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Monteggia Fracture

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Topic updated on 11/14/17 5:29pm

Snapshot
  • A 35-year-old man presents to the emergency room for severe right elbow and forearm pain after sustaining a blunt injury to his right arm. On examination, the affected arm is swollen and tender around his elbow. Radiographs demonstrate a displaced fracture of the proximal ulnar diaphysis and radial head dislocation. 
Introduction
  • Clinical definition
    • traumatic injury to the elbow and forearm characterized by the presence of two bony injuries
      • diaphyseal fracture of the proximal third of the ulna
      • radial head dislocation
  • Epidemiology
    • incidence
      • less common than other types of serious elbow injuries in children (e.g., supracondylar fracture, radial head subluxation, and lateral condylar fracture)
    • demographics
      • more common in children than adults
        • peak age range 4-10 years of age
  • Etiology
    • traumatic injury
      • Fall On an OutStretched Hand (FOOSH)
      • direct blow to the ulna
  • Pathoanatomy
    • normal anatomy of the elbow and forearm
      • forearm consists of 2 bones
        • radius
        • ulna
      • elbow consists of 3 joints
        • radiocapitellar joint
        • ulnohumeral joint
        • proximal radioulnar joint
    • fracture mechanics
      • fall on an outstretched hand or traumatic blow leads to proximal ulnar diaphyseal fracture and radial head dislocation
      • annular ligament may become interposed in the radiocapitellar joint, preventing reduction of the dislocated radial head
  • Associated conditions
    • may occur with other traumatic injuries to the elbow and forearm
      • distal radius fracture
      • olecranon fracture
      • radial head fracture
      • coronoid process fracture
  • Prognosis
    • unfavorable
      • delayed diagnosis
        • radial head dislocation can be missed on initial radiographs
Presentation
  • Symptoms
    • elbow pain and swelling
  • Physical exam
    • tenderness to palpation along the elbow
    • decreased elbow range of motion due to pain
    • radial head may be palpable if significantly dislocated
Imaging
  • Radiographs 
    • indication
      • radiographs are indicated if there is any suspicion for fracture
    • finding
      • proximal ulnar shaft fracture with radial head dislocation
        • ulna fracture will be easily visible in most cases
        • radial head dislocation can be missed
Differential
  • Galeazzi fracture 
    • distinguishing factors
      • radiographs will show radial diaphyseal fracture and distal radioulnar joint dislocation
      • patient generally will have pain localized to the wrist instead of the elbow
  • Supracondylar fracture 
    • distinguishing factors
      • radiographs will demonstrate evidence of fracture (e.g., fracture line or enlarged fat pads) along the supracondylar humerus without evidence of radial head dislocation
Treatment
  • Conservative
    • closed reduction +/- intramedullary fixation and casting
      • indication
        • used in some fractures in children
  • Operative
    • open reduction and internal fixation (ORIF)
      • indication
        • used in all adult fractures and more severe pediatric fractures
Complications
  • Posterior interosseous nerve (PIN) palsy
    • generally, a neuropraxia caused by anterior displacement of the radial head
    • spontaneous recovery is expected


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