title: Radial Head Subluxation After Malalignment of the Proximal Ulna: A Biomechanical Study.
abstract: OBJECTIVE
  Understanding the anatomy of proximal ulna is important when treating complex injuries, since nonanatomic reconstruction may lead to malunion, arthrosis, and instability. The proximal ulna has a sagittal bow, termed the proximal ulna dorsal angulation (PUDA). The purpose of this study was to evaluate the magnitude of angular malalignment at the PUDA that would lead to radial head subluxation.
  
  
  METHODS
  This biomechanical study was conducted on 6 fresh frozen upper extremities with an elbow movement simulator. An osteotomy was performed at the PUDA and stabilized with internal fixation at 5 angles. Lateral elbow fluoroscopic images were taken in 4 elbow and 3 forearm positions, with the annular ligament intact and then released. The displacement of the radial head was quantified with the radiocapitellar ratio measurement.
  
  
  RESULTS
  A significant interaction exists between elbow positions, angles of malalignment, and annular ligament integrity (P < 0.001). The greatest magnitudes of radial head subluxation were with annular ligament tear, ranging from -4% to 88% (P < 0.001). Significant differences were found between the different internal fixation angles (P = 0.002) and elbow positions (P < 0.001). Anterior subluxation increased as malalignment was fixed into extension and with progressive elbow flexion. Posterior subluxation increased as malalignment advanced into flexion and decreased with elbow flexion.
  
  
  CONCLUSIONS
  Proximal ulna malalignment combined with an annular ligament tear affect the biomechanics of the elbow and can lead to radial head subluxation. This study demonstrates the importance of an anatomic reconstruction, specifically recreation of each individual's unique PUDA. Thus, in the setting of a comminuted proximal ulna fracture with associated annular ligament insufficiency, radiographs of the contralateral elbow may assist with the restoration of the normal anatomy to limit radial head instability.
authors.affiliation: *Department of Orthopedic Surgery, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada; †Université de Montréal, Montreal, Canada; ‡École de Technologie Supérieure, Montreal, Canada; and §Department of Orthopedic Surgery, Hand and Upper Limb Center, St Joseph's Health Care, University of Western Ontario, Ontario, Canada.
authors.forename: Emilie
authors.initials: E
authors.lastname: Sandman
authors.forename: Fanny
authors.initials: F
authors.lastname: Canet
authors.forename: Yvan
authors.initials: Y
authors.lastname: Petit
authors.forename: George Y
authors.initials: GY
authors.lastname: Laflamme
authors.forename: George S
authors.initials: GS
authors.lastname: Athwal
authors.forename: Dominique M
authors.initials: DM
authors.lastname: Rouleau
mesh_terms: D000328:Adult; D000368:Aged; D001696:Biomechanical Phenomena; D017760:Bone Malalignment / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D002102:Cadaver; D004551:Elbow Joint; D005260:Female; D018460:Fractures, Comminuted / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D004204:Joint Dislocations / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D007593:Joint Instability / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D008023:Ligaments, Articular / Q000293:injuries* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011884:Radius; D014458:Ulna Fractures / Q000150:complications / Q000503:physiopathology / Q000601:surgery*