Patients with a Monteggia fracture should be placed in a sugar-tong splint with urgent referral to an orthopedist.Ĭhildren usually have better overall outcomes than adults. If the annular ligament is trapped within the joint, reduction may be unobtainable. In most circumstances, closed reduction should be attempted. Initial management for a suspected fracture includes rest, ice, immobilization, and elevation. Urgent orthopedic consultation is indicated for neurologic deficits without vascular compromise. Emergent orthopedic consultation is essential for open fractures and vascular compromise. Ulnar nerve injury is rare.Īll Monteggia fractures are considered unstable and require intervention. Although nerve injury is less common, examination of the radial and median nerve distribution is essential in identifying nerve damage. Inquire about numbness, weakness, paresthesias, and radiating pain. High mechanism crush injuries warrant a detailed neurovascular exam with repeat serial exams looking for signs of acute compartment syndrome. Examination of the proximal and distal joint should be performed to identify concomitant injuries. Gentle palpation should be performed identifying deformities and focal tenderness. It is imperative to identify wounds overlying fracture sites (i.e., open fracture), which requires immediate surgical intervention. An examination should begin with visual inspection paying close attention to the skin and soft tissue for visible bony deformities, muscle contusions, skin lacerations, tendon damage and neurovascular deficits. Patients with diaphyseal forearm fractures usually complain of pain at the site of injury. These types depend on the direction of the radial head dislocation. Jose Luis Babo classified Monteggia fractures into four types. The radiocapitellar joint primarily stabilizes the proximal forearm while the TFCC predominantly supports the distal forearm. The interosseous membrane is responsible for distributing axial load force to the forearm, 60% to the radiocapitellar joint and 40% to the ulnohumeral joint. The alignment and stability of the radius and ulna originate from three ligamentous structures: the interosseous membrane, the annular ligament, and the TFCC. Proximally, the ulna consists of the coronoid and olecranon. The ulnar head supplements the triangular fibrocartilage complex (TFCC) at the wrist. Distally, the radius connects with the scaphoid and lunate bones of the wrist. The proximal radial head articulates with the capitellum of the humerus (radiocapitellar joint), rotating within the annular ligament during pronation and supination. 2009 34(9):1618–24.The osseous forearm is composed of the radius and ulna bones. Long-term evaluation of surgically treated anterior monteggia fractures in skeletally mature patients. The posterior Monteggia lesion with associated ulnohumeral instability. Strauss EJ, Tejwani NC, Preston CF, Egol KA. The surgical treatment of isolated mason type 2 fractures of the radial head in adults: comparison between radial head resection and open reduction and internal fixation. Zarattini G, Galli S, Marchese M, Mascio LD, Pazzaglia UE. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions. Klug A, Konrad F, Gramlich Y, Hoffmann R, Schmidt-Horlohe K. Monteggia fractures in adults: long-term results and prognostic factors. Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia fractures in children and adults. Pediatric monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results. Monteggia fractures and variants: review of distribution and nine irreducible radial head dislocations. Management of adult elbow fracture dislocations. “Isolated” traumatic radial-head dislocation. Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs. Kunkel S, Cornwall R, Little K, Jain V, Mehlman C, Tamai J. A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows. Disruption of the radiocapitellar line in the normal elbow. Nerve injuries complicating Monteggia lesions. Neglected Monteggia fracture dislocations in children: a systematic review. Goyal T, Arora SS, Banerjee S, Kandwal P. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. Givon U, Pritsch M, Levy O, Yosepovich A, Amit Y, Horoszowski H. Monteggia fracture dislocations: a historical review. Rehim SA, Maynard MA, Sebastin SJ, Chung KC. Unstable fracture-dislocations of the forearm.
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