Monteggia fracture-dislocation

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Background

  • Proximal ulna fx with radial head dislocation
  • Common in kids (different treatment for kids); rare in adults
  • FOOSH
  • Easy to overlook the radial head dislocation (will result in worse outcome)

Clinical Features

  • Pain/swelling at elbow
  • Radial head may be palpable in an anterolateral or posterolateral location
  • Spontaneous relocation possible: must palpate directly over
  • May be associated with radial nerve injury (wrist drop, inability to extend the fingers)

Complex Associated Injuries

Differential Diagnosis

Forearm Fractures

Evaluation

  • Inspect skin for open fracture
  • Decreased ROM at elbow may indicate dislocation
  • PIN neuropathy most commonly associated (hand deviates radially with wrist extension)

Adult Imaging

  • Xray: AP, Lateral of elbow, forearm, wrist
  • CT scan: Fractures involving coronoid, olecranon, and radial head
  • Findings:
    • proximal 1/3 Ulna fracture + radial head dislocation (due to ulna shortening)
    • Radial head can dislocate anterior, posterior, or laterally

Pediatric Imaging

  • Xray: AP, Lateral of elbow, forearm, wrist
    • Assess radiocapitellar line on every lateral radiograph of the elbow: a line down the radial shaft should pass through the center of the capitellar ossification center[1]
  • Findings: Radial head dislocation + proximal ulna fracture or plastic deformation of the ulna without obvious fracture

Management

  • Consult ortho in the ED
  • Long arm posterior splint with 90 degrees of elbow flexion and the hand in a neutral position
  • Adults: likely requires ORIF
  • Peds: possible long arm cast vs ORIF[2]

Disposition

  • If splinted and stabilized, can be discharged after consultation with Ortho
  • Admit for:

Complications

  • Consider open fracture (look for puncture wounds)
  • Compartment syndrome
  • Posterior Interosseous Neuropathy (PIN) - radial nerve branch; affects ~10% of Monteggia fractures
    • Purely a motor syndrome resulting in finger drop, and radial wrist deviation on extension.
  • Malunion with radial head dislocation

See Also

References

[3]

  1. de laGarza JF. Monteggia fracture-dislocation in children. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins' Fractures in Children, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:491-527.
  2. de laGarza JF. Monteggia fracture-dislocation in children. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins' Fractures in Children, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:491-527.
  3. Waters PM. Monteggia fracture-dislocation in children. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.446-74.