JAMA 1940;115:1699-1705. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Successful Strategies for Managing Monteggia Injuries. - frx of proximal 1/3 of radius & frx of ulna at the same level; - Exam: Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. J Bone Joint Surg Am. 2023 Lineage Medical, Inc. All rights reserved. Take great care to avoid injury to the underlying skin. Wong JC, Getz CL, Abboud JA. A 45-year-old male falls off his motorcycle and injures his arm. J Orthop Trauma. 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. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. Monteggia GB. LIVIN' ON THE MD EDGE: Drive, Chip, and Putt Your Way to Osteoarthritis Relief, Osteoporosis and Osteopenia: Latest Treatment Recommendations, Osteoporosis: A Bare-Bones Guide to Diagnosis and Treatment. 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. 2022 Feb 1. Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. What is the most likely finding? J Bone Joint Surg Br. [QxMD MEDLINE Link]. Radiographically, there were 15 good results, seven fair results, and zero poor results. Then divide the underlying padding with scissors (2) and remove the protective strip to expose the skin. Fractures in children. Orthopaedic Specialists of North Carolina. 2012 Jun. 2023 Lineage Medical, Inc. All rights reserved. [Full Text]. 2018 Oct. 102 (Suppl 1):93-102. - immobilization is continued until there is union of the ulna; An Alternative to the Traditional Radiocapitellar Line for Pediatric Forearm Radiograph Assessment in Monteggia Fracture. A review of the complications. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; Orthopedics. Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee SurgeonsDisclosure: Nothing to disclose. [4] The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. (0/7), Level 2 (0/1). 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. Chin J Traumatol. Gemeinsam ist diesen 3 Formen die Kombination der Fraktur. The ulna and radius are in direct contact with each other only at the PRUJ and the DRUJ; however, they are unified along their entire length by the interosseous membrane. [QxMD MEDLINE Link]. EVANS EM. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Are you sure you want to trigger topic in your Anconeus AI algorithm? The radial head dislocation may not be apparent and will possibly be missed if the elbow is not included in the radiograph. Widen the split with a cast spreader. Findings associated with the concomitant radial head dislocation are often subtle and can be overlooked. The notoriously poor results of treatment of Monteggia fractures in adults improved dramatically after the development of modern techniques of plate-and-screw fixation, which facilitate early mobilization by ensuring anatomic reduction. Clin Orthop Relat Res. Philadelphia: Lippincott Williams & Wilkins; 2012: 351-65. - hence, these patients will require close follow up; - Treatment: [8] : The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation. 40 (3):e216-e221. 2020 Mar. The mean Broberg and Morrey score increased from 89 points to 94 points, and the median Disabilities of the Arm, Shoulder, and Hand (DASH)score was 7 points at long-term follow-up. "A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation. Telephone: 410.494.4994. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. 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. Vol 2: 520. 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. [14]. 2. [QxMD MEDLINE Link]. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. hyperextension theory; - Type I (or extension type) - 60% of cases: 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. Baltimore: Williams & Wilkins; 1943. Please confirm that you would like to log out of Medscape. The radial head should point towards the capitellum on all radiographs of the elbow. - anterior dislocation of the radial head; 1951 Feb. 33-B (1):65-73. 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. (1/7), Level 5 - realize that even w/ successful closed reduction of the ulna (and accompanying reduction of the radial head) that subsequently Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children. Reckling FW. 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). Kim JM, London DA. Vol 1: Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. al. The ulna fracture is usually noted, commonly in the proximal third of the ulna. A Monteggia fracture involves a fracture of the ulna with disruption of the proximal radio-ulnar joint (PRUJ) and radiocapitellar dislocation (Bado, 1967). [1] [2] Causes Mechanisms include: Fall outstretched hand with the forearm in excessive pronation (hyper-pronation injury). J Bone Joint Surg Am. J Am Acad Orthop Surg. [14]. 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. Indications for treatment of Monteggia fractures (seeTreatment) are based on the specific fracture pattern and the age of the patient (ie, pediatric or adult). 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 some cases, a direct blow to the forearm can produce similar injuries. 