids have few if any complaints- we do not recommend surgery.  However, in older kids, typically teenagers, pain can be an issue.  If the pain is a real issue, surgical excision of the radial head can be considered.  It should ideally be delayed until the growth plates are closed.  I have been very happy with our results with this operation but there are a couple of issues for families to consider.  First, the radius can move slightly proximally (away from wrist).  If it does, the ulna becomes prominent at the wrist and can be painful.  This can, in a small percentage of patients, require another surgery.  Second, we worry about the stability of the elbow and possibility of development of arthritis.  And third, excision of the radial head may improve elbow motion (best for rotation) but obviously does not make it normal.  We have published our results in this area with good outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23123151

Here are a few pictures of recent radial head excision in a teen with elbow pain.

AP x-ray of elbow with congenital radial head dislocation demonstrating deformity of radial head.  This teenager had pain.

Congenital radial head dislocation.  Not the head of the radius is out of place and misshapen.
The shape and appearance of the excised radial head.  The head should be round and completely covered in shiny, white cartilage.  This radial head in a 15 year old is arthritic and misshapen.  The separate piece of cartilage is also a problem- a loose body.

We take an x-ray of the wrist to understand the relationship of the radius and ulna before we remove the radial head.  This helps us understand issues later that might develop.



29 comments:

  1. What are the possibilities of person with this issue, birthing a child with the same issues? Also is it common to have hip dislocation along with this?

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    1. Patrice,

      Thank you for the comment. In most cases of isolated congenital radial head dislocation, one would not expect a child to have the disorder. However it is possible. There are numerous syndromes, such as nail patella syndrome, in which there is a strong genetic link.
      Second, while there is a relationship between congenital radial head dislocation and hip dislocation, the risk is quite low.
      I wish I could be more specific with my answers but the reality is that we have a difficult time providing specific percentages in these situations. Good luck!

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  2. How long foes it take to recover if I have surgery ? How long will it take until i could use my hand and resume my activities? Also, if I am not that much in pain, should I have the surgery just for the sake if improving motion ? Thanks

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    1. Oana,
      Thank you for your post. These are questions you will have to ask your surgeon but I can give you very general thoughts. First, there will be some pain with surgery but everyone is different. Typically one can use the hand right away (i.e., for typing and writing) but full use of the arm can take some time (4 weeks but again, quite different for each person).
      The last question is the most difficult. For my patients, I recommend surgery for pain relief. I do not recommend patients have the surgery in the hopes of improving motion as motion improvement can be unpredictable. So, it really depends on how much pain and how much your activities are being affected. Again, a discussion with your doctor is the best approach.

      Good luck!

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  3. Thank you so much for replying ! I would appreciate it if you could tell me one more thing : I understand the surgery might not improve motion, but is there any risk that it would make it worse? For instance, would I lose strength in my arm? The dislocated radius is on my right hand, my left one is deformed and can't use it at all, so I would be very worried about anything happening to the only hand I can use. Also, I was diagnosed with arthritis in my elbow, but really I don't have much pain at all, my only problem is that my elbow feels a bit stiff and I can't rotate my arm properly. I really don't know whether I should go ahead with surgery and any advice would be helpful . Again, thank you very much for answering me .

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    1. Oana,
      My pleasure. I have not had any patients lose motion. The main risk, in my view, is that about 1 or 2 patients out of each 10 with surgery may develop wrist pain. This is due to the radius moving proximally towards the elbow (by just a couple of millimeters) and thus causing prominence of the ulna at the wrist. If this occurs, it may cause wrist pain. The good news is that if this uncommon problem happens, it can usually be treated effectively but does require another surgery.

      I hope that helps somewhat.

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  4. I have NPS and want to know if this is a good surgery because I am starting to have a lot of pain in my elbow and would also like to know if this will allow me to fully extend my elbow and straighte y arm all the way out??

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  5. Nail patella syndrome can be associated with elbow pain with a dislocated radial head. While we never like to remove a radial head, when pain is present, surgery can be helpful to 1) decrease pain and 2) improve forearm rotation. It can improve elbow flexion and extension (i.e., straightening) but does not always make a big difference in this regard.

