- Must have high index of suspicion – high incidence of missed injuries (Waters, 2010)
- Appropriate radiographic imaging is essential to making the correct diagnosis
- Be aware of plastic deformation of the ulna
Description:A Monteggia fracture involves a fracture of the ulna with disruption of the proximal radio-ulnar joint (PRUJ) and radiocapitellar dislocation (Bado, 1967). 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.
Epidemiology:Monteggia fractures account for 0.4% of all forearm fractures in children. This fracture pattern was first described in 1814 by Giovanni Monteggia. They typically occur in children between 4 and 10 years of age after a fall onto an outstretched hand. The type of fracture depends largely on the mechanism of injury (Evans, 1949).
Clinical Findings:Patients usually present with a history of a fall onto an outstretched hand and pain in the forearm and elbow. Forearm deformity may or may not be present and limitations in range of motion are not always obvious. Neurologic deficit is present at presentation in 10-20% of the cases. This includes posterior interosseous nerve (PIN) and ulnar nerve neuropraxia, typically seen with Bado III and II, respectively (Waters, 2012).
Imaging Studies:Appropriate imaging is essential to avoid missing this injury. AP and lateral films of the forearm as well as the elbow and wrist should be obtained. 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. Beware of plastic deformation of the ulna, which can be easily missed but still associated with radiocapitellar dislocation. When unclear, obtaining an AP and lateral x-ray of the contralateral elbow can be helpful. Dynamic imaging with fluoroscopy may be helpful as well. Proximal radius dislocations can also occur with mid-shaft forearm fractures. Clinical diagnosis can be missed in the subtle ulna plastic deformation fracture and significantly displaced radius and ulna shaft fractures (Bae, 2016). 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.
Treatment:There are 3 important things to keep in mind when treating a monteggia fracture. You must correct the ulna deformity, reduce the radial head, and minimize future forces that may cause the radial head to re-dislocate.
Treatment is often dictated by the pattern of the ulna fracture (Ring, 1998; Ramski, 2015). Plastic deformation and incomplete fractures of the ulna can be treated with closed reduction of the ulnar bow and cast immobilization. If the radial head cannot kept reduced in a safe position of elbow flexion, ideally less than 100 degrees, the ulna will require stabilization. Non-surgical management of the ulna is possible but close monitoring is required the first several weeks after manipulation (Foran, 2017). 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. Long oblique or comminuted fractures of the ulna may require open reduction and internal fixation with plates and screws. If radial head reduction is not maintained, stable internal fixation may be safely performed up to several weeks after the injury with good outcomes.
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. This can be accomplished through a Kocher or posterolateral approach. The forearm should be kept in pronation during the approach to avoid injury to the posterior interosseous nerve. Open reduction and reconstruction of the annular ligament are rarely needed in the acute period.
Complications:Complications range from mild to severe. Failure to recognize a monteggia fracture can have severe consequences. Late reconstruction is difficult and often results in less than perfect results (Rang, 2005). 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). Results are less predictable when the radial head has become deformed.
Approximately 10% of these injuries have a transient PIN neuropraxia that resolves without treatment.
Elbow stiffness can be a problem with prolonged immobilization and is more frequently a problem in the setting of missed injury and delayed reconstruction.
Although not a frequent complication, compartment syndrome has been described and should be considered by anyone taking care of these injuries.
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Top Contributors:Mathilde Hupin Debeurme MD
Jennifer Powers MD