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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 60% 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 15%

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 20% Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head
Type IV 5% Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction  

Jupiter Classification of Type II Monteggia Fracture-Dislocations
Type IIA Coronoid level  
Type IIB

Metaphyseal-diaphyseal junction

 
Type IIC Distal to coronoid  
Type IID Fracture extending to distal half of ulna   
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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