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  6. My son was 2yrs old when we noticed his arm. Doctors tried popping it back into place but wasn't successful. They then stated that he may have been born like that or during birth it may have been dislocated but never detected until it was to late to fix. He's 14 now and plays sports.. I wanted to know if it is safe for him to lift weights because its a requirement for all athletes. If so should I take extra precautions like a arm brace to help support his elbow.

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    1. K. Monique, thank you for your question. Your son's story is common- it sure semms like he was born with it- a congenital radial head dislocation. I am happy to hear that he is active and playing sports! I can't comment on specific limitations for your son (as I obviously have not examined him, seen his x-rays, etc) but my general philosophy is to allow activities unless there is pain. But, also remember, we don't want to put large forces across an abnormal elbow joint so some common sense lifting limits are appropriate and activities such as push- ups might be best limited as well.

      Good luck!

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  7. Dr. Goldfarb,

    TL;DR: Are there any known cases of radial head excision (for a congenitally dislocated radial head) resulting in further complicating the patient’s condition rather than improving it? (e.g. introducing new elbow pain; complete or partial loss of arm function; etc.)

    Long version: I’m a 32 y.o. male with a congenitally dislocated radial head (left arm, photos linked to below). The arm functions decently enough, but has limited supination, is slightly weaker than the right arm, and can be painful after moderate to heavy use. What’s most unfortunate, however, is just how far the misguided radial head protrudes from my elbow. It has long been an extreme insecurity of mine, and has greatly contributed to my struggle with social anxiety.

    Up to this point, the only physicians/surgeons who’ve inspected my arm have had no personal experience with this particular condition, and have been reluctant to suggest surgery. Whether it’s because the surgery is particularly risky, or simply because they’ve never done it before, I can’t say for sure.

    So the question is: how great is the risk of damaging the elbow/arm further—or introducing new elbow pain, etc.—when excising a congenitally dislocated radial head?

    My x-rays and photos: http://imgur.com/a/2B6JP

    Thanks!

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    1. Thank you for the question. Yes, radial head excision can cause additional problems including elbow instability (shifting away from the body) and prominence of the ulna bone at the wrist (with wrist pain). Fortunately, both of these issues are uncommon but must be considered in the surgical decision making process. Previous studies (including ours) suggest this happen in anywhere from 15-30% of surgeries. The wrist issue can usually be improved with a surgery to shorten the ulna. Elbow instability is less common but more challenging to address. I hope this answers your questions.

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  8. Hi Dr. Goldfarb!

    My name is Joni Asercion, and my boyfriend and I are looking for a surgeon that can treat congenital radial head dislocation, as he is experiencing discomfort from Nail Patella Syndrome. I read this post as well as a lab report linked from another one of your blogs, regarding 16 patients that had congenital radial head dislocation.
    Here is a link to a case study of an alternative surgery performed on a patient with a congenital radial head dislocation: https://f1000research.com/articles/3-22/v1
    We would like to know your input on this method of surgery. As we live in California, do you know of any doctors that you recommend, specifically for treatment of this anomaly? We have been looking everywhere and have not found anyone that could help us. Thank you so much for your time.
    My boyfriend's email (with the NPS) is: gskrietzman@gmail.com
    My email is: asercionism@gmail.com
    Thank you!

    Sincerely,
    Graem and Joni

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    1. Joni,

      Thank you for the question and I am sorry to hear about his pain. I reviewed the article but have serious concerns about the technique described (and I am not familiar with this journal). The problem for older patients with a radial head dislocation is that the radial head and the capitellum have not formed correctly and forcing them back in joint does not typically help symptoms and can make it worse. There are surgeons with experience in this area at LA Childrens, Oakland Childrens, and the Shriners Hospital in Sacramento. I hope my thoughts are helpful.

