Monteggia fracture-dislocation: reference to the pediatric population

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Figure 1. Extension-type Monteggia fracture. Oblique fracture line seen in the proximal ulna with 15 dorsal and 30 ulnar deviation. The radial head is dislocated anteriorly. The term Monteggia fracture is used to refer to a dislocation of the proximal radioulnar joint in association with a forearm fracture. The ulna fracture is usually clinically and radiographically apparent. Findings associated with the concomitant radial head dislocation may be subtle and can be overlooked. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. This injury needs to be properly investigated and appropriate treatment institute in a timely fashion to avoid permanent injury and disability. These injuries are relatively uncommon, accounting for less than 5% of all forearm fractures1.

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 head2.This particular pattern is currently seen in around 60% of the injuries. This description of the injury emerged in the pre-x-ray era, based on the history of injury and on physical examinations. However, this particular fracture pattern only accounts for about 60% of these types of injuries. More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following 4 types2:

Type I Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head. Type II Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head. Type II Fracture of the ulnar metaphysis with lateral dislocation of the radial head. Type IV Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head. The Bado classification is based on the recognition that the apex of the fracture is in the same direction as the radial head dislocation (Figures 1-4).

Figure 2. Flexion-type Monteggia fracture. Oblique fracture of the proximal ulna with around 45 axis deviation towards the volar and ulnar aspects. The radius is dislocated towards the dorsal and radial direction. Anatomy briefly Ligaments: The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. The annular and radial collateral ligaments stabilize the radial head. These ligaments stretch or rupture during radial head dislocation.

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Monteggia fracture-dislocation: reference to the pediatric population

Interosseous membrane fills the space between the radius and ulna, accounting for the risk of displacement or injury to the radius with ulnar fractures. Nerves: The posterior interosseous nerve travels around the neck of the radius, ducking under the supinator as it courses into the forearm. The median and ulnar nerves enter the antecubital fossa just distal to the elbow. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury. Joints: The distal ulna and radius also articulate at the distal radioulnar joint. The ulna provides a stable platform for rotation of the radius and forearm. The ulna and interosseous membrane also may provide stable platforms for dislocation of the proximal radius, leading to the Monteggia fracture1. Presentation The ulna fracture is usuallylocated in the proximal third of the ulna, possibly the olecranon, midshaft, or the and distal shaft may be involved. Typical presentation includes elbow pain, elbow swelling, deformity, crepitus, and paresthesia or numbness. In some cases severely limited and painful elbow flexion and forearm rotation are primary observations. The dislocated radial head may be palpable in the anterior, posterior, or anterolateral position, even though the presenting edema may be a hindrance. In type I and IV lesions, the radial head can be palpated in the antecubital fossa. The radial head can be palpated posteriorly in type II lesions and laterally in type II lesions. Whenever a fracture of a long bone is noted, the joints above and below should be evaluated using radiographs in orthogonal planes (planes at 90 angles to each other). Separate radiographs should be taken of the elbow. The radial head should point towards the capitellum on all radiographs of the elbow. If one of the forearm bones is injured, injury should be looked for in the other bone and in associated joints of the forearm, elbow, and wrist. This principle also applies to a Galeazzi fracture, which is a fracture of the distal radius with concomitant dislocation of the distal radioulnar joint. An open fracture should be ruled out. Pulses and capillary refill should be carefully examined.

Figure 3. Adduction-type Monteggia fracture. Oblique fracture can be observed in the proximal third of the ulna with around 40 axis deviation towards the ulna. The radius is dislocated radially (no radial dislocation seen on the lateral film). Motor function must be thoroughly tested because the branches of the radial nerve can become entrapped, causing weakness or paralysis of finger or thumb extension. Monteggia fractures in the pediatric population typically manifest with unique features that have led to a decreased emphasis on the direction of the radial head dislocation and an increased focus on the character of the fracture of the ulna. Plastic deformation of the ulna in association with anterior radial head dislocation represents up to 31% of anterior Monteggia lesions. Poor recognition of this injury pattern can lead to recurrent or persistent dislocation because the radial head reduction remains unstable until the plastic deformity is corrected. Incomplete fractures of the ulna and greenstick fractures represent other variants that must be corrected along with the radial head dislocation1.

