forearm fracture pediatrics

1. Grand Round
By Dr. Yasir Jameel
Clinical fellow Orthopedic Trauma
02/04/2014

2. Case
• Yong male with history of fall on extended
forearm
• Pain and swelling right forearm

3. Case
• history

4. Case history
• Age, sex, occupation
• Presenting complain
• History of PC / Event
• Past medical history
• Past surgical history
• Drugs, Allergies
• Social history

5. Case- examination
• Look
• Feel
• Move
• Neurovascular status

6. investigations
• X-RAY
– Ap and lateral forearm exposing wrist and elbow

9. Fracture and its type
• Left ulna shaft fracture with radial head
dislocation
• Monteggia fracture
• Bado type 3

10. Montegia fracture
Giovanni Battista Monteggia of Milan.
1814Monteggia GB. Instituzioni Chirrugiche. vol 5. Milan: Maspero; 1814
• proximal ulna fracture with ant. Dislocation of
radial head
• Described in pre-roentgen era, on basis of
clinical examination.
• Perticular fracture patteren is 60% of total
monteggia lession

11. Bado classification
• 1967, Bado described term Monteggia lesion
– classified the injury in 4 types
– Bado JL. The Monteggia lesion. Clin Orthop Relat Res. Jan-Feb
1967;50:71-86
• Type I - Fracture of the proximal third of the ulna with
anterior dislocation of the radial head.
• Type II - posterior dislocation of the radial head
• Type III - lateral dislocation of the radial head
• Type IV - proximal radius fracture with anterior dislocation of
the radial head
Dislocation of radial head in the direction of ulna fracture apex.

12. Monteggia lession
• The Monteggia lesion is most precisely
characterized as a forearm fracture in
association with dislocation of the proximal
radioulnar joint.
• 5% of total forearm fracture.
• Type-I 59%, Type-III 26%, Type-II 5%, Type IV
1%.
– Bruce H.E., Harvey J.P., Wilson J.C. Monteggia Fractures. J Bone Joint Surg
Am. 1974;56:1563.
– Reckling F.W. Unstable fracture-dislocation of the forearm (Monteggia and
Galeazzi lesions). J Bone Joint Surg Am. 1982;64:857

13. Mechanism of injury
• Falls on an outstretched hand with forced pronation,
• In case of flexed elbow, the chance of a type II or III
lesion is greater,
• direct blow to the forearm
• High energy Trauma, RTA
• Low energy Trauma, fall from standing height
• Evans-1949 & Penrose-1951 studied the etiology of
Monteggia fractures on cadavers
– Evans EM. Pronation injuries of the forearm with special reference to anterior Monteggia fractures. J
Bone Joint Surg. 1949;31B:578-588.
– Penrose JH. The Monteggia fracture with posterior dislocation of the radial head. J Bone Joint Surg.
1951;33B:65-73.

14. Associated nerve injuries
• posterior interosseous nerve (branch of the
radial nerve) 10% in acute injuries
– particularly in Bado type II injuries
• Ruchelsman DE, Pasqualetto M, Price AE, Grossman JA. 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. Hand (N Y). Jun
2009;4(2):167-72
• Anterior interosseous nerve of median nerve and
lunar nerve injuries are aso reported
• Most nerve injuries are neurapraxias and typically
resolve over a period of 4-6 months

15. Treatment
• Factor effecting the treatment
• Age pediatric or adult
• Pediatric fracture pattern ( plastic deformity,
green stick, Transverse or short oblique,
comminuted or long oblique)
– Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad
Orthop Surg. 1998; 6(4):215–224.
– Ring D, Waters PM. Operative fixation of Monteggia fractures in children. J Bone Joint
Surg Br. 1996; 78(5):734–739
• Close reduction and casting preferred for
pediatric age group
• Adult group with ORIF

16. Treatment in pediatric group
• Why nonoperative treatment is successful for most
Monteggia injuries in children?
1. fractures are inherently stable
2. shorter time required for both the osseous and the
ligamentous injuries to heal.
3. Less elbow stiffness even after elbow imobilization for
4-6 wks.
4. remodeling of mild, residual angular deformities <
10°.
Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J
Am Acad Orthop Surg. 1998; 6(4):215–224.
Leonidou A, Pagkalos J, Lepetsos P, Antonis K, Flieger I, Tsiridis E, et al.
Pediatric Monteggia fractures: a single-center study of the
management of 40 patients. J Pediatr Orthop. Jun 2012;32(4):352-6

17. Treatment in pediatric group
• Fracture in children which are not stable and
comminuted or long obliqe recommended to
be treated with surgical management
intramadullary nailing or platting.

