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Monteggia Fracture

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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

Illustratin of Monteggia fracture (Bado Type II)[5]

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

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


Risk Factors

  • Male > Female
  • Sports
    • Football
    • Wrestling
  • Osteoporosis
  • Menopause

Differential Diagnosis

Differential Diagnosis Forearm Pain


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

Moteggia fracture. Note the midshaft ulna fracture and dislocated radial head. Soft tissue radiolucency suggests an open fracture
In this pediatric patient, a displaced and overlapped fracture of the ulnar shaft is present. Additionally the radial head is dislocated anteriorly. [8]

Radiographs

CT

  • Indications
    • May be used for operative planning
    • Better evaluates the coronoid, olecranon, radial head

MRI

  • Indications
    • Evaluate other soft tissue injuries

Classification

Illustrations of the Bado classification of Monteggia fracture-dislocations.[9]

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

Intraoperative fluoroscopy of open reduction and internal fixation.

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

Neglected Monteggia fracture. (a) Pre-operative clinical picture with cubital valgus of 45 degree and (b) Pre-operative radiograph with radial head dislocated anteriorly.[10]

Prognosis

  • Children tend to have better outcomes than adults
  • Delayed diagnosis/ proper treatment
    • Leads to deformities and dysfunction

Complications


See Also

Internal


References


  1. Monteggia GB. Lussazioni delle ossa delle estremita superiori. In: Monteggia GB, ed. Instituzioni Chirurgiches. 2nd ed. Vol. 5. Milan: Maspero; 1814:131e133.
  2. 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.
  3. . Bado JL. La lesion de Monteggia. Buenos Aires: Inter-Medica Sarandi; 1958:328
  4. 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.
  5. Image courtesy of https://www.rch.org.au/
  6. 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.
  7. Giannicola G, Sacchetti FM, Greco A, Cinotti G, Postacchini F (2010) Management of complex elbow instability. Musculoskelet Surg 94(Suppl 1):S25-36
  8. Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 8012
  9. 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.
  10. 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.
Created by:
John Kiel on 4 July 2019 07:11:33
Authors:
Last edited:
6 June 2024 20:40:05
Categories:
Trauma | Osteology | Forearm | Upper Extremity | Fractures | Acute