- See: Monteggia Fractures in Adults
- Discussion:
- all four types of Monteggia frx dislocation are pertinent to children, including Monteggia equivalents;
- diff dx: Monteggia equivalent (w/ fracture of proximal radius rather than dislocation of the radial head);
- Classification:
- type I:
- anterior dislocation of the radial head w/ apex anterior angulation of the ulnar frx;
- is most common type of this frx;
- type II frx:
- posterior dislocation of the radial head w/ posterior angulation of the ulnar frx;
- ref: Pediatric posterior monteggia lesion: a greenstick fracture of the proximal ulnar metaphysis with radial neck fracture. A case report.
- type III:
- lateral dislocation of radial head w/ ulnar metaphyseal fracture, usually a greenstick type of frx;
- commonly assoc w/ radial nerve injuries & is 2nd most common type of Monteggia frx (approx 1/4 of lesions);
- frx of ulna may be complete or incomplete (greenstick frx), w/ bowing of ulna due to plastic deformation;
- occasionally there is persistent ulnar bowing, occurring most often w/ type III lesions;
- this can produce subluxation of radial head w/ subsequent pain;
- ref: Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children.
- type IV:
- anterior radial head dislocation and fractures of both the proximal radius and ulna;
- Radiographs: (radiology of pediatric elbow)
- radial head does not ossify until age 4;
- ultrasound or MRI may be helpful with the diagnosis;
- be sure that radiographs include the distal radius, since upto 24% of these injuries may be associated with distal frx;
- also remember that the "isolated" ulnar green stick frx may actually represent a Monteggia equivalent lesion in which there has
been spontaneous reduction of the radial head;
- Treatment:
- in contrast to adults, most of these injuries are treated closed;
- reduction of the radial head, however, must be confirmed;
- for type I, III, and IV Monteggia injuries, immobilize elbow in 100 deg of flexion w/ forearm fully supinated for 6 weeks;
- for type II injuries, immobilize w/ elbow extended for four weeks;
- inability to achieve reduction;
- improper position of elbow ( < 110 deg of flexion)
- infolded annular ligament;
- radial head buttonholed thru capsule;
- open reduction is indicated if it is necessary to reduce radial head;
- if reduction of radial head is not maintained, IM fixation of ulna frx;
- post op:
- forearm immobilized within a cast with full supination and 110º of elbow flexion for 6 weeks.
- position relaxes biceps and tenses the interosseous membrane, and both stabilizes the reduction.
- references:
- Pediatric Monteggia Fractures: A Single-Center Study of the Management of 40 Patients
- Complications:
- misdiagnosis:
- chronic radial head dislocation;
- consider the Bell Tawse procedure (slip of triceps fascia is used to reconstruct the annular ligament);
- references:
- Missed Pediatric Monteggia Fractures
- The treatment of malunited anterior Monteggia fractures in children.
- Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children.
- Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children
- Missed radial head dislocations associated with ulnar deformation: treatment by open reduction and ulnar osteotomy
- Treatment of the missed Monteggia fracture in the child.
- Open Reduction and Annular Ligament Reconstruction With Fascia of the Forearm in Chronic Monteggia Lesions
- Open Reduction and Annular Ligament Reconstruction With fascia of the Forearm in Chronic Monteggia Lesions in Children.
- Angular remodeling of midshaft forearm fractures in children.
Acute Monteggia lesions in children.
Treatment of the missed Monteggia fracture in the child.
Monteggia fracture-dislocations in children.
Forearm fractures in children. Cast treatment with the elbow extended.
Monteggia-type elbow fractures in childhood.
The Monteggia lesion in children. Fracture of the ulna and dislocation of the radial head.
Monteggia injuries in children.