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  9. Hello Dr. Goldfarb,
    My daughter was born with a right radial dislocation. It was discovered around the age of three and now that she is almost 9 she has been complaining of elbow pain. The Ortho specialist we saw at Children's Hospital of Michigan years ago says nothing can be done until she stops growing well into her teens. Other than Motrin and heat is there anything we can do to alleviate the pain? Would a brace or physical therapy help? She does dance and drum/conga lessons. Could that cause the problem or just growing pains. Thanks N. Christian (Mom)

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    1. N Christian,
      Thank you for the question and I am sorry your daughter is having pain. It is, honestly, unusual to have pain at this age with a radial head dislocation but the direction of the dislocation may affect the pain. More commonly, I have heard complaints in the teenage years when a prominent radial head is bumped. Many times, providers don't want to offer surgery because they worry about the impact on the growth plate. However, depending on the level of pain and its impact, sometimes surgery can be the answer. In my experience with other patients, braces and therapy do not help. Medicines like motrin may temporarily help but taking those indefinitely is likely not the best course either. I hope this is somewhat helpful. The best course is to take your daughter to an experienced upper extremity surgeon (typically a hand surgeon specializing in 'congenital hand'). There are some pediatric orthopedic surgeons with good upper extremity experience but not all. Good luck

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  10. Hi-my 11 year old daughter was diagnosed with a congenitally dislocated right radial head at birth and saw two different orthopedic surgeons at two different hospitals before she was three. Both told her what you have said that the only surgery recommended would be later to reduce the radial head due to pain. However we have recently been told by the Paley Institute that her ulna can be lengthened and then her elbow can be put back in place to resolve the limb length discrepancy and the dislocation. Apparently the institute treats people with MHE that have a short ulna. But if my daughter's radius has historically been on a growth track to bow out, would her elbow eventually dislocate again anyway? What are your thoughts?

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    1. tbd,
      Thank you for the question. One of the challenges with a birth anomaly, like congenital dislocation of the radial head, is that the bone/ joint do not develop normally if not aligned. That is absolutely the case in this condition. The analogy of a square peg in a round hole is a bit of an exaggeration but not completely off. There is no doubt that the ulna can be lengthened (we do it regularly for different indications)- the question is whether it is the best option in this situation. This is not a surgery I would recommend for my patients. Feel free to email me directly with additional questions.

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  11. Thank you for this blog, I am a pediatric OT and find this helpful. Do you see this with arthrogryposis? Could it occur at a higher rate or same when compared to the general pop?I have a child right now who they saw this in. It sounds similar, both sides R/LUE and she is now right at that age you mentioned when it can start being an issue...thanks

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    1. Thank you for the question, Amalia. Yes, this can be seen with arthrogryposis and is likely more common that the general population. But, patients with arthrogryposis have decreased forearm rotation in general related to the underlying diagnosis. I hope this is helpful.

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  12. Good afternoon, Doctor!
    Thank you very much for this text, it's nice to explain everything.
    I have a daughter (4 years old) who has a congenital dislocation of the radial bone .. I noticed very early, since her birth was seen. Doctors saw her when she was 14 months old. her first operation was done when she was 16 months old. After surgery for 10 months, her arm was fine and after that, a spleen appeared again.
    The second surgery was made when she was 3 years old. After that operation, the arm was well 14 months. a couple of days ago they told us it was once again out of date. Doctors also propose a third operation for a couple of months.
    Her hand does not hurt. Going to physical therapy 2 times a year for a month. Doctors say there's a lot of good moves. Missing her to fix her hand and suppression movement.
    what do you think about the third operation? and the whole of her situation?
    Excuse me for my bad English language. I am from Serbia. I use google translate
    In Serbia, there is very little knowledge about the innate elimination of the elbow.

    Thanks in advance for your reply.



    tamara

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    1. Thank you for the question Tamara. This is tough to answer. In general, we do not operate on congenital dislocation of the radial head (although this is not always true). My personal approach in kids is NOT to keep repeating an operation if it does not provide the results we want. So, without knowing anything more about your daughter, I would not be excited about a third surgery unless something different was planned. Good luck.

