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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

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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t

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c

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e

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Articlehistory:

Received4November2015 Accepted1December2015 Availableonline15October2016

Keywords:

Radialheadfractures Radialnerve Hematoma

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b

s

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c

t

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).

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):725–729

Relatodecaso: 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

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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):725–729

Fig.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,

(5)

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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1.DaurkaJ,ChenA,AkhtarK,KamineniS.Tardyposterior interosseousnervepalsyassociatedwithradialheadfracture: acasereport.CasesJ.2009;2(1):22.

2.HirachiK,KatoH,MinamiA,KasashimaT,KanedaK.Clinical featuresandmanagementoftraumaticposterior

interosseousnervepalsy.JHandSurgBr.1998;23(3):413–7. 3.MarmorL,LawrenceJF,DuboisEL.Posteriorinterosseous

nervepalsyduetorheumatoidarthritis.JBoneJointSurgAm. 1967;49(2):381–3.

4.OginoT,MinamiA,KatoH.Diagnosisofradialnervepalsy causedbyganglionwithuseofdifferentimagingtechniques. JHandSurgAm.1991;16(2):230–5.

5.PikeJM,GrewalR,AthwalGS,FaberKJ,KingGJ.Open reductionandinternalfixationofradialheadfractures:do outcomesdifferbetweensimpleandcomplexinjuries?Clin OrthopRelatRes.2014;472(7):2120–7.

6.SpinnerM.ThearcadeofFrohseanditsrelationshipto posteriorinterosseousnerveparalysis.JBoneJointSurgBr. 1968;50(4):809–12.

7.TornettaP3rd,HochwaldN,BonoC,GrossmanM.Anatomy oftheposteriorinterosseousnerveinrelationtofixationof theradialhead.ClinOrthopRelatRes.1997;(345):215–8. 8.StrachanJC,EllisBW.Vulnerabilityoftheposterior

interosseousnerveduringradialheadresection.JBoneJoint SurgBr.1971;53(2):320–3.

9.PikeJM,AthwalGS,FaberKJ,KingGJ.Radialheadfractures– anupdate.JHandSurgAm.2009;34(3):557–65.

10.SudhaharTA,PatelAD.Ararecaseofpartialposterior interosseousnerveinjuryassociatedwithradialhead fracture.Injury.2004;35(5):543–4.

Imagem

Fig. 1 – Photograph of the patient showing extension of the fingers at the level of the metacarpophalangeal joints disability.
Fig. 2 – Radiograph in AP and lateral views showing the radial head fracture and anterior displacement of the fragment.
Fig. 5 – Patient on the fifth postoperative day. Complete metacarpophalangeal joint extension is observed.
Fig. 8 – Postoperative elbow AP radiograph showing the fixation of the radial head fracture with two micro fragment screws.

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