Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma AssociationDisclosure: Nothing to disclose. - non union of frx of ulnar shaft Orthopedics. Diagnosis can be made with plain radiographs of the elbow. Monteggia fracture-dislocations remain a relatively uncommon injury. Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. On examination, the affected arm is swollen and tender around his elbow. [QxMD MEDLINE Link]. Acute pediatric Monteggia fractures: A. conservative approach to stabilization. The original description is of a "traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius"" [1]. - radial head is gently repositioned by direct manual pressure anteriorly on the bone; 2015 Nov. 31 (4):565-80. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ anterior dislocation of radial head; - hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Treatment may be closed reduction and casting for length stable ulna fractures with a stable radiocapitellar joint. Reckling FW. Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment, Removal of forearm plates. Bado JL. In 1814, Giovanni Battista Monteggia of Milan first described this injury as a fracture to the proximal third of the ulna with associated anterior dislocation of the radial head. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. Monteggia fractures in adults: long-term results and prognostic factors. [QxMD MEDLINE Link]. Monteggia fracture-dislocations. - Post - Orthobullets Zivanovic D, Marjanovic Z, Bojovic N, Djordjevic I, Zecevic M, Budic I. Neglected Monteggia Fractures in Children-A Retrospective Study. Monteggia's Fracture : Wheeless' Textbook of Orthopaedics [QxMD MEDLINE Link]. [6] Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. 4 (2):167-72. [Full Text]. Persistent posterior interosseous nerve palsy associated with a chronic type I Monteggia fracture-dislocation in a child: a case report and review of the literature. Surgical Management of Complex Adult Monteggia Fractures. The remaining patients had fixation with a plate and screws. Undecided Neglected Monteggia fracture: a review - eor 1974 Dec. 56 (8):1563-76. The ulna and radius are in direct contact with each other only at the PRUJ and the DRUJ; however, they are unified along their entire length by the interosseous membrane. The character of the ulnar fracture is useful in determining optimal treatment. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. 2013 Jan;44(1):59-66. [QxMD MEDLINE Link]. Melvin P. Rosenwasser, MD (CSOT #21, 2016), Frontiers in Upper Extremity Surgery - 2016, Monteggia - Alfred W. Hess, MD (Frontiers #16, 2016), Monteggia Fracture Dislocation - Everything You Need To Know - Dr. Nabil Ebraheim, Undecided (4/7). 2009 Nov. 34 (9):1618-24. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. [14] Osteoarthritic changes were seen at the radiohumeral joint in four patients. - bony ankylosis may be more disabling than the joint instability Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. The anular (annular) and radial collateral ligaments stabilize the radial head. 2021 Apr-Jun. Fractures of the shafts of the radius and ulna. 3rd ed. - posterior or posterolateral dislocation of radial head (or frx); It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes. Introduction Giovanni Battista Monteggia, a surgical pathologist and public health official in Milan, first described the Monteggia fracture in 1814. - Discussion: The Orthobullets Podcast In this episode, we review the high-yield topic of Monteggia Fractures from the Trauma section. In a study evaluating long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in 22 children (14 boys, 8 girls; age range, 4 y to 15 y 11 mo), Nakamura et al noted that the postoperative Mayo Elbow Performance Index (MEPI) at follow-up ranged from 65 to 100, with 19 excellent results, two good results, one fair result, and zero poor results. Wong JC, Getz CL, Abboud JA. Data Trace Publishing Company 19 (74):164-167. (0/1), Level 1 (0/1). Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment. Monteggia Fracture - an overview | ScienceDirect Topics Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The character of the ulnar fracture is useful in determining optimal treatment. - type I, III, and IV lesions are held in 110 deg. Ramski, D., Hennrikus, W., Bae, D., et. Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. In essence, high-energy trauma (eg, a motor vehicle collision) and low-energy trauma (eg, a fall from a standing position) can result in the described injuries. In his classic 1943 text, Watson-Jones stated that "no fracture presents so many problems; no injury is beset with greater difficulty; no treatment is characterized by more general failure." [QxMD MEDLINE Link]. Although most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting, most adult fractures require open reduction and internal fixation (ORIF). This website also contains material copyrighted by 3rd parties. Bennett fracture is the most common fracture involving the base of the thumb. Monteggia Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports History Mystery: Did Subdural Hematoma Kill Thomas Aquinas? Unrecognized dislocations may result from reduction of the dislocated radius prior to presentation. PDF Case Report The MonteggiaFracture: literature review and report of a Clinical effect of manual reduction of humeroradial joint in the treatment of type - fresh Monteggia fracture in children. Vol 2: 520. Monteggia Fractures - Trauma - Orthobullets 2019 Feb. 31 (1):54-60. Kathmandu Univ Med J (KUMJ). The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. Anterior elbow dislocations occur most often as a fracture-dislocation in which the distal humerus is driven through the olecranon, thereby causing a complex, comminuted fracture of the proximal ulna. Adults and unstable injuries generally require ORIF of the ulna. The Monteggia lesion in children. Penrose considered type II lesions a variation of posterior elbow dislocation. [1] [2] Causes Mechanisms include: Fall outstretched hand with the forearm in excessive pronation (hyper-pronation injury). - lateral or anterolateral dislocation of the radial head; anterior dislocation of radial head; 2023 Lineage Medical, Inc. All rights reserved. (1/7), Level 1 Undecided of flexion for 6 weeks; - Delayed Dx: 2016 Jun. The radius and ulna are closely invested by the interosseous membrane, which accounts for the increased risk of displacement or injury to the radius when the ulna fractures. 2023 Lineage Medical, Inc. All rights reserved. Tan JW, Mu MZ, Liao GJ, Li JM. [QxMD MEDLINE Link]. Ruchelsman DE, Pasqualetto M, Price AE, Grossman JA. This is the most common type of Monteggia fracture. Removal of forearm plates. (0/1), Level 3 If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. Evans EM. Monteggia Fractures: Pearls and Pitfalls - ScienceDirect (1/1), Level 4 Chin J Traumatol. Floriano Putigna, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic AssociationDisclosure: Nothing to disclose. Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio The ulna fracture is usually clinically and radiographically apparent. [11, 12] Of the Monteggia fractures, Bado type I has been reported to be the most common (59%), followed by type III (26%), type II (5%), and type IV (1%). Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. [8] : The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation. Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. Thank you. 36 Suppl 1:S67-70. - ref: Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique. (0/8), Level 1 This is a report of two rare variants of Monteggia fracture-dislocation. This principle also applies to aGaleazzi fracture, which is a fracture of the distal radius with concomitant dislocation of the distal radioulnar joint (DRUJ). TraumaMonteggia Fractures - The Orthobullets Podcast - Podcast Musculoskelet Surg. The Monteggia fracture is relatively rare. 36 (2):65-73. An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. 2018 Feb. 104 (1S):S113-S120. [QxMD MEDLINE Link]. (2/7), Level 4 2. - medullary nail in this location may not fill the canal and may thus provide less than rigid fixation; plastic deformation of the ulna without obvious fracture, pain, swelling, and deformity about the forearm and elbow, isolated radial head dislocations almost never occur in pediatric patients, a line down the radial shaft should pass through the center of the capitellar ossification center, radial head is stable following reduction, 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, radial head is not stable following reduction, ulnar length is not stable (unable to maintain ulnar length), 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, 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, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Surgical treatment of Monteggia variant fracture dislocations of the Splinting of the wrist in extension and finger range-of-motion (ROM) exercises help prevent contractures from developing while the patient awaits resolution of the nerve injury. 2009 Jun. The Monteggia lesion. The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated PRUJ, and a dislocated radiocapitellar joint. Surgical Treatment of Neglected Adult Monteggia Fracture - ResearchGate 2022 Jul 22. A 45-year-old male falls off his motorcycle and injures his arm. 2023 Lineage Medical, Inc. All rights reserved. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Monteggia fracture-dislocation is rare in children 2,3,4. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. J Bone Joint Surg Am. 2012 Feb. 35 (2):138-44. Bae, D. Successful strategies for managing Monteggia Injuries. [QxMD MEDLINE Link]. Acta Orthop Belg. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India Separate radiographs should be taken of the elbow. Pediatric hand and upper limb surgery: a practicalguide. Ulnar fracture with late radial head dislocation: delayed Monteggia fracture. Orthopedics. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; 64 (6):857-63. The first case is a combined type III Monteggia injury with ipsilateral Type II Salter-Harris injury of the distal end radius fracture with metaphyseal fracture of the Monteggia Fractures in Pediatric and Adult Populations, Clifford R. Wheeless, III, M.D. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. (OBQ10.240) 2022 Feb 1. Stitgen A, McCarthy JJ, Nemeth BA, Garrels K, Noonan KJ. anteriorangulation (usually proximal third); - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; Monteggia fractures in children and adults. - Post - Orthobullets These ligaments stretch or rupture during radial head dislocation. J Pediatr Orthop. Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. Beutel BG. (0/1), Level 2 Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. Waters PM. The mechanism of injury is most often a fall on an outstretched hand. LIVIN' ON THE MD EDGE: Drive, Chip, and Putt Your Way to Osteoarthritis Relief, Osteoporosis and Osteopenia: Latest Treatment Recommendations, Osteoporosis: A Bare-Bones Guide to Diagnosis and Treatment. Key words: Monteggia's fracture; Radius fracture; Ulna [14]. [QxMD MEDLINE Link]. - radiohumeral ankylosis - angulated ulnar shaft is reduced by firm manual pressure; - Type II (flexion type) - 15% Bado type II lesion after open reduction and internal fixation. - exam: Richard L Ursone, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society of Military Orthopaedic SurgeonsDisclosure: Nothing to disclose. (0/7), Level 3 Monteggia described a fracture of the proximal third of the ulna with anterior dislocation of the radial head from both the proximal radioulnar and radiocapitellar joints. Monteggia fractures and their variants are often misdiagnosed, however, because of the numerous atypical presentations of this injury in children. Take great care to avoid injury to the underlying skin. J Pediatr Orthop. Subluxation of the radial head occurred in three patients; one patient experienced transient palsy of the posterior interosseous nerve; and distortion of the radial head (which had no bearing on function) occurred in three. Prompt recognition of this injury is imperative. Pediatric Monteggia fractures: a single-center study of the management of 40 patients. [QxMD MEDLINE Link]. 2023 Lineage Medical, Inc. All rights reserved. - frx of proximal 1/3 of radius & frx of ulna at the same level; - Exam: The present multicenter retrospective study compared results for the Bouyala procedure with versus without plasty of the annular ligament of the radial head in evolved radial head lesion (Monteggia lesion), assessing the benefit of associating ligamentoplasty to ulnar osteotomy. 7th ed. Kopriva J, Awowale J, Whiting P, Livermore A, Siy A, Hetzel S, et al. The distal ulna and radius also articulate at the DRUJ. Children (Basel). head is not promptly reduced; Watson-Jones R. Fracture and Joint injuries. The Monteggia lesion is most precisely characterized as a forearm fracture in association with dislocation of the PRUJ. Since Monteggia first described the fracture bearing his name in 1814, the association of radial head dislocation with ipsilateral ulnar fracture has been well described. Orthop Clin North Am. - radioulnar synostosis Gemeinsam ist diesen 3 Formen die Kombination der Fraktur. J Bone Joint Surg Br. 1951 Feb. 33-B (1):65-73. Monteggia Fracture: Practice Essentials, Anatomy, Pathophysiology [QxMD MEDLINE Link]. What is the most likely finding? [Full Text]. : A retrospective study. PDF Monteggia fracture dislocation equivalents analysis of eighteen cases Kim JM, London DA. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries. (16/80), Level 5 (0/8), Level 2 Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. Van Tongel A, Ackerman P, Liekens K, Berghs B. Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination.

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