Options for treatment include open ulnar osteotomy with rigid plate fixation with or without open reduction of the radiocapitellar joint and annular ligament repair or reconstruction (Waters 2012). Late reconstruction is difficult and often results in less than perfect results (Rang, 2005). Failure to recognize a monteggia fracture can have severe consequences. Open reduction and reconstruction of the annular ligament are rarely needed in the acute period.Ĭomplications range from mild to severe. The forearm should be kept in pronation during the approach to avoid injury to the posterior interosseous nerve. This can be accomplished through a Kocher or posterolateral approach. If the radial head remains irreducible or unstable after fixation of the ulna, it may be necessary to perform an open reduction and remove or repair any interposed soft tissues. If radial head reduction is not maintained, stable internal fixation may be safely performed up to several weeks after the injury with good outcomes. Long oblique or comminuted fractures of the ulna may require open reduction and internal fixation with plates and screws. Complete transverse or short oblique fractures can be treated with closed reduction +/- intramedullary Kirschner wire fixation of the ulna depending on the stability of the radial head after reduction. Non-surgical management of the ulna is possible but close monitoring is required the first several weeks after manipulation (Foran, 2017). If the radial head cannot kept reduced in a safe position of elbow flexion, ideally less than 100 degrees, the ulna will require stabilization. Plastic deformation and incomplete fractures of the ulna can be treated with closed reduction of the ulnar bow and cast immobilization. Treatment is often dictated by the pattern of the ulna fracture (Ring, 1998 Ramski, 2015). You must correct the ulna deformity, reduce the radial head, and minimize future forces that may cause the radial head to re-dislocate. There are 3 important things to keep in mind when treating a monteggia fracture. Non-pediatric orthopedic surgeons and emergency room/urgent care providers may not recognize the presence of a proximal radius dislocation because there may be no obvious ulnar fracture or all attention is focused on the more visible displaced fractures. Clinical diagnosis can be missed in the subtle ulna plastic deformation fracture and significantly displaced radius and ulna shaft fractures (Bae, 2016). Proximal radius dislocations can also occur with mid-shaft forearm fractures. Dynamic imaging with fluoroscopy may be helpful as well. When unclear, obtaining an AP and lateral x-ray of the contralateral elbow can be helpful. Beware of plastic deformation of the ulna, which can be easily missed but still associated with radiocapitellar dislocation. Radiocapitellar alignment should be checked on all views and the radial shaft should point to the center of the capitellum in all positions on any radiographic view. AP and lateral films of the forearm as well as the elbow and wrist should be obtained. This includes posterior interosseous nerve (PIN) and ulnar nerve neuropraxia, typically seen with Bado III and II, respectively (Waters, 2012).Īppropriate imaging is essential to avoid missing this injury. Neurologic deficit is present at presentation in 10-20% of the cases. Forearm deformity may or may not be present and limitations in range of motion are not always obvious. Patients usually present with a history of a fall onto an outstretched hand and pain in the forearm and elbow. The type of fracture depends largely on the mechanism of injury (Evans, 1949). They typically occur in children between 4 and 10 years of age after a fall onto an outstretched hand. This fracture pattern was first described in 1814 by Giovanni Monteggia. Monteggia fractures account for 0.4% of all forearm fractures in children. Proximal radius dislocations in skeletally immature teenagers and children occur in the setting of a spectrum of ulnar injuries that often do not follow classic adult patterns.
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