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.



18 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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