Once the cast is hardened, mark it, then split using an oscillating saw, a hand saw, or a sharp plaster knife (1). The character of the ulnar fracture is useful in determining optimal treatment. The first case is a combined type III Monteggia injury with ipsilateral Type II Salter-Harris injury of the distal end radius fracture with metaphyseal fracture of the In some cases, a direct blow to the forearm can produce similar injuries. History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures. Widen the split with a cast spreader. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. 3rd ed. Radial head dislocation may lead to radial nerve injury. Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture. Melvin P. Rosenwasser, MD (CSOT #21, 2016), Frontiers in Upper Extremity Surgery - 2016, Monteggia - Alfred W. Hess, MD (Frontiers #16, 2016), Monteggia Fracture Dislocation - Everything You Need To Know - Dr. Nabil Ebraheim. In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; (4/7). Richard L Ursone, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society of Military Orthopaedic SurgeonsDisclosure: Nothing to disclose. Adult Monteggia and Olecranon Fracture Dislocations of the Elbow. The ulna and interosseous membrane also may provide stable platforms for dislocation of the proximal radius, leading to the Monteggia fracture. Adults and unstable injuries generally require ORIF of the ulna. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). Thank you. Waters PM. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. - frx of proximal ulnar diaphysis with posterior angulation; [10] studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm. An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? [3]. A good radiographic result was seen in all patients who underwent open reduction within 3 years after injury or before reaching 12 years of age. Data Trace is the publisher of Orthopaedic Specialists of North Carolina. A Monteggia fracture-dislocation, or proximal ulnar fracture with associated radial head dislocation, is a complex injury of the forearm and elbow that can destabilize the elbow leading to poor functional outcomes. (0/1). Fractures in children. Kombinationsverletzungen des Unterarms werden nach ihrer Lokalisation als Galeazzi-, Monteggia- oder Essex-Lopresti-Lsionen bezeichnet. head is not promptly reduced; - keep elbow flexed ( > 90 deg), to relax biceps, so that full supination can be avoided w/o losing reduction; - Non Operative Treatment: Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Introduction Giovanni Battista Monteggia, a surgical pathologist and public health official in Milan, first described the Monteggia fracture in 1814. (0/1), Level 5 Splinting of the wrist in extension and finger range-of-motion (ROM) exercises help prevent contractures from developing while the patient awaits resolution of the nerve injury. Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. Since Monteggia first described the fracture bearing his name in 1814, the association of radial head dislocation with ipsilateral ulnar fracture has been well described. The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. [QxMD MEDLINE Link]. 2020 Sep. 40 (8):387-395. (0/8). Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. Van Tongel A, Ackerman P, Liekens K, Berghs B. Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination. When the ulna is fractured, energy is transmitted along the interosseous membrane, displacing the proximal radius. Purpose: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. (0/7), Level 2 J Bone Joint Surg Br. [1] [2] Causes Mechanisms include: Fall outstretched hand with the forearm in excessive pronation (hyper-pronation injury). J Pediatr Orthop. In his classic 1943 text, Watson-Jones stated that "no fracture presents so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure." The key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation. Monteggia GB. [QxMD MEDLINE Link]. If you log out, you will be required to enter your username and password the next time you visit. Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction. Xiao RC, Chan JJ, Cirino CM, Kim JM. Pediatric Monteggia fractures: a single-center study of the management of 40 patients. Bae DS. Undecided - achieved w/ forarm in full supination, & longitudinal traction; J Pediatr Orthop. constantpressure exerted by the dislocated radial head; Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. [QxMD MEDLINE Link]. - recurrent radial head dislocation [QxMD MEDLINE Link]. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma AssociationDisclosure: Nothing to disclose. ROM increased by an average of 30. Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children. Towson, MD 21204 2020 Oct 1. Events Search Events ; All Events List All Events Calendar Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand . Zivanovic D, Marjanovic Z, Bojovic N, Djordjevic I, Zecevic M, Budic I. Neglected Monteggia Fractures in Children-A Retrospective Study. Some injuries associated with radiocapitellar dislocation (such as the transolecranon fracture-dislocation of the elbow) are mislabeled as Monteggia lesions, when in fact the PRUJ remains intact. (OBQ10.240) Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. The ulna fracture is usually clinically and radiographically apparent. Rang, M., Pring, M. E., & Wenger, D. R. (2005). (2/8), Level 5 Monteggia fractures are one third as common as the more familiar Galeazzi fractures. More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following four types It is named after Giovanni Battista Monteggia. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). 2023 Lineage Medical, Inc. All rights reserved. J Bone Joint Surg Br. Rockwood CA, Green DP, Bucholz R, eds. Unrecognized dislocations may result from reduction of the dislocated radius prior to presentation. 2011 Feb. 77 (1):21-6. The Monteggia lesion is most precisely characterized as a forearm fracture in association with dislocation of the PRUJ. On examination, the affected arm is swollen and tender around his elbow. The Monteggia fracture with posterior dislocation of the radial head. Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and Florida Hospital - type II lesions with posterior dislocations should be maintained in about 70 deg. Bado JL. This is the most common type of Monteggia fracture. Beutel BG. [QxMD MEDLINE Link]. [1], The first challenge is correctly assessing the extent and nature of the injury. Hand (N Y). (0/1). Must have high index of suspicion high incidence of missed injuries (Waters, 2010), Appropriate radiographic imaging is essential to making the correct diagnosis, Be aware of plastic deformation of the ulna. [QxMD MEDLINE Link]. Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. 8 (10):18197-202. there may be slow and progressive shortening and angulation; Am J Orthop (Belle Mead NJ). Monteggia fracture-dislocations in children. 9 (8):[QxMD MEDLINE Link]. In a study evaluating long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in 22 children (14 boys, 8 girls; age range, 4 y to 15 y 11 mo), Nakamura et al noted that the postoperative Mayo Elbow Performance Index (MEPI) at follow-up ranged from 65 to 100, with 19 excellent results, two good results, one fair result, and zero poor results. - spontaneous recovery is usual & exploration is not indicated; Milan: Maspero; 1814. vol 5: Bado JL. Chronic Monteggia. 2012 Mar 7. (3/76), Level 1 If one of the forearm bones is injured, injury should be looked for in the other bone and in associated joints of the forearm, elbow, and wrist. [QxMD MEDLINE Link]. Subluxation of the radial head occurred in three patients; one patient experienced transient palsy of the posterior interosseous nerve; and distortion of the radial head (which had no bearing on function) occurred in three. Galezzi's fracture-fracture to the distal radius accompanied by ulnar head dislocation at distal radio-ulna joint. Philadelphia: JB Lippincott; 1991. The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Vol 1: Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Successful Strategies for Managing Monteggia Injuries. Type II lesions that are associated with ulnohumeral dislocation have been noted to have outcome scores with greater disability than those without ulnohumeral dislocation. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. Undecided Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury. This fracture refers to an intraarticular fracture that separates the palmar ulnar aspect of the first metacarpal base from the remaining first metacarpal. (1/7), Level 5 1998 Sep;27(9):606-9. Clinical effect of manual reduction of humeroradial joint in the treatment of type - fresh Monteggia fracture in children. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. A 45-year-old male falls off his motorcycle and injures his arm. It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. Stitgen A, McCarthy JJ, Nemeth BA, Garrels K, Noonan KJ. The character of the ulnar fracture is useful in determining optimal treatment. - lateral or anterolateral dislocation of the radial head; Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. Children (Basel). Speed JS, Boyd HB: Treatment of fractures of ulna with dislocation of head ofradius (Monteggia fracture). Philadelphia: Lippincott Williams &Wilkins; 2010: 446-74. 1967; 50:71-86. - ulnar frx is treated w/ compression plate (esp in proximal third) Findings associated with the concomitant radial head dislocation are often subtle and can be overlooked. Wang C, Su Y. Forearm fractures in children. - radiohumeral ankylosis - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ anterior dislocation of radial head; - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. What are floating elbow injuries and how are they treated? JAMA 1940;115:1699-1705. The aim of this study was to evaluate clinical outcomes of surgical treatment of Monteggia variant fracture dislocations with focus on the operative technique and management of associated radial head fractures. Diagnosis can be made with plain radiographs of the elbow. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. Floriano Putigna, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic AssociationDisclosure: Nothing to disclose. Type in at least one full word to see suggestions list, Scary Elbows: The Proximal Monteggia with David Stanley | OTS, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Monteggia Injury: Case of the Week - Joanne Wang, MD. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment, Removal of forearm plates. Prompt recognition of this injury is imperative. Events. The forearm structures are intricately related, and any disruption to one of the bones affects the other. 2009 Jun. J Pediatr Orthop. Epidemiology: plastic deformation of the ulna without obvious fracture, pain, swelling, and deformity about the forearm and elbow, isolated radial head dislocations almost never occur in pediatric patients, a line down the radial shaft should pass through the center of the capitellar ossification center, radial head is stable following reduction, radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length, for Type I, elbow flexion is the main reduction maneuver, if reduction of radiocapitellar joint is unsuccessful, annular ligament is most common block to reduction, radial head is not stable following reduction, ulnar length is not stable (unable to maintain ulnar length), older patients 10y if closed reduction is not stable, symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis, open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure, annular ligament reconstruction almost never required for acute fractures, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). 1974 Dec. 56 (8):1563-76. - key is to obtain length and alignment, which then allows the radial head to be reduced; The mechanism of injury is most often a fall on an outstretched hand. Are you sure you want to trigger topic in your Anconeus AI algorithm? Vol 2: 520. A review of the complications. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India Clin Orthop Relat Res. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. - Plating Techniques In essence, high-energy trauma (eg, a motor vehicle collision) and low-energy trauma (eg, a fall from a standing position) can result in the described injuries. [2 . Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. In 17 of the 22 patients, the radial head remained in a completely reduced position, and it was subluxated in five patients. Hume fracture - fracture of the olecranon accompanied by anterior dislocation of the radial head.
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