![]() Intra-operative fluoroscopic arthrogram may be the more expedient choice in this scenario. The use of MRI and ultrasound is not usually indicated, though these modalities may be used when fracture of a non-ossified radial head is suspected (in a child less than 4 years of age). ![]() Plain X-rays are usually sufficient, but CT can be of value in preoperative planning. Radiographs should also include the wrist, as there may be a concomitant fracture of the distal radius, which indicates higher energy and should raise suspicion for compartment syndrome, or disruption of the interosseous membrane and longitudinal forearm instability.Īssociated fractures around the elbow should be characterized to determine treatment plan, as these frequently impact elbow stability. Radial head dislocation and subtle ulnar bow. Injury films should be followed with post reduction X-rays to confirm concentric reduction of the ulnohumeral and radiocapitellar joints (Figure 1). The posterior ulnar cortex should be straight. The ulna should be scrutinized for plastic deformity or “bow sign”, with apex in the direction of radial head dislocation. This holds true for all projections, and whether the radial head is ossified or not. In the normal elbow, the central axis of the radius should pass through the center of the capitellum. Dislocations of the radial head may stretch and injure the posterior interosseous nerve.Īny radiographic series for forearm fracture must include quality AP and lateral views of the elbow, which are necessary and usually sufficient to identify radiocapitellar incongruity. In the pediatric patient, history of preceding injury, or pre-injury lack of full range of motion will alert the surgeon to a chronic or previously under-treated Monteggia variant, or to a history of congenital radial head dislocation.Ī full neurologic, vascular and compartment exam should be performed before and after reduction. In all patients, mechanism should be elicited, as this may inform the surgeon as to the involved force vectors and likely involved structures. History and physical exam begins any assessment. ![]() Jupiter sub-classified the type II fracture based on the pattern of the ulna fracture. A type IV indicates a radial shaft fracture accompanies the ulna fracture. Type III is an ulnar metaphysis fracture with apex lateral. Type I and II are ulnar diaphysis fractures with apex anterior and posterior, respectively. The Bado classification is a commonly used scheme that describes the direction of the radial head dislocation and the apex of the ulnar deformity. The most common fracture pattern involves an ulna with apex anterior deformity with a corresponding anteriorly dislocated radial head, consistent with a hyperextension mechanism. They present in very much the same way as other pediatric upper extremity fractures do, with pain, deformity and limited use after fall onto an outstretched arm. The pediatric Monteggia fracture typically affects children between the ages of 4 and 10 years of age. Achieving good results when treating these injuries depends on timely identification, understanding of the pathoanatomy, and appreciating the differences between the “personalities” of different injury patterns in adults and children. Improperly treated, these lead to severe disability related to loss of elbow and forearm range of motion. The Monteggia fracture, or fracture of the proximal third ulna with associated subluxation or dislocation of the radial head, in fact includes a wide variety of injuries to the proximal articulations between the humerus, radius, ulna, and the forearm axis of rotation.
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