1951;33:65-73. - line drawn thru radial shaft and radial head should align w/ capitellum in any position if the radial head is in normal position - type II lesions with posterior dislocations should be maintained in about 70 deg. The character of the ulnar fracture is useful in determining optimal treatment. Philadelphia: Lippincott Williams &Wilkins; 2010: 446-74. - angulated ulnar shaft is reduced by firm manual pressure; - Type II (flexion type) - 15% [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%). The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. On examination, the affected arm is swollen and tender around his elbow. Rang's children's fractures. Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio 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. [QxMD MEDLINE Link]. 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. Beutel BG. - 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. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries. Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating. 2013 Jan;44(1):59-66. (1/1), Level 4 Chin J Traumatol. [1], The first challenge is correctly assessing the extent and nature of the injury. - type I, III, and IV lesions are held in 110 deg. 36 (2):65-73. - radial head is gently repositioned by direct manual pressure anteriorly on the bone; - proposed mechanisms include direct blow & hyperpronation injuries as well-as the Pediatric hand and upper limb surgery: a practicalguide. Wheeless' Textbook of Orthopaedics. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India Monteggia Fractures in Pediatric and Adult Populations, Clifford R. Wheeless, III, M.D. 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, 2016 Current Solutions in Orthopaedic Trauma, Case Presentation: Chronic Monteggia Fx / Ulnar Nonunion. constantpressure exerted by the dislocated radial head; The character of the ulnar fracture is useful in determining optimal treatment. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). Kombinationsverletzungen des Unterarms werden nach ihrer Lokalisation als Galeazzi-, Monteggia- oder Essex-Lopresti-Lsionen bezeichnet. - Discussion: [3]. Instituzioni Chirrugiche. anteriorangulation (usually proximal third); Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. Curr Opin Pediatr. [QxMD MEDLINE Link]. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Epub 2012 Oct 10. Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. Undecided Are you sure you want to trigger topic in your Anconeus AI algorithm? Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. Purpose: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. This principle also applies to aGaleazzi fracture, which is a fracture of the distal radius with concomitant dislocation of the distal radioulnar joint (DRUJ). Evans EM. What preoperative planning is required for surgical treatment of. - frx of ulna just distal to coronoid process w/ lateral dislocation of radial head; - Type IV (5%) 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 In 1814, Giovanni Battista Monteggia of Milan first described this injury as a fracture to the proximal third of the ulna with associated anterior dislocation of the radial head. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Watson-Jones R. Fracture and Joint injuries. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 9 (8):[QxMD MEDLINE Link]. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. [Full Text]. The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. anterior dislocation of radial head; The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated PRUJ, and a dislocated radiocapitellar joint. Kopriva J, Awowale J, Whiting P, Livermore A, Siy A, Hetzel S, et al. The investigators evaluated outcomes on the basis of the 100-point MEPI, radiology, and questionnaire. J Pediatr Orthop. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Monteggia fracture-dislocations remain a relatively uncommon injury. - medullary nail in this location may not fill the canal and may thus provide less than rigid fixation; You can rate this topic again in 12 months. Thank you. The present multicenter retrospective study compared results for the Bouyala procedure with versus without plasty of the annular ligament of the radial head in evolved radial head lesion (Monteggia lesion), assessing the benefit of associating ligamentoplasty to ulnar osteotomy. (6/78), Undecided 2015 Nov. 31 (4):565-80. [QxMD MEDLINE Link]. Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury. Conclusions: Monteggia fracture dislocation equiva-lents are rare injuries and pre-surgery recognition by radio-graphs and 3-D CT helps make optimal plan. 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). 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. Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. Monteggia fractures in pediatric and adult populations. Foran, I., Upasani, V., Wallace, C., et.al. (0/8). Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Ohio State Medical Association, Ohio Osteopathic Association, American College of Osteopathic Surgeons, American Osteopathic AssociationDisclosure: Received grant/research funds from Tornier for other; Received honoraria from Tornier for speaking and teaching. The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Tan JW, Mu MZ, Liao GJ, Li JM. 