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MONTEGGIA

FRACTURE
DISLOCATOIN
By : Indriana Sari, S.Ked
Supervisor : dr. M Pandu Nugroho, Sp.
OT

DEFINITION
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

BADOS 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 bicepsafter 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

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 capitellumin any degree.

Management of monteggia
fractures

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 wksmobilization.
Full activity after 6-8 wks

OPERATIVE
INDICATIONS:
Failure of ulnar reduction
Failure 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

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: MRD
OPERATIVE:
if # is unstable-reduced and fixed
percutaneously with pinning.
12yrs or older plating of radius through
HENRYS extensile approach.
radial head is reduced by closed
Ulna plating or pinning.
After care: A/E cast at 100 to 120* of flxn4wks B/E cast for additional 4 wks with
early rom.

complications

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

Thank you

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