Note there is plastic deformation of the ulna without a complete fracture
Always assess the radial head, it should point towards the capitulum

MANAGEMENT
#Non-operative
- Closed reduction of ulna and radial head dislocation and long arm casting
- If no ortho available, attempt to reduce radial head and place in a posterior splint. 
- Axial traction traction to restore ulnar length
- Need to successfully reduce radial head dislocation as well
- Immobilize in 110 degrees flexion and full supination.

#Operative
- Indicated if radial head or ulnar length are unstable following reduction
- Indicated in Bado Type IV fractures (complete fx of Ulna and Radius)
- Frequently required in missed diagnosis.

DISCUSSION
- A Monteggia fracture is radial head dislocation plus a proximal ulna fracture or plastic deformation of the ulna
- Peak age range 4-10 years, fall onto pronated arm..
- Frequently missed since the ulna may only have plastic deformation, have a high suspicion if there is pain over the radial head or evidence of radial head dislocation.
- Complications include posterior interosseous nerve neurapraxia (finger drop, radial wrist deviation). 
- Loss of forearm motion with delayed treatment (2-3 weeks)
- Different classifications are present (Bado) but not as key as recognizing the fracture.
- This patient was casted and follow up arranged.

KEY POINTS
- Have a high index of suspicion when there is radial head tenderness or dislocation
- Ulna may show only plastic deformation
- Radial head should always point towards the capitulum
- Obtain contralateral arm films if comparison is needed.
- ED management without ortho includes reduction with posterior splint placement. Close f/u. 
- Majority of cases result in non-operative management.
- Frequently missed

By Dr. Mohamed El-Kara

REFERENCES
http://www.orthobullets.com/pediatrics/4015/monteggia-fracture--pediatric
http://emedicine.medscape.com/article/415822-overview#a5

HPI:  Middle age male who presents with left ankle pain, swelling, and deformity s/p fall down stairs. Unable to bear weight to LLE.

Physical Exam: obvious deformity, edema, ecchymosis to L ankle. TTP over medial and lateral malleolus. Unable to flex and extend at ankle 2/2 pain. DP/PT 2+. Normal sensation to light touch to dorsal surface/plantar surface/1st web space.

IMAGING:

Diagnosis and Management:  This patient has a Weber B distal fibula fracture with medial subluxation of the tibia and disruption of the mortise joint. Combination of distal fibula fracture and likely complete disruption of deltoid ligament is a bimalleolar fracture-dislocation equivalent.  Thus, this is an UNSTABLE ANKLE!

Patient’s ankle was reduced using axial traction and inversion, placed in posterior sugar tong splint. Injury required 3 reductions, which is common due to the instability of this injury. Patient was admitted to Orthopedic Trauma service and scheduled for next day ORIF. 

HPI: Middle-aged male s/p MCC.

PE:  Ecchymoses, swelling, and tenderness about ankle. Tender over proximal fibula and pain with squeezing of calf.

Ankle Sprains:
-        Divided into grades
o   I: Minor, no significant ligamentous damage. Able to bear weight.
o   II: Associated with partial ligamentous tear. Significant ecchymoses/swelling. Difficulty bearing weight.
o   III:  Associated with complete ligamentous tear. Significant functional loss and universal inability to bear weight.

-        When should we obtain radiographs?:
o   If pretest clinical suspicion is high based on mechanism of injury or patient cannot be ruled out for fracture based on Ottawa ankle rules:

Syndesmotic injuries (AKA “high” ankle sprains):
o   PE and mechanism:

• Physical exam may have tenderness with calf squeeze, pain in syndesmosis with external rotation and dorsiflexion of foot, and translation of fibula with anterior/posterior force.
  
• If mechanism of injury involves hyper-dorsiflexion or significant eversion of the ankle, and patient has tenderness of the medial malleolus, a maisonneuve fracture (proximal fibular fracture associated with syndesmotic tear and deep deltoid ligament rupture) should be suspected. Order both ankle films as well as tib/fib films.  As in patient above, Ankle film may show widened mortise, indicating joint instability.
  

o   Treatment:

• Non-operative: Patient may be made NWB and placed in a boot, short-leg cast, or posterior short-leg splint + sugar tong splint. 
  
• Indications for non-op management:

                  -   Syndesmotic sprain without diastasis or ankle instability
                  -   Otherwise patient needs syndesmotic screw fixation. Patient can be immobilized and follow-up as an outpatient for surgical fixation

HPI:  Patient presents with a grossly deformed right upper extremity.

PE:  Gross deformity of humerus, no open fracture.  Unable to extend wrist. Unable to hyper-extend MP joints of fingers and unable to flex IP joint of thumb.  Radial and ulnar pulses intact.

IMAGING:  Multi-factorial fracture along the mid third of humerus along the expected course of the radial nerve.

DISPO (if at free standing ED):  Transfer patient to ED with on-call orthopedics for definitive fixation.  Reduce and splint prior to transfer.

TREATMENT:  Nonoperative managment.  Splinted and cast at bedside.  Follow radial nerve palsy clinically for improvement.