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Updated: May 23 2024

Monteggia Fractures

Images i.lateral.jpg ii.lateral.jpg iii.ap.jpg
  • Summary
    • A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation.
    • Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture.
    • Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Adults and unstable injuries generally require ORIF of the ulna.
  • Epidemiology
    • Incidence
      • rare in adults
      • more common in children with peak incidence between 4 and 10 years of age
        • different treatment protocol for children
  • Etiology
    • Associated injuries
      • may be part of complex injury pattern including
        • olecranon fracture-dislocation
        • radial head fx
        • coronoid fx
        • LCL injury
        • terrible triad of elbow
  • Anatomy
    • Ligament
      • annular ligament
  • Classification
      • Bado Classification
      • 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
      • Fracture at Coronoid level
      • Type IIB
      • Fracture at Metaphyseal-diaphyseal junction
      • Type IIC
      • Fracture at Distal to coronoid
      • Type IID
      • Fracture at 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 and immobilization
        • indications
          • more common and successful in children
          • rarely indicated in adults, most require operative treatment
          • must ensure stability and anatomic alignment of ulna fracture
        • technique
          • cast in supination for Bado I and III
    • Operative
      • closed reduction of radial head, open reduction internal fixation (ORIF) of ulnar
        • indications
          • acute fractures which are open or unstable (long oblique)
          • comminuted fractures
          • most Monteggia fractures in adults are treated surgically
      • open reduction of radial head, open reduction internal fixation (ORIF) of ulnar
        • indications
          • failure to reduce radial head with ORIF of ulnar shaft only
            • ensure ulnar reduction is correct
          • complex injury pattern
          • Monteggia "variants" with associated radial head fracture
      • closed reduction of radial head and Intramedullary Fixation (IMN) of ulna
        • indications
          • transverse or short oblique fracture
          • radial head an ulnar shaft easily reduced with closed reduction
        • technique
          • closed reduction performed of the radial head and ulnar shaft fracture
          • percutaneous antegrade intramedullary nailing of ulna
  • Techniques
    • Open reduction internal fixation (ORIF) of ulna
      • 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
    • Open reduction of radiual head
      • approach
        • posterolateral (Kocher) approach
      • technique
        • annular ligament often found interposed in radiocapitellar joint preventing anatomic reduction after ulnar ORIF
          • treatment based on involved components (radial head, coronoid, LCL)
  • Complications
    • PIN neuropathy
      • incidence
        • up to 10% in acute injuries
      • mechanism
        • due to blunt trauma to nerve related to redial head dislocation
      • 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
  • Prognosis
    • Elbow stiffness
      • if diagnosis is delayed greater than 2-3 weeks complication rates increase significantly
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