Monteggia fracture dislocatioin

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  • 2. • It is a fracture of the proximal 3rd of the ulna with dislocation of the radial head
  • 3. HISTORY • 1814- Giovanni Batista MONTEGGIA described the fracture--# of the ulna between the proximal 3rd and the base of olecranon with an ant. Dislocation of the radial head. • Bado defined –radial head # or dislocation with # of the middle or proximal ulna.
  • 4. ANATOMY AND BIOMECHANICS • Structures related to fracture.. Ligaments: annular ligament Quadrate lig. Oblique lig. Interosseous mem. bones: radial head Radius Proximal ulna Muscles nerves
  • 5.  ANNULAR LIGAMENT: • for stability primary lig. • Failure of this leads to failure of others • It maintains the position of the radial head within the notch through entire rom. • Tighter in supination. • Reinforced by radial collateral lig.  QUADRATE LIG.: Lig.of Denuce • Between the radius and ulna distal to annular lig. • Dense ant. Boarder-tightens in supination. • Limits the rotation • Excessive pronation-instability of radial head.
  • 6. OBLIQUE LIG.:Lig of Weitbrecht • Ulna proximally to radius distally • Begins bellow the radial notch ends just bellow the biceps tuberosity on the radius. • Bow of the radius tightens the lig. In supination INTEROSSEOUS MEM.: distal to oblique lig. • Fibres in opposite direction. • Tightens in supination.
  • 7. Osseous relations  Radial head : • Elliptical • In supination long axis of the ellipse is perpendicular to ulna.-annular lig and ant boarder of quadrate lig stabilize PRUJ. • Contact between Radial head and notch max. in supination  Bow of the Radius: • Apex of the radial bow is lateral • Curvature allows increased range of pronation-as the radius rotates along the axis between PRUJ and DRUJ • Bow tightens the oblique and interrosseous mem. In supination
  • 8. MUSCLES • Plays an active role in # mechanism  Biceps brachii: • inserting into the biceps tuberosity—major deforming force. • Violently pulling the proximal radius away from the capitellum as the elbow goes into extension. • During treatment effect of biceps regulated by elbow flexion- prevents the recurrence of dislocation.  Anconeus and forearm flexors: • Acts to create a radially angulated bow in the ulna • Helps in stabilize the elbow in extension, creating a valgus • In Pronation couteracts the varus moment produced by pronator teres against an intact ulna. • Fore arm flexors create a bowstring effect on ulna.
  • 9. NERVES PIN: ant/ to the radial head and neck path through supinator. • Paresis Ulnar nerve : at risk in type 2 #
  • 11. BADO”S CLASSIFICATION • TYPE 1: ant dislocation of radial head + ulna diaphyseal # with ant.angulation.70% • Type 2: post/ dislocation of head + ulna# with post.angulation. Uncommon in children.3% • Type 3: lat/ dislocation of head + ulna metaphyseal # with lat angulation.23% • Type 4: type1+ radius #
  • 12. Letts peadiatric classification • Type A: ant. dislocation of radial head + plastic deformation of ulna. • Type B: ant.dislocation + greenstick # • TYPE C: ant.dislocation + complete # • Type D:post.dislocation + ulna # • Type E:lat. dislocation + ulna greenstick #
  • 13. MECHANISM OF INJURY TYPE 1: • Direct blow theory: blow on post aspect
  • 14. Hyper pronation theory : during fall out stretched hand-initially pronation is forced into further pronation
  • 15. Hyper extension theory: on out stretched hand with forward momentum elbow in hyper ext.-radius dislocates ant. By violent contracture of biceps- after wt transferred to ulna-resulting #
  • 16. Type 2: occurs when forearm is suddenly loaded in a longitudinal direction with elbow bent to 60* flexion provided the ant cortex is weakened otherwise post dislocation may occur.
  • 17. • Type 3: varus stress
  • 18. Clinical presentation radiography  Type 1: • Fusiform swelling at elbow • Painful movements • Angular change… apex at ant. • Tenting of the skin or ecchymosis. • Child may not be extend the digits at mcp joints or ip joint of the thumb-paresis of PIN  RADIOLOGY:x ray- AP, LAT • Radiocapitellar relation-lat view-line draw though the center of the radial neck and head should extend directly through the center of capitellum…in any degree.
