Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Ohio State Medical Association, Ohio Osteopathic Association, American College of Osteopathic Surgeons, American Osteopathic AssociationDisclosure: Received grant/research funds from Tornier for other; Received honoraria from Tornier for speaking and teaching. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Trauma10531822MonteggiaFracturesAuthor:Tracy JonesIntroductionInjury defined asproximal 1/3 ulnar fracture with associated radial head dislocation/instabilityEpidemiologyrare in adultsmore common in childrenwith peak incidence between 4 and 10 years of agedifferent treatment protocol for childrenAssociated injuriesmay be part of complex injury [5] The ulna provides a stable platform for rotation of the radius and forearm. Monteggia Fractures in Pediatric and Adult Populations, Clifford R. Wheeless, III, M.D. Philadelphia: Lippincott Williams &Wilkins; 2010: 446-74. J Bone Joint Surg Br. Wong JC, Getz CL, Abboud JA. - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; The radius and ulna are closely invested by the interosseous membrane, which accounts for the increased risk of displacement or injury to the radius when the ulna fractures. - frx of proximal 1/3 of radius & frx of ulna at the same level; - Exam: 2009 Nov. 34 (9):1618-24. A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. Int J Clin Exp Med. The remaining patients had fixation with a plate and screws. [QxMD MEDLINE Link]. [13] : Pain, nerve dysfunction, and cosmetic deformity are other factors to consider in evaluating the outcome of treatment in Monteggia fracture-dislocations. [1], The first challenge is correctly assessing the extent and nature of the injury. Kombinationsverletzungen des Unterarms werden nach ihrer Lokalisation als Galeazzi-, Monteggia- oder Essex-Lopresti-Lsionen bezeichnet. [9] and Penrose in 1951 Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. (16/80), Level 5 Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br. 1967; 50:71-86. [QxMD MEDLINE Link]. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. If you log out, you will be required to enter your username and password the next time you visit. Van Tongel A, Ackerman P, Liekens K, Berghs B. Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination. Although most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting, most adult fractures require open reduction and internal fixation (ORIF). [Full Text]. 16 (3):131-5. Material and method Are you sure you want to trigger topic in your Anconeus AI algorithm? Fractures in Adults. 2015 Sep. 99 Suppl 1:S75-82. The anular (annular) and radial collateral ligaments stabilize the radial head. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. [QxMD MEDLINE Link]. Copyright 2023 Lineage Medical, Inc. All rights reserved. 3rd ed. J Am Acad Orthop Surg. You are being redirected to Lateral ulnar collateral ligament disruption, Anterior band of the medial collateral disruption, Posterior band of the medial collateral ligament disruption. Musculoskelet Surg. The present multicenter retrospective study compared results for the Bouyala procedure with versus without plasty of the annular ligament of the radial head in evolved radial head lesion (Monteggia lesion), assessing the benefit of associating ligamentoplasty to ulnar osteotomy. Diagnosis can be made with plain radiographs of the elbow. Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. Undecided Monteggia fractures are primarily associated with falls on an outstretched hand with forced pronation. 2020 Mar. (1/1), Level 4 In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis Breaks, Fractures, and Dislocations Center, Association of Medical Consultants of Mumbai, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society. - hence, these patients will require close follow up; - Treatment: The ulna and radius are in direct contact with each other only at the PRUJ and the DRUJ; however, they are unified along their entire length by the interosseous membrane. Conclusions: Monteggia fracture dislocation equiva-lents are rare injuries and pre-surgery recognition by radio-graphs and 3-D CT helps make optimal plan. Am J Orthop (Belle Mead NJ). Application of this eponym to all injuries with radiocapitellar subluxation or dislocation has led to some confusion. 2012 Mar 7. Application of this eponym to all injuries with radiocapitellar subluxation or dislocation has led to some confusion. "A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation. A review of the complications. Acta Orthop Belg. [QxMD MEDLINE Link]. Evans in 1949 Floriano Putigna, DO, FAAEM Staff Physician, Florida Emergency Physicians, Inc, and Florida Hospital Bennett fracture is the most common fracture involving the base of the thumb. 2022 Feb 1. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? 2023 Lineage Medical, Inc. All rights reserved. The Galeazzi fracture is a fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint (DRUJ). 110 West Rd., Suite 227 of flexion; It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. 