Simultaneous dislocation of the radial head and distal radio-ulnar joint without fracture in an adult patient: a case report and review of literature

Abstract

Background: Simultaneous dislocation of the radial head and distal radio-ulnar joint without fracture (Criss-Cross Injury) in an adult patient is rarely reported in previous studies. The pathological changes and injury patterns have not been clearly demonstrated.

Case presentation: A 26-year-old woman presented with acute pain of the right wrist and elbow after a fall from cycling. Physical examination revealed an unstable elbow and wrist joint. Plain radiographs showed volar dislocation of the radial head and dorsal dislocation of the distal radius without associated fracture, forming a criss-cross appearance of the ulna and radius on the lateral radiograph. MRI images confirmed partial rupture of the proximal interosseous membrane from its dorsal attachment on the radius, as well as partial rupture of the medial collateral ligament. Conservative treatment failed because the radiocapitellar joint and distal radio-ulnar joint could not be simultaneously reduced. Surgical exploration revealed a highly unstable radial head, but the annular ligament was found to be intact. Manual force was applied to reduce the radial head and a percutaneous K-wire was used to stabilize the proximal radioulnar joint with the forearm in full supination. After surgery, the elbow was immobilized in 90° flexion by a long arm cast for 4 weeks. The K-wire was removed at 6 weeks postoperatively. At 18 months postoperatively, the patient had regained a full range of flexion and extension, with normal supination and a slight limitation in pronation.

Conclusions: The proximal IOM, especially the dorsal band, was injured in Criss-Cross injuries, while the central part of the IOM remained intact. This injury pattern distinguished itself from Essex-Lopresti injury, which mainly involves rupture of the central band of the IOM.

Keywords: Case report; Forearm injuries; Joint instability; Soft tissue injuries.

Fig. 1

Radiographs of the bilateral forearm. a: Anteroposterior view of the normal side; b: Anteroposterior view of the injured side; c: Lateral view of the normal side; d: Lateral view of the injured side demonstrating volar dislocation of the radial head and dorsal dislocation of the distal radius without associated fracture, thus forming a criss-cross appearance on the lateral radiograph

Fig. 2

Preoperative MRI images of the right forearm (MRI Sequence: PD_TSE_SPAIR). a: Coronal image shows bone contusion of the capitellum of the humerus and proximal ulna (White arrow), as well as partial rupture of the medial collateral ligament (Yellow arrow). b: Sagittal image shows high signal around the proximal IOM (Red arrow). c: Axial image shows rupture of the proximal IOM from the dorsal attachment (Red arrow). R: Radius; U: Ulna

Fig. 3

Three dimensional CT reconstruction of the DRUJ with the forearm in different rotation position. a: The distal radius dislocated dorsally with the forearm in supination. b: The DRUJ was reduced with the forearm in neutral position. c: The distal radius dislocated palmarly with the forearm in pronation. Red dotted line: Sigmoid notch; Yellow dotted circle: Ulnar head; R: Radius; U: Ulna

Fig. 4

Operative exploration revealed an abnormal radial head. Black arrow: Convex radial head. Yellow arrow: Bumpy articulation

Fig. 5

Postoperative radiographs of the injured forearm. a: Anteroposterior view; b: Lateral view

Fig. 6

Functional follow-up at 6 months postoperatively. a: Normal range of elbow extension. b: Normal range of elbow flexion. c: Normal range of supination. d: Slight limitation of pronation

Fig. 7

Radiographic follow-up at 6 months postoperatively. a: Lateral view of the elbow shows normal alignment between capitellum and the radial head. b: Lateral view of the wrist shows a reduced DRUJ