Monteggia Injuries Research Articles

Monteggia injuries.

The Monteggia injury is defined as radial head dislocation with a fracture of the ulnar shaft. This combination should be sought routinely in patients with ulnar fractures, even when the displacement is small. The emergent management is simple, as reducing the ulnar fracture is usually sufficient to stabilise the radial head. Internal fixation of the ulna deserves to be widely used to fully stabilise the radial head. Irreducibility of the radial head at the acute stage may indicate an interposition, which requires open surgery on the joint. Radial head dislocation may occur even with minimal displacement of the ulnar fragment. Chronic Monteggia fractures are more challenging to treat and their outcomes are more variable. The radial head becomes irreducible after 2 to 3 weeks. When a simple surgical approach fails to ensure stable reduction, the most widely used method at present is open reduction of the radial head and proximal osteotomy of the ulnar shaft. Stability must be obtained intra-operatively. Without treatment, radial head dislocation may be well tolerated for several months or even years. In the long term, however, osteoarticular remodelling results in loss of joint congruence, pain and, eventually, osteoarthritis. Radiographs must therefore be obtained on an emergency basis and analysed with great care to avoid missing a Monteggia fracture.

Open reduction combined with CORA-based osteotomy of the ulna in the treatment of missed Bado type I Monteggia injury: A retrospective study of 5 cases.

Open reduction combined with ulnar osteotomy is the most common approach to treating missed Monteggia injuries. The osteotomy is usually performed at the proximal ulna to ensure better healing and fewer complications. The purpose of this study is to present a center of rotation angulation (CORA)-based osteotomy of the ulna for treating Bado type I Monteggia injuries.We retrospectively reviewed the cases of patients who were treated with open reduction combined with a CORA-based ulnar osteotomy between February 2014 and December 2016. Each patient provided his or her internal control, and paired data of the involved and uninvolved sides were analyzed to evaluate forearm rotation function.Five patients (3 male, 2 female) with median age 5.7 years (range, 3.4–6.8 years) were operated on by the senior author in our hospital. The median interval between the original injury and the corrective surgery was 3 months (range, 1–4 months). In a median follow-up of 10 months (range, 6–17 months), all patients obtained stable reduction of the radial head and uneventful healing of the ulnar osteotomy. All patients had pain-free elbows with no neurological or vascular complications and no implant breakage. Patients showed excellent outcomes evaluated using the Broberg and Morrey index.Open reduction with a CORA-based osteotomy of the ulna for the treatment of missed Bado type I Monteggia injury with an obvious ulnar bowing deformity resulted in stable reduction of the radial head and excellent forearm function.

Successful Strategies for Managing Monteggia Injuries.

Monteggia fracture-dislocations refer to traumatic ulnar fractures associated with proximal radioulnar and radiocapitellar joint instability. Careful clinical and radiographic evaluation of the entire limb in the acutely injured child is critical for timely diagnosis and appropriate treatment. Treatment principles include restoring and maintaining both ulnar length and alignment as well as radiocapitellar joint reduction. Recent information suggests that surgical treatment of acute injuries associated with complete ulnar fractures is safe and effective in maintaining bone and joint alignment. In cases of late presentation or missed diagnoses, chronic reconstruction may be considered in symptomatic patients with preserved radiocapitellar morphology. Although challenging, ulnar osteotomy and open joint reduction with or without ligament reconstruction may restore joint congruity in the majority of patients.

Recognition and fixation of crista supinatoris fractures in Monteggia injuries.

In Monteggia fracture dislocations of the elbow, the lateral collateral ligament complex is disrupted as the radial head dislocates from the capitellum. A persistently incompetent lateral ulnar collateral ligament (LUCL) predisposes to posterolateral rotary instability of the elbow, thus restoration of the LUCL is essential for recovery. Although LUCL disruptions following elbow dislocations typically occur at the lateral humeral origin, we have identified a series of Monteggia injuries where the LUCL is avulsed from its ulnar insertion along with a fracture fragment containing the crista supinatoris. Failure to recognize and appropriately treat the crista supinatoris fracture in this injury may result in LUCL incompetence and risk symptomatic instability. The following technique describes the recognition and surgical treatment of Monteggia injuries, specifically recognizing the crista supinatoris fracture. Using this technique, patients reliably experience good functional outcomes with normal elbow stability.

Biomechanical analysis of the annular ligament in Monteggia fractures using finite element models.

