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Updated: Jul 5 2022

Monteggia Fracture - Pediatric

Images i.lateral_moved.jpg iii.ap_moved.jpg type ii.jpg type iv monteggia fx.jpg line on x-ray.jpg
  • summary
    • Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation.
    • Diagnosis can be made with plain radiographs of the elbow.
    • Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellar joint. Surgical management is indicated for radial heads that are not stable following closed reduction. 
  • Epidemiology
    • Demographics
      • 4 to 10 years of age is peak incidence
  • Etiology
    • Definition
      • radial head dislocation plus
      • proximal ulna fracture or
      • plastic deformation of the ulna without obvious fracture
  • Classification
      • Bado Classification
      • Type I
      • Apex anterior proximal ulna fracture with anterior dislocation of the radial head
      • Type II
      • Apex posterior proximal ulna fracture with posterior dislocation of the radial head
      • Type III
      • Apex lateral proximal ulna fracture with lateral dislocation of the radial head
      • Type IV
      • Fractures of both the radius and ulna at the same level with ananterior dislocation of the radial head (1-11% of cases)
  • Presentation
    • Symptoms
      • pain, swelling, and deformity about the forearm and elbow
    • Physical exam
      • must palpate over radial head with all ulna fractures because spontaneous relocation of radial head is common
      • must examine for plastic deformation of the ulna if there is a presumed isolated radial head dislocation
        • isolated radial head dislocations almost never occur in pediatric patients
  • Imaging
    • Radiographs
      • obtain elbow radiographs for all forearm fractures to evaluate for radial head dislocation
        • assess radiocapitellar line on every lateral radiograph of the elbow
          • a line down the axis of the radial neck should pass through the center of the capitellar ossification center
      • obtain forearm radiographs for all radial head dislocations
  • Treatment
    • Nonoperative
      • closed reduction of ulna and radial head dislocation and long arm casting
        • indications
          • Bado Types I-III with
            • radial head is stable following reduction
            • length stable ulnar fracture pattern
        • reduction technique
          • reduction technique uses traction
            • radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length
            • for Type I, elbow flexion is the main reduction maneuver
            • if reduction of radiocapitellar joint is unsuccessful, annular ligament is most common block to reduction 
        • immobilization
          • Type I 110° of flexion and full supination to tighten interosseous membrane and relax biceps tendon
          • Type II fulll extension.
          • Type III full extension and valgus mold
    • Operative
      • pinning/nailing of ulna + reduction of radial head ± annular ligament repair/reconstruction
        • indications
          • Bado Types I-III with
            • radial head is not stable following reduction
            • ulnar length is not stable (unable to maintain ulnar length)
          • acute Bado Type IV
          • open fractures
          • older patients ≥ 10y if closed reduction is not stable
          • symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis
        • technique
          • open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure
          • annular ligament reconstruction almost never required for acute fractures
      • ORIF similar to adult treatment
        • indications
          • closed physes
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