  • 19. Type 2; • Swelling • Post angulation • Associated fractures • Radiology: radial head dislocation Proximal metaphyseal # of ulna with possible extension into olecranon
  • 20. • Type 3: lat.swelling Varus deformity limitation of supination  Radiology: lat displacement of radial head Ulna metaphyseal # • Type 4: same as type 1 Risk of compartmental syndrome rare in children radiocapitellar joint should be examined. failure to recognise the dislocation is major complication  radiology: ant radial dislocation # bb at middle 3rd with radial # distal to ulna #
  • 21. Management of monteggia fractures in children  Type 1: o Conservative: MRD • Reduction of ulnar #: longitudinal traction and correction of angulation- supinated fully upto 10* angulation is acceptable. • Reduction of radial head:accomplished by flexing the elbow 90* or above – spontaneous reduction or post.directed pressure Flexion 110-120* stabilizes the reduction. • Check x ray • Alleviation of deforming forces: flexion to alleviate the force of the biceps supination • Immobilization and aftercare: a/e cast 3-4wks, serial x rays. b/e cast after 4 wks-mobilization. Full activity after 6-8 wks
  • 22. OPERATIVE • INDICATIONS: Failure of ulnar reduction Failure of radial head reduction: due to interposition of materials , or torn ligaments. o Surgical approach: BOYD approach • Extensive nature • incision : following the lat. boarder of triceps posteriorly to the lateral condyle and extending along the radial side of ulna. • Incision carried under the anconeus and ECU in extra periosteal manner • Elevating the fibers of supinator from ulna. • Down to the interosseous mem. Exposing the radiocapitellar joint., oblique lig.; .proximal radius and ulna
  • 23. TRETMENT OF ANNULAR LIG. • Head of the radius is repositioned anatomically after removing any portion of the annular lig. • A strip of fascia 1.3cm wide 11.5cm long is made free from the muscles of the forearm , leaving its attached to prox . ulna. • Strip is passed btwn the radial notch of the ulna and the tuberosity of the radius and around the neck. • Fastened itself with interrupted non absorbable sutures. • If still unstable fixed with a large smooth trans articular pin, through capitellum across the joint and into head and neck of radius, proximal end bent outside.wound closed. • Forearm kept in slight supination &a/e cast • Pin breakage,infection • Cast and pin removed at 3-6 wks
  • 24. Structures used for reconstruction: Bell-tawse: Strip of triceps tendon watson-jones : Palmaris longus tendon may and mauk Chromic ligature thompson and lipscom: Fascialata graft Radial head resection done in: • Chronic persistent dislocations • un treated isolated dislocations or • ignored until skeletal maturity If the ligament is intact it is incised and retracted to allow reduction-repair..
  • 25. Surgical Treatment of ulna fracture • If closed reduction is not satisfactory or child is older than 12yrs-internal fixation with IM pinning. • Minimally invasive • Stability • Single pin or multiple or plating • After care: A/E cast-90-110* flxn.
  • 26. Treatment in type 2 fractures Non operative: • longitudinal traction along the axis of forearm With elbow 60* of flxn. • Radius dislocation reduce spontaneously. • anteriorly directed pressure over post, aspect. • Elbow extended and immobilized in this position- 4 wks.
  • 27. Operative treatment • Byods approach can be used.. • Reduction and lig repair is same as type 1. • Ulna # exposed subcutaneously fixed with plating or pinning. • After care: cast either in extension or flexion to 80* ,if im pinning is used …for 3-4 wks.