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. Speed JS, Boyd HB: Treatment of fractures of ulna with dislocation of head ofradius (Monteggia fracture). J Bone Joint Surg Br. - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ The mechanism of injury is most often a fall on an outstretched hand. 1998 Sep;27(9):606-9. 3rd ed. In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis Adults and unstable injuries generally require ORIF of the ulna. J Clin Diagn Res. 4 (2):167-72. - immobilize forearm in neutral rotation w/ slight supination, w/ cast carefully molded over lateral side of ulna at level of fracture; Monteggia fracture-dislocation is rare in children 2,3,4. - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. Monteggia Fracture } Drake LeBrun MD Experts 3 Bullets 65 3.4 ( 5 ) 3 Images Snapshot A 35-year-old man presents to the emergency room for severe right elbow and forearm pain after sustaining a blunt injury to his right arm. - See: Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. The posterior interosseous nerve travels around the neck of the radius and dives under the supinator as it courses into the forearm. 28 (19):e839-e848. [QxMD MEDLINE Link]. J Bone Joint Surg Br. (0/1), Level 5 Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction. Towson, MD 21204 Data Trace Publishing Company Cast treatment with the elbow extended. 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, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Rockwood CA, Green DP, Bucholz R, eds. Few contraindications for surgery exist. 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. Which direction is the radial head most likely dislocated? - recurrent radial head dislocation 1949;31B:578-88. (0/1), Level 3 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. What are Monteggia fractures and how are they classified and treated? It is named after Giovanni Battista Monteggia. Acta Orthop Belg. J Bone Joint Surg Br. 39 (4):451-5. 1967; 50:71-86. Ring D, Jupiter JB, Waters PM. This allows the radius to rotate around the ulna. Galezzi's fracture-fracture to the distal radius accompanied by ulnar head dislocation at distal radio-ulna joint. [QxMD MEDLINE Link]. Advances in radiography and fracture research have helped define, classify, and guide operative management. Bae, D. Successful strategies for managing Monteggia Injuries. A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. - when > 3 months has elapsed, consider non op treatment because bony ankylosis of the elbow may occur following surgery; 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 - posterior or posterolateral dislocation of radial head (or frx); Chronic Monteggia. Datta T, Chatterjee N, Pal AK, Das SK. Richard L Ursone, MD Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, Brooke Army Medical Center You are being redirected to This may occur in the field spontaneously or as a result of manipulation by emergency responders. (10/80), Level 3 A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Share cases and questions with Physicians on Medscape consult. (2/7), Level 4 Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic - this ordinarily requires 6-10 wks depending on the age of pt; The original description is of a "traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius"" [1]. Pathology of the annular ligament in paediatric Monteggia fractures. Compartment Syndrome in Operatively Managed Pediatric Monteggia Fractures and Equivalents. However, this particular fracture pattern only accounts for about 60% of these types of injuries. Radial head dislocation may lead to radial nerve injury. Int J Clin Exp Med. (1/1), Level 4 (2/8), Level 5 J Bone Joint Surg Am. - fracture of ulnar metaphysis; J Pediatr Orthop. Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and Florida Hospital (0/1), Level 1 Monteggia Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports J Hand Surg Am. The anular (annular) and radial collateral ligaments stabilize the radial head. there may be slow and progressive shortening and angulation; Orthop Traumatol Surg Res. Type II lesions that are associated with ulnohumeral dislocation have been noted to have outcome scores with greater disability than those without ulnohumeral dislocation. - following reduction, radial head will be stable if left in flexion; 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. Hand Clin. (26/80), Level 4 [QxMD MEDLINE Link]. 2021 Nov. 46 (11):1006-1015. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. Pronation injuries of the forearm, with special reference to theanterior Monteggia fracture. Wang C, Su Y. Monteggia-type elbow fractures in childhood. Musculoskelet Surg. This fracture refers to an intraarticular fracture that separates the palmar ulnar aspect of the first metacarpal base from the remaining first metacarpal. 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. (0/8), Level 2 (0/8), Level 1 [QxMD MEDLINE Link]. Fractures of the shafts of the radius and ulna. - 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). 2023 Lineage Medical, Inc. All rights reserved, PediatricsMonteggia Fracture - Pediatric. Anderson LE, Meyer FN. Pronation injuries of the forearm, with special reference to the anterior Monteggia fracture. History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. 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.
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