Monteggia Fracture-Dislocation
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Background
The Monteggia Fracture is rare, accounting for less than 2% of forearm fractures in both adults and children (1).
It is defined as a fracture of the proximal 1/3 fracture of the ulna, with associated radial head dislocation.
High Yield Anatomy to Know…
- Bones of forearm and their features
- Elbow joint
- Annular ligament
- Radial and Posterior Interosseous Nerve
Galeazzi vs Monteggia
Many people may confuse these eponymous names with the respective similar fracture-dislocation presentation.
Therefore, the following aide memoir may be of use during this learning process…
Just remember the word ‘Mugger’ and that the aide memoir only refers to the fracture – so you just need to remember the other bone (not the fractured bone) is dislocated.
Monteggia fractures are often classified according to the Bado Classification (2).
The Bado Classification categorises these fractures into 4 types…
- Type I – anteriorly angulated ulna fracture with anterior dislocation of radial head.
- Type II – posteriorly angulated ulna fracture with posterior dislocation of radial head.
- Type III – laterally angulated fracture of ulna metaphysis with lateral radial head dislocation.
- Type IV – Proximal fracture of both ulna and radius.
Presentation
- Pain and swelling at the elbow.
- Loss of range of movement and instability at the elbow.
- PIN Compression Syndrome.
- Wrist extension weakness.
- MCP extension weakness.
- Thumb extension weakness.
Management
- ABCDE
- Appropriate analgesia (3)
- oral paracetamol for mild pain
- oral paracetamol and codeine for moderate pain
- intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
- Do not offer non-steroidal anti-inflammatory drugs (NSAIDs) to frail or older adults with fractures.
- Exclude compartment syndrome
- Assess neurological status (considering PIN and radial nerve – wrist and finger extension)
- Assess vascular status
- Skin condition?
- X-ray at least AP and lateral
- Social Hx – thinking discharge planning
- Any anticoagulation regular medication?
- Any other medications need to stop/change prior to surgery?
- Any polytrauma?
- Long lie? – ?rhabdomyolysis, check CK
- Other bloods: FBC, U&E, coag, group&save
- Does cause of fall need exploring? – ECG
- Bone health? – osteoporosis?
Imaging...
- X Ray: AP, Lateral, Oblique of Forearm, Elbow, Wrist
- Comment on…
- Pt Age (important to consider degree of bone ossification at the elbow if skeletally immature)
- Any concomitant distal radial fracture?
- Consider CT scan if involvement of coronoid, olecranon, radial head fracture.
See ‘The Orthopaedic X Ray’ for more information on fracture description/presentation.
Treatment Options...
Most will require open reduction and internal fixation (ORIF), due to the need to achieve reduction and stability of the fracture (2).
In the paediatric patient with a greenstick type fracture, closed reduction and cast immobilisation can be indicated if anatomic alignment of the ulna fracture and stability can be achieved (2).
Guidelines
Fractures (non-complex): assessment and management
NICE guideline [NG38]Published: 17 February 2016
https://www.nice.org.uk/guidance/ng38/chapter/Recommendations
BOAST – Early Management of the Paediatric Forearm Fracture. 21 May 2021.
https://www.boa.ac.uk/resource/boast-early-management-of-the-paediatric-forearm-fracture.html
References
- Delpont M, Louahem D, Cottalorda J. Monteggia injuries. Orthopaedics & Traumatology: Surgery & Research. 2018 Feb 1;104(1, Supplement):S113–20.
- Johnson NP, Silberman M. Monteggia Fractures. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470575/
- Recommendations | Fractures (non-complex): assessment and management | Guidance | NICE [Internet]. NICE; 2016 [cited 2024 Apr 19]. Available from: https://www.nice.org.uk/guidance/ng38/chapter/Recommendations#management-in-the-emergency-department