J Bone Joint Surg Br. Musculoskelet Surg. Acta Orthop Belg. 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. The Monteggia lesion is most precisely characterized as a forearm fracture in association with dislocation of the PRUJ. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. Delpont M, Louahem D, Cottalorda J. Monteggia injuries. Rang, M., Pring, M. E., & Wenger, D. R. (2005). Evans in 1949 Although most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting, most adult fractures require open reduction and internal fixation (ORIF). Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. Pathology of the annular ligament in paediatric Monteggia fractures EVANS EM. - angulated ulnar shaft is reduced by firm manual pressure; - Type II (flexion type) - 15% of flexion for 6 weeks; - Delayed Dx: 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. Events Search Events ; All Events List All Events Calendar Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand . 7th ed. Surgical Management of Missed Pediatric Monteggia Fractures: A Systematic Review and Meta-Analysis. J Bone Joint Surg Br. Modified technique for correction of isolated radial head dislocation without apparent ulnar bowing: a retrospective case study. Galezzi's fracture-fracture to the distal radius accompanied by ulnar head dislocation at distal radio-ulna joint. J Hand Surg Am. Monteggia fracture-dislocations in children. Fractures of the shafts of the radius and ulna. 2015. of flexion; Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and Florida Hospital - hence, these patients will require close follow up; - Treatment: [1], The first challenge is correctly assessing the extent and nature of the injury. Type in at least one full word to see suggestions list, 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. The mechanism of injury is most often a fall on an outstretched hand. [QxMD MEDLINE Link]. - when dx is delayed < 3 months, ORIF is indicated; Are you sure you want to trigger topic in your Anconeus AI algorithm? Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. [7] [Full Text]. Diagnosis can be made with plain radiographs of the elbow. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Neglected Monteggia fracture: a review - eor Monteggia fractures. - Post - Orthobullets Monteggia fractures are one third as common as the more . Monteggia Fracture - Orthopedics - Medbullets Step 2/3 The Galeazzi fracture is a fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint (DRUJ). The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. You are being redirected to [QxMD MEDLINE Link]. Please confirm that you would like to log out of Medscape. 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. The eponymous term "Monteggia fracture" is most precisely used to refer to dislocation of the proximal radioulnar joint in association with a forearm fracture. Monteggia Fractures in Pediatric and Adult Populations, Clifford R. Wheeless, III, M.D. 1951 Feb. 33-B (1):65-73. Fractures in Adults. Orthopaedic Specialists of North Carolina. Monteggia Fracture | Pediatric Orthopaedic Society of North - POSNA Telephone: 410.494.4994. [QxMD MEDLINE Link]. The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. [QxMD MEDLINE Link]. - exam: Philadelphia: JB Lippincott; 1991. 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 [QxMD MEDLINE Link]. - non union of frx of ulnar shaft A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. 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. Monteggia fracture-dislocation is rare in children 2,3,4. In a study evaluating long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in 22 children (14 boys, 8 girls; age range, 4 y to 15 y 11 mo), Nakamura et al noted that the postoperative Mayo Elbow Performance Index (MEPI) at follow-up ranged from 65 to 100, with 19 excellent results, two good results, one fair result, and zero poor results. 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. 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. Ramski, D., Hennrikus, W., Bae, D., et. Bae DS. For patient education resources, see theBreaks, Fractures, and Dislocations Center, as well asBroken Arm,Broken Elbow, andElbow Dislocation. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Data Trace Publishing Company AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. What are floating elbow injuries and how are they treated? Bado [1] classification in Monteggia fracture-dislocations and - frx of proximal ulnar diaphysis with posterior angulation; 2015 Sep. 99 Suppl 1:S75-82. Monteggia Fracture - an overview | ScienceDirect Topics - type II lesions with posterior dislocations should be maintained in about 70 deg. Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. Forearm fractures in children. [2 . Monteggia fractures and their variants are often misdiagnosed, however, because of the numerous atypical presentations of this injury in children. (0/1), Level 3 - spontaneous recovery is usual & exploration is not indicated; J Orthop Trauma. Monteggia Fractures - Trauma - Orthobullets 2018 Oct. 102 (Suppl 1):93-102. 1967 Jan-Feb. 50:71-86. Acute pediatric Monteggia fractures: A. conservative approach to stabilization. A review of the complications, Does a Monteggia variant lesion result in a poor functional outcome? 2023 Lineage Medical, Inc. All rights reserved, PediatricsMonteggia Fracture - Pediatric. As multiple variants of Monteggia fractures exist, it is most accurately described as a forearm fracture with dislocation of the proximal radioulnar joint.4 Subtle bowing of the ulna shaft with an asssociated radiocapitellar dislocation may be missed by the inexperienced clinician who is looking for a forearm fracture and therefore Bado initially described and classified these injuries. J Hand Surg Am. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Are you sure you want to trigger topic in your Anconeus AI algorithm? Pathology of the annular ligament in paediatric Monteggia fractures. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTIzMTQzOC1vdmVydmlldw==, Type I - Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (see the first and second images below), Type II - Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (see the third and fourth images below), Type III - Fracture of the ulnar metaphysis with lateral dislocation of the radial head (see the fifth and sixth images below), Type IV - Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head (see the seventh image below), Excellent - Union with less than 10 loss of elbow and wrist flexion/extension and less than 25% loss of forearm rotation, Satisfactory - Union with less than 20 loss of elbow and wrist flexion/extension and less than 50% loss of forearm rotation, Unsatisfactory - Union with greater than 30 loss of elbow and wrist flexion/extension and greater than 50% loss of forearm rotation, Failure - Malunion, nonunion, or chronic osteomyelitis. 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. (1/8), Undecided 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. - see: nerve injuries Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury. Radial head dislocation may lead to radial nerve injury. 2016 Jun. Adults and unstable injuries generally require ORIF of the ulna. The Monteggia lesion. Share cases and questions with Physicians on Medscape consult. The character of the ulnar fracture is useful in determining optimal treatment. 16 (3):131-5. With careful definition, specific subsets of patients may benefit from consideration as a separate type of Monteggia injury. Clin Orthop Relat Res. 2009 Jun. Introduction Giovanni Battista Monteggia, a surgical pathologist and public health official in Milan, first described the Monteggia fracture in 1814. J Bone Joint Surg Am. - then elbow is gently flexed to > 90 deg to relax biceps; It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. 1949;31B:578-88. Pronation injuries of the forearm, with special reference to theanterior Monteggia fracture. - attempt to palpate radial head (ant, post, or lateral); Kevin Strohmeyer, MD Consulting Surgeon, Department of Orthopedic Surgery, Darnall Army Community Hospital, Kevin Strohmeyer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons. Monteggia fractures in adults. - Post - Orthobullets J Pediatr Orthop 2017: 37(6): e335-e341.Penrose JH. 2023 Lineage Medical, Inc. All rights reserved. Compartment Syndrome in Operatively Managed Pediatric Monteggia Fractures and Equivalents. Transolecranon fracture-dislocation of the elbow - PubMed Di Gennaro GL, Martinelli A, Bettuzzi C, Antonioli D, Rotini R. Outcomes after surgical treatment of missed Monteggia fractures in children. 2013. Closed reduction; cast immobilization for Monteggia lesion - AO Foundation Children (Basel). Unrecognized dislocations may result from reduction of the dislocated radius prior to presentation. Kim JM, London DA. Fractures in children. Type II lesions that are associated with ulnohumeral dislocation have been noted to have outcome scores with greater disability than those without ulnohumeral dislocation. [6] Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. - apex of angular deformity of ulna usually indicates direction of radial head dislocation; - Reduction: Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellarjoint. - following reduction, radial head will be stable if left in flexion; The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Take great care to avoid injury to the underlying skin. It is named after Giovanni Battista Monteggia. The Monteggia fracture with posterior dislocation of the radial head. The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Monteggia fracture-dislocations. - Post - Orthobullets [Full Text]. Vol 2: 520. 9 (8):[QxMD MEDLINE Link]. [QxMD MEDLINE Link]. TraumaMonteggia Fractures - The Orthobullets Podcast - Podcast The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. - dislocation of radial head may be missed, eventhough frx of ulna is obvious (need AP, lateral and olbique X-rays of elbow) - paralysis of deep branch of radial nerve is most common; In his classic 1943 text, Watson-Jones stated that "no fracture presents so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure." PDF Case Report The MonteggiaFracture: literature review and report of a The investigators evaluated outcomes on the basis of the 100-point MEPI, radiology, and questionnaire. Application of this eponym to all injuries with radiocapitellar subluxation or dislocation has led to some confusion. 1967; 50:71-86. 4 (2):167-72. there may be slow and progressive shortening and angulation; This may occur in the field spontaneously or as a result of manipulation by emergency responders. [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]. J Pediatr Orthop 2015; 35 (2) 115-120. [QxMD MEDLINE Link]. The ulna and interosseous membrane also may provide stable platforms for dislocation of the proximal radius, leading to the Monteggia fracture. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; ORTHOBULLETS; Events. [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%). Successful Strategies for Managing Monteggia Injuries. Few contraindications for surgery exist. Monteggia fracture - Wikipedia 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. 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. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). The remaining patients had fixation with a plate and screws. Epidemiology: Ruchelsman DE, Pasqualetto M, Price AE, Grossman JA. Xiao RC, Chan JJ, Cirino CM, Kim JM. (0/1), Level 5 Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. Undecided The radial head should point towards the capitellum on all radiographs of the elbow. 2019 Feb. 31 (1):54-60. Pediatric Monteggia fractures: a single-center study of the management of 40 patients. 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). Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. J Bone Joint Surg Br. 1949 Nov. 31B (4):578-88, illust. Monteggia Fractures - Trauma - Orthobullets.pdf - Course Hero Data Trace is the publisher of Bennett Fracture - StatPearls - NCBI Bookshelf The olecranon, midshaft, and distal shaft may be involved. Bado type I lesion. If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. A Monteggia fracture involves a fracture of the ulna with disruption of the proximal radio-ulnar joint (PRUJ) and radiocapitellar dislocation (Bado, 1967). Once the cast is hardened, mark it, then split using an oscillating saw, a hand saw, or a sharp plaster knife (1). The distal ulna and radius also articulate at the DRUJ. Key words: Monteggia's fracture; Radius fracture; Ulna 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. In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis JAMA 1940;115:1699-1705. Philadelphia: Lippincott Williams &Wilkins; 2010: 446-74. Bado type III lesion with lateral displacement of the radial head. Undecided 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. Whenever a fracture of a long bone is noted, the joints above and below should be evaluated with radiographs in orthogonal planes (planes at 90 angles to each other). On examination, the affected arm is swollen and tender around his elbow. 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. J Am. 8 (6):LC01-4. Leonidou A, Pagkalos J, Lepetsos P, Antonis K, Flieger I, Tsiridis E, et al. 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. Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. - realize that even w/ successful closed reduction of the ulna (and accompanying reduction of the radial head) that subsequently Hand Clin. Evans EM. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. - when > 3 months has elapsed, consider non op treatment because bony ankylosis of the elbow may occur following surgery; [QxMD MEDLINE Link]. 2015 Nov. 31 (4):565-80. Gemeinsam ist diesen 3 Formen die Kombination der Fraktur. 1998 Dec;80(12):1733-44. 2009 Jun. A review of the complications. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. Which direction is the radial head most likely dislocated? Monteggia Fracture: Practice Essentials, Anatomy, Pathophysiology - Discussion: - immobilize forearm in neutral rotation w/ slight supination, w/ cast carefully molded over lateral side of ulna at level of fracture; [QxMD MEDLINE Link]. (8/80), Level 2 J Bone Joint Surg Am. Watson-Jones R. Fracture and Joint injuries. Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. 2014 Jun. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. [14]. 2009 Nov. 34 (9):1618-24. The forearm structures are intricately related, and any disruption to one of the bones affects the other. The posterior interosseous branch of the radial nerve, which courses around the neck of the radius, is especially at risk, particularly in Bado type II injuries. Chronic Monteggia. Bae, D. Successful strategies for managing Monteggia Injuries. Ring D, Jupiter JB, Waters PM. Monteggia fracture - fracture of the proximal 1/3 of the ulnar shaft accompanied by the dislocation of the radial head. Are you sure you want to trigger topic in your Anconeus AI algorithm? Chin J Traumatol. J Pediatr Orthop. Advances in radiography and fracture research have helped define, classify, and guide operative management. for: Medscape. Richard L Ursone, MD Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, Brooke Army Medical Center Adult Monteggia and Olecranon Fracture Dislocations of the Elbow. PENROSE JH. A high index of suspicion, therefore, should be maintained with any ulna fracture. Monteggia fracture-dislocation in children. : A retrospective study. Does a Monteggia variant lesion result in a poor functional outcome? Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). [QxMD MEDLINE Link]. - key is to obtain length and alignment, which then allows the radial head to be reduced; (0/8). 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. According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. 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. 2018 Feb. 104 (1S):S113-S120. Once the radial head is reduced in closed injuries, surgical treatment may be delayed until the patient is stable and the surgery may be performed in a more elective fashion. The Monteggia lesion. 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. Are you sure you want to trigger topic in your Anconeus AI algorithm? Anderson LE, Meyer FN. Monteggia fractures in children and adults. - Post - Orthobullets (2/8), Level 5 (10/80), Level 3 [4] The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. 2. Radial Head Fractures and Dislocations Questions & Answers - Medscape Removal of forearm plates. - this is esp true on the lateral projection; (0/7), Level 3 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. Complex Monteggia Fractures in the Adult Cohort: Injury and Management. 2012 Jun. - posterior or posterolateral dislocation of radial head (or frx); - Monteggia Fractures in Children. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction. J Am Acad Orthop Surg. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; Conclusions: Monteggia fracture dislocation equiva-lents are rare injuries and pre-surgery recognition by radio-graphs and 3-D CT helps make optimal plan. Separate radiographs should be taken of the elbow. (3/76), Level 1 A 45-year-old male falls off his motorcycle and injures his arm. 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, Undecided 35 (3):e434-7. Surgical management is indicated for radial heads that are not stable following closed reduction. Reckling FW. If one of the forearm bones is injured, injury should be looked for in the other bone and in associated joints of the forearm, elbow, and wrist. We present an unreported configuration of a traumatic olecranon fracture with a concomitant medial radial head dislocation in a 3-year-old male.. - Type III - 20% [QxMD MEDLINE Link]. Kopriva J, Awowale J, Whiting P, Livermore A, Siy A, Hetzel S, et al. You can rate this topic again in 12 months. 2011 Feb. 77 (1):21-6. 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 2023 Lineage Medical, Inc. All rights reserved. - Plating Techniques 2023 Lineage Medical, Inc. All rights reserved. A good radiographic result was seen in all patients who underwent open reduction within 3 years after injury or before reaching 12 years of age.