MONTEGGIA FRACTURE DISLOCATOIN

Dr. D.SUDHEER KUMAR, P.G M.S(Ortho), GANDHI HOSPITAL.

• It is a fracture of the proximal 3rd of the ulna with dislocation of the radial head

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.

ANATOMY AND BIOMECHANICS

• Structures related to fracture.. Ligaments: annular ligament Quadrate lig. Oblique lig. Interosseous mem. bones: radial head Radius Proximal ulna Muscles nerves

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.

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.

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

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.

NERVES

PIN: ant/ant.lat to the radial head and neck path through supinator.

• ParesisUlnar nerve : at risk in type 2 #

MONTEGGIA FRACTURE IN CHILDREN

CLASSIFFICATION AND MECHANISM OF INJURY• EXTENSION INJURY• FLEXION INJURY• ADDUCTION INJURY

BADO”S CLASSIFICATION

• TYPE 1: ant dislocation of radial head + ulna diaphyseal # with ant.angulation.70%

• Type 2: post/post.lat dislocation of head + ulna# with post.angulation. Uncommon in children.3%

• Type 3: lat/ant.lat dislocation of head + ulna metaphyseal # with lat angulation.23%

• Type 4: type1+ radius #

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 #

MECHANISM OF INJURY

TYPE 1:• Direct blow theory: blow on post aspect

Hyper pronation theory : during fall out stretched hand-initially pronation is forced into further pronation

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 #

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.

•

Type 3: varus stress

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.

Type 2;• Swelling• Post angulation• Associated fractures• Radiology: radial head dislocation Proximal metaphyseal # of ulna

with possible extension into olecranon

• 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 #

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

OPERATIVE• INDICATIONS:Failure of ulnar reductionFailure 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

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

Structures used for reconstruction: Bell-tawse: Strip of triceps tendon watson-jones : Palmaris longus tendon may and mauk Chromic ligature thompson and lipscom: Fascialata graftRadial head resection done in: • Chronic persistent dislocations • un treated isolated dislocations or• ignored until skeletal maturityIf the ligament is intact it is incised and retracted to

allow reduction-repair..

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.

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.

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.

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

Treatment in type 4

Non operative: MRDOPERATIVE: • 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.

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.

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.

Dangers of early excision of head

• Traumatic ossification• Proximal migration and dislocation of DRUJ.• Impaction on capitellum.

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 #.

Monteggia equivalents

Type 2: post.dislocation of elbow.Type 3:ulna# +# lat.condyleType 4: # distal humerus, ulna diaphysis,

radiusHybrid lesion;type1+ # extends into olecranon.

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:diaphysealType2d:# extends to proximal 3rd to half of the ulna.Bado type 2 and jupiter type2a has worst

prognosis.

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

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

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.

Treatment of old fracture

• For injuries 6wks or old-excision of head.• Ulna plating with graft

complications

• PIN palsy• Malunion or non union• Radiohumeral fibrous ankylosis• Radioulnar synostosis• Recurrence of dislocation• Myositis ossificans• VIC

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.

• 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.