With careful definition, specific subsets of patients may benefit from consideration as a separate type of Monteggia injury. Type II lesions that are associated with ulnohumeral dislocation have been noted to have outcome scores with greater disability than those without ulnohumeral dislocation. - angulated ulnar shaft is reduced by firm manual pressure; - Type II (flexion type) - 15% Evans in 1949 Monteggia fracture-dislocations in children. These ligaments stretch or rupture during radial head dislocation. Kopriva J, Awowale J, Whiting P, Livermore A, Siy A, Hetzel S, et al. 2008 Apr. - radioulnar synostosis If the elbow is flexed, the chance of a type II or III lesion is greater. 9 (8):[QxMD MEDLINE Link]. - type II lesions with posterior dislocations should be maintained in about 70 deg. 2023 Lineage Medical, Inc. All rights reserved. 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. A review of the complications. - frx of proximal 1/3 of radius & frx of ulna at the same level; - Exam: 2021 Nov. 46 (11):1006-1015. AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. 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. Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. and radial deviation of head; - Complications: - associated nerve injury: The ulna fracture is usually noted, commonly in the proximal third of the ulna. Monteggia fractures and their variants are often misdiagnosed, however, because of the numerous atypical presentations of this injury in children. Lateral ulnar collateral ligament disruption, Anterior band of the medial collateral disruption, Posterior band of the medial collateral ligament disruption. Li H, Cai QX, Shen PQ, Chen T, Zhang ZM, Zhao L. Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; Bado type II lesion after open reduction and internal fixation. - spontaneous recovery is usual & exploration is not indicated; Datta T, Chatterjee N, Pal AK, Das SK. Acute pediatric Monteggia fractures: A. conservative approach to stabilization. there may be slow and progressive shortening and angulation; J Hand Surg Am. Epidemiology: Persistent posterior interosseous nerve palsy associated with a chronic type I Monteggia fracture-dislocation in a child: a case report and review of the literature. - anterior dislocation of radial head (or frx) and fracture of ulnar diaphysis at any level w/ Pronation injuries of the forearm, with special reference to theanterior Monteggia fracture. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; Pathology of the annular ligament in paediatric Monteggia fractures. Foran, I., Upasani, V., Wallace, C., et.al. [Full Text]. 35 (3):e434-7. Children (Basel). Radiographically, there were 15 good results, seven fair results, and zero poor results. 64 (6):857-63. - frx of proximal ulnar diaphysis with posterior angulation; 2020 Sep. 40 (8):387-395. - keep elbow flexed ( > 90 deg), to relax biceps, so that full supination can be avoided w/o losing reduction; - Non Operative Treatment: Acta Orthop Belg. Diagnosis can be made with plain radiographs of the elbow. - fracture of ulnar metaphysis; A review of the complications, Does a Monteggia variant lesion result in a poor functional outcome? Gemeinsam ist diesen 3 Formen die Kombination der Fraktur. Monteggia described a fracture of the proximal third of the ulna with anterior dislocation of the radial head from both the proximal radioulnar and radiocapitellar joints. Share cases and questions with Physicians on Medscape consult. A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. Galeazzi fracture: Distal radial shaft fracture with associated distal radio-ulnar joint (DRUJ) dislocation Special Investigations Imaging '2 views and 2 joints': Always get a minimum of two views (AP and LAT) that include the joint above and below the injury (two joints). 2020 Aug. 23 (4):233-237. In some cases, a direct blow to the forearm can produce similar injuries. Kombinationsverletzungen des Unterarms werden nach ihrer Lokalisation als Galeazzi-, Monteggia- oder Essex-Lopresti-Lsionen bezeichnet. - proposed mechanisms include direct blow & hyperpronation injuries as well-as the [1], The first challenge is correctly assessing the extent and nature of the injury. Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. [6] Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. - key is to obtain length and alignment, which then allows the radial head to be reduced; The radius and ulna are closely invested by the interosseous membrane, which accounts for the increased risk of displacement or injury to the radius when the ulna fractures. [14]. Fractures of the forearm with dislocation of the proximal radioulnar joint are known as Monteggia frac tures26'847. Undecided The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated PRUJ, and a dislocated radiocapitellar joint. constantpressure exerted by the dislocated radial head; [Full Text]. (0/1), Level 2 Milan: Maspero; 1814. vol 5: Bado JL. 2009 Jun. [10] studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm. [QxMD MEDLINE Link]. Reckling FW. This website also contains material copyrighted by 3rd parties. Datta et al conducted a prospective, longitudinal study of 21 children with Monteggia fracture with dislocation (18 type I, three type III), all of whom were treated by modified Hirayama corrective osteotomy of the ulna with wedge bone grafting, restoration of bone length, reconstruction of the anular ligament using the Bell Tawse method, and fixation of the radial head with transcapitellar Kirschner wire (K-wire). 1998 Dec;80(12):1733-44. 36 (2):65-73. Removal of forearm plates. 110 West Rd., Suite 227 Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. anterior dislocation of radial head; 2013. (2/8), Level 5 J Bone Joint Surg Br. [Full Text]. The ulna fracture is usually clinically and radiographically apparent. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Xiao RC, Chan JJ, Cirino CM, Kim JM. EVANS EM. Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. Fractures in children. - posterior or posterolateral dislocation of radial head (or frx); (OBQ09.264) Monteggia fractures in pediatric and adult populations. Leonidou A, Pagkalos J, Lepetsos P, Antonis K, Flieger I, Tsiridis E, et al. 39 (4):451-5. Are you sure you want to trigger topic in your Anconeus AI algorithm? (26/80), Level 4 History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? Int J Clin Exp Med. [5] The mean arc of forearm rotation increased from 145 to 149. - achieved w/ forarm in full supination, & longitudinal traction; Fractures of the shafts of the radius and ulna. Adults and unstable injuries generally require ORIF of the ulna. The distal ulna and radius also articulate at the DRUJ. (1/1), Level 4 (0/1), Level 3 The Monteggia lesion. J Am Acad Orthop Surg. Cast treatment with the elbow extended. hyperextension theory; - Type I (or extension type) - 60% of cases: Watson-Jones R. Fracture and Joint injuries. - Monteggia Fractures in Children. Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating. The mechanism of injury is most often a fall on an outstretched hand. [QxMD MEDLINE Link]. We present an unreported configuration of a traumatic olecranon fracture with a concomitant medial radial head dislocation in a 3-year-old male.. Cao YQ, Deng JZ, Zhang Y, Yuan XW, Liu T, Li J, et al. These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures. Conclusions: Monteggia fracture dislocation equiva-lents are rare injuries and pre-surgery recognition by radio-graphs and 3-D CT helps make optimal plan. Anterior elbow dislocations occur most often as a fracture-dislocation in which the distal humerus is driven through the olecranon, thereby causing a complex, comminuted fracture of the proximal ulna. 2018 Feb. 104 (1S):S113-S120. of flexion for 6 weeks; - Delayed Dx: Pronation injuries of the forearm, with special reference to the anterior Monteggia fracture. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Van Tongel A, Ackerman P, Liekens K, Berghs B. Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination. More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following four types [QxMD MEDLINE Link]. - paralysis of deep branch of radial nerve is most common; Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellarjoint. Hand (N Y). Undecided 2023 Lineage Medical, Inc. All rights reserved. Modified technique for correction of isolated radial head dislocation without apparent ulnar bowing: a retrospective case study. In a retrospective study on the functional and radiologic long-term outcome of ORIF in 11 skeletally mature patients with Bado type I Monteggia fractures, Guitton et al found that the mean arc of elbow flexion increased from 110 at early follow-up to 120 at late follow-up. (OBQ10.240) The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. (1/7), Level 5 - myositis ossificans, The challenge of Monteggia-like lesions of the elbow mid-term results of 46 cases, Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). Surgical Management of Complex Adult Monteggia Fractures. Which direction is the radial head most likely dislocated? Adult Monteggia and Olecranon Fracture Dislocations of the Elbow. 1951 Feb. 33-B (1):65-73. Orthopedics. J Pediatr Orthop. Curr Opin Pediatr. [7] The poor re-sults usually relate to intraarticular damage, coronoid frac-tures and comminution of the ulna and radial head fractures. 