Pediatric Monteggia Fractures

HPI:
5 year old female presents with right arm pain after falling on a chair. Her arm was pinned in between the chair and the floor. She had immediate pain but it resolved. The following day she has increased pain and swelling in the right arm.

EXAM:
Swelling is noted in the proximal forearm. Tenderness to palpation present on the proximal ulna as well as radial head. No tenderness to the medial condyle, lateral condyle, or olecranon. Passive and active range of motion of the elbow is full but painful. No motor or sensory deficits of the hand.

IMAGING.
AP and lateral views of the elbow. 

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