Isolated Dislocation of the Distal Radio-Ulnar Joint: An Unrecognized Emergency
Ralahy Fanjalalaina, Randimbinirina Zakarimanana, Andrianimaro Florelia, Rohimpitiavana Amboara, Razafimahandry Henri
Ministry of Public Health Ringgold Standard Institution, Fianarantsoa, Madagascar
Correspondence to: Dr. Ralahy Fanjalalaina, Email: firstname.lastname@example.org
Dislocation of the isolated distal radio-ulnar joint (DRU) is rare. The clinical and radiological signs are not very suggestive, which make the diagnosis difficult and sometimes late. The care remains disparate for both recent forms and neglected forms. In order to illustrate the management of these lesions in the light of data from the literature, we report two cases of isolated dislocation of the distal radioulnar joint. The first patient was a 22-year-old woman who presented with a recent palmar traumatic dislocation of the left DRU whose reduction followed by immobilization restored the function and mobility of the wrist. The second patient was a 34-year-old man with dislodged dorsal dislocation from the DRUJ who received a Sauvé-Kapandji intervention with a marked improvement in wrist mobility.DRUJ dislocations must be diagnosed and reduced early as neglected or recurrent lesions require surgery. For the case, the intervention of Sauvé-Kapandji gave good result.
Key words: Dislocation, Distal Radioulnar, Sauvé-Kapandji, Surgery, Wrist
Ann Afr Surg. 2019; 17(1):***
Conflicts of Interest: None
© 2019 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Distal radioulnar dislocation is usually associated with fracture of the forearm bones. First described by Desault , isolated distal radio-ulnar dislocation is a rare clinical entity. The mechanism is always traumatic and consists of a strong supination of the forearm for palmar dislocation, or a strong pronation for dorsal dislocation . The direction of dislocation is defined by the position of the ulnar head with respect to the distal radius . The care remains controversial for both recent forms and neglected forms. Authors routinely recommend surgery [1,4], while others suggest nonoperative therapy [5,6]. The aim of this work is to illustrate the management of isolated distal radio-ulnar dislocations in light of literature data by reporting two clinical cases.
She was a 22-year-old student who consulted at the emergency department after a left wrist injury by a sports accident followed by fall with reception on her left wrist in supination. The patient complained of severe pain in her wrist associated with functional impairment. The examination showed distortion of the left wrist with loss of the medial concavity of the wrist that giving way to an asymmetrical concavity compared to the contralateral side. The X-ray of the wrist and left forearm face and profile showed palmar dislocation of the distal radioulnar joint without associated fracture (Figure 1). A closed reduction under general anesthesia was performed followed by a brachio-antebrachio-palmar cast in neutral position for 3 weeks (Figure 2), the elbow was released at third week and the wrist was kept for 3 additional weeks. After 2 weeks of rehabilitation, she resumed her daily activities without difficulty. At 2 decline years, no recurrence of luxation was noticed.
The second patient was a 34-year-old computer scientist, right-handed. He had come to see for painful functional impotence of the right wrist. He reported an imprecise mechanism trauma to his wrist dating back more than 5 months. He received anti-inflammatory treatment associated with immobilization and some traditional massage sessions but no improvement was found. During the examination, he was complaining of right wrist pain with functional impairment. The wrist had circumferential oedematous infiltration. The right hand was blocked in pronation and slightly extended (Figure 3). Supination was impossible without the participation of the shoulder. Flexion, active and passive extension were limited by pain. The preoperative Cooney wrist score was 50 (poor). X-ray of the right wrist in frontal and lateral incidence showed dorsal dislocation of the distal radioulnar without associated fracture image (Figure 4). After failure of orthopedic reduction attempts, surgery was performed under general anesthesia by distal resection of ulna associated with DRU arthrodesis (Sauvé-Kapandji technique). The wrist was immobilized by posterior splint. The operative sequence was uncomplicated. Rehabilitation started at the 6th week after removal of the cast. At 6 months of follow-up, pronosupination was comparable to the healthy side with stabilization of pseudarthrodesis (Figure 5-6). The postoperative Cooney wrist score was 90 (excellent)
Distal radioulnar dislocation is usually associated with fracture of the forearm bones forming the classic Goyrand-Smith fracture. Isolated distal radio-ulnar dislocation is rare According to Floares  the first case of distal radio-ulnar dislocation was described by Desault in 1777 on a cadaver. Since then, occasional cases have been reported in the literature. Depending on the position of the ulnar head with respect to the distal radius, a dislocation DRU may be anterior (palmar) or posterior (dorsal) . In the literature, dorsal dislocation is more common than palmar dislocation [8-9]. The mechanism of a distal radioulnar dislocation is always traumatic . It occurs during wrist trauma in hypersupination of the forearm for palmar dislocation and hyperpronation for posterior dislocation [8, 10]. Szabo  described that the head of the ulna moves forward during supination and backwards during pronation. Isolated distal radioulnar dislocation passes unnoticed in more than 50% of cases . Hence, most of the cases reported in the literature, which present themselves as distal radio-ulnar dislocations.
The signs presented on the physical examination are not obvious, such as a blocking of prono-supination, mechanical wrist pain, limitation of flexion-extension of the wrist, abnormal projection of the ulnar styloid with respect to the side healthy. Inspection may reveal wrist deformity with erasure of the ulnar styloid . In both cases, an impossible supination associated with mechanical wrist pain prompted the request for an X-ray of the wrist to look for the lesion. The radiograph of the wrist face and especially comparative strict profile are usually enough to make the diagnosis. In contentious situations, a CT-scan confirms diagnosis [13-14]. The CT-scan specifies the ratio of the ulnar head with the triangular fibro- cartilaginous complex. MRI and CT arthrography are of no particular interest except to eliminate carpal instability lesions . For our cases, the clinical examination associated with a standard x-ray of the wrist was sufficient to make the diagnosis. A radiograph of the forearm was required to eliminate a fracture of both bones.
The majority of recent work on distal radio-ulnar isolated dislocations shows that the therapeutic decision depends on the evolution and the complexity of the lesion . Usually reduction is easy by performing a maneuver opposed to the causal mechanism associated with direct manipulation on the ulnar head. In certain situations, the reduction can be blocked by an incarceration of the triangular ligament or the contraction of the square pronator. A reduction under general anesthesia followed by an immobilization plastered of 8 weeks is the choice in case of a simple and recent form. Authors recommend immobilizing the forearm in pronation for palmar dislocations . For our first case, the forearm was immobilized in the neutral position after a pronosupination stability test.
In case of failure of orthopedic treatment, irreducibility, recurrence, and an old and complex form, surgical treatment is necessary to reduce the ulnar head and repair the triangular fibro-cartilaginous complex. Several surgical technics have been described in the literature such as the Darrach procedure, the "Sauvé -Kapandji" procedure. The distal diaphyseal resection associated with a distal radioulnar arthrodesis or the Sauvé-Kapandji procedure  was our choice, which is a recurrent and old dislocation. In chronic, degenerative or delayed diagnosis, this technique seems to give satisfactory results according to the intended functional objective .
Isolated distal radioulnar dislocation is a rare lesion and often unnoticed. Wrist X-Rays can sometimes be non-contributive, and a CT arthrography or magnetic resonance imaging is required to confirm the diagnosis. Management must be done urgently to avoid neglected forms by applying surgical treatment.
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