How common are they and how do they occur? TIP: A line drawn down the shaft of the radius should point to the center of the capitellum (radiocapitellar line) in both AP and lateral x-ray views to exclude joint dislocation. 42-2A). Most complications arise from missed or delayed diagnoses of Monteggia fracture-dislocations. Depending on the patient, healing time can take six weeks or longer. If an ulna fracture is present, always look for a radial head dislocation. It is associated with higher energy injuries, fractures of the radial head, and multiple attempts at manipulation. Originally described by Giovanni Battista Monteggia in 1814, Monteggia fracture dislocations refer to fractures of the ulna associated with proximal radioulnar joint (PRUJ) dissociation and radiocapitellar dislocations.2, 3 These injuries comprise <1% of all pediatric forearm fractures, typically affecting patients between 4 and 10 years of age. He is the one who described this fracture in the early 1800’s. What is the usual ED management for this fracture? To diagnosis a Monteggia fracture the radiographer will use an x-ray machine to visualize the joints and bones in your arm. The forearm may look deformed if the ulna fracture is displaced. It should be straight, not bowed. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way, Monteggia fracture-dislocations - Fracture clinics. A radial head dislocation is evident as shown by the radiocapitellar line. When a person has this type of fracture it is normally very evident because it causes extreme pain. 26% in most series) Injuries to the radial nerve, particularly the posterior interosseous branch, occur frequently with this lesion. Lippincott Williams & Wilkins, Philadelphia 2010. p.446-74. Fig : long armed cast Monteggia Fracture Dislocation. However, the Monteggia fracture is often still associated with various complications, poor functional outcomes and a relatively high rate of revision surgeries. After the surgery is finished a cast will normally be applied to give it stability during healing. It is on the pinky-finger side of your arm near the radius bone, which is the lateral bone of your forearm between your elbow and hand. Complications of Monteggia fractures often result from nonanatomic or loss of fixation of the ulna fracture, leading to recurrent dislocation of the radial head. Other indications for prompt consultation include: The arm should be splinted and the nearest on call orthopaedic service be consulted. Monteggia fracture dislocations are a relatively rare entity and they represent less than 2% of forearm fractures, the diagnosis can be missed in up to 50% of the time. However if the ulna has a greenstick fracture or 'plastic bowing', deformity is mild and the fracture can be easily missed. Monteggia fracture-dislocations can be easily missed on x-ray. Taking either a prescription medication or over-the –counter medication for the pain. He is the one who described this fracture in the early 1800’s. Smoking status. If an ulna fracture is present, always look for a radial head dislocation.All Monteggia fracture-dislocations require an urgent orthopedic assessment. In this case report of a 35-year-old man the nerve became wrapped around an anterolaterally dislocated radial head in the course of an unsuccessful attempt as closed reduction. 2 . When is reduction (non-operative and operative) required? Monteggia Fractures- Bado Classification. Complications: Complications range from mild to severe. In Rockwood and Wilkins' Fractures in Children, 7th Ed. The only general symptoms of having a Monteggia fracture are swelling and pain at the elbow joint, You may also have pain in your arm that gets worse every time you move your elbow or wrist, When looking at it you may or may not see any obvious dislocation but you may notice that there may be loss of range of motion at the elbow because of the dislocation, You may also have swelling in your hand, wrist, and forearm, Hyperextension, which is when you move your tendons, muscles, or joints beyond the normal range of motion, Falling on an outstretched hand to break your fall. Monteggia fracture-dislocations - Fracture clinics. In particular the ramus profundus of the radial nerve is exposed to injury but other nerves may also be involved. Your ulna is a bone in your forearm that is broader near your elbow and tapers as it approaches your wrist. Fifty-one adults who had a fracture of the forearm and dislocation of the proximal radioulnar joint (a Monteggia fracture) were managed at Massachusetts General Hospital between January 1985 and December 1994. Follow-up in fracture clinic needs to be in 7 days with an x-ray. All Monteggia fracture-dislocations require an urgent orthopedic assessment. Dr Ian Bickle ◉ and Assoc Prof Frank Gaillard ◉ ◈ et al. This is when the tissue and bone die because they are not being supplied with blood or there is an infection. It is rare for an adult to have a Monteggia fracture