Monteggia Fracture
Other Names
- Monteggia Fractures
- Monteggia Fracture
- Neglected Monteggia Fracture
- Monteggia Lesion
- Monteggia-equivalent Injuries
- Monteggia Fracture Dislocation
- Monteggia-like-lesion
- Monteggia-lesion
Background
- This page refers to the eponymous Monteggia Fracture
History
- Originally described by Italian Surgeon Giovanni Battista Monteggia in 1814[1]
- Eponymously named as the Monteggia fracture by Perrin in 1909[2]
- In 1958, Uruguayan surgeon Bado elaborated on the pathomechanics and management[3]
Epidemiology
- Rare, account for 1-5% of all forearm fractures[4]
- Bimodal: young males, elderly females
- More common in children between ages 4 and 10 (need citation)
Pathophysiology
General
- Defined as a fracture of the proximal Ulna associated with a dislocation of the Radial Head
- Typically occurs due to a direct below to forearm with elbow extended and forearm pronated
- The diagnosis can be made with forearm and elbow radiographs
- An unstable fracture pattern requiring emergent orthopedic consultation and surgical correction
Pathoanatomy
- Forces are transmitted along the interosseous membrane
- This leads to injury of the following structures
- Ulna
- Radius and Radial Head
- Annular Ligament
- Quadrate Ligament
- Radiocapitellar Joint
Etiology
- Falls from height[6]
- Sports
- MVC
- Low level trauma in elderly
- Direct blow to the forearm with elbow extended, forearm pronated
Modern Definition
- Monteggia-like lesions include multiple injury patterns of the proximal ulna and radial head
- Giannicola expanded on the classical pattern, identifying additional injuries including[7]
- Ulno-humeral dislocation
- Proximal radio-ulnar dislocation
- Radial fracture
- Distal radio-ulnar joint lesion
- For this reason, definition of injury patterns is inconsistent throughout the literature
- This makes it difficult to compare different treatment strategies
Associated Injuries
- Radial Head Fracture
- Coronoid Process Fracture
- Olecranon Fracture
- Elbow LCL Injury
- Terrible Triad Elbow Injury
Risk Factors
- Male > Female
- Sports
- Football
- Wrestling
- Osteoporosis
- Menopause
Differential Diagnosis
Monteggia Fracture Differential Diagnosis
- Elbow Dislocation
- Proximal Radius Fracture
- Midshaft Ulna Fracture (night stick)
- Monteggia Fracture
- Galeazzi Fracture
- Essex Lopresti Fracture
- Distal Radius Fracture
- Radius Ulna Fracture (bone bone)
Differential Diagnosis Forearm Pain
- Fractures
- Pediatric Specific Fractures
- Dislocations & Instability
- Soft Tissue Trauma
- Tendinopathies
- Neuropathies
- Pediatric Considerations
Clinical Features
History
- Will have history of some type of trauma
- Patient typically reports pain, swelling
- Ask about any neurological symptoms
Physical Exam: Physical Examination Forearm
- Deformities, tenderness at the fracture site
- Radiocapitellar dislocation may not be obvious
- Evaluate for any breaks in the skin/ skin integrity
- Carefully evaluate the elbow and wrist joints
- Elbow joint ROM may be diminished due to dislocation
- Perform a thorough neurovascular exam, especially of the radial and median nerves
- Posterior Interosseous Nerve (radial deviation of hand with extended wrist)
- Palpate all compartments to confirm they are soft
Evaluation
Radiographs
- Typically need to obtain
- Findings
- Radial head dislocation
- Displaced diaphyseal ulnar fracture
- Radiocapitellar Line
- Radial head dislocations can be subtle and missed
- The radiocapitellar line can be used in suspected Monteggia fracture's in which the dislocation is not radiographically apparent
CT
- Indications
- May be used for operative planning
- Better evaluates the coronoid, olecranon, radial head
MRI
- Indications
- Evaluate other soft tissue injuries
Classification
Bado Classification
- Type 1
- Frequency: 60%
- 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
- Frequency: 15%
- 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
- Frequency: 20%
- Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head
- Type IV
- Frequency: 5%
- Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction
Jupiter Classification for Type II Monteggia Fracture-Dislocation
- Type IIA: Fracture at Coronoid level
- Type IIB: Fracture at Metaphyseal-diaphyseal junction
- Type IIC: Fracture at Distal to coronoid
- Type IID: Fracture at Fracture extending to distal half of ulna
Management
Nonoperative
- Generally a surgical injury, however nonoperative approach may be attempted in appropriate patient
- Recommend making decision in collaboration with orthopedic surgeon
- Can attempt closed reduction in minimally displaced ulna fractures
- This is more successful in children
- Cast: Long Arm Cast with wrist in supination
Operative
- Indications
- Most cases are considered surgical
- All adults
- Unstable pediatric fractures
- Technique
- Open reduction, internal fixation
Pediatric Considerations
- In children with a stable radiocapitellar joint, closed reduction can be definitive
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/Work
- Variable
- Surgical cases require at least 6 weeks
- Discretion of surgeon
Prognosis and Complications
Prognosis
- Children tend to have better outcomes than adults
- Delayed diagnosis/ proper treatment
- Leads to deformities and dysfunction
Complications
- Neglected Monteggia Fracture
- Happens with delayed diagnosis/ proper treatment
- Patientss develop humeroradial deformities, cubitus valgus, osteoarthritis
- Posterior Interosseous Nerve Syndrome
- Most likely nerve injury
- Malunion/ Nonunion
- Rates are as high as 10%, higher than the average forearm rate (need citation)
- TFCC Injury
- Acute Compartment Syndrome
- Radioulnar synostosis
- Elbow stiffness from prolonged immobilization
- Myositis Ossificans
- Ulnohumeral Osteoarthritis
- Wound Infection
See Also
Internal
External
References
- ↑ Monteggia GB. Lussazioni delle ossa delle estremita superiori. In: Monteggia GB, ed. Instituzioni Chirurgiches. 2nd ed. Vol. 5. Milan: Maspero; 1814:131e133.
- ↑ Perrin J. Les fractures du cubitus accompagnees de luxation de l’extremite superieur du radius. In: Perrin J, ed. These de Paris. Paris: G Steinheil; 1909.
- ↑ . Bado JL. La lesion de Monteggia. Buenos Aires: Inter-Medica Sarandi; 1958:328
- ↑ Josten C, Freitag S (2009) Monteggia and monteggia-like-lesions: classification, indication, and techniques in operative treatment. Eur J Trauma Emerg Surg 35(3):296–304.
- ↑ Image courtesy of https://www.rch.org.au/
- ↑ Calderazzi F, Galavotti C, Nosenzo A, Menozzi M, Ceccarelli F. How to approach Monteggia-like lesions in adults: A review. Ann Med Surg (Lond). 2018 Nov;35:108-116.
- ↑ Giannicola G, Sacchetti FM, Greco A, Cinotti G, Postacchini F (2010) Management of complex elbow instability. Musculoskelet Surg 94(Suppl 1):S25-36
- ↑ Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 8012
- ↑ Lopez, Belen, Luis Caro, and Antonio F. Pardinas. "Type I Monteggia fracture-dislocation in a monk from a 17th–18th century necropolis of Valladolid (Spain)." Anthropological Science 119.1 (2011): 39-47.
- ↑ Gooi, S. G., et al. "Ulnar osteotomy with 2-pin unilateral gradual distraction for treatment of chronic Monteggia fracture: a case report." Malaysian orthopaedic journal 11.1 (2017): 79.