BackgroundThe pathogenesis of Monteggia injuries remains controversial. The current study biomechanically explored the pathological changes during Monteggia fractures using finite element analysis.MethodsTwo cadaveric forearm specimens underwent computed tomography in both the prone and supine positions. The images were imported to Mimics to construct three-dimensional images. The obtained models of the annular ligaments were assembled onto the bones. Two thin gaps were produced at the proximal third of the ulna to simulate a Monteggia fracture. The models were analyzed mechanically. The initial fracture process was simulated by constraining the distal portions of the radius and ulna and the dorsal fracture sites of the ulna. The mechanical changes of the annular ligament in the two positions were observed and compared.ResultsIn the prone position, the maximum Z-axial displacement of the annular ligament was close to that along the Y-axis, although with a significant difference (P < 0.01). In the supine position, the X-axial displacement dramatically increased (P < 0.01), while it was noticeably decreased along the Z-axis (P < 0.01).ConclusionsBiomechanical changes may partially explain the pathological changes in the annular ligament during Monteggia fractures; longitudinal displacement of the radial head causes it to slip out of the annular ligament while the ligament remains intact.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion

IntroductionThe aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. Material and methodsThis retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. ResultsTwenty-eight patients were reviewed, at a mean 6 years’ follow-up (range, 2–34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. DiscussionProximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. Level of evidenceIV (retrospective).

"Sliding angulation osteotomy": preliminary report of a novel technique of treatment for chronic radial head dislocation following missed Monteggia injuries.

Neglected anterior radial head dislocation in type I Monteggia lesions leads to restriction of movement, deformity and instability of the affected elbow. If left untreated this leads to a painful arthritic elbow due to secondary degenerative changes. This is a difficult problem to manage and many intra-articular, extra-articular and combined procedures have been described with variable results. We report a new technique of sliding angulation osteotomy for this condition, which allows both lengthening and angulation of the ulna. A novel technique of sliding angulation osteotomy of the proximal ulna was done to achieve reduction of the radial head. Four patients with persistent anterior radial head dislocation were treated at our institution with this technique. All of them had good clinical and radiological outcomes at final follow-up. Sliding angulation osteotomy is a technically simple procedure, which achieves lengthening and angulation of the ulna simultaneously in the sagittal plane and reduces the radial head.

Treatment of late-presenting Monteggia variant with an isolated, simple flexion ulnar osteotomy

Radial head dislocation in children is usually associated with complete elbow dislocation or occurs as a part of a Monteggia injury. In patients without an obvious fracture of the ulna, recognizing that plastic deformation of the ulna leads to pathological bowing is a key concept in the management of this injury. Although good results have been published using osteotomy of the ulna to maintain stability after open reduction, we hypothesize that ulnar osteotomy alone may be enough to enable stable enlocation of an irreducible radial head in patients who are identified early. We present two cases of irreducible radial head dislocation, treated with ulnar osteotomy and closed radial head reduction. Both osteotomies united and both patients had an excellent functional outcome with the absence of pain or deformity and early return to function. We explain the surgical technique and compare the outcomes with alternative surgical treatments.

Distribution of Coronoid Fracture Lines by Specific Patterns of Traumatic Elbow Instability

To determine if specific coronoid fractures relate to specific overall traumatic elbow instability injury patterns and to depict any relationship on fracture maps and heat maps. We collected 110 computed tomography (CT) studies from patients with coronoid fractures. Fracture types and pattern of injury were characterized based on anteroposterior and lateral radiographs, 2- and 3-dimensional CT scans, and intraoperative findings as described in operative reports. Using quantitative 3-dimensional CT techniques we were able to reconstruct the coronoid and reduce fracture fragments. Based on these reconstructions, fracture lines were identified and graphically superimposed onto a standard template in order to create 2-dimensional fracture maps. To further emphasize the fracture maps, the initial diagrams were converted into fracture heat maps following arbitrary units of measure. The Fisher exact test was used to evaluate the association between coronoid fracture types and elbow fracture-dislocation patterns. Forty-seven coronoid fractures were associated with a terrible triad fracture dislocation, 30 with a varus posteromedial rotational injury, 1 with a anterior olecranon fracture dislocation, 22 with a posterior olecranon fracture dislocation, and 7 with a posterior Monteggia injury associated with terrible triad fracture dislocation of the elbow. The association between coronoid fracture types and elbow fracture-dislocation patterns, as shown on 2-dimensional fracture and heat maps, was strongly significant. Our fracture maps and heat maps support the observation that specific patterns of traumatic elbow instability have correspondingly specific coronoid fracture patterns. Knowledge of these patterns is useful for planning management because it directs exposure and fixation and helps identify associated ligament injuries and fractures that might benefit from treatment. Two-dimensional fracture and heat mapping techniques may help surgeons to predict the distribution of coronoid fracture lines associated with specific injury patterns.

