Updated: 10/6/2018

Monteggia Fracture - Pediatric

Topic
Review Topic
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0
Questions
7
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0
Evidence
8
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0
Videos
1
Cases
3
https://upload.orthobullets.com/topic/4015/images/type i.lateral_moved.jpg
https://upload.orthobullets.com/topic/4015/images/bado type ii.jpg
https://upload.orthobullets.com/topic/4015/images/type iii.ap_moved.jpg
https://upload.orthobullets.com/topic/4015/images/bado type iv monteggia fx.jpg
https://upload.orthobullets.com/topic/4015/images/radiocapitellar line on x-ray.jpg
Introduction
  • Definition
    • radial head dislocation plus
    • proximal ulna fracture or
    • plastic deformation of the ulna without obvious fracture 
  • Epidemiology
    • 4 to 10 years of age is peak incidence
  • Treatment differs from adult Monteggia fractures
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 an anterior 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 radial shaft 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
      • 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
    • plating 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
      • technique
        • annular ligament reconstruction almost never required for acute fractures
        • 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 
        • symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis
    • ORIF similar to adult treatment 
      • indications
        • closed physes
Complications
  • Neurovascular
    • posterior interosseous nerve neurapraxia (10% of acute injuries)
      • almost always spontaneously resolves
  • Delayed or missed diagnosis
    • common when evaluation not performed by an orthopaedic surgeon
    • complication rates and severity increase if diagnosis delayed >2-3 weeks
 

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Questions (7)
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(OBQ07.143) 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? Review Topic

QID: 804
FIGURES:
1

Bracing and early range of motion

3%

(20/757)

2

Closed reduction and casting in supination and flexion

9%

(65/757)

3

Open reduction internal fixation of medial epicondyle fracture

6%

(47/757)

4

Open reduction internal fixation of lateral condyle fracture

10%

(76/757)

5

Open reduction of radial head dislocation with casting in supination and flexion

72%

(542/757)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ09.81) 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: Review Topic

QID: 2894
FIGURES:
1

Combined radius and long oblique ulnar fracture and reduced radial head dislocation

6%

(131/2373)

2

Incomplete ulnar fracture with lateral radial head dislocation that is successfully reduced

91%

(2160/2373)

3

Ulnar communition with ulnar shortening

2%

(36/2373)

4

One week post-reduction/casting radiograph showing loss of radial head reduction

1%

(14/2373)

5

Long oblique ulnar fracture with irreducible radial head dislocation

1%

(17/2373)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ10.42) 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: Review Topic

QID: 3130
1

Tightening the interosseous membrane

82%

(1625/1986)

2

Tightening the biceps

6%

(124/1986)

3

Eliminates plastic deformation

3%

(67/1986)

4

Relaxes the pronator quadratus

7%

(144/1986)

5

Protects the posterior interosseous nerve

1%

(19/1986)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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ARTICLES (23)
VIDEOS (1)
CASES (3)
Topic COMMENTS (17)
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