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Monteggia fracture-dislocation: reference to the pediatric population

Severity of Monteggia fractures in children is also dictated by the type of associated ulnar fracture. The possible patterns may include: plastic deformation, incomplete (greenstick or buckle) fracture, complete transverse or short oblique fracture, comminuted or long oblique fracture1.

Watson-Jones stated in 1943 that no fracture presents so many problems; no injury is beset with greater difficulty; no

treatment is characterized by more general failure4. The Monteggia lesion is characterized as a forearm fracture in association with dislocation of the proximal radioulnar joint. Monteggia fractures make up less than 5% of forearm fractures, with published literature supporting around 1-2%5, 6. Of the Monteggia fractures, Bado type I is the most common (59%), followed by type II (26%), type II (5%), and type IV (1%). Monteggia fractures are one third as common as the more familiar Galeazzi fractures. Mechanism of injury

Figure 4. Bado-type 4 fracture. Plastic deformity and longitudinal fracture line in the proximal ulna. The radius is dislocated in the volar and radial direction. Monteggia fractures are primarily associated with falls on an outstretched hand with forced pronation. If the elbow is flexed, the chance of a type II or II lesion is greater. In some cases, a direct blow to the forearm can produce similar injuries. Evans in 1949 and Penrose in 1951 studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm6, 7. 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. A high index of suspicion, therefore, should be maintained with any ulna fracture. The forearm structures are intricately related, and any disruption to one of the bones affects the other. The ulna and radius are in direct contact with each other only at the proximal and distal radioulnar joints; however, they are unified along their entire length by the interosseous membrane. This allows the radius to rotate around the ulna. When the ulna is fractured, energy is transmitted along the interosseous membrane, displacing the proximal radius. The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated proximal radioulnar joint, and a dislocated radiocapitellar joint1. Radial head dislocation may lead to an injury of the radial nerve. The posterior interosseous branch of the radial nerve, which courses around the neck of the radius, is especially at risk, particularly in Bado type II injuries. Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. Splinting of the wrist in extension and finger rangeof- motion exercises help to prevent contractures from developing while the patient awaits resolution of the nerve injury1. Treatment modalities

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Monteggia fracture-dislocation: reference to the pediatric population

Almost all adult fractures require open reduction and internal fixation. With advancing internal fixation techniques and hardware, the pediatric Monteggia patients in our practice are also being treated operatively, as compared to the previous conservative methods of closed reduction and long arm casting. The radial head dislocation should be reduced emergently. Closed reduction should be performed as soon as the child can be anesthetized. This is usually achieved with supination of the forearm, but it may require traction and direct pressure on the radial head. If closed reduction is unsuccessful, open reduction should be sought. Delay in reduction of the radius is a cause of articular damage and further nerve injury, thus treatment should be timely. An open fracture requires emergent operative intervention Detailed discussion on treatment is in the Appendix. Plain radiography: Conventional, yet vital Views of the forearm in orthogonal planes (planes at 90 to each other) are needed with the wrist and elbow joints included. Separate radiographs of the elbow should also be obtained to assess for proximal radioulnar and ulnohumeral articulation, and the radiocapitellar joint. The ulna fracture is usually obvious, but the findings associated with the radial head dislocation may be subtle and overlooked. In order to assess the radiocapitellar joint, a line should be drawn parallel to the long axis of the radius. This line should point directly at the capitellum on any projection of the elbow. The radial head dislocation almost always points in the same direction as the apex of the ulna fracture. It is vital to recognize a plastic deformation of the ulna in children, which may also lead to radial head dislocation. Complications Complications include infection (post operative), bleeding, malunion, nonunion, nerve injury, redislocation of the radial head, radioulnar synostosis, and chronic pain. Results In 1991, Anderson and Meyer used criteria to evaluate forearm fractures and their prognosis, as follows9: Excellent Union with less than 10 loss of elbow and wrist flexion/extension and less than 25% loss of forearm rotation. Satisfactory Union with less than 20 loss of elbow and wrist flexion/extension and less than 50% loss of forearm rotation. Unsatisfactory Union with greater than 30 loss of elbow and wrist flexion/extension and greater than 50% loss of forearm rotation. Failure Malunion, nonunion, or chronic osteomyelitis. The pediatric population pecularities Monteggia fractures are more commonly seen in adults but they are well described in children. Bado Type I, the original Monteggia fracture, is the most common lesion seen in children. Type II describes a posterior dislocation associated with an