Monteggia Fracture Dislocations: A Historical Review

The eponym Monteggia fracture dislocation originally referred to a fracture of the shaft of the ulna accompanied by anterior dislocation of the radial head that was described by Giovanni Battista Monteggia of Italy in 1814. Subsequently, a further classification system based on the direction of the radial head dislocation and associated fractures of the radius and ulna was proposed by Jose Luis Bado of Uruguay in 1958. This article investigates the evolution of treatment, classification, and outcomes of the Monteggia injury and sheds light on the lives and contributions of Monteggia and Bado.

Type III monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report

BackgroundAlthough previously reported, ipsilateral Monteggia fracture dislocation and distal radius fracture in a child is still a rare occurrence. A full clinical examination may be difficult but should not be ignored. Full length forearm radiographs are ideal but proper limb positioning may be difficult. The injury pattern can be easily missed.Case presentationA five-year- old right hand dominant Caucasian male presented with a history of fall on outstretched hand. Clinical examination was difficult and X - rays confirmed type III Monteggia fracture with an ipsilateral Type II Salter Harris injury of the distal radius and ulna.ConclusionThis report highlights the need for relevant examination of the wrist and elbow in young children. Appropriate radiographs must also be performed to prevent missing these injuries.

Treatment of Monteggia and Transolecranon Fracture-Dislocations of the Elbow: A Critical Analysis Review.

The uninjured elbow is an inherently stable joint. The skeletal articulations, surrounding capsuloligamentous structures, and muscular attachments maintain stability. The primary stabilizers of the elbow are the coronoid process, olecranon, trochlea, and collateral ligaments1. Traumatic dislocations without substantial skeletal injury are considered simple and usually do not require operative repair. In contrast, complex dislocations, which are associated with fracture and may involve one or more of the primary stabilizing structures of the elbow, are unstable and typically require operative reduction and internal fixation to achieve stability. Complex elbow fracture-dislocations follow a subluxation or dislocation event. These injuries range from ulnohumeral dislocations with radial head and coronoid process fracture (“terrible triad” injuries) to ulnar fractures with an associated injury of the proximal part of the radius, proximal radioulnar joint, radiocapitellar joint, or ulnohumeral joint. Monteggia injuries involve a proximal ulnar fracture with disruption of the proximal radioulnar joint. Transolecranon fracture-dislocations involve a proximal ulnar fracture at the greater sigmoid notch and anterior dislocation of the elbow, without disruption of the proximal radioulnar joint. Some fracture-dislocations do not follow either pattern but have features consistent with one or the other that help to guide treatment. The focus of this article …

Type II Monteggia injury in a toddler

Monteggia type fracture dislocations of the elbow are a common occurrence in children. Bado types I and III are the most common types comprising 70 and 23%, respectively, and type II injuries account only for 6%. We present an interesting case of Monteggia type II fracture dislocation in an 11-month-old child, which has not been described before in a child younger than 11 years of age. Any ulnar fracture, especially in a child, should be evaluated carefully. Closed reduction is the mainstay of treatment in Monteggia type II fracture dislocation in children.

Posterior Monteggia Fractures in Adults with and Without Concomitant Dislocation of the Elbow

Background The present study comprised a retrospective review aiming to identify the differences between patients with a posterior Monteggia injury with and without concomitant dislocation of the elbow. Methods Forty-nine consecutive adult patients with 50 posterior Monteggia fractures were identified that had operative treatment. Demographics and injury characteristics were recorded for the entire cohort (13 with and 36 without ulnohumeral dislocation) and final motion was recorded in 29 patients (10 with and 19 without dislocation) that had more than 10 months of follow-up. Results Fractures with concomitant elbow dislocation occur in younger patients (45 years versus 56 years; p = 0.046); are associated with higher-energy injuries (54% versus 21%, p = 0.037); are more likely to have a Regan-Morrey type 2 (85% versus 26%, p = 0.003)/Mayo type 1 coronoid fractures (85% versus 21%; p &lt; 0.001); and are more likely to have a Mason type 2 radial head fracture (61% versus 30%; p = 0.046). Conclusions Patients with a posterior Monteggia fracture and concomitant elbow dislocation have smaller coronoid fractures and worse ultimate ulnohumeral motion than patients without anelbow dislocation.

