Monteggia fractures and neglected cases A simple presentation to understand the fracture and its classifications and answer some coomonly asked questions regarding the neglected cases managment

1. Monteggia
Fracture, Variants & Neglected cases
Abdelrahman Haroun
MSc, MRCS
El-Menshawy Pediatric Trauma Orientation Course June 2022

2. ILOs
• Background
• Definition
• Classification
• Diagnosis
• Treatment methods
• Chronic lesions

3. Background
• 1814 Giovanni Monteggia
Surgical Pathologist 2 cadavers
Fracture of the shaft of
the ulna accompanied by
anterior dislocation of the radial
head .

4. • 1909 Perrin
Named the fracture
• 1958 Jose Bado
Described the first and still the most widely used
classification.

5. Epidemiology
• Age 4 ~ 10
• Less than 1 in 100,000
• < 1 % of pediatric forearm fractures
• One of the most commonly missed fractures
• A chronic Monteggia lesion can result in a substantial
morbidity, and is far more complex in management than acute
injuries

6. Classification
I to IV according to the level and angulation of ulna shaft fracture and the direction
of dislocation of the radial head
+
Monteggia-equivalent injury that differed in radiological appearance but possessed
similar characteristics especially in the mechanism of injury and in its treatment

7. • Type I 60 to 70 %
Fracture ulna in diaphysis or
metaphysis
Anterior radial head dislocation
Mechanism of injury
• Direct blow to posterior elbow
Most common type in children accounting for 70% of cases, 15% of cases in adults

8. • Hyper-pronated force on an
outstretched arm.
• Contracted biceps resists
forearm extension causing
dislocation and followed by
impact leading to ulna
fracture.

9. • Type II 15%
Fracture ulna is usually metaphysial
Posterior radial head dislocation
Most common type in adults accounting for approximately 80% of cases
High rates of posterior interosseous nerve injury.
• Axial load directed up the forearm with a slightly
flexed elbow.
Mechanism of injury

10. • Type III 20 %
Fracture ulna is usually metaphysial
lateral or anterolateral dislocation of the radial
head
Mechanism of injury
• Varus force on an extended
elbow leads to a greenstick
fracture of the ulna.

11. • Type IV 1 %
Diaphyseal fracture of the shaft of the radius and ulna
Anterior dislocation of the radial head
Rarest type and poorly understood mechanism

12. Equivalents
Type I equivalents
• A: Isolated anterior radial
head dislocation.
• B: Ulnar fracture with
fracture of the radial neck.
• C:Isolated radial neck
fractures.
• D: Elbow dislocation with or
without fracture of the
proximal radius.

13. Added Type V by Dormans and Rang in 1990
Type II equivalents
• Posterior radial head
dislocations associated with
fractures of the proximal
radial epiphysis or radial
neck.
Type III and IV
equivalents
Habitual dislocation of the radiocapitellar joint and proximal
radio-ulnat joint

14. Letts et al
According to radial head dislocation and type of ulna fracture
Bado I is subdivided
• Ulna plastic deformation
• Green stick fracture
• Complete fracture

15. Jupiter Type II sub-classification
IIA: fracture of the ulna involves the
distal olecranon and coronoid process
IIC: fracture of the ulna is
diaphyseal.
IIB: fracture of the ulna is distal to the
coronoid process, involving the metaphyseal
and diaphyseal junction
IID: fracture of the ulna that extends
from the diaphysis to the olecranon

16. Diagnosis
Clinical Picture
• History
• Ex.
– Pain
– Swelling
– Deformity
– ROM
– Neurological (PIN)

17. Radiological
• Proper X-rays of the elbow should be obtained if suspected
Monteggia lesion
• A-P
• Lateral
• CT ?
• Radiocapitellar relation
A line drawn down the long axis of the radius bisects the capitellum of the
humerous.

18. Treatment
“At the end of the treatment the arm swelling has resolved, but only
the dislocation of the radius that was not easy to reduce.... I applied
compression and a new bandage again to contain it, but it did not want
to stay in place” Giovanni Monteggia
Restore ulnar length - Reduce redial head - Maintain reduction
Non-Operative
• Closed reduction
– Traction
• + Supination I
• + Pronation II
• + Valgus stress III
• Cast immobilization
• Flexion 110 I & III
• Flexion 70 II
• Supination III

19. Operative treatment
Failed reduction or failed maintaining reduction
• C.R.P.P
• Failed radial head reduction
More with Bado III soft tissue interposition
Kocher or Boyd approach
Remove entrapped soft tissue +/- A.L. repair

20. Neglected Monteggia
Qs ?
Is it too late to operate?
• No chondoral defect
• Preserved radial head shape
Radial osteotomy ?
• No definite indications for radial osteotomy or its preference
over ulnar osteotomy were mentioned.

21. Ulnar osteotomy
The osteotomy depends on the interosseous membrane to bring the radial
head back to the acceptable position
Where to do ulnar osteotomy ?
Proximal is better
• Single approach if needed
• Near the CORA
How to do ulnar osteotomy ?
Oblique osteotomy allow lengthning while mainating bone
contact.

22. • How to fix your osteotomy ?
• Plates > wires
• 2.7 locked plate > 3.5 small DCP
• Ilizarov ?
• Bone graft ?
• Age
• Gap
• Periosteum

23. What about ALR ?
• Never alone
• Ulnar osteotomy is your main task
• If stable after ulnar osteotomy no need for ALR
• If unstable you should consider adjusting your
osteotomy
• If unstable in full pronation after adjusting osteotomy go for ALR
• Triceps tendon slip , forearm fascia , ALR remnants

25. Can I put K-wire ?
• Indications for the use of a transcapitellar wire cannot be
standardized, but it can be avoided in patients with a stable
reduction
Conflicting results of stiffness

26. Is excision a good option ?
• Improve the movements, particularly rotation
• Can lead to instability
• Weakness in the elbow
• Risk of progressive valgus deformity
• Synostosis
• Proximal migration
• Wrist pain
Thus, patient satisfaction from this procedure can be poorer
compared with radial head preservation

27. Expected Complications
• Residual sublaxation
• ROM specially pronation
More with ALR
• Synostosis
• PIN injury
• Skin complications

28. Take Home Message
• Monteggia fracture while relatively rare can have catastrophic
consequences if missed.
• Remember to check the elbows
• Counsel the family for common complications
• Ask for help in neglected cases

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