SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Case
Report
Radial
head
fracture
associated
with
posterior
interosseous
nerve
injury
夽
Bernardo
Barcellos
Terra
∗,
Tannus
Jorge
Sassine,
Guilherme
de
Freitas
Lima,
Leandro
Marano
Rodrigues,
David
Victoria
Hoffmann
Padua,
Anderson
de
Nadai
SantaCasadeMisericórdiadeVitória,DepartamentodeOrtopediaeTraumatologia,Vitória,ES,Brazil
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Articlehistory:
Received4November2015 Accepted1December2015 Availableonline15October2016
Keywords:
Radialheadfractures Radialnerve Hematoma
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Fracturesoftheradialheadandradialneckcorrespondto1.7–5.4%ofallfracturesand approximately30%maypresentassociatedinjuries.Intheliterature,therearefewreports ofradialheadfracturewithposteriorinterosseousnerveinjury.Thisstudyaimedtoreport acaseofradialheadfractureassociatedwithposteriorinterosseousnerveinjury.
Casereport:Amalepatient,aged42years,soughtmedicalcareafterfallingfroma skate-board.Thepatientrelatedpainandlimitationofmovementintherightelbowanddifficulty toextendthefingersoftherighthand.Duringphysicalexamination,thumbandfingers extensiondeficitwasobserved.Thewristextensionshowedaslightradialdeviation.After imaging,itbecameevidentthatthepatient hadafracture oftheradialhead thatwas classifiedasgradeIIIintheMasonclassification.Thepatientunderwentfracturefixation; atthefirstpostoperativeday,thumbandfingersextensionwasobserved.Althoughrare, posteriorinterosseousnervebranchinjurymaybeassociatedwithradialheadfractures. Inthepresentcase,theauthorsbelievethatneuropraxiaoccurredasaresultofthefracture
hematomaandedema.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Fratura
da
cabec¸a
do
rádio
associada
a
lesão
do
nervo
interósseo
posterior
Palavras-chave:
Fraturasdorádio Nervoradial Hematoma
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e
s
u
m
o
Asfraturasdacabec¸aedocolodorádiocorrespondema1,7%a5,4%detodasasfraturas e30%podemapresentarlesõesassociadas.Naliteraturaexistempoucoscasosdescritos defraturadacabec¸adorádiocomlesãodonervointerósseoposterior.Oobjetivodeste trabalhoérelatarumcasodefraturadacabec¸adorádioassociadaalesãodonervointerósseo posterior(NIP).
夽
StudyconductedattheSantaCasadeMisericórdiadeVitória,DepartamentodeOrtopediaeTraumatologia,Vitória,ES,Brazil.
∗ Correspondingauthor.
E-mail:bernardomed@hotmail.com(B.B.Terra). http://dx.doi.org/10.1016/j.rboe.2016.10.002
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rev bras ortop.2016;51(6):725–729Relatodecaso: Pacientemasculino,42anos,procurouatendimentomédicoapósquedade skate.Relatavadorelimitac¸ãodemovimentodocotovelodireito,bemcomodificuldade deestenderosdedosdamãoipsilateral.Duranteoexamefísico,evidenciou-sedéficitde extensãodopolegaredosdedosdamão.Aextensãodopunhoapresentavaumlevedesvio radial.Apósexamesdeimagem,ficouevidenciadoqueopacienteapresentavaumafratura dacabec¸adorádiotipograuIIIdeMason.Opacientefoisubmetidoàfixac¸ãodafratura;no primeirodiadopós-operatórionotou-seoretornodaextensãodopolegaredosdedosda mão.Apesarderara,alesãodoramointerósseoposteriorpodeestarassociadaafraturas dacabec¸adorádio.Nopresentecaso,acredita-sequeaneuropraxiasedeuemdecorrência dohematomaedoedemafraturário.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Fracturesoftheradialheadandneckcorrespondto1.7–5.4% ofallfracturesandaround33%ofallelbowfractures;almost 30%haveassociatedinjuries.1
Theincidence of associatedinjuries increases with the
severity of the fracture, ranging from 20% in cases of
fractures without deviation to 80% in multifragmentary
fractures.1,2
Theassociationwithneurologicinjuryisrare,anditmay occurmainlyinfractureswithanteriordeviation,Monteggia fracture-dislocations,andopengunshotfractures.Inthe lit-erature, there are few reportsof radialhead fracture with posteriorinterosseousnerveinjury.2–4
Thisstudyaimedtoreportacaseofradialheadfracture associatedwithposteriorinterosseousnerve(PIN)injury.
Case
report
Male patient, aged42 years,without comorbidities,sought medicalcare aftera skateboardfall. Hereported pain and
rangeof motionimpairmentin theright elbow,as well as
difficultyinextendingthefingersoftheipsilateralhand. Onphysicalexamination,edemaofthe lateralaspectof theelbowwasobserved,withoutpainorecchymosisonthe medialregion;limitedrangeofmotion(ROM)wasobservedfor
bothflexion-extensionandpronosupination.The
neurovas-cularexaminationshowedextensiondeficitoffingersatthe metacarpophalangeal joint level, as well asabduction and extensiondeficitofthethumb(Fig.1).Thepatientalso pre-sentedradialdeviationduringwristextension.Hedidnothave sensitivealterations;theneurologicalexaminationofmedian andulnarnerveswasnormal.Peripheralpulsesandperfusion wereunaltered.
Elbowradiographswereinitially requestedandaMason typeIII radialhead fracture was observed, withan anteri-orlydeflectedfragmentconsistingof40%oftheradialhead area (Fig. 2). To better understand and visualize the
frac-ture,aCTscanoftheelbowwasperformedandassociated
fractures were observed (Figs. 3 and 4). Given the frac-turepatternandneurologicaldeficit,surgicaltreatmentwas chosen.