Anterior Olecranon Fracture-Dislocations of the Elbow in Children

A subset of olecranon fractures with loss of normal articular apposition (subluxation or dislocation) is recognized in adults as anterior and posterior olecranon fracture-dislocations1-6, but such injuries in skeletally immature patients have been rarely described7-9. The anterior olecranon fracture-dislocation may resemble an anterior Monteggia lesion in that there is anterior dislocation of the radial head with respect to the capitellum; however, the forearm (the radioulnar relationship) remains intact and the injury is primarily to the ulnohumeral joint by means of disruption of the trochlear notch (Figs. 1-A and 1-B). The coronoid is fractured in approximately half of the patients, the radial head is rarely injured, and the collateral ligaments are generally spared10. Olecranon fractures are relatively uncommon in skeletally immature patients11-13, and we were able to identify the cases of only three skeletally immature patients with an apparent anterior olecranon fracture-dislocation reported in the literature7-9. Figs. 1-A and 1-B Drawings differentiating between anterior olecranon fracture-dislocation and anterior Monteggia injuries. Fig. 1-A In the anterior olecranon fracture-dislocation, the proximal radioulnar joint remains aligned and intact, but there is an anterior dislocation of the radiocapitellar joint along with the rest of the forearm. Fig. 1-B In the anterior Monteggia fracture, there is a fracture of the ulna with anterior dislocation of the radial head. We identified four skeletally immature patients with an anterior olecranon fracture-dislocation from a fracture registry. This report describes the injury characteristics, treatment methods, and results of these four patients. ### Materials and Methods Between 1974 and 2002, all fractures treated at our institution were entered into a database …

Inveterate Monteggia Injury. Results of 3 cases with the modified Bell-Tawse procedure

Purpose Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Materials and methods The mean age of the 3 patients was 7 years (range: 5-9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results There were no complications. After a mean follow-up of 35 months (range: 9-84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head.

Lesión de Monteggia inveterada. Resultados con la técnica de Bell-Tawse modificada en tres casos

Purpose Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Case reports The mean age of the 3 patients was 7 years (range: 5–9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell-Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results There were no complications. After a mean follow-up of 35 months (range: 9–84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head.

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

We present a rare case of persistent complete posterior interosseous nerve palsy associated with a chronic type I Monteggia elbow fracture-dislocation consisting of anterior dislocation of the radial head and malunion of the ulna in an 8-year-old child requiring surgical treatment. Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head. This report describes combined treatment of the nerve and skeletal injury for the chronic type I Monteggia injury. The literature is reviewed, and diagnostic challenges with and treatment options for chronic Monteggia fracture-dislocations in children are discussed.

Simultaneous monteggia type I fracture equivalent with ipsilateral fracture of the distal radius and ulna in a child: a case report.

IntroductionSimultaneous Monteggia injuries of the elbow and ipsilateral distal radius and ulna fractures are very rare.Case PresentationA unique case of a type I Monteggia fracture equivalent with ipsilateral fracture of the distal radius and ulna (Salter-Harris type II) in a child is reported. We describe the management of this unique fracture and discuss the possible mechanism of injury.ConclusionWe have highlighted a rare combination of injuries. Early recognition and prompt surgical intervention can lead to a satisfactory outcome even in these complex injuries.

Die elastisch-stabile Marknagelung als Therapiealternative in der Versorgung kindlicher Monteggia-Frakturen

Forearm fractures are some of the most common injuries in childhood. Monteggia fractures and Monteggia equivalents are rare injuries of the proximal forearm, but they are important because of their special biomechanics. Many authors have reported good results with excellent function if the Monteggia injuries are diagnosed primarily and treated by an axial reposition of the ulna and by an exactly repositioned proximal radioulnar joint. In our investigation, some clinical cases of pediatric Monteggia fractures were operated upon using the technique of elastic stable intramedullary nailing (ESIN). In correct indications, ESIN could be used as a minimally invasive therapeutic alternative to plate osteosynthesis for treating pediatric Monteggia injuries.