but is most common in children between the ages of four and ten. When a person has this type of fracture it is normally very evident because it causes extreme pain. The health information provided on this web site is for educational purposes only and is not to be used as a substitute for medical advice, diagnosis or treatment. This is referred to as a, Resting your arm by elevating it higher than your heart, Cold compresses but you have to be careful not to get the cast wet. Delayed diagnosis is the most frequent complication. Your range of motion will also be limited. Alcohol use. Type I fractures are usually a result of a fall on an outstretched hand with hyperpronation or hyperextension of the forearm. The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint in association with a forearm fracture. The Bado classification system (Table 1) describes four types. The casting is done by an orthopedic physician who is trained in the branch of medicine that deals with your musculoskeletal system. In three months after the cast is removed the orthopedic physician or surgeon will have you start rehabilitation. Type I Monteggia fracture-dislocation (with plastic deformation of ulna). After your arm has been in a cast for several weeks your physician will order more x-rays to confirm that the healing is even and the bones are knitting together. It can also predispose you to another fracture. History of the Monteggia fracture-dislocation 1812 – Giovanni Battista Monteggia (1762 – 1815) recorded two observations of a traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal radius in ‘ Lussazioni delle ossa delle estremita superiori.’ A big risk with an open fracture, which means that your skin has been damaged during the injury or the bone has broken through your skin, is necrosis. There may be diffuse swelling around the elbow, but the degree is variable. Anteroposterior (AP) and lateral x-rays of the forearm that include the wrist and elbow should be ordered. Rehabilitation is necessary in order for your muscles to become stronger. The radial nerve is the most commonly injured nerve (10-20%). It is concluded that Monteggia lesions … Beaty JH, Kasser JR (Eds). Type I Monteggia fracture-dislocation (with ulna mid shaft fracture). relationship between anatomy and the neuropathy which is a frequent complication in Monteggia lesions. The posterior border of the ulna should also be assessed. The injury is usually a neuropraxia. Anterior dislocation of the radial head with fracture of the ulna shaft (diaphysis), Posterior dislocation of the radial head with fracture of the ulna shaft (diaphysis) or metaphysis, Lateral dislocation of the radial head with fracture of the ulna metaphysis, Anterior dislocation of the radial head with fracture of the shaft (diaphysis) of the ulna and radius. 20%. fracture clinics for other potential complications. Many times the Monteggia fracture will have to be treated using surgery. If identified early, these injuries will do well. Delayed or missed diagnosis is the most frequent complication. No patient who had an anterior (transolecranon) fracture-dislocation of the elbow was included in the present study4,42. If it is not straight, it indicates a plastic deformation injury. 7 Pictures : How Monteggia Fracture Looks like? Failure to recognize a monteggia fracture can have severe consequences. This type of surgery is referred to as open reduction internal fixation. A Monteggia fracture is an injury in which the radial head is dislocated in conjunction with a fracture or angulation of the ulna. Figure 1. Reduction is always required. Undiagnosed radial head dislocations over 2-3 weeks can require more challenging and invasive surgical intervention and are at higher risk of complications. They will take several angles so they can tell the full extent of your injury. Peripheral nerve examination needs to be documented. Poor outcomes can also be due to heterotopic ossification with proximal radioulnar synostosis. If the Monteggia fracture is severe you may need to have surgery. Unless the fracture appears problematic casting is often sufficient for younger patients. A Monteggia fracture is a severe type of broken arm that might lead to major complications if not treated quickly. Due to inaccurate diagnosis of the initial trauma, neglected Monteggia fracture-dislocation may proceed with pain, mobility limitations loss of motion (especially flexion and supination), elbow stiffness, deformity, loss of strength, late neuropathy and osteoarthritis. If they have pulled out of position or not healing the cast will be remove to correct the situation. J Bone Joint Surg Am 2010; 92(3): 756-64. The Monteggia fracture, or fracture of the proximal third ulna with associated subluxation or dislocation of the radial head, in fact includes a wide variety of injuries to the proximal articulations between the humerus, radius, ulna, and the forearm axis of rotation. Clin Ortho Relat Res 2005; 432: 