Monday, May 26, 2014

Congenital Radial Head Dislocations: Elbow or forearm problem?

I have previously blogged about congenital radial head dislocation at least several times Previous posts .

However, like most upper extremity anomalies, not all patients with a congenital radial head dislocation present alike.  Consider first that most of these dislocate so that the radial head moves in the posterior and lateral (outside) direction.  A smaller number dislocate in the anterior direction.  And anterior dislocations are most likely to block elbow flexion.  These dislocations may be accompanied but limited forearm rotation (i.e., palm up and palm down) and, less commonly, pain.   But, each child presents differently.

In the recent Oberg Manske Tonkin classification scheme for upper extremity anomalies, congenital radial head dislocation is categorized as a malformation (i.e., problem with limb formation while the baby is in the womb) involving the entire limb but in the radial- ulnar (inside, outside) direction (technically a I.A.2.v).  And while our future understanding of these anomalies will undoubtably grow, I believe this grouping is the right place for this condition.  I believe the following child shows why.


Congenital radial head dislocation with a lack of elbow straightening.

Congenital radial head dislocation with good but not perfect elbow bending.

Congenital radial head dislocation with a very limited ability to supinate (turn palms up).

Congenital radial head dislocation with near perfect pronation (turning palm down).
Congenital radial head dislocation x-rays.  Both the right and left side look the same.  Notice that the radial head is dislocated in the anterior direction.

Congenital radial head dislocation x-ray showing the whole forearm.  This problem is not confined to the elbow but really involves the entire relationship between the radius and the ulna.  The ulna is too long compared to the radius (i.e., at the wrist).


Congenital radial head dislocation is often thought of as an isolated problem to the elbow.  But it is more likely to involve a bigger segment of the limb- the relationship between the radius and the ulna.  This case shows that well and, I believe, a new research project we are working on will confirm that theory.  We have previously looked at a wrist problem Madelungs study a found that a large number of these children actually have a problem in the whole forearm.  Additionally, we have previously shown that surgery at the elbow (i.e., removal of the dislocated radial head) can, in a small % of patients, lead to problems at the wrist.  Which, if you believe that Congenital radial head dislocation involves the whole forearm in some patients, makes complete sense.  Surgery Outcome Results

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

7 comments:

  1. Could this Congenital radial head dislocation happen to newborn baby/

    William
    babyfirstyear.org

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  2. Thank you for the question. Yes, this would be present at birth but typically is not recognized until the child is older and more functional. There have been various surgeries recommended for children when this problem is recognized early but, in my experience, these are not typically successful.

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  3. After knocking his elbow a few weeks ago, we have just discovered that our 12 year old son's left arm has a congenital radial head dislocation in the anterior direction. We were aware that his elbows hyperextended and he was not able to turn his palms up, but we had no idea about the dislocation. We've been advised that there is no treatment other than stabilise and manage the pain with sport to be reintroduced as long as it doesn't hurt. We are surprised that such a benign knock would now cause him this much pain. Do you see a future for 3D printing of elbow joints in adults with this condition, or is this not possible for this condition?

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    1. Marie Ann,

      Thank you for the question. Your son's story is not uncommon. And I agree with the recommendation- return to sports when he feels up to it. The challenge we have, in some cases, is distinguishing between kids with a congenital radial head dislocation and those with a new dislocation. Usually that difference can be determined by x-rays but it can be a challenge. Unfortunately, in answer to your question, I think we are long way off before we can 3D print joints. One day yes, but many years from now.

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  4. Hello,
    My daughter was diagnosed with bilateral radial head dislocation at the age of one. I noticed when she was a baby that her arms wouldn't fully extend. I took her to the orthopedic and he was able to confirm the diagnosis with an x-ray. I also took her to a geneticist to make sure the condition wasn't linked to any other chromosomal abnormality. Everything else came back negative. My daughter is now four, almost five, and so far hasn't complained at all about pain. My main concern is what limitations she may face in the future. I don't want her to further hurt her elbow with certain physical activities, especially when she begins physical education in school. I am also curious about what causes this condition, since my husband and I don't have anyone else in the family who suffers from this. Any insight would be greatly appreciated.

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    1. Thank you for the question. Your daughter's elbow seems to be an idiopathic (unknown cause) radial head dislocation. As your doctors stated, we do not know the cause in such kids although in other children we can identify a cause or at least some associated conditions (such as ulnar deficiency or nail patella syndrome). We would not expect any other kids of yours or your daughter's kids to be affected.

      Pain is unusual in kids with radial head dislocation although occasionally will happen in the adolescent. Kids with pain have markedly prominent radial heads that hurt when bumped. I do not usually limit the activities of my patients as physical activity is so important and we do not know of any negatives in this situation.

      I hope this helps.

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  5. I just thought I'd share some information. This condition seems to be fairly uncommon. My 12 year old daughter was diagnosed to bilateral radial head dislocated before she was 1. She also was diagnosed with bicoronal craniosynostosis. Im not sure how often the 2 conditions occur together. She has adapted well to her limitations but she does suffer some discomfort with activities requiring a lot of extension. Such as riding a bicycle or playing basketball. Onset around age 8. We don't set physical limitations but instead allow her to dictate which activities she's comfortable doing and refraining from ones that cause discomfort.

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