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Monteggia fracture-dislocation: reference to the pediatric population

ulnar metaphyseal fracture, with Type IlIl being a lateral dislocation of the radial head. Type IV is the combination of both ulnar and radial fractures with an anterior radial head dislocation, and the Monteggia equivalent describes more unusual varieties. Plastic deformation of bone is a recognized characteristic unique to children, the radiographic appearance of which is an abnormal curvature in a long bone. It is felt to be the stage in bone bending that leads to a greenstick fracture but, the force applied to the bone is removed before the fracture occurs and the bone is left with a characteristic bend. The ulnar fracture is readily diagnosed but, the radial head dislocation is often missed. The majority of radial head dislocations in children can be reduced with manipulation under general anaesthesia but, if the diagnosis is made late, open reduction is commonly required. This may involve repair or reconstruction of the annular ligament to prevent recurrent dislocation. Gleeson and Beattie reviewed their series of 220 forearm fractures (12 Monteggia fractures) over a period of 5 years. 50% of Monteggia fractures in their series were misdiagnosed. To avoid missing Monteggia fractures they presented the following recommendations10: (1) One should ensure that true anteroposterior and lateral radiographs of the elbow/ forearm are taken. (2) One should be aware that a line drawn through the radial shaft and head should align with the capitulum in all views. If it does not, then the radial head is dislocated. (3) It should be noted that isolated fractures of the ulnar shaft are rare (two out of 220 in the authors series) and when they occur, one should specifically look for a radial head dislocation. The joint above and below a fracture should be visualized. (4) Doctors should be aware that children have the unique characteristic of plastic deformation of bone, and that the ulnar fracture may not be present to alert one to the possibility of a radial head dislocation. (5) Doctors should not wholly rely on the radiologists report. Inadequate or inaccurate information on the radiograph request may lead to a misdiagnosis on the part of the radiologist. (6) Early review of elbow injuries10. References 1. Putigna F, Strohmeyer K,Ursone RL. Monteggia Fracture. eMedicine [serial online]. Available at http:// emedicine.medscape.com/ article/1231438-overview 2. Monteggia GB. InstituzioniChirrugiche. Vol 5. Milan: Maspero; 1814. 3. Bado JL. The Monteggialesion. Clin Orthop Relat Res 1967;50:71-86. 4. Watson-Jones R. Fractureand Joint injuries. Vol. 2., 3rd edition. Baltimore: Williams and Wilkins; 1943:P. 520. 5. Bruce HE, Harvey JP, Wilson JC. Monteggia Fractures. J Bone Joint Surg Am 1974;56:1563. 6. Reckling FW. Unstablefracture-dislocation of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am 1982;64:857. 7. Evans EM. Pronationinjuries of the forearm with special reference to anterior Monteggia fractures. J Bone Joint Surg 1949;31B:578-88. 8. Penrose JH. The Monteggia fracture with posterior dislocation of the radial head. J Bone Joint Surg 1951;33B:65-73.

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Monteggia fracture-dislocation: reference to the pediatric population

9. Anderson LE, Meyer FN. Fractures of the shafts of the radius and ulna. In: Rockwood CA, Green DP, and Bucholz R, eds. Fractures in Adults. Vol 1., 3rd ed. Philadelphia, Pa: JB Lippincott; 1991. 10. Gleeson AP, Beattie TF. Monteggia fracture-dislocation in children. Journal of Accident and Emergency Medicine 1994;11:192-4. Absztrakt: Monteggia fracture-dislocation in children is not frequent. Correct diagnosis and administration of appropriate treatment is imperative in preventing elbow dysfunction. Monteggia fracture-dislocations are often overlooked. Kulcsszavak: Monteggia fractura radial head ulnar fracture Abstract: Monteggia fracture-dislocation in children is not frequent. Correct diagnosis and administration of appropriate treatment is imperative in preventing elbow dysfunction. Monteggia fracture-dislocations are often overlooked. Keywords: Monteggia fracture, radial head, ulnar fracture

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