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Updated: Dec 27 2021

Monteggia Fracture

  • 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
  • Prognosis
    • Unfavorable
      • delayed diagnosis
        • radial head dislocation can be missed on initial radiographs
  • 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
  • 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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