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A 4-year-old girl sustains a buckle fracture of the ulna and associated radial head dislocation. Closed reduction and immobilization of the arm in 110 degrees of flexion (as swelling allows) and full supination enhances the stability of the injury by which of the following:
Tightening the interosseous membrane
Tightening the biceps
Eliminates plastic deformation
Relaxes the pronator quadratus
Protects the posterior interosseous nerve
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Closed reduction and immobilization of the arm in 110 degrees of flexion (as swelling allows) and full supination enhances the stability of the injury by tightening the interosseous membrane and relaxing the biceps tendon. A Monteggia lesion is a fracture of the proximal ulna with an associated radial head dislocation. When the ulna fracture is incomplete (greenstick or buckle), these injuries are most often successfully treated with closed reduction, and operative management is not needed. The article by Ring et al is a review of Monteggia fractures and states that immobilization in supination is a key element in successful nonoperative treatment of Monteggia fractures.
Ring D, Jupiter JB, Waters PM
J Am Acad Orthop Surg. 6(4):215-24. PMID: 9682084 (Link to Abstract)
Ring, JAAOS 1998
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A 7-year-old girl falls off of her bike and sustains the injury depicted in Figures A & B. All of the following are indications for surgical management of Monteggia fractures EXCEPT:
Combined radius and long oblique ulnar fracture and reduced radial head dislocation
Incomplete ulnar fracture with lateral radial head dislocation that is successfully reduced
Ulnar communition with ulnar shortening
One week post-reduction/casting radiograph showing loss of radial head reduction
Long oblique ulnar fracture with irreducible radial head dislocation
Monteggia fractures include a combination of ulnar fracture and radial head dislocation. Pediatric patients have better outcomes than adults. The Bado classification names patterns based on direction of the radial head dislocation(1=anterior, 2=posterior, 3=lateral) with Bado Type 4 being a both bone forearm fracture with associated radial head dislocation. Initial management for Type 1-3 injuries is closed reduction and long arm casting if the ulna is at appropriate length and the radial head is reduced.
The review articles by Ring and Wilkins discuss operative indications to include failure to maintain ulnar reduction or radial head anatomic position and a Type 4 Bado injury (whether or not the radial head can be successfully closed reduced).
J Pediatr Orthop. 2002 Jul-Aug;22(4):548-54. PMID: 12131457 (Link to Abstract)
Wilkins, JPO 2002
This video describe the clinical presentation and XR findings in Monteggia fract...
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A 6-year-old boy fell off the monkey bars 3 months ago and has had pain and decreased elbow motion since his fall. His radiographs are shown in figures A and B. Closed reduction was unsuccessful. What is the most appropriate treatment?
Bracing and early range of motion
Closed reduction and casting in supination and flexion
Open reduction internal fixation of medial epicondyle fracture
Open reduction internal fixation of lateral condyle fracture
Open reduction of radial head dislocation with casting in supination and flexion
The radiographs show a dislocation of the radiocapitellar joint. This is going to require open reduction due to the chronicity of the injury. Treatment options include annular ligament repair, ulnar osteotomy, radial osteotomy or a combination of these procedures. Also, the annular, quadrate, oblique & interosseous ligaments tighten in supination, providing further stability to the proximal radioulnar joint and decreasing the risk of re-dislocation.
It has been published by many authors, including Lincoln et al, that an isolated radial head dislocation does not occur in the pediatric population and that plastic deformation or malunion of the ulna is typically present creating a Monteggia fracture-dislocation variant. The ulnar deformity, if significant, may need to be addressed via osteotomy in the corrective procedure in order to obtain a secure reduction of the radiocapitellar joint. In treating the traumatic radial head dislocation, it is important to consider congenital radial head dislocation and occult Monteggia fracture (plastic deformation of the ulna) in the differential diagnosis as this could alter your treatment strategy.
Lincoln TL, Mubarak SJ.
J Pediatr Orthop. 1994 Jul-Aug;14(4):454-7. PMID: 8077426 (Link to Abstract)
Lincoln, JPO 1994
HPI - 12 yo boy presents with Left elbow pain and a history of an ulna shaft fracture 3 years ago.
He was treated with closed reduction and casting at the time of the initial injury. The boy's parents report that his arm never looked right after the injury. He continued to have pain in the lateral aspect of his elbow, with an associated prominence anterolaterally. They were advised to wait two years which did not yield significant improvement, so they finally sought treatment elsewhere.
The patient presents with his parents with complaints of left elbow pain with movement and inability to participate in sports. The patient is right hand dominant and this is a left-sided injury.
Only one XRay is available from the initial injury, which is shown.
Three current XRays are shown.
Would you order further imaging on this patient?
HPI - Patient presented after a fall from a slide on his left arm. Patient denied any other trauma. Patient's parents think he fell on an outstretched arm.
What is the most likely diagnosis?
HPI - pai and limitation of elbow since 2 years
How would you treat this patient