Fig.1–Photographofthepatientshowingextensionofthe fingersatthelevelofthemetacarpophalangealjoints disability.
Surgical
technique
AlateralKocherapproachwasused,wherebytheelbowjointis exposedbetweentheanconeusandtheextensorcarpiulnaris muscles.5Thejointcapsulewasopenedwiththeforearmin
pronation,throughwhichalargeamountofthehematoma
wasdrained.Noinjuryorinstabilitysignswereobservedin thelateralligamentcomplex.Afterirrigatingthejoint,itwas observedthattherewasnoavulsionoftheanteriorcapsule,
but a chondralinjury was observedinthe capitellum, and
theradialheadfragmentwasinanteriorposition.Anatomical reductionoftheradialheadfracturewasperformed,with tem-poraryfixationwithKirschnerwirestoaidpermanentfixation
withtwo2.7-mmscrewsusinginterfragmentarycompression
technique. Thejoint capsuleand the muscle interval were
sutured.Theauthorschosenottoexplorethenerve,asthe lit-eraturereportsthattheposteriorinterosseousnerveinjuries areusuallyduetoindirectnervecompressionbytheanterior fragmentoftheradialheadorbythejointhematoma.1
Fig.2–RadiographinAPandlateralviewsshowingtheradialheadfractureandanteriordisplacementofthefragment.
In the second day after surgery, normal posterior
interosseousnervefunctionwasobserved,withfullextension ofthefingersandnormalfunctionofthethumb.
Threemonthsaftersurgery(Figs.5and6),thepatientwas
completelyasymptomatic,withROMinflexion-extensionof
0–140degreesand90–80degreesofpronosupination. Radio-graphsshowedcompletefracturehealing(Figs.7and8).
Discussion
The radialnerve originates from the posterior cordof the brachialplexusalongwiththeaxillarynerve,withitsfibers originatinginC6,C7,andC8roots,andsometimes,T1;itis majorlyamotornerve.Theradialnerveisresponsibleforthe
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rev bras ortop.2016;51(6):725–729Fig.4–CTscanshowingtheradialheadfracture.
Fig.5–Patientonthefifthpostoperativeday.Complete metacarpophalangealjointextensionisobserved.
innervationofthetriceps,anconeus,extensorcarpiradialis longusandbrevismuscles.6–8
ThePINisamotorbranchoftheradialnerve;ithassix sub-branches, whichare responsible forthe innervationof theextensordigitorumcommunis,extensorindicisproprius, extensorpollicisbrevisandlongus,abductorpollicislongus,
Fig.6–Patientonthefifthpostoperativeday.Complete thumbextensionandabductionareobserved.
Fig.7–Postoperativelateralviewelbowradiographin showingthefixationoftheheadfracturewithtwomicro fragmentscrews.
supinator,andextensorcarpiulnarismuscles.Thebranchto
the supinator muscle emerges beforethe nerve enters the
arcadeofFrohse,andtheotherbranchesemergeafterwards.6 Due tothissubdivisions,Spinner6divided PINcompression intotwotypes:typeI,inwhichallbranchesarecompressed, andtypeII,inwhichtheisolatedcompressionofabranchmay occur.
Thediagnosisofneurologicalinjuriesisclinical,beinga partoftheorthopedicphysicalexamination.Upon examina-tion,thepresentpatientshowedactivewristextensionwith radialdeviation, sincetheradialwristextensors are inner-vatedbytheradialnerve,butwasunabletoextendthefingers
and thumb, demonstratinginvolvement of the PIN, which
isresponsiblefortheinnervationoftheextensordigitorum communis,extensorindicisproprius,extensorpollicisbrevis andlongus,abductorpollicislongus,andtheextensorcarpi ulnaris.
Neuropraxia oftheinterosseousposterior branchofthe radialnervehasbeenreportedinfracturesoftheproximal thirdoftheradius,elbowfracture-dislocations(Monteggia),
and fractures due to firearm injuries, as well as
com-pression syndromes at the level of the arcade of Frohse,
Fig.8–PostoperativeelbowAPradiographshowingthe fixationoftheradialheadfracturewithtwomicrofragment screws.
temporaryPINdysfunctionwasduetocompressionbyboth
theintra-articularhematomaandtheanteriordisplacement oftheradialheadfragment.
The literature on the association of PIN neuropraxia
withisolated radialhead fracture is scarce, with few case reports.1,9–11TheproximityofthePINwiththeradialneck cre-atestheriskofinjuriesinthisregion,aswellasinitssurgical approaches.2Anatomicalstudieshaveshownthatthemean distancebetweentheradiocapitellarjointandthePINorigin isbetween1.2cm±−1.9mmandonly1%areincontactwith theradius.8
Thereisnoconsensusintheliteratureregardingthebest treatmentinsuchcases;therearereportsofconservativeand surgicaltreatmentswithorwithoutnerveexploration.1,5 In the present case, the authors opted for surgicaltreatment withoutnerveexploration,duetothedeviationoftheradial
headfragment,asthepatienthadnocapsularinjurynor evi-dencesuggestingdirecttraumatothenerve.
Surprisingly,the patienthad afullrecoveryofwristand fingersmotionontheseconddayaftersurgery.Sixmonths
postoperatively, he presented full ROM, with radiographic
signsoffracturehealing.
Conclusion
Althoughrare,posteriorinterosseousnervebranchinjurymay beassociatedwithacuteorlateradialheadfractures,evenin undisplacedfractures.Properclinicalandneurologic assess-mentswereimportantintheinitialcareofthispatient.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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