28 (19):e839-e848. Hand (N Y). Philadelphia: JB Lippincott; 1991. The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. Injury. Anderson LE, Meyer FN. The mechanism of injury is most often a fall on an outstretched hand. 2009 Jun. The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. - type II lesions with posterior dislocations should be maintained in about 70 deg. 2022 Jul 22. Hume fracture - fracture of the olecranon accompanied by anterior dislocation of the radial head. different treatment protocol for children, may be part of complex injury pattern including, Fracture of the proximal or middle third of the ulna with, Fracture of the ulnar metaphysis (distal to coronoid process) with, Fracture of the proximal or middle third of the, Jupiter Classification of Type II Monteggia Fracture-Dislocations, Fracture extending to distal half of ulna, may or may not be obvious dislocation at radiocapitellar joint, may be loss of ROM at elbow due to dislocation, radial deviation of hand with wrist extension, AP and Lateral of elbow, wrist, and forearm, helpful in fractures involving coronoid, olecranon, and radial head, must ensure stabilty and anatomic alignment of ulna fracture, acute fractures which are open or unstable (long oblique), most Monteggia fractures in adults are treated surgically, ORIF of ulna shaft fracture, open reduction of radial head, failure to reduce radial head with ORIF of ulnar shaft only, Monteggia "variants" with associated radial head fracture, lateral decubitus position with arm over padded support, midline posterior incision placed lateral to tip of olecranon, develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally, and interval between FCU and ECU distally, with proper alignment of ulna radial head usually reduces and open reduction of radial head is rarely needed, failure to align ulna will lead to chronic dislocation of radial head, treatment based on involved components (radial head, coronoid, LCL), if no improvement obtain nerve conduction studies, usually caused by failure to obtain anatomic alignment of ulna, If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. The character of the ulnar fracture is useful in determining optimal treatment. (3/76), Level 1 Monteggia fracture-dislocations in children. Advances in radiography and fracture research have helped define, classify, and guide operative management. 64 (6):857-63. Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating. The Orthobullets Podcast In this episode, we review the high-yield topic of Monteggia Fractures from the Trauma section. Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee SurgeonsDisclosure: Nothing to disclose. J Bone Joint Surg Am. [QxMD MEDLINE Link]. In addition, there are substantial differences between Monteggia injuries in children and adults. Bado JL. Chronic Monteggia. The relatively good results associated with nonoperative treatment of pediatric Monteggia injuries reflect the prevalence of stable (incomplete) fractures in children. [Full Text]. Waters PM. You can rate this topic again in 12 months. 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. PENROSE JH. Monteggia-type elbow fractures in childhood. What is the most likely finding? 2019 Feb. 31 (1):54-60. The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. It is named after Giovanni Battista Monteggia. - immobilize forearm in neutral rotation w/ slight supination, w/ cast carefully molded over lateral side of ulna at level of fracture; Treatment can be isolated closed reduction in the pediatric population (if radiocapitellar joint remains stable). Purpose: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. Scary Elbows: The Proximal Monteggia with David Stanley | OTS, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Monteggia Injury: Case of the Week - Joanne Wang, MD, 2016 Current Solutions in Orthopaedic Trauma, Case Presentation: Chronic Monteggia Fx / Ulnar Nonunion. 19 (74):164-167. This fracture refers to an intraarticular fracture that separates the palmar ulnar aspect of the first metacarpal base from the remaining first metacarpal. The original description is of a "traumatic lesion distinguished by a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius"" [1]. - note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. - ulnar frx is treated w/ compression plate (esp in proximal third) - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well- as the hyperextension theory; plastic deformation of the ulna without obvious fracture, pain, swelling, and deformity about the forearm and elbow, isolated radial head dislocations almost never occur in pediatric patients, a line down the radial shaft should pass through the center of the capitellar ossification center, radial head is stable following reduction, radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length, for Type I, elbow flexion is the main reduction maneuver, if reduction of radiocapitellar joint is unsuccessful, annular ligament is most common block to reduction, radial head is not stable following reduction, ulnar length is not stable (unable to maintain ulnar length), older patients 10y if closed reduction is not stable, symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity) who had delayed treatment or missed diagnosis, open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure, annular ligament reconstruction almost never required for acute fractures, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). (1/8), Undecided 2020 Sep. 40 (8):387-395. [QxMD MEDLINE Link]. 2014 Jun. Are you sure you want to trigger topic in your Anconeus AI algorithm? 