Grand Round

By Dr. Yasir Jameel

Clinical fellow Orthopedic Trauma

02/04/2014

Case

• Yong male with history of fall on extended forearm

• Pain and swelling right forearm

Case

• history

Case history

• Age, sex, occupation

• Presenting complain

• History of PC / Event

• Past medical history

• Past surgical history

• Drugs, Allergies

• Social history

Case- examination

• Look

• Feel

• Move

• Neurovascular status

investigations

• X-RAY

– Ap and lateral forearm exposing wrist and elbow

Fracture and its type

• Left ulna shaft fracture with radial head dislocation

• Monteggia fracture

• Bado type 3

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

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.

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

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.

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

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

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

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.

Treatment in pediatric group• In case of delayed diagnosis or missed

dislocation

• Multiple surgical interventions can b used e.gulnar osteotmy, open reduction of radial head with anular ligament repair, transcapitalarwire fixation.

Degreef I, De Smet L. Missed radial head dislocations in children associated with ulnardeformation: 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

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 subluxatedin 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

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

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

Adult treatment

• Retrospective analysis of 47 adult Monteggiafracture 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

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

Thank you