65-72. What are the potential complications associated with this injury? Plastic deformation of the ulna. Second in frequency to anterior type I Monteggia fracture dislocations( approx. Monteggia fracture-dislocations consist of a fracture of the ulnar shaft with concomitant dislocation of the radial head. After surgery there could be complications or long range problems such as: If the fracture does not heal correctly you could have one arm that is shorter than the other arm. Pediatric Monteggia fracture dislocations are characterized by an ulna fracture associated with a disruption of the proximal radioulnar joint and a radial head dislocation. Pediatric fractures of the forearm. To identify this injury, it is essential to have x-rays that include both the elbow and forearm. There is an ulna midshaft fracture. All Monteggia fracture-dislocations require an urgent orthopaedic assessment. Periarticular ossification - this can occur in 3-7% of Monteggia fracture-dislocations. The patients were managed by a number of surgeons, and no standard treatment or rehabilitation protocols were used. No complications were observed; the only complaint was salience of the ulnar plate. The line drawn down the shaft of the radius does not pass through the centre of the capitellum. The gold standard of treatment in adults has been open reduction and internal fixation, and closed reduction and cast immobilization in pediatrics. The posterior interosseous nerve can also be injured due to its proximity to the radial head. There must also be a true AP and lateral view of the elbow (not just a forearm view) to assess the radiocapitellar joint. Because it is a very complex surgery you may need several surgeries to correct a Monteggia fracture. The immediate postoperative radiographs showed inaccurate reduction of the proximal ulnar fracture, resulting in abnormal articular congruence of the elbow joint. The line drawn down the shaft of the radius does not pass through the centre of the capitellum (asterix). Unfortunately, a Monteggia fracture-dislocation is often missed during diagnostic testing and results in a chronic Monteggia fracture-dislocation. What classification they fall into depends on the displacement of the radial head. Put the ice pack into a plastic bag and wrap in a towel before you put it on the cast so the cast will not get wet. The peak incidence is 4-10 years of age. This is an arm fracture in which the joint with the radial head at your elbow becomes dislocated and the ulna, one of the bones in your forearm is broken. Although the exact treatment used depends on how severe the fracture is the conservative treatment for a Monteggia fracture is to cast it in order to immobilize the arm so the joint and the ulna have a chance to heal. The results for six patients were presented in an earlier … They are referred to as Bado classifications. Type II Monteggia fracture-dislocations are rare. Monteggia fracture-dislocation in children. 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. Complications: Neurovascular. Delayed or missed diagnosis is the most frequent complication. The surgery is done to pin the fractured ulna and to stabilize the joint if necessary. 15%. See It is named after Giovanni Battista Monteggia. There are four classifications of a Monteggia fracture. Fracture complications are often variably defined, and there is a lack of consensus in their assessment, which makes their incidence difficult to estimate. There is plastic deformation of the ulna. Late reconstruction is difficult and often results in … Monteggia fracture refers to a dislocation of the radial head in association with a fracture of the ulna (one of the bones of the forearm) at the elbow joint. Open reduction of the radial head often is necessary because of interposition of soft tissue between it and the ulna or capitellum. The nerve injury is usually treated expectantly. Normal ulna with straight border (red line). It is rare for an adult to have a Monteggi… This can affect elbow ROM. How long a cast will stay on depends on the classification of the fracture. I – Extension type (60%): Ulna shaft angulates anteriorly (extends) Radial head dislocates anteriorly. Treatment after delayed diagnosis is much more complex and the outcomes are much less satisfactory. The prompt diagnosis and treatment of these acute injuries result in excellent outcomes. It will be painful to move the elbow in any plane. A Monteggia fracture is often managed with resetting and casting in children. Originally described by Giovanni Battista Monteggia in 1814, the Monteggia fracture is a fracture of the proximal ulna associated with a dislocation of the radial head. Notice that the ulna border is not straight (shaded area). A radial head dislocation is evident as shown by the radiocapitellar line (white line). Improperly treated, these lead to severe disability related to loss of elbow and forearm range of motion. During the surgery, the radial head will return to its correct position. Mechanism: More common in children fall on outstretched hands either in hyperpronation or in hyperextension . 