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    2. Thank you very much for the answer. doctors in Belgrade want to use the same techniques to operate again. Yesterday we were examined by a doctor from Russia. he suggests using the iliseuron method to extend the bone and then bring the bone back to its place. Can I send you an X-ray? It means a lot to me for your opinion.

      thanks a lot.

      tamara

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    3. I would be happy to review. Please send to congenitalhand@wudosis.wustl.edu

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  13. Hi Doctor,
    My son, age 12, was just diagnosed with bilateral elbow deformities. Up until recently he was active in all sports including baseball, football and basketball. Over the last several months he developed increased pain in his right elbow with some swelling that came and went. His diagnostics show some bone trauma (the doctor mentioned avasculur necrosis) possibly from the bone bumping? We tried a pause in sports for a period of time in the hope he would improve but he does not seem to be getting better. The doctor wants to remove the radial head on the right to reduce pain issues and try and get him active again in the activities he likes to do. On the left, he is leaving it alone since he doesn't have any pain issues. Is this a proper plan of action for the right? Does this type of surgery have a good possibility of reducing pain and allowing him to be more active? Are there issues with the growth plate on the radial bone if the head is removed? Any thoughts would be appreciated. Thanks, RC

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    1. RC,
      Thank you for the question and I am sorry to hear your son is having elbow trouble. Unfortunately, I can't be too helpful via email. In general, removal of the radial head does help pain in the short term and perhaps in the long term as well. But it can be associated with other issues including medial elbow pain and wrist pain. The growth of the radius bone is usually ok although we try to delay removing the radial head for growth reasons. Good luck

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  14. Hey RC,

    I just thought I'd drop a line to let you know I grew up my whole life playing Hockey, Lacrosse and also did a lot of weight lifting with bilateral congenital radial head dislocation. When I turned 17 after a hockey injury I found out about my condition and was given an MRI that showed aside from a bit of fluid build up from my injury all was well (minus the condition).

    What I'm trying to get to is I was told not to do anything I had used to do and I began to lose muscle mass causing my elbows to actually hurt more. I understand everyone is different, but for myself working out and maintaining a relatively large amount of muscle mass on my arms seems to minimize pain (I have NO idea why). I am not limited in any range of motion like others and I've never had protruding swelling from the area and the only corrective action I took was to switch playing contact sports for basketball and running.

    I went to multiple doctors (not specialist) who had never seen your sons and mine condition. The day my life changed is when I saw a Toronto, Ontario specialist who literally told me exactly what I had been doing is what I need to keep doing (working out staying fit) at the time I wanted to be a Police Officer and assumed I wouldn't be able to follow my dream.. Well long story short I achieved my dream (I am no longer a Police Officer but once was)..

    I just want to say this because, I want your son (and anyone with our condition) to live to best you can.. I understand some people have varying forms of dislocations etc and need excision, but my specialist explained it would by far cause more joint issues.

    If your son ever needs support from someone who hasn't let this condition dictate their life I'd be happy to help, as I can say this condition caused me way more mental issues then physical due to constantly being told I couldn't be the person I have become.

    I wish the best for you and your son.

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    1. Thanks for your insights Michael. Helpful to hear for sure.

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    2. Hi. My daughter, almost 6, apparently was born with a right congenital elbow, first discovered when she was 4. As a nurse, I’ve looked back through years of pictures to make sure that it wasn’t a fall, or injury, that I possibly could have prevented, or missed, and didn’t get treatment. There is little relief in not finding evidence in it being my fault, in an injury, versus possible congenitally, something that I may have unknowingly caused as well. To add to that, I’ve found through numerous blogs, there is very little to treat it. As I know that it causes little pain, until later in life, possibly, I can only try to pray for the best, and hope that after I am long gone, she is not in pain. Ok, so this post is not to depress everyone who is reading, but to possibly find any support groups, or website for those with this diagnosis, as a means of supporting each other. It’s so little discussion, even amongst health professionals, about this.

      Happily, she does everything that everyone else does. She has trouble if she has something in her left hand and someone attempts to hand her change or something in her right hand. She also has trouble carrying a plate to the table. She will hold the plate with her left, while sitting/balancing on her right. This hurts my soul, deep within, but she has absolutely no worries.

      My sole relief is that since this is something she was born with, it is all she knows, and adapts like anyone who only has two legs—no adaption needed. It’s normal.

      Any help in finding support, more for later in life, would be helpful.

      Thanks Dr. Goldfarb! And a specially thank you for keeping the blog open for over five years, and continuing to answer our questions and respond to our concerns.

      Sonja

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