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Monteggia Fractures

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Topic updated on 02/28/16 11:17am
Introduction
  • Injury defined as
    • proximal 1/3 ulnar fracture with associated radial head dislocation/instability 
  • Epidemiology
    • rare in adults
    • more common in children with peak incidence between 4 and 10 years of age
      • different treatment protocol for children
  • Associated injuries
    • may be part of complex injury pattern including
      • olecranon fracture-dislocation
      • radial head fx
      • coronoid fx
      • LCL injury
      • terrible triad of elbow
  • Prognosis
    • if diagnosis is delayed greater than 2-3 weeks complication rates increase significantly
Anatomy
  • Ligament
    • annular ligament
Classification

Bado Classification
Type I Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (most common in children and young adults)
Type II

Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)

Type III Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head
Type IV Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction  

Presentation
  • Symptoms
    • pain and swelling at elbow joint
  • Physical exam
    • inspection
      • may or may not be obvious dislocation at radiocapitellar joint
      • should evaluate skin integrity
    • ROM & instability
      • may be loss of ROM at elbow due to dislocation
    • neurovascular exam
      • PIN neuropathy
        • radial deviation of hand with wrist extension
        • weakness of thumb extension
        • weakness of MCP extension
        • most likely nerve injury
Imaging
  • Radiographs
    • recommended view
      • AP and Lateral of elbow, wrist, and forearm
  • CT scan
    • helpful in fractures involving coronoid, olecranon, and radial head
Treatment
  • Nonoperative
    • closed reduction 
      • indications
        • more common and successful in children
        • must ensure stabilty and anatomic alignment of ulna fracture
      • technique
        • cast in supination for Bado I and III
  • Operative
    • ORIF of ulna shaft fracture
      • indications
        • acute fractures which are open or unstable (long oblique)
        • comminuted fractures
        • most Monteggia fractures in adults are treated surgically
    • ORIF of ulna shaft fracture, open reduction of radial head
      • indications
        • failure to reduce radial head with ORIF of ulnar shaft only
          • ensure ulnar reduction is correct
        • complex injury pattern
    • IM Nailing of ulna
      • indications
        • transverse or short oblique fracture
Techniques
  • ORIF of ulnar shaft fracture
    • approach
      • lateral decubitus position with arm over padded support
      • midline posterior incision placed lateral to tip of olecranon
      • develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally, and interval between FCU and ECU distally
    • techniques
      • with proper alignment of ulna radial head usually reduces and open reduction of radial head is rarely needed
      • failure to align ulna will lead to chronic dislocation of radial head
  • ORIF of radial head
    • approach
      • posterolateral (Kocher) approach
    • technique
      • annular ligament often found interposed in radiohumeral joint preventing anatomic reduction after ulnar ORIF
        • treatment based on involved components (radial head, coronoid, LCL)
Complications
  • PIN neuropathy
    • up to 10% in acute injuries
    • treatment
      • observation for 2-3 months
        • spontaneously resolves in most cases
        • if no improvement obtain nerve conduction studies
  • Malunion with radial head dislocation
    • usually caused by failure to obtain anatomic alignment of ulna
    • treatment
      • ulnar osteotomy and open reduction of the radial head

 

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Qbank (2 Questions)

TAG
(OBQ10.240) A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding? Topic Review Topic

1. Lateral ulnar collateral ligament disruption
2. Anterior band of the medial collateral disruption
3. Posterior band of the medial collateral ligament disruption
4. Annular ligament interposition
5. Anconeus muscle interposition

PREFERRED RESPONSE ▶
TAG
(OBQ09.264) A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated? Topic Review Topic

1. Lateral
2. Posterior
3. Posterolateral
4. Anterior
5. Anteromedial

PREFERRED RESPONSE ▶



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