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. Approximately 90% of children with Monteggia fracture-dislocations have good to excellent results. Reduction is always required. Compartment syndrome, which is an increase in pressure in one of your body’s compartments that contains nerves and muscles. The surgery is done by an orthopedic surgeon, who is a surgical specialist that has received special training working with injuries to the bone, especially this type of fracture. What radiological investigations should be ordered? Figure 1: Ten year old girl with type I Monteggia fracture-dislocation. For children who have a type four classification they may use intramedullary wires or plate fixation to stabilize the fracture. Major complications were defined as those requiring an unplanned second procedure (other than implant removal) or that may result in long-term disability (residual radial head subluxation/dislocation). Nutritional staus. A Monteggia fracture-dislocation refers to dislocation of the radial head (proximal radioulnar joint) with fracture of the ulna. Your range of motion will also be limited. If diagnosis is delayed, reconstructive surgery is needed and complications are much more common and results poorer. This can be around the radial head or the annular ligament. A neurologic complication following Monteggia fracture. Scherl S, Schmidt A. Pediatric trauma: Getting through the night. Figure 3: Nine year old girl with type III Monteggia fracture-dislocation. Spar I. Posterior interosseous nerve palsy can occur following a Monteggia fracture by a variety of mechanisms. 14 The radial head should align with the cap-itellum regardless of the radiographic view. Achieving good results when treating these injuries depends on timely identification, understanding of the pathoanatomy, and appreciating the differences … If an ulna fracture is present, always look for a radial head dislocation. See also: The radial head is a bone that makes up part of your elbow. In children, the results of early treatment are always good, typically normal or nearly so. After having surgery there will be a restriction on range of motion on the elbow but that is normally lifted after three months. If you or a loved one has developed complications following a broken arm that was suffered in an accident, please give me a call at (800) 404 … The radius bone is always aligned with your thumb. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked, with potentially serious functional and medico-legal ramifications. Figure 2: Type I Monteggia fracture-dislocation. A closed Monteggia fracture with comminution of the proximal ulna and luxation of the head of the radius was present (Fig. Monteggia Fracture-Dislocations Acute Complications Failure to make the diagnosis is the most common, acute complication of a Monteggia fracture-dislocation. Fracture upper third of ulna with dislocation head of the radius . 3 . These fractures are a less common injury compared to forearm fractures. Complications clearly vary with fracture site and nature and with quality of surgery but many also vary with patient attributes such as: Age. Waters PM. This is an arm fracture in which the joint with the radial head at your elbow becomes dislocated and the ulna, one of the bones in your forearm is broken. Monteggia fracture-dislocations can be easily missed on x-ray. Technological advances in radiography and fracture research have helped to better define, … Conclusions: Our results demonstrated an effective option for the treatment of chronic Monteggia fracture-dislocation in children, even with a small study sample, following the presented technical and surgical strategies. posterior interosseous nerve neurapraxia (10% of acute injuries) almost always spontaneously resolves; ... - Monteggia Fracture - Pediatric E 11/30/2015 904 . In adults, the healing is slower and results usually not as good. Treatment of a Monteggia fracture-dislocation is with surgery to repair the ulna fracture. Rodríguez-Merchán EC. Figure 4: Lateral x-ray of Monteggia type IV fracture in a six year old boy, as evident by dislocation of the radial head with fractures of both the shafts of the radius and ulna. These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures. This should be arranged by the consulting orthopaedic team after their reduction and stabilisation of the injury. This is why litigation is common. It is named after Giovanni Battista Monteggia. Chronic pain that is associated with surgical hardware like the plates, pins, and screws. Monteggia fracture-dislocations typically involve a dislocation of the radial head with an associated fracture of the ulnar shaft. Monteggia fracture-dislocations can be easily missed on x-ray. Table 1: Bado classification of Monteggia fracture-dislocations.