2020 Aug. 23 (4):233-237. The character of the ulnar fracture is useful in determining optimal treatment. - key is to obtain length and alignment, which then allows the radial head to be reduced; Bado initially described and classified these injuries. What are floating elbow injuries and how are they treated? Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture. The mean Broberg and Morrey score increased from 89 points to 94 points, and the median Disabilities of the Arm, Shoulder, and Hand (DASH)score was 7 points at long-term follow-up. 8 (6):LC01-4. AP and lateral radiographs reveal a proximal ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Bado believed that the type III lesion, the result of a direct lateral force on the elbow, was primarily observed in children. Must have high index of suspicion high incidence of missed injuries (Waters, 2010), Appropriate radiographic imaging is essential to making the correct diagnosis, Be aware of plastic deformation of the ulna. Soni JF, Valenza WR, Pavelec AC. Which direction is the radial head most likely dislocated? - fracture of ulnar metaphysis; [1] The injury is typically caused by axial loading on a partially flexed metacarpal and may be associated with other carpal bone fractures or ligament injuries. Proximal radius dislocations in skeletally immature teenagers and children occur in the setting of a spectrum of ulnar injuries that often do not follow classic adult patterns. [10] studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm. 2015 Nov. 31 (4):565-80. A review of the complications, Does a Monteggia variant lesion result in a poor functional outcome? Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. Persistent posterior interosseous nerve palsy associated with a chronic type I Monteggia fracture-dislocation in a child: a case report and review of the literature. Melvin P. Rosenwasser, MD (CSOT #21, 2016), Frontiers in Upper Extremity Surgery - 2016, Monteggia - Alfred W. Hess, MD (Frontiers #16, 2016), Monteggia Fracture Dislocation - Everything You Need To Know - Dr. Nabil Ebraheim. These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures. Canton G, Hoxhaj B, Fattori R, Murena L. Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique. - exam: Monteggia fractures are one third as common as the more familiar Galeazzi fractures. (20/80). 1949;31B:578-88. Cast treatment with the elbow extended. - treated by reduction and stabilization of ulna followed by reduction of radial head via supination & direct pressure; Chin J Traumatol. : A retrospective study. The Monteggia lesion. Type in at least one full word to see suggestions list, Scary Elbows: The Proximal Monteggia with David Stanley | OTS, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Monteggia Injury: Case of the Week - Joanne Wang, MD. Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. [QxMD MEDLINE Link]. Undecided [QxMD MEDLINE Link]. Whenever a fracture of a long bone is noted, the joints above and below should be evaluated with radiographs in orthogonal planes (planes at 90 angles to each other). EVANS EM. Subluxation of the radial head occurred in three patients; one patient experienced transient palsy of the posterior interosseous nerve; and distortion of the radial head (which had no bearing on function) occurred in three. 1974 Dec. 56 (8):1563-76. Monteggia Fractures in the pediatric population are defined as proximal ulna fractures or plastic deformation of the ulna with an associated radial head dislocation. 35 (3):e434-7. As multiple variants of Monteggia fractures exist, it is most accurately described as a forearm fracture with dislocation of the proximal radioulnar joint.4 Subtle bowing of the ulna shaft with an asssociated radiocapitellar dislocation may be missed by the inexperienced clinician who is looking for a forearm fracture and therefore Since Monteggia first described the fracture bearing his name in 1814, the association of radial head dislocation with ipsilateral ulnar fracture has been well described. (0/8), Level 1 (0/1), Level 5 Orthop Traumatol Surg Res. Key words: Monteggia's fracture; Radius fracture; Ulna - spontaneous recovery is usual & exploration is not indicated; - Radiographs: Monteggia fractures account for fewer than 5% of forearm fractures, with published literature supporting figures in the range of 1-2%. The treating physician may reduce an unrecognized dislocation while reducing or immobilizing the ulna fracture. 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. The olecranon, midshaft, and distal shaft may be involved. Richard L Ursone, MD Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, Brooke Army Medical Center 2023 Lineage Medical, Inc. All rights reserved. - this ordinarily requires 6-10 wks depending on the age of pt; The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Surgical management is indicated for radial heads that are not stable following closed reduction. J Clin Diagn Res. Rang, M., Pring, M. E., & Wenger, D. R. (2005). [15] The average follow-up period was 5.5 years. The radial head should point towards the capitellum on all radiographs of the elbow. Datta T, Chatterjee N, Pal AK, Das SK. Data Trace Publishing Company there may be slow and progressive shortening and angulation; 1951 Feb. 33-B (1):65-73. Complex Monteggia Fractures in the Adult Cohort: Injury and Management. This injury