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Monteggia Fracture - Pediatric

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Topic updated on 08/09/16 4:43pm
Introduction
  • Definition
    • radial head dislocation plus
      • proximal ulna fracture or
      • plastic deformation of the ulna without obvious fracture 
  • Epidemiology
    • 4 to 10 years of age is peak incidence
  • Treatment differs from adult Monteggia fractures
Classification

Bado Classification
Type I  Apex anterior proximal ulna fracture with anterior dislocation of the radial head   
Type II Apex posterior proximal ulna fracture with posterior dislocation of the radial head
Type III Apex lateral proximal ulna fracture with lateral dislocation of the radial head   
Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head (1-11% of cases)


Presentation
  • Symptoms
    • pain, swelling, and deformity about the forearm and elbow
  • Physical exam
    • must palpate over radial head with all ulna fractures because spontaneous relocation of radial head is common
    • must examine for plastic deformation of the ulna if there is a presumed isolated radial head dislocation
      • isolated radial head dislocations almost never occur in pediatric patients
Imaging
  • Radiographs
    • obtain elbow radiographs for all forearm fractures to evaluate for radial head dislocation
      • assess radiocapitellar line on every lateral radiograph of the elbow 
        • a line down the radial shaft should pass through the center of the capitellar ossification center 
    • obtain forearm radiographs for all radial head dislocations
Treatment
  • Nonoperative
    • closed reduction of ulna and radial head dislocation and long arm casting
      • indications
        • Bado Types I-III with
          • radial head is stable following reduction
          • length stable ulnar fracture pattern
      • reduction technique
        • reduction technique uses traction
          • radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length
      • immobilization
        • immobilize in 110° of flexion and full supination for Types I and III to tighten interosseous membrane and relax biceps tendon 
  • Operative
    • flexible IM nailing or plating of ulna with reduction of radial head   
      • indications
        • Bado Types I-III with
          • radial head is not stable following reduction
          • ulnar length is not stable (unable to maintain ulnar length)
        • acute Bado Type IV 
        • open fractures
      • technique
        • plate fixation for comminuted fractures or length-unstable ulna fractures in children 8 years or older
        • annular ligament reconstruction almost never required for acute fractures
        • open reduction of radial head through a lateral approach if needed
    • ulnar osteotomy and annular ligament reconstruction 
      • indications
        • chronic (>2-3 weeks old) Monteggia fractures
        • symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis
      • technique
        • reduce surgically within 6-12 months postinjury
    • ORIF similar to adult treatment 
      • indications
        • closed physes
Complications
  • Neurovascular
    • posterior interosseous nerve neurapraxia (10% of acute injuries)
      • almost always spontaneously resolves
  • Delayed or missed diagnosis
    • common when evaluation not performed by an orthopaedic surgeon
    • complication rates and severity increase if diagnosis delayed >2-3 weeks

 

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Qbank (5 Questions)

TAG
(OBQ10.42) A 4-year-old girl sustains a buckle fracture of the ulna and associated radial head dislocation. Closed reduction and immobilization of the arm in 110 degrees of flexion (as swelling allows) and full supination enhances the stability of the injury by which of the following: Topic Review Topic

1. Tightening the interosseous membrane
2. Tightening the biceps
3. Eliminates plastic deformation
4. Relaxes the pronator quadratus
5. Protects the posterior interosseous nerve

PREFERRED RESPONSE ▶
TAG
(OBQ09.81) A 7-year-old girl falls off of her bike and sustains the injury depicted in Figures A & B. All of the following are indications for surgical management of Monteggia fractures EXCEPT: Topic Review Topic
FIGURES: A   B        

1. Combined radius and long oblique ulnar fracture and reduced radial head dislocation
2. Incomplete ulnar fracture with lateral radial head dislocation that is successfully reduced
3. Ulnar communition with ulnar shortening
4. One week post-reduction/casting radiograph showing loss of radial head reduction
5. Long oblique ulnar fracture with irreducible radial head dislocation

PREFERRED RESPONSE ▶
TAG
(OBQ07.143) A 6-year-old boy fell off the monkey bars 3 months ago and has had pain and decreased elbow motion since his fall. His radiographs are shown in figures A and B. Closed reduction was unsuccessful. What is the most appropriate treatment? Topic Review Topic
FIGURES: A   B        

1. Bracing and early range of motion
2. Closed reduction and casting in supination and flexion
3. Open reduction internal fixation of medial epicondyle fracture
4. Open reduction internal fixation of lateral condyle fracture
5. Open reduction of radial head dislocation with casting in supination and flexion

PREFERRED RESPONSE ▶
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