  • 28. Treatment in type 3  Non operative: • Longitudinal traction in extension. • Valgus stress placed on ulna-reduction. • Radial head reduce spontaneously. • Or pressure over lat.side. • Check x ray- A/e cast in flxn.  Operative: • Radial head reduced through byods approach. • Repair of lig. • Ulna plating or pinning. • After care:A/E cast in 110* flxn.-3-4wks. • Removable splint for additional 3-4wks • Early rom
  • 29. Treatment in type 4 Non operative: MRD OPERATIVE: • if # is unstable-reduced and fixed percutaneously with pinning. • 12yrs or older plating of radius through HENRY’S extensile approach. • radial head is reduced by closed • Ulna plating or pinning. • After care: A/E cast at 100 to 120* of flxn-4wks B/E cast for additional 4 wks with early rom.
  • 30. Old Monteggia in children • Present with-pain Instability Restricted motion Late neuropathy Valgus deformity and prominence at ant. Aspect • Indications: marked limitation of flexion Progressive cubitus valgus <12yrs- radial should be replaced in its position by ORIF. Radial head can be reduced as late as 6 months or more.requires osteotomy of angulated ulna. Reconstruction of lig.
  • 31. Open reduction SPEED AND BOYD; • Through the boyds approach # ulna and radial head exposed. • If ulna has united in malposition osteotomy done. • Fixation done with compression plate or medullary nail • Reconstruction of annular lig done.
  • 32. Dangers of early excision of head • Traumatic ossification • Proximal migration and dislocation of DRUJ. • Impaction on capitellum.
  • 33. Monteggia equivalents Type 1: • Isolated dislocation of radial head • Radial neck # • Radial neck # with # ulna diaphysis. • # ulnar diaphysis + radial head dislocation+ olecranon #. • Post.dislocation of ulnohumeral joint with or without proximal radius #.
  • 34. Monteggia equivalents Type 2: post.dislocation of elbow. Type 3:ulna# +# lat.condyle Type 4: # distal humerus, ulna diaphysis, radius Hybrid lesion;type1+ # extends into olecranon.
  • 35. Monteggia fracture dislocation in adults • Classification; Bado –same as in children. • Jupiter discribed sub groups in type 2. Type 2a:ulna # involves the distal olecranon and coronoid. Type2b: ulna # is at M/D JN.distal to coronoid. Type2c:diaphyseal Type2d:# extends to proximal 3rd to half of the ulna. Bado type 2 and jupiter type2a has worst prognosis.
  • 36. Treatment  Good results in- • Early accurate diagnosis • Rigid fixation of ulna • Accurate reduction of radial head • Post-op immobilization to allow ligaments to heal.  Treatment plans: acute; • closed reduction of head + rigid fixation of proximal ulna by plating • In interposition of lig/capsule-open reduction and repair or reconstruction of lig.+ ulna plating. • OLD:6wks or older dislocation never reduced .excision of head+ ulna plating +graft
  • 37. Various methods of ulna fixation • Intramedullary fixation; with rush nails or square nails. Best for segmental #, open #, pathological , failed plating; and in multiple injuries. Non union due to; u/3rd wide cavity insufficient apposition of frag. side to side,rotatory motion angulation
  • 38. Open reduction with plate and screws • 3.5 DCP or LCDCP used • Incision along the subcutaneous boarder after reduction plating done. • Post. Splint in 120* to prevent redislocation of radial head. 4-6 wks after cuff and collar. • Extension is not permitted until 6 wks.
  • 39. Treatment of old fracture • For injuries 6wks or old-excision of head. • Ulna plating with graft
  • 40. complications • PIN palsy • Malunion or non union • Radiohumeral fibrous ankylosis • Radioulnar synostosis • Recurrence of dislocation • Myositis ossificans • VIC
  • 41. PIN palsy: • nerve passes beneath the fibrous arch of supinator. • Sensory Br. Separates before passing beneath the arch ..motor br. Below the arch • Pure motor deficit with intact sensation by compressive lesion. • Combined due to stretching. • Function usually returns in 2-3 months.. Exploration not required.
  • 42. • Mal union : if few degrees of malunion or subluxation- resection of head. Moderate to severe –osteotomy + plating + resection of radial head • Non union : resection of head + ulna plating + graft • Radiohumeral fibrous ankylosis: due to repeated closed attempts. Treatment is continuous passive motion. • Radioulnar synostosis:fibrous/bony:even after resection results are poor, best to leave and allow shoulder compensatory motions.