is frequently confused with anterior Monteggia lesions by virtue of the readily apparen 2015. (1/1), Level 4 Monteggia Fracture } Drake LeBrun MD Experts 3 Bullets 65 3.4 ( 5 ) 3 Images Snapshot A 35-year-old man presents to the emergency room for severe right elbow and forearm pain after sustaining a blunt injury to his right arm. According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Diagnosis is made with forearm and elbow radiographs to check for congruency of the radiocapitellar joint in the setting of an ulna fracture. (0/1), Level 1 The Monteggia fracture with posterior dislocation of the radial head. [QxMD MEDLINE Link]. Wheeless' Textbook of Orthopaedics. This article describes the diagnosis, treatment, and potential pitfalls encountered in the treatment of Monteggia fractures. Penrose considered type II lesions a variation of posterior elbow dislocation. [Full Text]. - spontaneous recovery is usual & exploration is not indicated; J Orthop Trauma. J Bone Joint Surg Am. J Pedtiatr Orthop 2016; 35:S67-S70. (10/80), Level 3 Surgical Management of Missed Pediatric Monteggia Fractures: A Systematic Review and Meta-Analysis. Kevin Strohmeyer, MD Consulting Surgeon, Department of Orthopedic Surgery, Darnall Army Community Hospital, Kevin Strohmeyer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons. 2011 Feb. 77 (1):21-6. JAMA 1940;115:1699-1705. - radiohumeral ankylosis [14]. Li H, Cai QX, Shen PQ, Chen T, Zhang ZM, Zhao L. Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children. Rockwood CA, Green DP, Bucholz R, eds. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India 1949 Nov. 31B (4):578-88, illust. Adults and unstable injuries generally require ORIF of the ulna. J Bone Joint Surg Am. Galezzi's fracture-fracture to the distal radius accompanied by ulnar head dislocation at distal radio-ulna joint. Ulnar fracture with late radial head dislocation: delayed Monteggia fracture. Dhoju D, Parajuli B. Functional Outcome of Pediatric Monteggia Fracture Dislocation Treated Surgically in a Tertiary Care Centre of Nepal. - then elbow is gently flexed to > 90 deg to relax biceps; - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ different treatment protocol for children, may be part of complex injury pattern including, Fracture of the proximal or middle third of the ulna with, Fracture of the ulnar metaphysis (distal to coronoid process) with, Fracture of the proximal or middle third of the, Jupiter Classification of Type II Monteggia Fracture-Dislocations, Fracture extending to distal half of ulna, may or may not be obvious dislocation at radiocapitellar joint, may be loss of ROM at elbow due to dislocation, radial deviation of hand with wrist extension, AP and Lateral of elbow, wrist, and forearm, helpful in fractures involving coronoid, olecranon, and radial head, must ensure stabilty and anatomic alignment of ulna fracture, acute fractures which are open or unstable (long oblique), most Monteggia fractures in adults are treated surgically, ORIF of ulna shaft fracture, open reduction of radial head, failure to reduce radial head with ORIF of ulnar shaft only, Monteggia "variants" with associated radial head fracture, lateral decubitus position with arm over padded support, midline posterior incision placed lateral to tip of olecranon, develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally, and interval between FCU and ECU distally, with proper alignment of ulna radial head usually reduces and open reduction of radial head is rarely needed, failure to align ulna will lead to chronic dislocation of radial head, treatment based on involved components (radial head, coronoid, LCL), if no improvement obtain nerve conduction studies, usually caused by failure to obtain anatomic alignment of ulna, If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Clin Orthop Relat Res. Successful Strategies for Managing Monteggia Injuries. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. of flexion for 6 weeks; - Delayed Dx: If the elbow is flexed, the chance of a type II or III lesion is greater. Splinting of the wrist in extension and finger range-of-motion (ROM) exercises help prevent contractures from developing while the patient awaits resolution of the nerve injury. The Monteggia fracture is relatively rare. Ramski, D., Hennrikus, W., Bae, D., et. 2012 Feb. 35 (2):138-44. (0/7), Level 2 al. Monteggia GB. Delpont M, Louahem D, Cottalorda J. Monteggia injuries. The Monteggia lesion is most precisely characterized as a forearm fracture in association with dislocation of the PRUJ. - following reduction, radial head will be stable if left in flexion; Bado type I lesion. Once the radial head is reduced in closed injuries, surgical treatment may be delayed until the patient is stable and the surgery may be performed in a more elective fashion. In a study evaluating long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in 22 children (14 boys, 8 girls; age range, 4 y to 15 y 11 mo), Nakamura et al noted that the postoperative Mayo Elbow Performance Index (MEPI) at follow-up ranged from 65 to 100, with 19 excellent results, two good results, one fair result, and zero poor results. Diagnosis can be made with plain radiographs of the elbow. - Plating Techniques Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury.

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