40 (3):e216-e221. 3rd ed. - lateral or anterolateral dislocation of the radial head; On examination, the affected arm is swollen and tender around his elbow. 2012 Jun. Orthop Traumatol Surg Res. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. Data Trace Publishing Company 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. 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. [1] [2] Causes Mechanisms include: Fall outstretched hand with the forearm in excessive pronation (hyper-pronation injury). Rang, M., Pring, M. E., & Wenger, D. R. (2005). 2016 Jun. - this is esp true on the lateral projection; Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. (0/1). [QxMD MEDLINE Link]. Are you sure you want to trigger topic in your Anconeus AI algorithm? This eponym is among the most widely recog nized by orthopaedic surgeons, largely because of the notoriously poor results associated with the treatment of these injuries, particularly in adults83948. [2]. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. different treatment protocol for children, may be part of complex injury pattern including, Fracture of the proximal or middle third of the ulna with, Fracture of the ulnar metaphysis (distal to coronoid process) with, Fracture of the proximal or middle third of the, Jupiter Classification of Type II Monteggia Fracture-Dislocations, Fracture extending to distal half of ulna, may or may not be obvious dislocation at radiocapitellar joint, may be loss of ROM at elbow due to dislocation, radial deviation of hand with wrist extension, AP and Lateral of elbow, wrist, and forearm, helpful in fractures involving coronoid, olecranon, and radial head, must ensure stabilty and anatomic alignment of ulna fracture, acute fractures which are open or unstable (long oblique), most Monteggia fractures in adults are treated surgically, ORIF of ulna shaft fracture, open reduction of radial head, failure to reduce radial head with ORIF of ulnar shaft only, Monteggia "variants" with associated radial head fracture, 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, 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, treatment based on involved components (radial head, coronoid, LCL), if no improvement obtain nerve conduction studies, usually caused by failure to obtain anatomic alignment of ulna, If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Kim JM, London DA. Diagnosis can be made with plain radiographs of the elbow. - when > 3 months has elapsed, consider non op treatment because bony ankylosis of the elbow may occur following surgery; 2015. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. [QxMD MEDLINE Link]. 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. 19 (74):164-167. (0/1), Level 1 Am J Orthop (Belle Mead NJ). Events Search Events ; All Events List All Events Calendar Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand . Copyright 2023 Lineage Medical, Inc. All rights reserved. Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. Monteggia fractures are one third as common as the more . Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and Florida Hospital Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. 2022 Feb 1. 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. Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. Monteggia fracture-dislocations remain a relatively uncommon injury. [11, 12] Of the Monteggia fractures, Bado type I has been reported to be the most common (59%), followed by type III (26%), type II (5%), and type IV (1%). [Full Text]. Trauma10531822MonteggiaFracturesAuthor:Tracy JonesIntroductionInjury defined asproximal 1/3 ulnar fracture with associated radial head dislocation/instabilityEpidemiologyrare in adultsmore common in childrenwith peak incidence between 4 and 10 years of agedifferent treatment protocol for childrenAssociated injuriesmay be part of complex injury 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. Bado initially described and classified these injuries. [QxMD MEDLINE Link]. 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 Clin Orthop Relat Res. - PIN palsy is most common in type I frx and may occur in a delayed fashion if theradial Clinical effect of manual reduction of humeroradial joint in the treatment of type - fresh Monteggia fracture in children. [QxMD MEDLINE Link]. - reduction: - PIN or radial nerve palsy from anterior displacement of radial head; Undecided Tan JW, Mu MZ, Liao GJ, Li JM. - anterior dislocation of the radial head; 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.
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