18. Treatment in pediatric group
• In case of delayed diagnosis or missed
dislocation
• Multiple surgical interventions can b used e.g
ulnar osteotmy, open reduction of radial head
with anular ligament repair, transcapitalar
wire fixation.
Degreef I, De Smet L. Missed radial head dislocations in children associated with ulnar
deformation: treatment by open reduction and ulnar osteotomy. J Orthop Trauma.
2004; 18(6):375–378.
Hui JH, Sulaiman AR, Lee HC, Lam KS, Lee EH. Open reduction and annular ligament
reconstruction with fascia of the forearm in chronic monteggia lesions in children. J
Pediatr Orthop. 2005; 25(4):501–506.
David-West KS, Wilson NI, Sherlock DA, Bennet GC. Missed Monteggia injuries. Injury. 2005;
36(10):1206–1209
Ladermann A, Ceroni D, Lefevre Y, De Rosa V, De Coulon G, Kaelin A. Surgical treatment of
missed Monteggia lesions in children. J Child Orthop. 2007; 1(4):237–242

19. Treatment in pediatric group
• Nakamura et al evaluated the long-term clinical and
radiographic outcomes after open reduction for the
treatment of missed Monteggia fracture-dislocations in
22 children (14 boys, 8 girls; age range, 4 y to 15y 11
mo). The postoperative Mayo Elbow Performance
Index at follow-up ranged from 65 to 100, with 19
excellent results, 2 good results, 1 fair result, and zero
poor results. In 17 patients, the radial head remained
in a completely reduced position, and it was subluxated
in 5 patients. Osteoarthritic changes were seen at the
radiohumeral joint in 4 patients. Radiographically,
there were 15 good results, 7 fair results, and zero poor
results. A good radiographic result was seen in all
patients who underwent open reduction within 3 years
after injury or before reaching 12 years of age
Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term
clinical and radiographic outcomes after open reduction for missed Monteggia fracture-
dislocations in children. J Bone Joint Surg Am. Jun 2009;91(6):1394-404

20. Forearm outcome criteria
• In 1991, Anderson and Meyer used criteria to
evaluate forearm fractures and their prognosis, as
follows:
– Excellent: Union with less than 10° loss of elbow and
wrist flexion/extension and less than 25% loss of
forearm rotation
– Satisfactory: < 20° loss of elbow and wrist
flexion/extension & < 50% loss of forearm rotation
– Unsatisfactory: > 30° loss of elbow and wrist
flexion/extension & > 50% loss of forearm rotation
– Failure: Malunion, nonunion, or chronic
osteomyelitis
Anderson LE, Meyer FN. Fractures of the shafts of the radius and ulna. In:
Rockwood CA, Green DP, and Bucholz R, eds. Fractures in Adults. vol 1. 3rd ed.
Philadelphia, Pa: JB Lippincott; 1991

21. Adult treatment
• Close reduction and casting fails in adults due
to shortning and angulation in ulna post
reduction
• Recommended in adult ORIF with platting
– Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg
Am. 1998; 80(12):1733–1744.
– Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior
monteggia fractures in skeletally mature patients. J Hand Surg Am. 2009;
34(9):1618–1624

22. Adult treatment
• Retrospective analysis of 47 adult Monteggia
fracture cases, Konrad et al identified several
negative prognostic indicators for patients
undergoing operative treatment. They found
that Bado type 2 fractures, coronoid process
fractures, radial head or neck fractures, and
complications necessitating additional surgery
correlated with poorer clinical outcomes.
– Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia
fractures in adults: long-term results and prognostic factors. J Bone Joint
Surg Br. 2007

23. Adult treatment
• Guitton et al performed a retrospective study on the functional and
radiologic long-term outcome of open reduction and internal
fixation in 11 skeletally mature patients with Bado type 1
Monteggia fractures. Two patients had subsequent surgery for
nonunion, and 3 elbows had radiographic signs of arthrosis. The
mean arc of elbow flexion increased from 110º (range, 35º-140º) at
early follow-up to 120º (range, 40º-150º) at late follow-up. The
mean arc of forearm rotation increased from 145º (range, 90º-180º)
to 149º (range, 90º-180º). The mean Broberg and Morrey score
increased from 89 points (range, 62-100 points) to 94 points (range,
76-100 points), and the median DASH score was 7 points (range, 0-
34 points) at long-term follow-up.
– Guitton TG, Ring D, Kloen P. Long-term evaluation of surgically treated anterior
monteggia fractures in skeletally mature patients. J Hand Surg Am. Nov
2009;34(9):1618-24

26. Thank you